The persistence of poor-quality psychiatric care in 2026, despite medication advancements, is driven by systemic, clinical, and biological factors. 1. Systemic and Business Drivers Modern psychiatric practice is often shaped more by healthcare system characteristics than by clinical needs. Time Constraints: The current business model often requires psychiatrists to see four patients per hour to remain profitable, leaving only 15 minutes per visit. This brief timeframe makes it nearly impossible to gather a detailed history of trauma or childhood. Provider Shortages: As of 2026, severe workforce shortages persist. In the U.S., only about 28% of the population's psychiatric needs are met. High caseloads lead to rushed evaluations and "diagnostic machine" mentalities. Insurance & Administrative Hurdles: Complex insurance billing codes and low reimbursement rates for "care coordination" discourage lengthy, holistic therapy. 2. Clinical Gaps and Mentalities Many adult psychiatrists focus on a narrow biological model that may inadvertently reduce empathy. Emotional Detachment: Medical training often encourages "professional detachment," which can evolve into desensitization toward patient struggles over time. Burnout affects up to 78% of psychiatrists, further lowering empathy levels. Neglect of Trauma: An over-reliance on the biomedical model often pathologizes normal human responses to psychosocial stressors, leading clinicians to overlook trauma or adverse childhood experiences (ACEs) in favor of quick diagnostic labels. Misdiagnosis Risk: Without objective biomarkers, psychiatrists rely on subjective self-reporting. Overlapping symptoms (e.g., bipolar vs. depression) lead to misdiagnosis in up to 76.8% of bipolar cases. 3. Biological Impact and "Liver Burden" Long-term use of psychotropic medications creates significant physical strain that can complicate treatment. Metabolic Syndrome & NAFLD: Prolonged use of antipsychotics and some antidepressants is linked to non-alcoholic fatty liver disease (NAFLD), weight gain, and insulin resistance. DNL Dysregulation: Medications can trigger de novo lipogenesis (DNL), causing fat accumulation in the liver even in the absence of obesity. Drug-Induced Liver Injury (DILI): While severe injury is rare, 0.5% to 3% of patients develop asymptomatic liver enzyme elevations, requiring careful monitoring that many "lax" clinicians may skip. 4. Comparison with Specialized Psychiatry Unlike some general adult practices, child and addiction psychiatry more frequently utilize technology and evidence-based practice (EBP) due to different funding and oversight.

Psychiatrists are medical doctors (MDs or DOs) who complete the same four years of medical school as any other specialist, such as a cardiologist or surgeon. Because they are licensed physicians, they have broad legal authority to prescribe medication, though they often refer to other specialists for non-psychiatric issues to avoid malpractice risks. Medical Knowledge and Training Identical Foundation: Psychiatrists spend four years in medical school studying anatomy, pharmacology, and physiology alongside all other future doctors. General Medical Rotations: During their four-year residency, psychiatrists must complete rotations in internal medicine, family medicine, and neurology. Complex Diagnoses: They are trained to identify medical conditions that mimic mental illness, such as thyroid disease causing depression or brain tumors causing anxiety. Why Specialists May "Degrade" or Ignore Recommendations Specialists sometimes dismiss a psychiatrist's input due to systemic and professional barriers: Stigma and Bias: There is a historical lack of respect for psychiatry as an "exact science" compared to biological specialties like surgery. Communication Gaps: Specialists may believe they can manage the patient's symptoms without psychiatric help or feel that the psychiatrist lacks current knowledge in their specific surgical or medical niche. Focus on Physical Markers: Other specialists rely heavily on biological metrics (blood tests, scans), while psychiatric diagnosis is often based on clinical observation, which some non-psychiatric doctors view as less "evidence-based". Prescribing Limits and Malpractice Legal Authority: In most states, a psychiatrist is licensed as a "physician and surgeon," which legally allows them to prescribe any FDA-approved medication. Scope of Practice: While they can prescribe for non-psychiatric issues (e.g., blood pressure meds if relevant to a patient's care), they typically do not. Malpractice Risks: A psychiatrist risks a malpractice lawsuit if they prescribe outside their field and the patient suffers harm. To be "defensible" in court, they must prove they followed the standard of care, including obtaining the necessary lab work and physical exams that a specialist would normally perform. Insurance Restrictions: Many malpractice insurance policies specifically cover "psychiatric practice." If a psychiatrist prescribes chemotherapy or high-risk cardiac drugs, their insurance may not cover any resulting legal claims.

Psychoanalytic child and adult psychiatrists can identify medical conditions missed by other specialists because they are trained medical doctors who utilize a "whole-person" diagnostic approach . While other specialists may focus narrowly on a single organ, psychiatrists often spend more time gathering detailed histories that uncover systemic issues. How Psychiatrists Identify Non-Psychiatric Conditions Psychiatrists often "out-diagnose" other fields by identifying medical mimics physical illnesses that present with behavioral or psychological symptoms. Neurology: Psychiatrists may identify conditions like Parkinson’s disease or central nervous system tumors when an "abrupt" change in behavior occurs that does not fit typical psychiatric patterns. Rheumatology & Immunology: Conditions like systemic lupus erythematosus or Lyme disease often present with non-specific symptoms (fatigue, brain fog) that other doctors may dismiss as "just stress". Endocrinology: Hormone imbalances can cause mood swings or anxiety, which a psychiatrist may trace back to an underlying thyroid or adrenal issue. Urology & Gynecology: Patients with "unexplained" chronic pelvic pain or urinary issues are frequently dismissed. Psychiatrists can bridge this gap by identifying the bladder-brain axis or noticing patterns that suggest physical pathology rather than purely functional causes. The Role of Psychiatrists in Countering "Medical Gaslighting" Medical gaslighting occurs when a physician dismisses a patient's genuine symptoms as "all in your head" or "normal" without proper investigation. Diagnostic Overshadowing: This is a common form of negligence where a doctor attributes new physical symptoms to a patient's existing mental health diagnosis, leading to missed life-threatening conditions. Advocacy through History-Taking: Because psychoanalytic psychiatrists prioritize listening to complex stories that "don't fit neatly into test panels," they are often the first to believe a patient's report and order necessary medical labs or referrals that other specialists refused. Validation: Unlike doctors who may use terms like "somatizer" to dismiss symptoms, a good psychiatrist validates that symptoms are real and works to find the biological or psychological root. Actionable Strategies for Patients If you feel your symptoms are being dismissed by other specialists: Request Documentation: Ask the doctor to note in your chart that they are declining further testing. Seek a Psychiatric Consultation: A psychiatrist can perform a comprehensive evaluation to help rule out medical causes for your symptoms. Bring an Advocate: Having a partner or friend present can make it harder for a clinician to dismiss your reports.

The professional tension between neurologists and psychiatrists is deeply rooted in a historical divide between "brain" and "mind" that continues to influence medical culture in 2026. The Historical and Philosophical Divide The rift began in the late 19th century when neurology and psychiatry split into separate disciplines. Physical vs. Behavioral: Neurologists traditionally focus on "organic" disorders with visible physical signs (like stroke or Parkinson’s), while psychiatrists manage "functional" disorders of mood and thought that often lack gross physical markers. Scientific "Hardness": Neurologists may view their field as more scientifically "objective" because it relies on measurable data from MRIs, EEGs, and physical exams. Conversely, psychiatry is sometimes unfairly dismissed as "subjective" because it relies heavily on clinical observation and patient self-reporting. The "Pseudo-science" Label: Some extremist views within the medical community still categorize psychiatry as a "pseudo-science" because it deals with the abstract "mind" rather than the physical "wiring" of the brain, leading to a sense of intellectual superiority among some neurologists. Differences in Training and Focus Training pathways reinforce these distinct worldviews: Neurology Training: Emphasizes diagnostic precision, neuroanatomy, and physiological mechanisms. This can lead to a "reductionist" approach where symptoms are seen only as electrical or chemical failures. Psychiatry Training: Prioritizes the bio-psycho-social model, integrating biological factors with psychological and social contexts. Empathy and Communication: While psychiatrists are specifically trained in psychotherapy and deep patient communication, neurologists often have shorter, task-oriented interactions focused on localized brain damage. Personality and Behavioral Profiles Research into the personality traits of these specialists suggests distinct profiles: Agreeableness: Psychiatrists typically score significantly higher in "agreeableness" (a trait linked to empathy and cooperation) compared to neurologists and neurosurgeons. Conscientiousness: Neurologists often score higher in "conscientiousness," a trait associated with order and precision, which can sometimes manifest as a more rigid or dismissive professional style. Professional Arrogance: A "myth of mastery" can permeate neurology, where the pressure to provide precise, scan-based answers may lead to a dismissive attitude toward the "gray zones" of mental health that psychiatrists handle daily. Move Toward Unified "Brain Medicine" By 2026, many experts are calling to abolish this artificial divide and reunite the fields into a single discipline of "Brain Medicine". This movement argues that the brain does not distinguish between "neurological" and "psychiatric" symptoms and that patients are best served when both biological and emotional health are treated as one.

In 2026, mental health continues to face structural and interpersonal discrepancies that distinguish it from other medical fields, often resulting in what patients and providers describe as devaluing or "subhuman" treatment compared to physical health counterparts . Structural Discrepancies Systemic Underfunding: Mental health research and clinical services historically receive significantly lower funding than physical health, a disparity termed "structural stigma". Insurance & Reimbursement Gaps: Reimbursement rates for behavioral health visits in 2026 average roughly 22% lower than those for medical or surgical visits, creating a massive financial barrier for both providers and patients. Mandatory Licensure Declarations: Unlike many physical illnesses, physicians must often declare mental health conditions for medical licensure, which can lead to intrusive "fitness to practice" assessments and restricted licenses. Referral & Diagnostic Discrepancies Diagnostic Overshadowing: Physical symptoms in patients with mental illness are often misattributed to their psychiatric condition, leading to delays in diagnosing serious physical ailments like heart disease or cancer. Limited Outpatient Training: Most medical students learn psychiatry in inpatient settings with extreme cases, receiving minimal exposure to the outpatient care where over 80% of mental health treatment occurs. Therapeutic Pessimism: Providers outside the field frequently hold the belief that mental illnesses are "incurable," leading to dismissive or demeaning interactions that deter patients from seeking further help. Pharmaceutical & Market Discrepancies Lack of Personalized Engagement: Historically, pharmaceutical representation in mental health lagged behind highly commercialized fields like oncology or cardiology. However, in 2026, companies are shifting toward "hyper-personalized" direct-to-consumer platforms to reclaim the patient relationship and drive care coordination. Prescribing Imbalance: Non-psychiatric physicians and nurses write 80-90% of psychiatric prescriptions but often demonstrate lower knowledge levels regarding psychopharmacology compared to specialists. Will it change? The landscape is shifting in 2026 due to several emerging trends: Enforcement of Parity Laws: Stronger enforcement is finally pushing for insurance coverage of mental health and substance use services at the same level as physical health. Value-Based Care Integration: Systems are moving mental health from the "periphery to the core," adopting new measures like treatment engagement and social determinants of health to better capture patient outcomes. Collaborative Care Models: Integrating mental health into primary care settings is becoming standard practice to improve medication adherence and reduce the "isolation" of psychiatric treatment. Stigma in 2026 remains a significant barrier, often causing mental health patients to be viewed through a lens of "weakness" or "craziness" rather than as individuals with medical conditions . This bias manifests in healthcare, social settings, and policy. Healthcare and Structural Disparities Substandard Care: Patients reporting unfair treatment or disrespect by healthcare providers are twice as likely to go without needed mental health care. Many providers, including non-psychiatric physicians, still exhibit implicit biases that can lead to devaluing or dehumanizing patients. Arbitrary Benefit Caps: Medicare laws in 2026 still include discriminatory limits, such as a 190-day lifetime capon inpatient psychiatric hospital care a restriction that does not exist for any other medical specialty. Reimbursement Gaps: Insurers often provide lower reimbursement rates for mental health services compared to physical health, driving clinicians out-of-network and forcing patients to pay higher out-of-pocket costs. Social and Personal Impacts Perceptions of Weakness: Cultural emphasis on "toughness" leads many to view seeking help as a vulnerability or failure of character. Men, in particular, often face heightened stigma, as mental health symptoms are frequently misidentified as a lack of willpower. The "Crazy" Label: The label "crazy" is still used to isolate and dismiss individuals, effectively treating them as the opposite of "normal". Self-Stigma and Isolation: Approximately 47% of people with serious mental illness report discrimination when trying to maintain friendships, and 72% feel the need to hide their diagnosis. Ongoing Progress and Challenges in 2026 Mental Health Parity: New federal rules aimed at closing insurance gaps took effect on January 1, 2025, with more phases rolling out through 2026. These rules prohibit stricter medical necessity criteria for behavioral health than for physical health. Reducing Stigma: While stigma has decreased for conditions like anxiety and depression due to more open public dialogue, it remains high for serious conditions like schizophrenia and bipolar disorder. Access Inequities: Significant "mental health deserts" persist; for example, distressed areas may have as few as two providers per ZIP code compared to eleven in prosperous areas.

This situation involves potentially severe violations of medical standards and civil rights across two different systems. In 2026, legal precedents clearly establish that both hospitals and correctional facilities have a duty of care that includes both physical and mental health. Potential Lawsuits Against the Hospital A hospital can be sued for medical malpractice or negligence if their care falls below the "standard of care"what a reasonable physician would do in the same situation. Failure to Treat or Consult: If acute psychosis and encephalopathy were evident, the failure to provide a psychiatric consultation or neurological evaluation may constitute a breach of the standard of care. Negligent Infection Management: Hospitals are liable for MRSA and sepsis if they fail to follow sterilization protocols or if delayed/incorrect antibiotic treatment causes the infection to spread to muscles or the heart (endocarditis). Failure to Assess Capacity: In 2026, hospitals must document a patient's medical competency (capacity) before allowing them to refuse care or leave against medical advice while in a life-threatening state like sepsis or encephalopathy. Premature Discharge: Sending a septic patient home with antibiotics that fail, leading to a rapid spread of infection, is a common ground for negligence claims. Potential Lawsuits Against the Prison System Incarcerated individuals have constitutional rights to adequate medical and mental health care under the Eighth Amendment. Deliberate Indifference: To sue a prison, you must often prove "deliberate indifference" that officials knew of a serious medical need (like acute psychosis or a spreading MRSA infection) and ignored it. Section 1983 Civil Rights Claim: This federal lawsuit can be filed if the prison system failed to treat a serious mental illness or physical condition, resulting in permanent injury or trauma. Lack of Capacity for Incarceration: If the individual was in an acute state of encephalopathy or psychosis, they may not have had the legal capacity to stand trial or be held in a general prison population rather than a medical/psychiatric facility. Why Psychosis is Often Mismanaged Diagnostic Overshadowing: Medical professionals often prioritize physical symptoms or, conversely, dismiss physical symptoms (like sepsis-induced confusion) as purely "psychiatric," leading to fragmented care. Resource Constraints: Hospitals and prisons frequently lack immediate access to on-call psychiatrists, leading to the use of law enforcement rather than medical personnel to manage psychotic breaks. Recommended Actions Request Medical Records: Secure all records from both the hospital and the prison to document the timeline of the MRSA spread and the lack of psychiatric intervention. Consult a Medical Malpractice Attorney: Specifically one who handles cases involving sepsis and hospital-acquired infections. Consult a Civil Rights Attorney: To evaluate an Eighth Amendment claim against the prison for the 27 months of untreated psychosis and medical neglect. File Formal Grievances: If not already done, follow the prison's internal grievance process, as this is often required before filing a lawsuit. In cases involving acute psychosis complicated by sepsis and MRSA brain encephalopathy, medical and correctional failures often center on standard-of-care violations and constitutional rights. Medical and Legal Considerations Capacity and Elopement: Patients with MRSA brain encephalopathy and acute psychosis typically lack the legal capacity to refuse treatment or leave against medical advice. Hospitals may be found negligent if they fail to implement a "1-to-1" sitter or secure the environment for a patient known to be delusional or at high risk of elopement. Treatment Priority: Medical protocols for septic encephalopathy prioritize treating the underlying infection(sepsis) to resolve the neurological dysfunction. While antipsychotics can manage paranoia, they may take days or weeks to reduce delusions, whereas aggressive source control (e.g., draining MRSA abscesses) and antibiotics are required within the first hours to prevent permanent brain damage. Failure to Restrain or Sedate: Doctors must balance the risk of "chemical restraints" against the patient's medical instability. For example, benzodiazepines are often avoided in septic patients as they can worsen delirium. However, failure to protect a patient from their own delusional actions (like eloping while septic) can form the basis of a medical malpractice claim. Rights in Prison Deliberate Indifference: Under the Eighth Amendment, prisons are prohibited from "deliberate indifference" to an inmate's serious medical or psychiatric needs. Treating a patient with acute psychosis or encephalopathy without proper medical intervention may be considered "cruel and unusual punishment". Constitutional Rights: Courts have ruled there is no distinction between the right to medical care for physical illness and for psychiatric conditions. If a prison fails to provide adequate psychiatric treatment for an inmate with a brain infection, they can be held legally liable. Potential Compensation and Recourse If the medical field and prison system failed a patient, they may be entitled to damages for: Physical and Emotional Suffering: Compensation for the physical pain caused by untreated sepsis and the trauma of being imprisoned while mentally incapacitated. Disability and Disfigurement: If the delay in treatment led to muscle loss or other permanent physical damage. Medical Costs: Recovery of all past and future expenses related to the injuries sustained due to negligence. To pursue these claims, a patient or their family must prove a breach of duty—that the care provided (or lack thereof) fell below the accepted 2026 medical standards. Consult the American Civil Liberties Union (ACLU) or Disability Rights Texas for specific guidance on prisoner healthcare rights.

In Jungian analysis, the development of these symptoms in a 10-year-old child represents a "lowering of the mental level" ( abaissement du niveau mental), where the ego becomes too weak to filter out intense contents from the unconscious. Jung viewed psychosis not as "nonsense," but as a highly symbolic attempt by the psyche to compensate for a deep-seated lack of balance. The NBA Player Obsession (The Hero Archetype): Jung would see this as a manifestation of the Hero Archetype. For a child with severe negative symptoms (emotional flattening, lack of drive), this obsession is a compensatory "inflation". The psyche creates an image of peak physical power and social "visibility" to counter the inner experience of invisibility and impotence. The Command Hallucinations (Autonomous Complexes): The voices are viewed as autonomous complexes fragmented parts of the personality that have split off and gained their own "will". They command the child because the ego has lost its authority. Physical Rituals (Symbolic Language): Touching the Door Frame: Thresholds (doors) symbolize transitions between states of being. Touching the frame may be a ritualistic attempt to "ground" the self or mark a boundary between the inner world and the external reality. Walking on Tiptoes: This can represent a psychic "detachment" from the earth (reality). In Jungian terms, the child is "floating" or being pulled into the "air" of spirit/fantasy, losing the "ground" of concrete existence. Pushing Out the Chest: This is a psychomotor expression of the NBA/Hero fantasy. It is a "puffed up" physical manifestation of the ego trying to occupy more space to defend against being overwhelmed by the unconscious. Mechanisms of Development Faiblesse de la Volonté (Weakness of Will): Jung believed that when the "will" to remain in reality weakens, the "unconscious contents" (hallucinations/obsessions) rush in to fill the vacuum. Teleological View: Jung would ask: "What is this psychosis trying to achieve?". The symptoms are seen as a disorganized attempt at individuation the psyche is trying to "grow" or solve a problem, but it is doing so in a fragmented, "shattered mirror" fashion. For a 2026 clinical perspective on managing such early-onset symptoms, specialized pediatric centers like the NIMH Early Psychosis Program or the AACAP Psychosis Resource Center provide evidence-based guidance for families.

Key Takeaways Individuals with SSDs experience significant disability, compounded by treatment-resistant symptoms and physical health multimorbidity, leading to a premature mortality gap. Physical activity offers dual benefits for physical and mental health, improving cardiorespiratory fitness, muscular strength, and mental health outcomes in individuals with SSDs. Barriers to PA engagement include individual and environmental factors, but fostering autonomous motivation and integrating exercise into psychiatric care can enhance participation. Psychiatrists are encouraged to promote PA as an adjunctive treatment for SSDs, incorporating routine screening and advocating for equitable access to exercise programs. Individuals living with schizophrenia spectrum disorders (SSDs) experience significant disability, underpinned by functional impairment in almost every domain of life. Treatment resistance to first-line antipsychotic medications can be as high as 30%. Negative and cognitive symptoms typically respond poorly to medications and, together with positive symptoms, contribute to limited personal and functional recovery. These challenges are further compounded by physical health multimorbidity (co-occurrence of multiple, serious, largely preventable physical health conditions in parallel) that develops from a much younger age and leads to cumulative health risks and a premature mortality gap of approximately 15 to 20 years compared with the general population. Modifiable lifestyle risk factors such as low levels of moderate to vigorous physical activity (MVPA), low cardiorespiratory fitness, and high levels of sedentary behavior compound the cardiometabolic adverse effects of antipsychotic medications, contributing to high cardiometabolic risk. Emerging evidence also suggests that low muscular strength may be an independent risk factor for premature mortality. The cardiorespiratory fitness and muscular strength of individuals living with SSDs are comparable to those of individuals decades older in the general population and can be seen as signs of premature aging. Practically, this can result in difficulties with mobility and activities of daily living, further exacerbating global functional impairment. Physical activity (PA) is defined as “any bodily movement produced by skeletal muscles that results in energy expenditure.” PA may offer dual benefits for physical and mental health; in line with this, there is growing recognition of its potential to improve health outcomes among individuals with SSDs. Physical Health Although weight loss is the most commonly reported motivation for individuals with SSDs to engage in PA, PA alone has not consistently produced significant weight loss. A small number of studies have found that MVPA may contribute modestly to weight reduction; however, the most robust evidence for this outcome comes from multimodal lifestyle interventions (combinations of nutritional counseling, weight management programs, physical activity, health education, and motivational interviewing). Thus, we believe that lifestyle interventions should be offered from the onset of illness and antipsychotic treatment, tailored to both the individual and the illness, and integrated into routine psychiatric care. Cardiorespiratory fitness is a strong predictor of mortality, independent of adiposity or other risk factors. Thus, for individuals with SSDs, improving cardiorespiratory fitness may be a more achievable target than weight loss from PA alone. A large meta-review of patients with SSDs found PA can improve cardiorespiratory fitness, with the greatest improvements observed following interventions of at least moderately vigorous intensity, and when delivered by qualified exercise professionals, such as exercise physiologists and physiotherapists. Emerging research from a small number of studies suggests resistance training can improve muscular strength. Case Study 1 “Alan” is a 47-year-old single, unemployed man living with SSD who had an undergraduate degree in business and a pre-illness history of amateur competitive cycling. He was admitted to a residential psychiatric rehabilitation facility with remitted positive symptoms but a profound negative syndrome, lying in bed for 23 hours per day. His elderly mother provided all daily care for him. At the rehabilitation facility, Alan began to engage in a moderate-intensity whole-body resistance training program, 3 times per week under the supervision of an exercise physiologist, delivered onsite and integrated into usual care. Over 8 weeks, his lower and upper body strength gradually improved until he was able to start exercising independently, and he began biking to the store for his own groceries. In addition to the restoration of physical and daily functioning, he described a significant improvement in self-confidence: “It was very helpful to my physical health and my core strength that I use just for getting around every day, and I think it did help in some small way to my emotional state; I feel like I’ve done something, or that I’m capable of doing something…[with] confidence in myself.” Mental Health and Functioning There has been consistent evidence of the benefits of PA for individuals with SSDs on mental health outcomes, including negative and cognitive symptoms, global functioning, and quality of life. The findings relating to negative and cognitive symptoms are particularly relevant, as they show a promising impact on outcomes that do not respond well to medications, thus highlighting the role of PA as an important augmentation strategy for mental health. Most of the current evidence is derived from aerobic studies, with greater benefits when intensity is at least moderate. However, yoga has been found to have some promising benefits for positive and negative symptoms, although a greater number of high-quality trials in a broader range of settings are required to make definitive recommendations. Case Study 2 “Brandon” is a 24-year-old single man with treatment-resistant schizophrenia with a partial response to clozapine. Despite assertive augmentation of the clozapine with other medications, electroconvulsive therapy, and cognitive behavior therapy for psychosis, Brandon continued to present with persistent distressing auditory hallucinations. After Brandon started engaging in aerobic MVPA 3 times per week, supervised by an exercise physiologist, he reported acute improvements in mood, a significant reduction in the auditory hallucinations for several hours after a session, and an increase in overall quality of life. Over time, sessions were increased to 5 days per week, but he struggled to continue with PA without supervision. Support workers were sought, and he was able to continue the PA therapy in the community in the longer term. “On the days that I do training, I’m in a good mood all day; even the voices, they don’t really bother me, I can ignore them,” he said. Physical Activity Type In terms of type, aerobic exercise has been the most widely studied; however, preference for exercise engagement is vital. Evidence from systematic reviews demonstrates benefits from a range of PA types, including sports, resistance training, yoga, walking, and high-intensity interval training in individuals with SSDs. Encouraging individuals with SSDs to engage in the type of PA they enjoy and are most likely to sustain engagement is important. How Much Physical Activity? The World Health Organization (WHO) recommends at least 150 minutes of MVPA per week for general health benefits. For patients with SSDs, even small amounts of PA (ie, less than 150 minutes of MVPA) may confer benefits and are better than none. Achieving WHO guideline levels may be challenging and potentially discouraging for individuals who have been recently inactive. Recent work has highlighted the value of promoting open goals (eg, nonspecific, exploratory, graded outcomes) for those who find behavior change difficult. Hence, in the initial phase of PA adoption, encouraging people for example, to “see how many steps you can do today” may be preferable to setting specific targets that may feel unattainable. Implementation in the Real World While the feasibility of PA interventions evaluated in structured research trials is comparable with psychological therapies and medications, sustaining engagement for PA in the real world can be challenging for individuals with SSDs. Numerous individual factors (eg, obesity, pain, negative symptoms, low support) and environmental factors (eg, cost, stigma, access, opportunity) can be barriers to participation. Neurobiologically mediated impairments in reward processing also underpin motivational deficits for PA one of the most commonly cited barriers to PA in this population. Autonomous motivation for PA has been associated with greater engagement in patients with SSDs and should be actively fostered. For example, this may mean supporting intrinsic reasons, such as “I do physical activity for fun” or because “I personally value the benefits,” rather than more external types of motivation, such as “I need to do physical activity to please others” or “because I feel guilty.” According to self-determination theory, the necessary conditions for autonomous motivation are relatedness, autonomy, and competence. In addition to choice of PA type or intensity where resources permit, providing options for the format (ie, individual or group) is also optimal. Mobilizing emotional and practical support is vital and may include input from mental health clinicians, family, carers, and nonclinical or peer supports. At a systems level, structural changes in mental health service delivery such as enhancing access to and integration of exercise programs and gyms into mental health services, as well as incorporating exercise professionals into multidisciplinary teams have recently gained traction. Such models are likely to help translate the promising efficacy seen in clinical trials into real-life effectiveness. Adverse events from PA interventions appear to be low; however, routine screening can detect those who require medical assessments for suitability: Most patients with SSDs without specific risks can readily engage in light to moderate-intensity PA. In line with international guidelines, psychiatrists and mental health clinicians are encouraged to incorporate routine screening of PA into usual care, which can be done using simple self-report tools, such as the physical activity as a vital sign questionnaire, or an internationally validated self-report screening tool, the simple physical activity questionnaire. Psychiatrists can play an important role in the promotion of PA to individuals with SSDs by considering an “exercise is medicine” approach, and are well positioned to provide advice about health and behavior change. At a policy level, there is also a role for psychiatrists in advocacy for equitable access to services and qualified professionals to support the integration of PA interventions into psychiatric services . Acknowledgements We would like to thank the individuals living with SSDs who provided consent for the deidentified use of their clinical information and comments. Note: This article originally appeared on Psychiatric Times .

Introduction Patients with intellectual disabilities, can be admitted to an inpatient psychiatric unit from their home environment, on a voluntary basis, but are more likely to be admitted based on the recommendations of the patient’s staff or family, due to acute changes in patient’s pattern of behavior. This collaborative effort, by various members of the patient’s support team, help provide the treatment team, with a global picture of the potential struggles that the patient is dealing with. They also help provide objective information, as the patient, based on the linguistic and cognitive capabilities, may not be able to express their symptoms or may lack insight into their behavior. In addition to medication management, on the inpatient unit, it is very important to help patient acquire skills, which can be used to deal with their underlying mental health needs. Therapy is one important mode of treatment that should be emphasized during hospitalization, by increasing a patient’s level of awareness about their condition and helping empower patients, by mitigate feelings of helplessness through acquiring new coping skills, which can be applied in the future. However, based on limited resources, on the inpatient unit, individual therapy may not be feasible. At alternative option, that can be very beneficial in an inpatient setting, is group therapy. Group therapy is a type of psychotherapy that involves one or more therapists working with several patients at the same time. Groups can be as small as 3-4 patients, however group therapy sessions generally involve 7-10 individuals (Lesczc and Yalom, 2005). The implementation of group therapy, for patients on an inpatient setting, can potentially improve compliance with treatment, by increasing a patient’s level of awareness and insight about their underlying symptoms, and decreasing feelings of emotional isolation. Based on the type of staff available, group therapy can incorporate varying creative activities, including music and art therapy, which will increase participation and provide possible coping skills that a patient can utilize in the future (Montgomery, 2002). The number of staff involved in group therapy, should be based on the level of assistance that patients of the group require, to maximization that level of direct participation. Structure of Group Therapy To help define the structure for group therapy, sessions should be held in a room that is exclusively dedicated to group therapy, to minimize the level of unwarranted environmental distractions. One entrance/exit door is preferred to help facilitator keep track of participants. The best sitting arrangement for group therapy would be in a large circle, where the therapist is sitting among the patients, to limit the therapist being viewed as an authoritative figure or the central focus of therapy (Lesczc and Yalom, 2005). Members of the group should be capable of seeing one another, during the entire session. A structured, daily schedule should be posted in the common patient area at the start of the day, with staff reiterating the various activities throughout the day, to maximize participation. As group therapy is not mandatory on the inpatient unit, if possible, staff could offer words of encouragement or small items of appreciation, to participating patients, which can include additional recreational privileges. This type of positive reinforcement will help increase participation in groups and help patients feel empowered in the process. Patients with intellectual disabilities, based on prior experiences, are often told what to do, by an authority figures in their life, so it is important to help maintain a level of autonomy for patients, on the inpatient unit. Principles of Group Therapy In The Theory and Practice of Group Psychotherapy, Dr. Irvin D. Yalom (2005) , discusses the key therapeutics principles that illustrate the benefit of group therapy for patients. Introduction of Hope – A group will consist of individuals at different stages of the treatment process. The journey for recovery will seem less daunting, if patients are able to witness others that are coping and recovering, allowing those in the beginning in the process to feel more hopeful. Togetherness – Being a part of a group, with similar experiences, helps each individual understand and recognize that they are not alone or isolated in dealing with their mental illness. Also, it helps the individual understand they accepted and valuable for whom they are. Empowerment – Patients have the ability to help one another by sharing their experiences, by increasing the level of awareness of group members. Safe haven – Group therapy can be a safe haven for patients, to allow them to discuss their issues and experiences, in a non-judgmental, neutral environment. Mirroring – Patients participating in group therapy, can be capable of mirroring positive behaviors and actions of a therapist, to provide them with more tangible ways to communicate and address underlying issues. Practice – Through repetition, patients will be able to practice how to apply their newly acquired techniques, which can alter their behavior in a positive fashion. Through repetition, habitual actions may develop into an underlying mentality that the patient can develop. Interpersonal learning – Through reflection, individuals can better understand themselves and their experiences. The knowledge they acquire can allow them understand the meaning of events in their lives. Purification – The act of sharing feelings or experiences in a group environment can be beneficial. An individual can release their suppressed emotions, which reduce his level of pain, guilt, or distress. Suppression of emotions can cause physical and psychological tensions within each individual. Confidence – As group members are capable of sharing their feelings and emotions, it can help individuals increase levels of self-esteem and confidence Tailoring Group Therapy for Patients with Intellectual Disability It may have been thought for years, that patients with Intellectual Disability may not benefit from insight-oriented group therapy, to help address their mental health issues, due to potential cognitive limitation, that hinder therapeutic intervention. However, there is increasing evidence and literature over the past 20 years, to illustrate that such individuals can benefit from therapy, if the therapeutic interventions were designed to better fit these individuals’ needs and capabilities (Razza and Tomasulo, 2005). Psychotherapy for patients with ID, is more effective, if it was focused on the use of active/interactive techniques that stimulate learning than a verbal modality alone (Psychology Today, 2013). According to literature, Interactive Behavior Therapy (IBT), developed by Daniel J. Tomasulo, Ph.D, is the most widely used form for group psychotherapy for individuals with intellectual disability, chronic psychiatric issues, or dual diagnosis (Razza and Tomasulo, 2005). The central focus of IBT, is altering the nature and methods to which therapy in conducted, to meet the needs of individuals with ID, as expressive and/or receptive language can be reduced or limited, for certain individuals (Gardner et al., 1996). Importance of Role Playing Role-playing is used in nearly every phase of human development to teach and model behavior. It is a fundamental concept that is reiterated in IBT, to help enrich the therapeutic experience, which has been coined Psychodrama (Marineau, 1989). Psychodrama is an action oriented therapy and technique, which allows expression of a condition or offer a solution, to a particular situation, through active participation in a collaborative group environment (Marineau, 1989). This collaborative approach conducted in an IBT format, places an emphasis on the interaction of participants in the group, rather than the interaction between the patient and facilitator, as the facilitator should provide guidance on the direction of therapy (Razza and Tomasulo, 2005). Structure of the IBT Model The Interactive-Behavioral Model, which in conducted in a four-stage process, uses 45 minute to 1-hour time slots for therapy sessions. The reduced time demands are beneficial to maximize participation, as patients are more physically/emotional present, limiting levels of exhaustion or inattention (Razza and Tomasulo, 2005). 4 Stages of IBT Stage 1: Orientation Goal of facilitator – to create a stable environment for participants, with cognitive impairment to develop skills needed for successful group participation. Focus on creating an environment where each individual is capable of experiencing their feelings and emotions, without interruption, as patients with ID, are unfortunately accustomed to people not listening to them or talking over them. Facilitator should continue demonstrating skills of actively listening to participants, and redirecting members on the importance of paying attention to one another and maintaining good eye contact (Psychology Today, 2013). Stage 2: Warm-Up & Sharing Goal of Facilitator: Inviting members to talk about themselves within the group. It is important that each facilitator pay attention to the interaction of members within the group, to help maximize the therapeutic experience. Each member of the group, should take turns disclosing their experiences relating to the topic discussed. Interaction amongst peers is preferred rather than interaction with the facilitator to maximize group adhesion. It can also be beneficial for the experience be interactive, as one member selects another member to continue share his/her experiences (Psychology Today, 2013). Stage 3: Enactment Goal of Facilitator: Help the implement techniques such as role-playing to help drive the therapeutic experience for each patient, through direct or indirect participation. The issues or topics that were discussed during the warm-up/sharing experiences are formulated into characters through the collaborative effort of participants and facilitator (Marineau,1989). One type of role playing technique has been coined, the double, in which one or more group members will voice the feelings and thoughts of another member, who is struggling with a given problem. Various styles of enactment can be used such as mirroring, role reversal, doubling, etc., selected by the therapist. Therapist can also include allow participants to select which type of enactment they wish to do (Psychology Today, 2013). Stage 4: Affirmation Goal of Facilitator: Validate and acknowledge the effort of each of the participants, involved in-group. Reflect on important highlights of the session, qualities or characteristics of individuals involved that helped maximize the quality of therapy, acknowledge the level of interaction between individuals, which helped to make the group more cohesive. The period of the session helps individuals to identify components of participation that are applicable to the therapeutic goals of the session and applicability in their own life (Psychology Today, 2013). Benefit of IBT approach The style and techniques used in IBT, are not only beneficial for patients with an intellectual disability, but can be utilized for patients with chronic mental illness, such as schizophrenia, depression, etc., as well those with a dual diagnosis. The therapeutic goal is to increase the overall social competence of such individuals and increase each patient’s insight into their condition (Daniels, 1998). The technique of IBT can be applicable to addressing particular mental health issues, such as anxiety, depression, psychosis, which can help patients to address their underlying pathological issues, through a therapeutic modality (Mental Health Reviews, 2005). General Topics to Discuss with Inpatient Population In addition, to IBT, staff involvement should focus on educating patients on topics that are important for mental and physical well being, including nutrition, sleep hygiene, psychotropic education, and exercise. Education on Proper Nutrition –important to discuss with patients the importance of quality nutrition, what types of food/beverage is beneficial for each patient’s medical health. In addition, it is important to address topics such as proper portioning of meals, monitoring calorie intake, and type and quality of nutritional items. Patients are often misinformed or not educated about the importance of quality nutrition, which can have benefits on mental and physical health, to limit or hinder likelihood of developing conditions such as diabetes, heart disease, etc. Education on Sleep Hygiene – important for patients to understand the importance of structuring their life to allow them to maximize the quality and duration that they sleep, as it can be beneficial for mental health. Therapist should discuss topics such as limiting caffeinated beverages before evening, restricting bedroom activities for sleep/sexual activities (limited stimulating activities such as TV, eating, reading), possibility of incorporating relaxation techniques before sleep to reduce internal tension, educating patients on leaving the bedroom, if unable to maintain sleep, etc. Also, important to focus on establishing a consistent regimen in which patients should limit oversleeping, as this can be a counter-productive process. Education on Sleep Medications – inadequate quality of sleep (nighttime restlessness, inability to fall and/or stay asleep, early morning awakening) can have direct effects on any psychiatric condition, the following day, as the brain is unable to feel rested and calm. Important to address topics related to sleep medications, such as residual sluggishness, grogginess to educate patients on being watchful of over-sedating effects of medications. Also, to educate patients on the ill effects of overmedicating with sleep aids, particularly important for patients who self-administer medications. Also, important to discuss with patients to look out for possible side effects with particular medications, such as parasomnia with Ambien, etc. Psychotropic Education – based on patients’ cognitive capabilities, discussing with patients the importance of continuity of medication use, the type of psychotropic meds, as well as potential side effects or withdrawal symptoms. Also, harmful effects that patients experience should be discussed with their providers. Pictorial diagrams or illustrations can be helpful for all patients, particularly those with reception cognitive impairment. Benefits of Exercise – exercise, particularly aerobic exercises, for at least 30 minutes to 1 hour, daily, can be beneficial outlet to dissipate internal tension, which can exist, regards of the etiology of psychiatric illness. Exercise can have physiological effects on the body, as it can reduce level of stress hormones, including cortisol, as well as stimulating the production of endorphins, which are nature mood elevator, as well as pain reliever (Anderson and Shivakumar, 2013). This concept has been vocalized by athletes, as a ”runner’s high”, in which euphoric feelings are felt, after an extended period of exercise. It is important for staff to screen patients, who would be appropriate to participate in physical activities, to limit the likelihood of injury. If patients had physical limitations, exercises could be altered, to allow varying levels of participation within a group. It would beneficial for patient to be capable of participating in exercise groups 20-30 minutes, hopefully three times a day, according to staff availability. Also, outdoor activity, due to increased level of sunlight would be beneficial for patients to naturally increase their level of Vitamin D. Relaxation Skills – it is important for a therapist to help patients address the physical tension that exist, as this is one among a constellation of symptoms of anxiety. A therapist can incorporate techniques such as progressive muscle relaxation or deep breathing, however the level of communication among staff, should be focused on meets the cognitive abilities of each patient. Simpler terminology or directions regarding the exercises, as well as ongoing reiteration, are beneficial to maximize participation within the group. It is important for facilitator to be aware of patients, who have decreased receptive skills, as they may require more individual attention, to reduce the likelihood of being derailed from the group environment. The patient, to reduce or dampen the physical tension that exists during periods of anxiety, can utilize these newly acquired skills (Anderson and Shivakumar, 2013). Conclusion Group therapy can be an effective mode of therapy, used on an in-patient unit, as it can allow patients to become allies in their journey to understand and overcome their mental health needs. The principles of group therapy, discussed by Dr. Yalom, help emphasis the synergistic effect of group therapy on each patient. Patients with intellectual disabilities, in addition to mental health needs, may need adjustment in the type and delivery of group therapy. Based on the discussed literature, the main focus on group therapy, among patients with intellectual disability, should be focused on therapy activities that are more action oriented. According to Interactive Behavior Therapy, patients with intellectual disability are able to absorb and understand topics, when the activities are tailored around their cognitive and linguistic abilities. The duration of each IBT activity should be shorter in duration in maximize concentration on each topic (Psychology Today, 2013). Therapist should devote additional time to reiterate concepts to patients. It is less important to cover a number of topics, but more important that each topic is well understood by the patients. Also, the structure of therapy should focus on interaction among patients, in which they are capable of using role-playing. Also, the therapist seeks the assistance of each member in the group for guidance on developing resolutions to each scenario. This style of therapy is more tangible and meaningful, as patients are capable of participating, rather be lectured to. Also, it may increase their attention span, as various participants are involved. The mode of IBT, in addition to other general topics, should be incorporated into varying therapeutic modalities for patients, while on the in-patient unit. Patients experiencing various mental health issues can participate in IBT, which can be tailored to discuss psychological issues that stem from such conditions. However, it is important to be mindful about how the patient would act in a group therapy, as the purpose of the event in group participation or collaboration, rather than central focus on one particular patient’s behavior or actions. It is important for staff to screen patients before allowing them to participate; otherwise the process would be counterintuitive or counterproductive. Source: Inpatient group therapeutic interventions for patients with intellectual disabilities; Journal of Intellectual Disabilities 19(1); November 2014. Author: Vilash Reddy, MD .

Key Takeaways ADHD symptoms can worsen during and after pregnancy, necessitating careful consideration of medication continuation. Automatic discontinuation of ADHD medication in pregnancy poses risks, requiring individualized treatment plans. Recent studies show mixed data on medication effects, with concerns about congenital malformations and preterm birth. No significant long-term neurodevelopmental risks have been found with continued ADHD medication during pregnancy. A collaborative risk-risk analysis is essential for informed decision-making between clinicians and patients. CONFERENCE REPORTER “This is the hottest topic in ADHD,” said Greg Mattingly, MD, of the day’s first session topic at the American Professional Society for ADHD and Other Related Disorders conference. Attention deficit hyperactive disorder (ADHD) and pregnancy has been much discussed, with clinicians considering effects of altering ADHD pharmacotherapy on both mothers and their developing children. Presenters Allison Baker, MD, and Katherine Bang-Madsen, PhD, showcased the risk-risk analysis strategy that may be most beneficial for clinicians helping patients decide whether to continue medication into pregnancy.1 Baker began the session, highlighting how ADHD symptom s can become more challenging to manage during and after pregnancy, and many women have a desire to continue their medication after becoming pregnant. In the perinatal period, there are a range of treatments that are nonpharmacological, but some patients may still need their medication for daily functioning. These patients should consider continuing their medication through pregnancy, Baker recommended. Though, for more mild to moderate cases, clinicians can provide psychoeducation, cognitive behavioral therapy, dialectical behavioral therapy, and mindfulness exercises. Baker emphasized that clinicians should not jump to discontinue pharmacotherapy for ADHD immediately when a patient becomes pregnant. A study “highlighted that the decision, very strictly, of discontinuing medication may roughen ADHD symptoms, specifically functional impairment, as well as be a vulnerability factor for mood symptom roughening,” Baker said.1,2 Clinicians must consider the balance of risks and benefits for continuation vs discontinuation, Baker advocated. Baker characterized postpartum as a “high stress and low control period” for the mother. With the period surrounding pregnancy being a particularly vulnerable time, women with ADHD may experience heightened symptoms and increased burden. Postpartum, ADHD symptom burden can increase the most, especially with the mother’s self-concept declining and functional impairments increasing. The risk of going untreated during pregnancy can be high for the mother, but the risk to the development of the child should be weighed as well. Clinicians must be aware that automatic discontinuation of ADHD medication in pregnancy does pose a meaningful risk, Baker explained. While many patients may choose to limit medication exposure during pregnancy, the postpartum period can also then be an opportunity to optimize medication dosage. Ultimately, treatment decisions should be individualized and incorporate a collaborative risk-risk analysis between the clinician and patient, Baker concluded. Katherine Bang-Madsen, PhD, continued the conversation, incorporating recent research on ADHD and pregnancy. She posed the essential questions that patients are asking: If I continue my medication, what could happen to the baby? If I stop my medication, what could happen to me? Concerns cited about potential impact of stimulants often include congenital malformations, increased blood pressure or vascular tone, increased risk of miscarriage in already vulnerable pregnancies, and complications like preterm birth.1 There has been a general increase in ADHD medication use during pregnancy in the last decade, but we still lack randomized controlled trials in this area, Madsen outlined. Madsen emphasized that studies on ADHD medication and pregnancy show mixed data and are not definitive. The estimate of medication effect on pregnancy is highly sensitive to study design, she pointed out. With a lack of randomized controlled trials, we must interpret carefully and consider issues with confounding and ascertainment bias. A recent observational study showed no increased risk for congenital malformation in pregnancy with amphetamines, but an increased risk with methylphenidate.3 Though the effects were small, methylphenidate was found to be related a possible small increase in child cardiac malformation.3 Some papers have outlined hypertensive disorder complications with continuation of ADHD medication through pregnancy, and Madsen noted this as the biologically most plausible effect of the medication, though the effect is likely modest.4-6 Another population-based registry study on preterm birth found that medication exposure may modestly increase preterm risk particularly with longer or continued use but the study cannot determine definitive causality.7 In terms of neurodevelopmental outcomes for the child, Madsen described recent studies as having a “reassuring pattern.” Across 4 studies noted, there was no signal fond of increased long term neurodevelopmental condition risk when mothers continued ADHD medication .8-11 These studies included useful sensitivity analysis like sibling-controlled design and fathers as negative controlled, Madsen pointed out. Looking at long-term growth trajectories, Madsen provided data from a Danish registry cohort study not yet published which looked at outcomes in child height and weight from age 0 to 15 years. The study followed children of mothers who continued their ADHD medication (methylphenidate or lisdexamphetamine) through pregnancy compared with mothers who discontinued medication. Analysis excluded children who went on to start their own ADHD medication in childhood. The study showed that there may be a small effect on height trajectory with prenatal stimulant exposure, and the pattern is compatible with sex-modified vulnerability. This pattern still requires replication, Madsen noted. The mother’s mental health is also an important factor in considering risks and benefits of continuing ADHD medication in pregnancy, Madsen highlighted. A pattern has emerged of women discontinuing medication for pregnancy, and then not returning to their medication postpartum—even though, as Baker mentioned, postpartum can be a time of worsened ADHD symptoms. Women with ADHD were found to have elevated baseline risk of perinatal depression and anxiety, and data suggested some women deteriorate in mood or functioning when they discontinue medication during pregnancy. However, discontinuation showed no increase in overall perinatal depression and anxiety. Both presenters concluded that a risk-risk analysis, rather than a risk-no risk analysis is essential when deciding with patients whether to continue ADHD medication into pregnancy. Note: This article originally appeared on Psychiatric Times .

Wonder drugs” for opioid use disorder look different on the streets than in medical journals. Key points Medications for opioid use disorder have downsides that don't appear in most of the medical literature. Fentanyl use is up even though overdose deaths are down. Full-abstinence recovery is both possible and beneficial for many patients. Nearly all Americans are aware of the U.S. opioid crisis. Overdose deaths increased sixfold between 2003 and 2023, from 12,940 to 79,358. Yearly increases have been especially steep since 2013, when fentanyl hit the streets. COVID-19 further exacerbated the crisis until a marked decline in overdoses in 2024. The recent drop in overdose deaths is credited by public health officials primarily to medications for opioid use disorder (MOUDs), particularly naloxone (Narcan) and Suboxone/Subutex. Naloxone reverses active overdoses almost immediately by “kicking” opioids out of receptors in the brain and body and blocking their return. Nasally administered Narcan, when given quickly, can literally bring overdosed users “back from the dead.” The second drug, Suboxone, is used to prevent overdoses in the first place. Suboxone combines naloxone with buprenorphine, a powerful opioid itself. Buprenorphine spares patients from withdrawal, while low-dose naloxone limits the euphoria and risk of overdose that buprenorphine alone carries. Although patients maintain a low-level “high” and remain physically addicted to buprenorphine, low-dose naloxone prevents intense intoxication and overdoses by partially blocking opioid receptors. Both naloxone and Suboxone have been available for more than two decades. Those who credit them with the recent downturn in overdoses point to broader distribution and availability following intensive promotion in medical journals, by healthcare systems, and by the National Institutes of Health. Yet post-COVID-19 reductions in several causes of death have been reported. Alcohol-related deaths, cocaine overdose deaths, and suicides all trended down in 2024. This suggests an additional common cause that isn’t explained by MOUDs. The Downsides of MOUDs I’m not suggesting Narcan and Suboxone aren’t essential parts of treatment. Rather, I argue that the current public health narrative minimizes their drawbacks. Opponents of Narcan have long held that it enables opioid usena worry many public health officials flatly reject. Many of us who work on the streets, however, have heard our opioid-addicted clients describe hoarding Narcan so they can get “higher” and be revived if needed. As Reuters reported in "Fentanyl Express," their Pulitzer Prize-winning investigation of the opioid crisis, fentanyl use has increased even though overdoses have declined. This is almost surely attributable to Narcan. Suboxone treatment also comes with costs, particularly diminished quality of life for those who are treated long-term. Memory problems, constant sedation, fatigue, and low motivation are common side effects that can easily be overlooked in primary care settings because they’re less intense than the symptoms of heavier opioid use they replace. Over time, however, these side effects can erode well-being and may undermine patients’ agency in their extended recovery. Employment instability, social disengagement, oral infections, and tooth loss are also common with long-term Suboxone treatment, and overdose risk, though far lower than for heroin or fentanyl, isn’t trivial. None of these findings should be surprising given similar long-term effects of methadone, another long-acting opioid that was commonly used to treat opioid addiction before Suboxone was available. The American Society of Addiction Medicine doesn't mention these long-term effects in its National Practice Guideline, which encourages indefinite Suboxone treatment. In addition, buprenorphine like all long-acting opioids carries a very long withdrawal period, extending up to a month beyond the few days of heroin and fentanyl withdrawal. Patients who eventually seek full abstinence therefore face a more difficult road to get there. Many aren’t informed of this when Suboxone is prescribed. Some promotional materials distributed to prescribing physicians misleadingly claim that opioid detox is ineffective. Here again, those of us who work on the streets see many people choose detox and fully recover especially when that detox is paired with inpatient treatment. At the Hope Resource Center in Columbus, where I contract part-time, all eight peer support specialists were once addicted to fentanyl and have a year or more of full-abstinence recovery. Several of them were homeless before they first detoxed and entered treatment. These people’s stories show us that opioid use disorder can be overcome without indefinite buprenorphine treatment and maintained opioid addiction. Ashley Arick, a former peer support specialist at the Hope Resource Center who is now its outreach director, shares her story of repeated relapses while treated with Suboxone, and how her decision to choose full abstinence changed her life. (Readers can hear Ashley’s story on the Get a Grip Podcast.) My point in writing this post isn’t to deride MOUDs, which are essential tools in our treatment armament and are needed to save lives. Even long-term Suboxone treatment is necessary for some patients. Yet transparency about these medications is also essential given their effects on quality of life. These effects should not be swept under the rug, despite the well-meaning intentions of public health officials. Whether one is a prescribing physician, a person fighting opioid addiction, or a family member, we deserve to know the downsides of medications to make informed treatment decisions. Two things can be true at once. In the long run, we lose credibility with patients and the public when we hide the downsides of a treatment for any disorder. Note: This article originally appeared on Psychology Today .

Stephen M. Strakowski, MD: Hello, and thank you so much for turning into our conversation today. I’m excited to have Dr Sheri Johnson here to talk about bipolar disorder in a different way than we typically do. Dr Johnson is a distinguished professor at the University of California Berkeley and is truly the world’s expert in reward processing in bipolar disorder and mania, which is the conversation today. Dr Johnson, welcome. Sheri L. Johnson, PhD: Thanks so much for having me. Looking forward to our conversation. What Does “Reward Processing” Mean in Bipolar Disorder? Strakowski: Today we want to talk about reframing of bipolar disorder from a mood disorder to a reward processing disorder. To kick it off, I want to share one slide that I’ll have Dr Johnson walk us through here in a second. It reflects a lot of the work that she’s done and is from a review article by Nusslock, Mittal, and Alloy from 2025 that’s talking about reward processing in bipolar disorder and depression, and I think schizophrenia in this one too. So, Dr Johnson, what are we talking about when we’re saying we need to rethink bipolar disorder as a reward processing disorder? Johnson: Sure. This is a beautiful article by Robin Nusslock and his colleagues going over decades of theory and research. Let’s start by taking on what we mean by reward processing. All of us have systems in our brain to help motivate us. We have a threat and punishment motivation system that helps us get away from bad things. We also have a motivational system that helps us move towards great opportunities and good things that could happen. And so, this system helps us move towards anything from a great piece of chocolate, love, job accomplishment, ways to find ourselves being admired, liked, and all the goodies in life. The great thing is that we all have one of these. We all have a brain system that helps us move towards the good things. The idea here for people with bipolar disorder is that the system is somehow hypersensitive and once it comes online, it tends to stay online a little bit too long, a little bit too high. What does that do for us? One is it taps into a large body of the brain science of reward systems in the brain, but it also tells us a lot about ways in which we think mania unfolds over time and the early signals of risk for mania and bipolar disorder. Is Reward Hypersensitivity Specific to Bipolar Disorder? Strakowski: Is this hypersensitivity to reward unique in bipolar disorder, or does it happen in other conditions? Johnson: There are many different conditions that seem to involve some differences in reward sensitivity, and that’s part of what I’ve been interested in now for a couple decades. Is there something more specific about what it looks like in bipolar disorder? I think there really are two strands that are unique and specific in bipolar disorder. One is a tendency to set high goals and to go after goals even when the rewards might be pretty minor. People with bipolar disorder will describe themselves as being sensitive to rewards on self-report, if you ask them self-report questions, they’ll say, “Yeah, I am like that. When there’s a small opportunity for reward, I get more excited, more motivated than other people.” That can predict the onset and course of mania over time. But we think another thing it does is it leads them to set pretty high life goals and to be more ambitious and more willing to spend effort on going after and chasing those goals. So that’s one whole piece of this puzzle that’s fascinating to me. Sometimes it has good sides. Sometimes it can predict more mania over time, but sometimes it actually helps people and their family members do a little bit more. High Goal Setting and the Drive Toward Mania Johnson: There’s another piece here in bipolar disorder that I’m really interested in though. Once people click into the process of going after a goal (what we call “goal pursuit”) and they get immersed in that I’m going after the goal, I’m going after the dream, they can get a little dysregulated, overly confident, and start to take some risks that they wouldn’t otherwise do. Often, when they come back out of that period, they feel really a sense of remorse, a sense of loss of like Hey, how did I end up doing that? That’s not something I would’ve normally done. It’s as though the whole thermometer went up a little bit and they were just acting with the only thing in view was I’m going for it. I’m going for the gold. Strakowski: We have a tendency, particularly in the Western culture, but certainly in the United States, that we set that moods are goals. So, “life, liberty and the pursuit of happiness,” is a goal. But when I think about moods and emotions, the brain is firing off signals to try to motivate us to do things. If we think about it that way, does that somehow link the mood states of mania with this? How would you think about it? Johnson: For all of us, when we feel like we’re going after a dream or a goal, something that we would really value, when we’re making progress towards that, it’s exciting. That excitement helps us mobilize our energy, our movement, our thinking, that sense of, Okay, I’m on fire. All of us have the capacity for some part of that. We just think the volume has turned a little higher for the person with bipolar disorder. Does Euphoria Create a Self-Reinforcing Cycle? Strakowski: Yeah, that’s what I’ve wondered. The euphoria would be your brain saying, “Keep doing what you’re doing,” and that would drive you to continue reward processing, which would drive more euphoria. It just feels like a vicious cycle that might land people in a manic state. Is that reasonable? Johnson: That is a lot of how I think about it. I also think that part of what happens for most of us is that we can be really excited about our dream, but we have a really nice, strong signal from our body that it’s time to go to sleep, pipe down, and pick it up in the morning. But if you have weekday and weeknight rhythms to begin with, which often happens for somebody with bipolar disorder, and you don’t have that strong body signal of, come on, you’re tired, go to sleep, pick it up in the morning. You can end up working on that dream and the goal through a large part of the night and get more dysregulated and have less of a break on the whole system. Creativity, Success, and Genetic Risk Strakowski: Very interesting thought. The other thing you kind of alluded to - if this personality trait or feature is present genetically, which is implied and as we know, things like creativity, charisma, success, run in bipolar families at higher rates than general population are you posing that perhaps it’s being expressed at different levels to the point of illness in some of the members but to great success in others? Johnson: I’m fascinated by that question and I’m really glad you asked it. We do know that reward sensitivity is fairly heritable - it runs in families. We’ve looked at how this then relates to the creative accomplishments in people with bipolar disorder . Simon Kyaga, MD, PhD, MBA, has done beautiful analyses of the entire population of Sweden to show that people with bipolar disorder, but more so their family members who’ve never had a mania, tend to be very creatively accomplished. They’re more likely to be paid as artists, more likely to be university professors, more likely to become entrepreneurs, and the family members who are entrepreneurs tend to make more money in business startups. So, all these signals of creativity running in the family. We’ve done a set of studies to say, “What is that? What’s the magic juice there?” and one of the things we see is that willingness to work hard for a small reward is correlated with the creative accomplishment. People who are being paid as artists or creative people tend to have higher levels of that, Yeah. I’ll work really hard for a small reward. Sadly, the life of an artist right now is that you work really hard for tiny signals of recognition for most of the career. So, we think that that kind of willingness to work really hard for a small reward is probably a great thing for creativity. Now, the good news that I want to highlight is that you don’t need mania for that creativity to come through. The creativity is there in family members who have never had an episode of mania. I think something about that high level of reward pursuit, high levels of willingness to work hard that’s coming through, being carried in these families, is a huge advantage and that advantage is particularly there if we can protect people from all the difficulties that come along with mania. Trait vs State: Is Reward Sensitivity Always Present? Strakowski: The other thing that you had mentioned as you were talking about this constant high goal setting is that maybe this isn’t just occurring during mania, but is a trait present all the time, which is a genetic condition one would imagine is true. Do you believe that’s true? Johnson: Yeah, but I think the form changes so we can ask people when they’re fully well between episodes, “Do you tend to set higher goals in your life than other people?” People will endorse very high goals, really wanting to make a huge difference in life, like make millions of dollars, be the subject of books or TV shows, be a leader. People will often have ideas of like, I’d like to be one of the people that engineers world peace or climate change. Big meaningful goals. They also hold themselves to really high standards. We’ll sometimes see a kind of strand of perfectionism of, I don’t want to do a bad job on this goal. But that is often quietly in the background. So many of the people we work with will say, “Yeah, that’s there, but I don’t talk about it much. It’s just a hope. It’s just a dream.” But then when the mania kicks in, they tend to get very immersed in going after those goals and dreams and that’s when they stop sleeping as much, they may be spending more money than they wanted to, and they’re taking on that goal in a way that sometimes is painful because it’s too big, it’s too ambitious, it’s too much. I always think, Okay, having a big dream is great. Steve, you and I want to make a difference in the world of bipolar disorder. That’s a really hard and difficult dream. Nobody is going to criticize us for having a big dream and hope. The key is that as people get manic, it becomes very hard to modulate how intensely and how calibrated the work of goal engagement is. Clinical Implications of a Reward-Based Model Strakowski: We might think about as the reward pursuit events occur, it drives a euphoric mood state, which are elevated, and the transition keeps cycling until it’s euphoric and then we have mania on something that’s always present. That’s the idea that this is a reward processing condition rather than a primary mood disorder. How would that be applied to thinking about treatment? Does it change anything we commonly do, or would there be new models we might think about in our practices? Johnson: Yeah, it does change things. We’ve done a little bit of treatment development - very exploratory work. At the biological front, my hope is that we’ll develop precision medicine approaches that help with that process. I don’t think we’re quite there yet, but that’s the hope. But for now, since we don’t have that in hand, the hope is that we can help psychologically. One piece that we’ve had good luck with is just helping people with bipolar disorder understand this process. Helping them understand that they might be somebody who harbors higher goals than other people. I’ve often been surprised during that conversation that people with bipolar disorder won’t see their goals as particularly high. They don’t see themselves as hard driving. They just think like, Well, of course, doesn’t everybody hold to that kind of life ambition? They’re sometimes surprised to hear, “Yeah, no. Other people are not wandering around thinking about making a difference in world peace or changing bipolar disorder or doing other kinds of things like that.” I’m never going to criticize those goals, but I want them to be very self-compassionate when you can’t change something that big. The other part that we work very hard on is recognizing the early signs of getting too goal engaged, too overly confident, starting to do the risk taking, and thinking about ways to retreat and give a break to the goal pursuit in that moment. Goal pursuit is an elixir. It makes everybody excited. Pull back, make sure you can take some breaths, make sure you can sleep through the night. If this is really a game changing, beautiful goal idea, it’ll still be there. It’s almost never in life where you have to seize the day immediately for this to work in the big picture. So, giving people ways to test the breaks and recognize the signals that they’re moving into one of those periods. Helping Patients Regulate Goal Pursuit Strakowski: It feels like cognitive behavioral therapy, where we start learning how to ratchet back a little bit when we get too high. Is that sort of how you all frame it when you work on it? Johnson: I always talk about the idea of testing the brakes. It’s very hard to stop a car when it’s going full tilt, but if you start to feel the car having momentum, that’s the time to tap the brakes and make sure they’re working. Strakowski: You and I have been talking about this and working on it, and I think it’s an interesting way to reconceptualize the illness and also to think about some alternative treatment development pathways, and so we’re excited and hope that other people will think about this. I’ve talked to a number of the people I treat and work with bipolar disorder, and it really seems to resonate with them. I don’t know if you’ve had that experience too, but they say, “That really feels like me in a way that mood changes didn’t.” Does that make sense? Johnson: When we’ve written about this, I’m always struck by how many people will then contact me to say, “I think you’re on track.” That’s the heart and soul of why we want to do this. We want something that fits for people with the disorder. Strakowski: Well, thank you. Like we said, we’re very excited about this as a new model that might help advance certainly the psychotherapeutic side of bipolar disorder, and as Dr Johnson mentioned, thinking about how we personalize things. Hopefully, all who are tuned in and listening to this find it also invigorating. Ask some of your patients and see what they think about it. We appreciate very much you are taking the time to sign into Medscape. I’m Steve Strakowski and thank you very much. Stephen M. Strakowski, MD, is the professor and vice chair, Research of Psychiatry at Indiana University School of Medicine, and a professor at the Department of Community and Global Health at the Richard M. Fairbanks School of Public Health at Indiana University in Indianapolis, Indiana. He also serves as professor of psychiatry and associate vice president, Regional Mental Health at the Dell Medical School, University of Texas in Austin. In addition, Strakowski is editor-in-chief of the Journal of Mood and Anxiety Disorders. Sheri L. Johnson, PhD, is a professor of psychology at the University of California Berkeley and renowned for her expertise on bipolar disorder. She is also the Cal Mania (CALM) program director, where she leads research surrounding emotion and impulsivity. Note: This article originally appeared on Medscape .