Key points Obstructive sleep apnea (OSA) is the world’s most common sleep-related breathing disorder. Individuals with OSA are at an increased risk of anxiety, depression, and cognitive impairment. Among men in their 50s, OSA is associated with a 6-fold increase in risk of cognitive impairment. Clinicians should always inquire into patients’ sleep health to determine if OSA is contributing to symptoms. Clinical diagnostic work is very similar to detective work. During the initial evaluation of the patient, we gather evidence from signs and symptoms, inquire into potential connections that may not be obvious to the untrained eye, and then use our medical knowledge to form a hypothesis and recommend treatments. It is rare that patients’ signs and symptoms perfectly match the textbook definition of a disorder. More likely, they will fixate on a few symptoms but fail to mention others because they don’t think they are relevant. Knowing how to ask the right questions ensures these clues don’t go unmentioned. For clinical psychiatrists, a key part of every interview should center on the subject of sleep. While hypersomnia tends to be associated with major depressive episodes, insomnia is associated with far too many disorders to name, and most clinicians recognize that it is a good indication that the patient may be experiencing psychological distress. However, one type of sleep disorder that regularly escapes clinicians’ observation is obstructive sleep apnea. Recent research has shown that OSA is an independent risk factor for depression, anxiety, and more importantly cognitive decline/dementia, which is why it is vital that clinicians always ask their patients if they have been diagnosed with OSA or if they have some of the symptoms associated with the disorder. Obstructive Sleep Apnea at a Glance Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder in the world. It is estimated that 39 million adults in the United States have OSA and that the global figure is as high as 936 million. Risk factors for OSA include obesity, older age, male sex, a history of alcohol or tobacco use, a family history of OSA, and structural abnormalities in the throat or neck. OSA occurs when the throat muscles relax during sleep, leading to an interruption in the flow of air through the nose or mouth. The cessation in airflow is jarring enough to rouse a person from sleep so that they can reopen their airway, but the arousal is so brief that it does not get stored in memory. Patients with mild OSA tend to experience between five and ten apneic episodes per hour of sleep. In extreme cases, patients may experience over 30 episodes per hour. As far too many spouses know, the main symptoms of OSA are loud snoring with intervals where breathing ostensibly stops for a few seconds before resuming. In some cases, it can sound like the individual is choking. Patients with OSA tend to experience daytime sleepiness, fatigue, morning headaches, morning confusion, and decreased libido. Patients with OSA are also at an increased risk of medical problems, such as cardiac arrhythmias, hypertension, and metabolic syndrome. Evidence of Correlation The simple explanation for the association between psychiatric disorders and OSA is that our brain needs sleep to function properly. While most people need between seven and nine hours each night for optimal health, no one is going to develop a psychiatric disorder by sacrificing a few hours of sleep every once in a while. However, when one’s sleep is regularly disrupted due to OSA, there is a cumulative effect. A cross-sectional study from 2003 involving almost 19,000 participants revealed that patients with major depressive disorder are five times more likely to have OSA. Meanwhile, a 2023 study involving just under 10,000 individuals found that patients with OSA are 1.36-fold more likely to experience depression and that the severity of OSA positively correlates with depressive symptoms. A systematic review and meta-analysis published in 2020 showed a notably high presence of both depressive and anxiety symptoms among individuals with OSA—35 percent and 32 percent, respectively. A similar correlation is evident with respect to mild cognitive impairment and dementia. Older patients with OSA appear to be at a higher risk of both, with one study finding a 1.7-fold increase in risk among all participants. The risk was more pronounced among men with OSA in their 50s and women with OSA aged 70 years or older. The risk of impairment was found to be 6-fold greater and 3.2-fold greater, respectively. Potential Mechanisms Broadly speaking, research has indicated that these disorders can be traced back to two mechanisms: sleep fragmentation and intermittent hypoxia. Sleep fragmentation leads to increases in sympathetic nervous system activity, oxidative stress, and neuroinflammation. Sleep fragmentation also leads to decreases in vasomotor reactivity. Intermittent hypoxia occurs when patients with OSA are momentarily (but repeatedly) starved of oxygen over the course of the night. This can accelerate cerebral small vessel disease, leading to hypoperfusion (i.e., a lack of nutrients to an organ; in this case the brain), white matter integrity anomalies, gray matter loss, increased permeability of the blood-brain barrier, and neuroinflammation. These interrelated processes compound one another, resulting in neuronal damage, neurodegenerative processes, vascular depression, and cognitive impairment. Treating OSA The first line of treatment in obese patients with mild symptoms or only recently developed OSA should be lifestyle interventions with a combination of dietary changes and increases in physical activity, which should make them less prone to apneic episodes. In cases where an intervention is more urgent, continuous positive airway pressure (CPAP) can open breathing passages and prevent apneic episodes. If a specific abnormality of the upper airway is found, surgical intervention can take place. Special consideration should be given to older patients, as they are already at a greater risk of cognitive impairment and dementia—especially given the fact that obesity rates among seniors have nearly doubled within a generation. Screening for and treating OSA—as well as other sleep disturbances—can help stem neurodegeneration and decline. The important takeaway is that OSA can cause significant complications but that it is treatable. As clinicians, we need to take a more proactive approach to treating OSA in high-risk populations because it has the potential to balloon into a major public health problem. However, one problem is that proper sleep studies are rarely covered by insurance, making it difficult to formally diagnose OSA and obtain CPAP machines with the help of insurance. To provide symptom relief to patients who possibly have OSA, clinicians can encourage lifestyle modifications like those noted above. These changes carry no risk and involve no expensive devices, but still reduce the severity of OSA and improve patient quality of life. Note: This article originally appeared on Psychology Today.

Adult ADHD is a condition that is often underappreciated in older adults, with less than half being diagnosed and many never receiving treatment. Negative consequences can include job loss, suppressed income levels, low educational attainment, and difficulty maintaining relationships. Primary care physicians or family medicine clinicians are often best placed to diagnose ADHD in older adults, but they may struggle to distinguish ADHD symptoms from other conditions of aging such as mild cognitive impairment. Although no formal US guidelines exist on diagnosis of adult ADHD , adults usually present with symptoms such as chronic forgetfulness, distractibility, or procrastination. Hyperactivity is more internalized as a feeling of internal restlessness in this age group, rather than the more visible hyper behavior seen in children. To assess the possibility of ADHD, clinicians can use a six-item screening test or a longer 18-item screening tool developed by the World Health Organization. To make an ADHD diagnosis definitively, a patient needs to report sustained difficulties in at least two aspects of life: work, home, or social situations, and indicate that these troubles began before age 12. Undiagnosed adults may develop coping mechanisms without being aware of them, such as avoiding socializing, being overly punctual, studying in a cold basement, having structured checklists, and finding ways to work without paper. ADHD symptoms result from brain differences of disordered self-regulation and executive functioning, and people with ADHD need to learn to think and act differently. On average, three-fourths of adults with ADHD never receive an accurate diagnosis or effective treatment, despite having the condition since childhood. Over their lifetimes, undiagnosed adults may develop coping mechanisms and compensations, some more helpful than others, without being aware of why they are doing so. Some coping mechanisms may look like obsessive-compulsive behaviors, but the difference between true OCD and ADHD is that true OCD is a more complex condition that requires a combination of medication and lifestyle changes.

Key Takeaways Complex PTSD is not formally recognized in DSM-5-TR, affecting clinical understanding and treatment development. Historical events, like the Vietnam War and women's rights movements, influenced PTSD's diagnostic evolution. Only two medications are FDA-approved for PTSD, highlighting the need for more treatment options. Clinicians should prioritize trauma screening and education to improve patient care and treatment outcomes. "This was a tragic exclusion,” wrote Bessel van der Kolk, MD, one of the world’s experts in posttraumatic stress disorder (PTSD), following the publication of DSM-IV in 1994 when it failed to include a new diagnosis of complex PTSD . Yet here we are, 30 years and 3 DSMs later, with no formal or professional recognition of complex PTSD as a very different disorder than what DSM-5-TR describes for PTSD. In fact, DSM-5-TR provides only 2 specifiers to further differentiate PTSD: PTSD with dissociative symptoms (depersonalization vs derealization) and PTSD with delayed expression (ie, “the full diagnostic criteria are not met until at least 6 months after the event”). This misstep has had a cascading impact on the lack of clinical understanding of the complexities and differences in symptoms that can result from the experience of different types of trauma. Additionally, it has created a cloud of confusion regarding the PTSD diagnosis , which in turn results in the lack of tools and treatments that should be utilized in subpopulations of individuals with varying trauma histories. Finally, the vagueness of the DSM’s characterization of trauma has likely prolonged the considerable unmet need of additional pharmacological treatments. It is possible that if the US Food and Drug Administration Advisory Board had a more comprehensive understanding of the effects of different types of trauma and the wide range of treatments that should be available, it would have reached a different conclusion when it recommended against approval of midomafetamine (MDMA)–assisted psychotherapy this past June. Notably, the 2 phase 3 studies submitted to the FDA primarily included individuals who likely would have met the diagnostic criteria for complex PTSD; all participants in one of the studies met the criteria for severe PTSD, and 73% of participants in the second. Exploring the Evolution of PTSD in Psychiatry In 1896, Sigmund Freud, MD, published “The Aetiology of Hysteria,”4 in which he hypothesized that hysteria was caused by the sexual abuse of children before the onset of puberty based on his analysis of 18 adult patients with hysteria who reported a history of childhood sexual abuse and incest; this became known as the seduction theory. When Freud presented this paper at Vienna’s Society for Psychiatry and Neurology, he received a cold reception from the audience. His colleague who presided over the presentation characterized the paper as “a scientific fairy tale.” Due to continued criticism from his medical and psychiatric colleagues, he publicly retracted the seduction theory by 1905. During World Wars I and II, millions were exposed to horrific warfare. Soldiers were particularly impacted and reported loss of memory and ability to feel. It was reported that during World War I, 40% of British battle casualties were due to “mental breakdowns.” Shell shock was the term used to describe what had caused the severe emotional distress of soldiers. Trauma expert Judith Herman, MD, wrote, “It was recognized for the first time that any man could break down under fire and that psychiatric casualties could be predicted in direct proportion to the severity of combat exposure.”5 Herman further wrote about how “the lasting effects of war trauma were once again forgotten,” shortly after World War II. During the 1960s and 1970s, the Vietnam War facilitated an upheaval throughout the US after Americans witnessed via television the horrific nature of war and gained a growing awareness of the impact of these violent experiences on individuals. Veterans who were traumatized—often decorated war heroes—would not let us forget. Vietnam veterans organized groups to support one another. In 1970, psychiatrists met with a veteran-formed group called Vietnam Veterans Against the War and saw firsthand the effects of combat trauma exposure. Coinciding with the activism of the Vietnam veterans, the country also saw a new wave of the women’s rights movement. In 1970, the 50th anniversary of suffrage, people participated in the Women’s Strike for Equality, the largest women’s rights demonstration since suffrage. This demonstration raised national awareness on many issues related to women’s rights, health, safety, and equality. In 1973, the National Organization for Women (NOW) started the NOW Task Force on Rape, advocating for legal reform at the state level. The convergence of this activism likely had a significant impact on updating and revising 1968’s DSM-II. In 1980, DSM-III was introduced with the new diagnostic entity “posttraumatic stress disorder.” Significantly, PTSD was clustered under the category of “anxiety disorders” from 1980 until the publication of DSM-5 in 2013. It was then separated into a new category titled “trauma- and stress- or related disorders,” where it remains today. The Diagnosis of ‘PTSD’ Is Too Nonspecific With the DSM-III acknowledging the primary role of trauma in psychological distress, the symptoms of PTSD, and as a common etiological primary factor contributing to other psychiatric and medical comorbidities, trauma-related research exploded. Experts in trauma-related disorders, including van der Kolk and Herman, quickly recognized the limitations of a single and generally defined diagnosis for individuals’ experiences and the life-altering impact of those experiences, either immediately after the trauma occurred or decades later. In the early 1990s, van der Kolk was put in charge of a field trial by Robert Spitzer, MD, as revisions to DSM-III were being considered to produce DSM-IV. The field trial used a rating scale incorporating the many trauma symptoms found in the medical literature; the scale was administered during the interviews with 525 adult patient participants across the US. The goal was to investigate whether subpopulations with differing traumatic exposures demonstrated clinically different symptoms. The study populations included adult patients who had been physically or sexually abused in childhood by their caregivers, adult patients who were victims of recent domestic violence, and adult patients who had recently experienced a natural disaster. Significantly, the adults who had been abused in childhood by their caregivers demonstrated very different symptoms in adulthood than the other groups. A previous study by van der Kolk et al demonstrated that a history of sexual or physical abuse in childhood was a strong risk factor for recurrent self-cutting and suicide attempts later in life.8 The authors hypothesized that early-life severe trauma instills a feeling of lack of safety with others, leaving a lacuna in the structure of the self in contrast to the other subpopulations that had a template for feeling safe from long ago that could be accessed again through healthy adult relationships or therapy. Upon completion of this field trial, van der Kolk’s DSM-IV PTSD work group voted 19 to 2 to create a new diagnosis for patients with significant symptoms resulting from severe interpersonal trauma. They recommended the addition of the diagnosis “disorders of extreme stress, not otherwise specified,” also known as “complex PTSD,” to the DSM-IV.9-12 To their surprise and disappointment, their recommendation was ignored; no one in the PTSD work group was consulted. Conclusion The good news is that much progress has been made in developing evidence-based nonpharmacological treatments (Table 2). Although only 2 medications are approved by the FDA for treating PTSD (the selective serotonin reuptake inhibitors sertraline [Zoloft], approved in 1999, and paroxetine [Paxil], approved in 2000), 2 agents with very different mechanisms of action are in the review process. Garnering recent press is MDMA, which is meant to be used as part of structured medication-assisted psychotherapy; the FDA requested an additional phase 3 study. Brexpiprazole (Rexulti; FDA vote on approval is expected on February 8, 2025) is meant to be used as an augmentation agent for patients already on sertraline who only partially respond to treatment. As clinicians, we can and should educate ourselves further about the important and complex field of trauma and its treatment. Screening for past trauma in new and established patients is essential. It may take months, years, or even decades before our patients with a significant history of trauma, especially early-life trauma, develop enough trust to share their story with us. Yet past trauma is likely a contributing factor in many patients who present with anxiety, depression, substance use disorders, and many somatic complaints or diagnoses. The aforementioned book by van der Kolk1 comprehensively reviews what we have learned since 1980, and I highly recommend it as a good starting point. Often, our patients don’t know what to say or how to start to talk about their trauma. They are quietly waiting for us to begin the conversation. Note: This article originally appeared on Psychiatric Times .

LOS ANGELES — Artificial intelligence (AI) falls short of human therapists when it comes to empathy and emotional connection in the delivery of cognitive behavioral therapy (CBT) , initial results of a new pilot study suggested. However, the results showed that AI performed well in providing a structured therapeutic approach. “While AI may offer structured CBT components and serve as a supplementary or triage tool, it lacks the nuance and flexibility to serve as a stand-alone therapy,” study investigator Esha Aneja, a fourth-year medical student at California Northstate College of Medicine, Elk Grove, California, told Medscape Medical News. “Physicians and therapists should view AI as a potential adjunct, not an alternative.” “Human oversight, ethical safeguards, and empathy remain essential to safe and effective mental health care.” The findings were presented on May 17 at the American Psychiatric Association (APA) 2025 Annual Meeting . Demand for CBT Outstripping Supply Currently, there aren’t enough psychiatric professionals in the United States — or globally — to meet the growing demand for CBT. Patients frequently face delays in accessing care, so more are turning to AI tools like ChatGPT to address their mental health needs, said Aneja. However, she noted in her presentation that large language model (LLM)–based AI chatbots for text-based therapy are still largely theoretical in psychiatric literature. While LLMs have been integrated into electronic health records for diagnostic purposes, the ability of AI to execute CBT remains understudied. The goal of the study was to compare the effectiveness of therapy delivered by humans with AI. Experts familiar with CBT principles using the Cognitive Therapy Rating Scale (CTRS) compared a human therapist with an AI model (ChatGPT-3.5) in responding to a third-party patient presenting with a specific mental health concern. CTRS is a gold-standard observational tool for assessing the quality and fidelity of CBT sessions. It evaluates multiple domains, each rated on a 0-6 scale, with higher scores reflecting more skilled therapeutic delivery. Both the human therapist, who conducted the session over Zoom, and the AI therapist, ChatGPT-3.5 (the most current version at the time), interacted with the patient solely via text chat. Reviewers received transcripts of each session but were blinded to whether the responses came from a human or AI. The study surveyed 75 reviewers to compare the quality of human-based and ChatGPT-3.5-based interactions with patients. Participants included medical students, social work students, psychiatric residents, and board-certified psychiatrists. Humans Win the Day The human therapist outperformed ChatGPT-3.5 across all domains. Areas where the differences in mean CTRS scores were statistically significant included feedback (4.48 vs 3.03), collaboration (4.91 vs 3.84), pacing (4.60 vs 3.67), and guided discovery (0.35 vs 3.45), as well as “focus on key cognitive behaviors” and “application of CBT techniques” (P = .001 for all). Areas where the ratings were similar between the two groups included agenda setting, understanding, interpersonal effectiveness, and strategies for change. When it came to therapeutic approach and empathy, respondents disagreed on whether the human therapist demonstrated enough empathy, Aneja reported. “Some praised their warmth and responsiveness, while others felt the therapist focused too much on technique and missed emotional cues,” she said. “In contrast, AI was more uniformly described as ‘robotic’ or ‘surface-level’ in its empathy, with little variation.” While AI may become “cognitively empathetic” in the future and therefore able to respond more appropriately, “emotional or embodied empathy, the kind that comes from shared human experience, is beyond its current capabilities,” said Aneja. And, even in the areas that were more compatible with AI such as structure and agenda, respondents felt AI was “too wordy” and “robotic” and included “a lot of lecturing,” she added. They also noted AI lacked personalized recommendations with respect to patient understanding and tailored approaches. While the researchers suspected AI might fall short, this new study “quantifies and contextualizes those limitations in a real-world CBT framework,” said Aneja. AI could “definitely” be used as a screening tool in psychiatry, particularly when patients can’t get to see a provider in a timely manner, she said. It could “look for things like suicidality or situations where urgent attention is important.” However, therapists should keep the tool’s limitations in mind, especially the empathy component, she added. Weighing in on these results, Howard Liu, MD, chair of the Department of Psychiatry at the University of Nebraska Medical Center, Omaha, Nebraska, and chair of the APA Council on Communications, Washington, DC, called the study “fascinating,” especially with the backdrop of psychiatrist shortages across the country. However, he stressed the importance of informing patients when using AI. “Different health systems have different policies about whether you can, in fact, feed in protected health information into these systems,” he pointed out. Philip R. Muskin, MD, professor of psychiatry at the Columbia University Irving Medical Center, New York City, said he was not surprised by the findings overall or the comments about the “lecture-like quality” of the AI “therapist.” “Human responses vary, even when rigidly following a CBT agenda,” he told Medscape Medical News. “Reading about therapy, which is essentially what the AI software does, isn’t comparable to a therapist who has read training materials but has incorporated the information through human interaction.” Note: This article originally appeared on Medscape .

Fecal microbiota transplantation (FMT) may be an effective adjunctive therapy for depression , especially in patients with symptoms linked to gut disorders such as irritable bowel syndrome (IBS). However, experts caution that the evidence is preliminary. A large meta-analysis showed that FMT significantly reduced depressive symptoms in the short and medium term. Both oral capsule and direct gastrointestinal (GI) delivery were effective, although the benefits were greater with direct GI administration. However, the researchers cautioned that the overall quality of the evidence was rated as low to very low and highlighted the need for more robust and targeted research. The study was published online on October 5 in Frontiers in Psychiatry . Does Fixing the Gut Boost Mood? Depression, which affects over 280 million people globally, is increasingly linked to gut microbiome imbalances. FMT involves transferring gut bacteria from a healthy donor into a recipient’s GI tract to restore microbial balance. Long used for recurrent Clostridioides difficile infections, it is now under investigation for conditions linked to the gut-brain axis. Preclinical and clinical work suggests that restoring healthy microbial diversity may influence inflammation, neurotransmitter activity, and mood regulation. Yet current evidence on FMT for depression is “fragmented and inconclusive,” the researchers, with first author Xiaotao Zhang, of Nanjing University of Chinese Medicine, Nanjing, China, wrote. To gain a better understanding of the therapeutic potential of FMT for depressive symptoms, they synthesized data from 12 randomized controlled trials with 681 participants across China, Australia, Canada, Finland, and the US. All trials consistently evaluated the impact of FMT on depressive symptoms whether as a primary or secondary outcome using validated scales such as the Hamilton Depression Rating Scale, Montgomery-Åsberg Depression Rating Scale, and Hospital Anxiety and Depression Scale. The trials included patients with various conditions. Five trials focused on IBS and one on ulcerative colitis. Two trials targeted neurologic disorders including progressive supranuclear palsy-Richardson syndrome and Parkinson’s disease with comorbid GI disorders. Four trials included patients with COVID-19 experiencing diarrhea and depressive symptoms, severe obesity with insulin resistance, or fibromyalgia. Only one trial specifically included patients diagnosed with major depressive disorder (MDD) . The pooled results showed a significant reduction in depressive symptoms in the FMT group compared to the control group (standardized mean difference [SMD], -1.21; P = .0003). Although the included studies were highly heterogeneous, sensitivity analyses showed that depressive symptom scores were significantly improved in the FMT group compared with the control group (SMD, -0.56; P = .0003). Subgroup analysis showed stronger effects in patients with IBS (SMD, -1.06) than in those with neurologic/psychiatric-related conditions (SMD, -0.67), with moderate heterogeneity. Both oral capsules and direct GI administration (via endoscopy or enema) were effective, with slightly greater effects observed for direct GI delivery (SMD, -1.29 vs -1.06). Improvement in depressive symptoms was most notable in short- to mid-term follow-up, with the effects diminished by 6 months. To advance the field, the researchers recommended that future trials focus on clinically diagnosed depression, use standardized FMT protocols, and include long-term follow-up to evaluate sustained effects on depressive symptoms. They also emphasized the need to systematically account for factors such as diet, medications, and psychological therapies to minimize confounding. A New Therapeutic Target? Valerie Taylor, MD, PhD, professor and head of the Department of Psychiatry at the University of Calgary, Calgary, Alberta, Canada, who wasn’t involved in the study, told Medscape Medical News there is a “growing body of research to support really examining the gut microbiome as a therapeutic target in mental illness treatment.” “While we need to do longer studies to understand dosing and efficacy, this is an exciting new area. This study highlights there is successful translational work occurring in this space,” Taylor said. Her team in Calgary recently completed a study on FMT for treatment-resistant MDD, which is currently under review, she said. Jessica Green, MBBS, PhD, consultant psychiatrist and senior research fellow at the Food & Mood Center, Deakin University in Geelong, Australia, also wasn’t involved in the study, but was a reviewer on the paper. She said that while FMT is a “very promising” potential treatment for depression, the paper is “perhaps more optimistic about its interpretation of the findings than is justified by the preliminary nature of the data at this stage.” “That’s because the analysis uses data from studies that weren’t designed or powered for measuring depression, and it wasn’t known if a population was clinically depressed or not at baseline; if they weren’t clinically depressed, then improvement in the depression rating scale is not very meaningful,” Green said. She noted that most of the studies included people diagnosed with a range of disorders including IBS combined with mild-to-moderate anxiety/depression, COVID-19 with associated diarrhea and depressive symptoms and fibromyalgia. “You would expect mood to be impacted in these patients and if mood improved, it’s unclear whether the improvements were due to FMT or simply because IBS had resolved,” Green said. Still, Green said there is “every reason theoretically” that FMT could help with depression and “hopefully, we’ll get a better signal soon.” Note: This article originally appeared on Medscape .

Key points Pediatricians have experienced a dramatic increase in patient visits for psychiatric conditions. This increase has occurred in both children (age 4 to 12) and adolescents (age 13 to 17). Much of this increase is attributed to an increase in anxiety disorders. It is critical that pediatric residents receive adequate exposure to child and adolescent psychiatry. Much has been written recently about an increase in the number of American youths experiencing mental health conditions. In fact, several national medical associations, including the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry, declared an emergency in child and adolescent mental health in 2021. Considering the relatively small number of child and adolescent psychiatrists practicing in the U.S., pediatricians are increasingly seeing these patients. A recent study published in Psychiatric Services by Alex Gertner and colleagues demonstrated a marked increase in the percentage of visits to primary care physicians by 4- to 17-year-old children and adolescents for psychiatric disorders. The researchers investigated which conditions are most responsible for this upsurge and whether demographic factors are associated with the increase. The investigators analyzed data from the 2005-2019 waves of the National Medical Ambulatory Care Survey. Through a complex sampling design, this survey provides representative estimates of office-based physicians and outpatient visit characteristics. Gertner and colleagues restricted their analyses to data from visits involving 4- to 17-year-old individuals. They counted a psychiatric diagnosis if it was listed by the treating physician in one of the top three diagnostic fields on forms that were filled out during each visit. Physicians utilized International Classification of Diseases (ICD)-9 (2005-2015) and ICD-10 (2016-2019) codes to classify psychiatric disorders. The research team grouped psychiatric disorders into the following categories: adjustment disorders, anxiety disorders, mood disorders, developmental disorders leading to mental impairment (including attention-deficit/hyperactivity disorder [ADHD] ), conduct-related disorders, and other disorders (which included substance use disorders, psychotic disorders, eating disorders, personality disorders, and other less common disorders). They also collected information about psychiatric medications. For the purposes of their study, the authors combined data from the 2005-2011 surveys and compared it to combined data from 2012-2019. Key Findings This study produced several key findings: Pediatric outpatient visits to primary care physicians for mental health conditions increased about 45 percent from 2005-2011 to 2012-2019. An increase was observed for both children aged 4 to 12 and adolescents aged 13 to 17. For 4- to 12-year-old children, the percentage of visits addressing psychiatric conditions increased from 8.7 to 11.4 percent. For adolescents aged 13 to 17 years, the percentage of mental health visits increased from 10.5 to 17.4 percent. The diagnosis most responsible for these increases was anxiety disorder. Among those with any mental health diagnosis, anxiety disorder diagnoses increased from 9 to 12.2 percent in the younger group and 14.8 to 26.4 percent in the older group. Among those with any mental health diagnosis, the percentage of visits for anxiety disorders increased from 16.7 to 26.9 percent in females and 8.5 to 13.6 percent in males. Statistically significant increases in pediatric mental health visits were seen for non-Hispanic White and Hispanic young people but not for Black youths. Psychiatric medications were prescribed at about 70 to 75 percent of pediatric mental health visits, and this percentage remained stable over time. Our Thoughts Primary care physicians, especially pediatricians, are responsible for treating an increasing number of children and adolescents suffering from anxiety disorders . Treatment typically involves medications and psychotherapy. However, treating a 4-year-old with anxiety is different from treating a 17-year-old. Basic science and psychosocial science research are advancing our understanding of anxiety. These advances are informing treatment approaches. Because of the prevalence of psychiatric conditions now seen by pediatricians and the impact of advances in psychiatric research on treatment, it is imperative that pediatric residents gain meaningful experience in child and adolescent psychiatry. While such clinical training for pediatric residents is increasing, it must become part of all general pediatric residency programs. Collaborative care models with psychiatrists as consultants can also help pediatricians manage more complex patients. The rise in youth mental health conditions is a national public health concern. There is a critical shortage of child and adolescent psychiatrists and, unfortunately, this will not change in the foreseeable future. Therefore, pediatricians will continue to play a central role in diagnosing children and adolescents with psychiatric conditions and coordinating their treatment. Note: This article originally appeared on Psychology Today .

As the name implies, it is about living your “one life” to its fullest potential without any psychological or psychiatric limitations. My practice is about the holistic model for mental health with medications, therapy, and alternatives. It is an integration of optimal aspects of Western medicines (avoiding potential side effects or complications) with various therapy modalities (CBT, DBT, Psychodynamic Psychotherapy, etc). One Life Psychiatry provides a unique blend of patient-driven treatment, from an educational perspective, empowering the patient to select a treatment modality that aligns with his/her values, whether it be medications (psychopharmacology), therapy, and alternatives. In addition, I will explore and find whole body alternatives (if you prefer). As a child psychiatrist, I was very attuned to over prescription of medicines that could have potentially long-term consequences, including addiction, among the least. I will integrate nutritional supplements, herbal/plant based meditation, meditation/mindfulness, and particularly important health habits such as sunlight (vitamin D3), etc. I will continue update these pages with diagnosis, treatments options (including pros and cons), alternatives, knowledge about the different types of therapy (particularly what conditions they are effective for, alternative remedies, self-help books, clips on philosophy. Anything that will give you hope for a first quality of life and a healthy transformation.

Schizophrenia is a chronic brain disorder that affects less than one percent of the U.S. population . When schizophrenia is active, symptoms can include delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation. However, with treatment, most symptoms of schizophrenia will greatly improve and the likelihood of a recurrence can be diminished. While there is no cure for schizophrenia, research is leading to innovative and safer treatments. Experts also are unraveling the causes of the disease by studying genetics, conducting behavioral research, and using advanced imaging to look at the brain’s structure and function. These approaches hold the promise of new, and more effective therapies. The complexity of schizophrenia may help explain why there are misconceptions about the disease. Schizophrenia does not mean split personality or multiple-personality. Most people with schizophrenia are not any more dangerous or violent than people in the general population. While limited mental health resources in the community may lead to homelessness and frequent hospitalizations, it is a misconception that people with schizophrenia end up homeless or living in hospitals. Most people with schizophrenia live with their family, in group homes or on their own. Research has shown that schizophrenia affects men and women fairly equally but may have an earlier onset in males. Rates are similar around the world. People with schizophrenia are more likely to die younger than the general population, largely because of high rates of co-occurring medical conditions, such as heart disease and diabetes. Definitions Psychosis refers to a set of symptoms characterized by a loss of touch with reality due to a disruption in the way that the brain processes information. When someone experiences a psychotic episode, the person’s thoughts and perceptions are disturbed, and the individual may have difficulty understanding what is real and what is not. Delusions are fixed false beliefs held despite clear or reasonable evidence that they are not true. Persecutory (or paranoid) delusions, when a person believes they are being harmed or harassed by another person or group, are the most common. Hallucinations are the experience of hearing, seeing, smelling, tasting, or feeling things that are not there. They are vivid and clear with an impression similar to normal perceptions. Auditory hallucinations, “hearing voices,” are the most common in schizophrenia and related disorders. Disorganized thinking and speech refer to thoughts and speech that are jumbled and/or do not make sense. For example, the person may switch from one topic to another or respond with an unrelated topic in conversation. The symptoms are severe enough to cause substantial problems with normal communication. Disorganized or abnormal motor behavior are movements that can range from childlike silliness to unpredictable agitation or can manifest as repeated movements without purpose. When the behavior is severe, it can cause problems in the performance of activities of daily life. It includes catatonia, when a person appears as if in a daze with little movement or response to the surrounding environment. Negative symptoms refer to what is abnormally lacking or absent in the person with a psychotic disorder. Examples include impaired emotional expression, decreased speech output, reduced desire to have social contact or to engage in daily activities, and decreased experience of pleasure. Symptoms When the disease is active, it can be characterized by episodes in which the person is unable to distinguish between real and unreal experiences. As with any illness, the severity, duration and frequency of symptoms can vary; however, in persons with schizophrenia, the incidence of severe psychotic symptoms often decreases as the person becomes older. Not taking medications as prescribed, the use of alcohol or illicit drugs, and stressful situations tend to increase symptoms. Symptoms fall into three major categories: Positive symptoms: (those abnormally present) Hallucinations, such as hearing voices or seeing things that do not exist, paranoia and exaggerated or distorted perceptions, beliefs and behaviors. Negative symptoms: (those abnormally absent) A loss or a decrease in the ability to initiate plans, speak, express emotion or find pleasure. Disorganized symptoms: Confused and disordered thinking and speech, trouble with logical thinking and sometimes bizarre behavior or abnormal movements. Cognition is another area of functioning that is affected in schizophrenia leading to problems with attention, concentration and memory, and to declining educational performance. Symptoms of schizophrenia usually first appear in early adulthood and must persist for at least six months for a diagnosis to be made. Men often experience initial symptoms in their late teens or early 20s while women tend to show first signs of the illness in their 20s and early 30s. More subtle signs may be present earlier, including troubled relationships, poor school performance and reduced motivation. Before a diagnosis can be made, however, a psychiatrist should conduct a thorough medical examination to rule out substance misuse or other neurological or medical illnesses whose symptoms mimic schizophrenia. Risk Factors Researchers believe that a number of genetic and environmental factors contribute to causation, and life stressors may play a role in the start of symptoms and their course. Since multiple factors may contribute, scientists cannot yet be specific about the exact cause in each individual case. Treatment Though there is no cure for schizophrenia, many patients do well with minimal symptoms. A variety of antipsychotic medications are effective in reducing the psychotic symptoms present in the acute phase of the illness, and they also help reduce the potential for future acute episodes and their severity. Psychological treatments such as cognitive behavioral therapy or supportive psychotherapy may reduce symptoms and enhance function, and other treatments are aimed at reducing stress, supporting employment or improving social skills. Diagnosis and treatment can be complicated by substance misuse. People with schizophrenia are at greater risk of misusing drugs than the general population. If a person shows signs of addiction, treatment for the addiction should occur along with treatment for schizophrenia. Rehabilitation and Living With Schizophrenia Treatment can help many people with schizophrenia lead highly productive and rewarding lives. As with other chronic illnesses, some patients do extremely well while others continue to be symptomatic and need support and assistance. After the symptoms of schizophrenia are controlled, various types of therapy can continue to help people manage the illness and improve their lives. Therapy and psychosocial supports can help people learn social skills, cope with stress, identify early warning signs of relapse and prolong periods of remission. Because schizophrenia typically strikes in early adulthood, individuals with the disorder often benefit from rehabilitation to help develop life-management skills, complete vocational or educational training, and hold a job. For example, supported-employment programs have been found to help people with schizophrenia obtain self-sufficiency. These programs provide people with severe mental illness competitive jobs in the community. For many people living with schizophrenia family support is particularly important to their health and well-being. It is also essential for families to be informed and supported themselves. Organizations such as the Schizophrenia and Related Disorders Alliance of America (SARDAA), Mental Health America (MHA) and the National Alliance on Mental Illness (NAMI) offer resources and support to individuals with schizophrenia and other mental illnesses and their families (see Additional Resources). Optimism is important and patients, family members and mental health professionals need to be mindful that many patients have a favorable course of illness, that challenges can often be addressed, and that patients have many personal strengths that must be recognized and supported. Related Conditions Delusional Disorder Delusional disorder involves a person having false beliefs (delusions) that persist for at least one month. The delusions can be bizarre (about things that cannot possibly occur) or non-bizarre (things that are possible but not likely, such as a belief about being followed or poisoned). Apart from the delusion(s), it does not involve other symptoms. The person may not appear to have any problems with functioning and behavior except when they talk about or act on the delusion.Delusional beliefs can lead to problems with relationships or at work, and to legal troubles. Delusional disorder is rare: around 0.2% of people will have it in their lifetime. Delusional disorder is treated with individual psychotherapy, although people rarely seek treatment as they often do not feel they need treatment. Brief Psychotic Disorder Brief psychotic disorder occurs when a person experiences a sudden short period of psychotic behavior. This episode lasts between one day and one month and then the symptoms completely disappear, and the person returns to normal. Brief psychotic disorder involves one (or more) of the following symptoms: Delusions, Hallucinations, Disorganized speech Grossly disorganized or catatonic behavior. Although the disturbance is short, individuals with brief psychotic disorder typically experience emotional turmoil or overwhelming confusion. Brief psychotic disorder can occur at any age, though the average age at onset is the mid-30s. It is twice as common in females than in males. It is important to distinguish symptoms of brief psychotic disorder from culturally appropriate responses. For example, in some religious ceremonies, an individual may report hearing voices, but these do not generally persist and are not perceived as abnormal by most members of the individual’s community. Schizophreniform Disorder The symptoms of schizophreniform disorder are similar to those of schizophrenia, but the symptoms only last a short time—at least one month but less than six months. If the symptoms last longer than six months, then the diagnosis changes to schizophrenia. Schizophreniform disorder involves two or more of the following symptoms, each present for a significant portion of time during a one-month period (or less if successfully treated):: Delusions, Hallucinations Disorganized speech, Grossly disorganized behavior or catatonic behavior, and/or Negative symptoms. A diagnosis of schizophreniform disorder does not require problems in functioning (as schizophrenia does). In the U.S., schizophreniform disorder is significantly less common than schizophrenia. About one-third of individuals with an initial diagnosis of schizophreniform disorder recover within the 6-month period and schizophreniform disorder is their final diagnosis. Most of the remaining two-thirds of individuals will eventually receive a diagnosis of schizophrenia or schizoaffective disorder. Schizoaffective Disorder People with schizoaffective disorder experience symptoms a major mood episode of depression or bipolar disorder (major depression or mania) at the same time as symptoms of schizophrenia (delusions, hallucinations, disorganized speech, grossly disorganized behavior, or negative symptoms). Symptoms of a major mood episode must be present for the majority of the duration of the active illness and there must be a period of at least two weeks when delusions or hallucinations are present in the absence of a mood episode. Schizoaffective disorder is about one-third as common as schizophrenia, affecting about 0.3% of people at some time in their lives. The typical age at onset of schizoaffective disorder is early adulthood, although it can begin anywhere from adolescence to late in life. A significant number of individuals initially diagnosed with another psychotic illness later receive the diagnosis schizoaffective disorder when the pattern of mood episodes becomes apparent. Source: American Psychiatric Association

Iloperidone, a second-generation antipsychotic used to treat schizophrenia, appears to be safe and effective in the treatment of bipolar mania, new research suggested. Results of the phase 3 randomized double-blind placebo-controlled trial show patients with bipolar mania who received iloperidone had significantly greater change from baseline to 4 weeks on the Young Mania Rating Scale (YMRS) compared with placebo, an improvement detected as early as 14 days from the initial dose. The incidence of akathisia and extrapyramidal symptoms (EPS) was low in the treatment group, and the medication was well-tolerated. "This study provides evidence that iloperidone improves the symptoms of bipolar mania in adults and can be a useful treatment option for people with bipolar disorder," the investigators, led by Rosarelis Torres, PhD, of Vanda Pharmaceuticals Inc., and colleagues wrote. The study was published online on January 15 in the Journal of Clinical Psychiatry . Early Improvement Iloperidone was first approved by the US Food and Drug Administration in 2009 for treatment of schizophrenia. The current study included 414 participants (mean age, 43 years; 56% male) across 17 US and international sites. Patients with psychotic features received a fixed daily dose of 24 mg of iloperidone (n = 206) or placebo (n = 208). Participants completed a screening period of up to 7 days before randomization, followed by a 1-day baseline evaluation period and a 28-day treatment phase. The primary efficacy endpoint was change from baseline to week 4 on the YMRS (vs placebo), while secondary efficacy endpoints included change from baseline on the Clinical Global Impressions-Severity and Clinical Global Impression of Change scales (CGI-S and CGI-C, respectively). Compared with placebo, iloperidone was associated with significant improvement of mania symptoms at week 4, with a mean reduction on the YMRS scale of −4.0 (P = .000008), and significant decreases on the CGI-S (mean, −0.4; P = .0005) and CGI-C scales (mean, −0.5; P = .0002). Statistically significant differences between iloperidone and placebo were observed as early as day 14 and continued through days 21 and 28. Post hoc analyses found no difference in efficacy even when patients who had received benzodiazepines were excluded, regardless of the presence or absence of psychotic features at baseline. Favorable Akathisia Profile As for safety, 68% of patients in the iloperidone group experienced at least one adverse event, compared with 49% of patients in the placebo group. Patients in the treatment group had a higher rate of withdrawal from the study than those in the placebo group (32.9% vs 27.1%), and more patients in the iloperidone group experienced treatment-emergent adverse events (TEAEs) leading to study drug discontinuation (8.7% vs 5.3%). However, no TEAEs associated with discontinuation occurred in more than two patients in either group, and none of the participants experienced any AE leading to death. The most common adverse events (AEs) were tachycardia (18%), dizziness (11%), dry mouth (9%), increased alanine aminotransferase (7%), nasal congestion (6%), weight gain (6%), and somnolence (5%). Five serious AEs were reported in four participants in the treatment group and one in the placebo group. Two were identified as related to the study medication. These included sedation and spontaneous penile erection. Changes from baseline in clinical laboratory parameters were not largely different between the groups, but there were post-randomization changes in QT interval in three iloperidone patients. The incidence of orthostatic response was also higher for iloperidone vs placebo. Although "much improved compared to early antipsychotics, SGAs can still cause considerable adverse motor side effects," the authors wrote. "However, among all SGAs, iloperidone's akathisia profile is favorable." Antipsychotic-induced akathisia has been reported more frequently in patients with bipolar disorder than in those with schizophrenia treated with the same medication, investigators noted. One study limitation is the fact that long-term efficacy in the prevention of manic or depressive episodes was not assessed. Potential Second-Line Treatment Commenting on the study for Medscape Medical News, Richard Louis Price, MD, assistant professor of psychiatry, at Weill Cornell Medical College, New York City, said the findings suggest iloperidone may be "modestly effective" for patients with bipolar 1 mania or mixed episodes. "It's helpful to have new treatment options, especially for patients who have difficulty tolerating other agents," said Price, who was not involved with the study. Also commenting on the research for Medscape Medical News, Roger S. McIntyre, MD, professor of psychiatry and pharmacology, University of Toronto, Toronto, Ontario, Canada, noted iloperidone's "interesting antipsychotic pharmacodynamic," highlighting the drug's high-binding affinity for serotonin 5HT2A and dopamine D2 and D3 receptors, as well as the noradrenergic α1 receptors. The drug's profile "suggests benefit in manic features and agitation, perhaps with a lower propensity to EPS, which is especially important in persons at higher risk, like persons living with bipolar disorder," McIntyre said. McIntyre, who was not involved with the study, added iloperidone could be a second-line therapy because of its tolerability profile, provided the study results can be replicated. "When considering alternatives with similar efficacy, absence of titration (or simple titration) minimal to no weight gain, no orthostatic hypotension, and no potential concerns with QT, those alternatives would have to be considered first-line, assuming that the study results are replicated," he said. Note: This article originally appeared on Medscape

The commercialization of cannabis that followed its legalization for nonmedical use was associated with an increase in hospitalizations for cannabis-related health problems, including cannabis-induced psychosis, according to new research. In a repeated cross-sectional analysis that included some 26.9 million individuals, researchers found that the rate of hospitalizations due to cannabis increased 1.62 times between 2015 and 2021. The rate of hospitalizations increased most precipitously after commercialization, including a 40% increase in hospitalizations for cannabis-induced psychosis. Decline With Legalization Canada has a universal healthcare system, and the researchers accessed health administrative databases that recorded all acute hospitalizations for patients aged 15 to 105 years in the four most populous provinces: Ontario, Quebec, Alberta, and British Columbia. They compared changes in rates of hospitalizations due to cannabis over the following three time periods: prelegalization (January 2015 to September 2018), legalization with product and store restrictions (October 2018 to February 2020), and commercialization (March 2020 to March 2021). There were 105,203 hospitalizations due to cannabis during the study period. Most (65.8%) were in males, and one third were in adolescents and young adults aged 15 to 24 years. The age- and sex-standardized rate of hospitalizations due to cannabis increased 1.62 times: from 3.99 per 100,000 individuals in January 2015 to 6.46 per 100,000 individuals in March 2021. The largest relative increase in hospitalizations was for cannabis-induced psychosis, which rose 40% during the commercialization period, compared with the prelegalization period (rate ratio, 1.40). The period of legalization with restrictions was associated with a gradual monthly decrease of −0.06 in hospitalizations due to cannabis per 100,000 individuals. During the commercialization period, which coincided with the COVID-19 pandemic, there was an immediate increase of 0.83 hospitalizations due to cannabis per 100,000 individuals. 'Legalization, Not Commercialization' Legalizing cannabis removes an important reason for incarceration, said Myran. "That is an important public health gain. There’s very compelling data that making cannabis illegal ended up giving a lot of young people criminal records, and in Canada, it’s disproportionately in Black and indigenous youth. You get a criminal record, and it has major social harms." Before cannabis was legalized in Canada, it became easier to obtain. Gray market stores selling cannabis were no longer being closed by the police. In the lead-up to legalization, cannabis use increased. But once legalization with restrictions was instituted, hospitalizations for cannabis use declined, said Myran. "Legalization in Canada has taken a graduated rollout, so you have an initial legalization with restrictions, where the government would only allow the sale of dried cannabis flower, there were almost no stores, and you actually see these rates decline. But later on, when the market matures and you have a vast amount of stores, new products like vape pens and edibles and concentrates and cannabis-infused beverages, and which happens to overlap with the COVID-19 pandemic, you see a jump in cannabis hospitalizations," he said. Cannabis use can be very harmful for some individuals. It is well known that cannabis use in adolescents and young adults is associated with the development of psychosis, said Myran. "There are individuals who are predisposed to develop psychosis, and cannabis seems to bring on psychotic episodes in those who are vulnerable. In one study, 26% of people who presented to the emergency department with an episode of cannabis-induced psychosis went on to develop schizophrenia within the next 3 years," he said. We need legalization, not commercialization, Myran said. Promoting Cannabis Misuse? Increased commercialization is increasing the availability of cannabis, hence problems with abuse and overuse will occur, he added. Sherry did not participate in the research. "We know from the alcohol literature, the tobacco literature, and increasingly from the cannabis literature that with the increase of the physical availability of cannabis outlets, you also increase potential for abuse of cannabis," he said. While claims that sales of cannabis products provide a source of revenue for governments may be true, the main source of that revenue is the regular user, Sherry said. "The dirty secret in the legalization and commercialization of cannabis is that most of the revenue comes from frequent or addicted customers. Someone who buys 1 gram and uses it recreationally in a month is not a good customer. The good customers are frequent and addicted individuals who are going to smoke 5 grams of cannabis a day." Commercialization results in more direct appeals to addiction-prone people, Sherry added. "For instance, in Nova Scotia, we promote cannabis as a way to relax and enhance your experience. If you are addiction-prone, that messaging, and the increased physical availability of cannabis with commercialization, means that we are going to see more cannabis problems. So, if you add more cannabis outlets, as you heavily commercialize cannabis products, you add more cannabis problems to our society." Cannabis is not a benign substance, Sherry emphasized. Increasing awareness of the associated harms, as has occurred with tobacco, would be a better way of marketing cannabis, he suggested. "Rather than the current relaxed and permissive attitude, we need to switch to one of grudging tolerance, recognizing that cannabis is going to be part of our landscape, that some people are going to use it and some are going to misuse it, and that we need to discourage the consumption of cannabis as a public health problem," said Sherry. The study was supported by a grant from the Canadian Centre on Substance Use and Addiction and fellowships from the Canadian Institutes of Health Research and the University of Ottawa Department of Family Medicine. Myran reported grants from Canadian Institutes of Health Research during the conduct of the study. Sherry reported no relevant financial relationships. Related Topics: One Life Psychiatry

Schizophrenia TOPLINE: Suicide is a main cause of death among people with schizophrenia , even years after diagnosis, and deaths from medical conditions and diseases also occur prematurely, results of a long-term study suggest. The results show "an urgent need for new efforts to improve the disparities in health that lead to this increased mortality," the researchers conclude. METHODOLOGY: The life expectancy of patients with schizophrenia is 10-12 years less than in the general population, and as the mortality gap seems to be worsening, it's important to learn more about the patterns behind it. The analysis included 578 participants in the OPUS study , a randomized controlled trial of patients in Denmark with a first-time diagnosis of a schizophrenia spectrum disorder who were assessed after 2, 5, 10, and 20 years. From linked databases, researchers collected clinical and sociodemographic data and information about time and cause of death and determined baseline predictors of mortality and predictors that remained significant during follow-up. The primary outcome was death, which researchers divided into death due to external causes, and death from medical conditions and diseases; secondary outcomes were cause-specific mortality rates. TAKEAWAY: During 20 years of follow-up, 82 participants (14.2%) died, compared to a mortality rate of 4.4% in a matched group from a background population. Mortality rates were higher among men, those aged 40 or older at baseline, and people with substance abuse at the time of diagnosis. About half the deaths were due to external causes, and half were from medical conditions and diseases . The most common external cause was suicide , which accounted for 27.5% of the total number of deaths. The most common medical causes were cardiovascular disease and cancer, both representing 8.3% of the total. At baseline, employment (hazard ratio [HR], 0.47; 95% CI, 0.22 – 0.1; P = .049), psychotic disorders other than schizophrenia (HR, 0.36; 95% CI, 0.15 – 0.83; P = .017), and longer duration of untreated psychosis (HR, 0.57, 95% CI, 0.33 – 0.98; P = .042) predicted lower mortality, while substance use predicted higher mortality (HR, 2.56; 95% CI, 1.50 – 4.36; P < .001). As for predictors of mortality later in the illness, symptom remission without use of antipsychotic medication was associated with a significantly decreased risk for mortality (HR, 0.08; 95% CI, 0.1 – 0.6; P = .013), as was being in recovery (HR, 0.21; 95% CI, 0.05 – 0.84; P = .028), whereas substance use (HR, 3.64; 95% CI, 2.36 – 5.61; P < .001), cancer (HR, 6.31; 95% CI, 3.12 – 12.77), cardiovascular disease (HR, 2.25; 95% CI, 1.36 – 3.71; P = .002), and pulmonary disease (HR, 2.15; 95% CI, 1.36 – 3.42; P = .001) predicted increased mortality. IN PRACTICE: That the rate of death due to suicide remained steady over time underlines the continuous need for suicide-preventive measures for people with schizophrenia, said the authors, adding more regular screening for suicide risk in aging patients with schizophrenia could help prevent some later suicides. SOURCE: The study was conducted by Marie Stefanie Kejser Starzer, Copenhagen Research Center for Mental Health, Copenhagen University Hospital, and the Department of Clinical Medicine, University of Copenhagen, Denmark, and colleagues. It was published online August 1, 2023, in the Schizophrenia Bulletin in the Journal of Psychoses and Related Disorders . LIMITATIONS: Although the cohort was large and follow-up lengthy, the number of deaths is still small. It's possible that those who were lost to follow-up represent a group with an increased risk of morality. The cohort was obtained from a clinical trial, and participants in this trial might not represent all patients with a first schizophrenia spectrum diagnosis. As all patients in Denmark have access to free, well-resourced healthcare, the findings are not representative of all patients. DISCLOSURES: The study was supported by the Tryg Foundation, the Lundbeck Foundation, and Helsefonden. The authors had no competing interests.

By the end of August 2022, overall use of mental health services was almost 40% higher than before the COVID-19 pandemic, while spending increased by 54%, according to a new study by researchers at the RAND Corporation. During the early phase of the pandemic, from mid-March to mid-December 2020, before the vaccine was available, in-person visits decreased by 40%, while telehealth visits increased by 1000%, reported Jonathan Cantor, PhD, and colleagues at RAND, and at Castlight Health, a benefit coordination provider, in a paper published online August 25 in JAMA Health Forum . Between December 2020 and August 2022, telehealth visits stayed stable, but in-person visits creeped back up, eventually reaching 80% of pre-pandemic levels. However, "total utilization was higher than before the pandemic," Cantor, a policy researcher at RAND, told Medscape Medical News . "It could be that it's easier for individuals to receive care via telehealth, but it could also just be that there's a greater demand or need since the pandemic," said Cantor. "We'll just need more research to actually unpack what's going on," he said. Initial per capita spending increased by about a third and was up overall by more than half. But it's not clear how much of that is due to utilization or to price of services, said Cantor. Spending for telehealth services remained stable in the post-vaccine period, while spending on in-person visits returned to pre-pandemic levels. Cantor and his colleagues were not able to determine whether utilization was by new or existing patients, but he said that would be good data to have. "It would be really important to know whether or not folks are initiating care because telehealth is making it easier," he said. The authors analyzed about 1.5 million claims for anxiety disorders , major depressive disorder, bipolar disorder, schizophrenia, and posttraumatic stress disorder, out of claims submitted by 7 million commercially insured adults whose self-insured employers used the Castlight benefit. Cantor noted that this is just a small subset of the US population. He said he'd like to have data from Medicare and Medicaid to fully assess the impact of the COVID-19 pandemic on mental health and of telehealth visits, also. "This is a still-burgeoning field," he said, about telehealth. "We're still trying to get a handle on how things are operating, given that there's been so much change so rapidly." Meanwhile, 152 major employers responding to a large national survey this summer said that they’ve been grappling with how COVID-19 has affected workers. The employers include 72 Fortune 100 companies and provide health coverage for more than 60 million workers, retirees, and their families. Seventy-seven percent said they are currently seeing an increase in depression , anxiety , and substance use disorders as a result of the pandemic, according to the Business Group on Health's survey . That's up from 44% in 2022. Going forward, employers will focus on increasing access to mental health services, the survey reported. "Our survey found that in 2024 and for the near future, employers will be acutely focused on addressing employees’ mental health needs while ensuring access and lowering cost barriers," said Ellen Kelsay, president and CEO of Business Group on Health, in a statement. The study was supported by grants from the National Institute of Mental Health and the National Institute on Aging. Co-author Dena Bravata, a Castlight employee, reported receiving personal fees from Castlight Health during the conduct of the study. Co-author Christopher Whaley, a RAND employee, reported receiving personal fees from Castlight Health outside the submitted work.