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Psilocybin Reduces Symptoms, Disability in Major Depression A single dose of an experimental psilocybin drug offered significant sustained improvement in symptoms and disability in patients with major depressive disorder (MDD) over a 6-week period, a new study suggests. The randomized, phase 2 trial was conducted at 11 sites across the US and is the latest to demonstrate the psychedelic drug's potential as a treatment for depression. The project was funded by Usona Institute, a nonprofit medical research organization based in Madison, Wisconsin. The institute issued a press statement, but researchers did not comment further on the findings. "As the largest and most rigorous study conducted across a wide spectrum of individuals with major depressive disorder, the results show promise for all people struggling with this condition," lead author Charles Raison, MD, director of clinical and translational research at Usona, said in the statement. The 34 co-authors on the study are affiliated with public universities, research centers, and private companies. Eight of the investigators are identified as employees of Usona Institute. Declining further comment, an institute spokesperson told Medscape Medical News that, "Usona has chosen the approach of no interviews, and this applies for all co-authors." Largest Study to Date Usona's investigational psilocybin drug has been granted a breakthrough designation by the US Food and Drug Administration, a process designed to speed drug development and review. Previous smaller studies have suggested a rapid antidepressant response with psilocybin, but they have been small, unblinded, and have had short duration of follow-up, they write. This randomized, double-blind, phase 2 clinical trial is the largest study of psilocybin for depression to date, the researchers note. It included 104 adults aged 21-65 years with MDD who had a current depressive episode of at least 60 days and a Montgomery-Åsberg Depression Rating Scale (MADRS) total score of 28 or more at baseline. Participants had to be free of psychedelic drugs for at least 5 years, have had no active suicidal ideation or suicidal behavior in the prior 12 months, no personal or first-degree family history of psychosis or mania and no history of moderate/severe alcohol or drug use disorder. Before the study, participants had a 7- to 35-day screening period for psychiatric medication tapering, underwent baseline assessments and received 6-8 hours of preparation with two facilitators who would be with them during dosing. Dosing occurred within 7 days of baseline assessments. During the 6- to 8-hour session, participants received either a single 25-mg oral dose of psilocybin or 100-mg dose of niacin. One participant randomly assigned to receive psilocybin received the incorrect treatment, resulting in 50 participants receiving psilocybin and 54 receiving niacin. Participants returned the next day, the next week, and then every 2 weeks for assessments, for a follow-up of 6 weeks. Psychosocial Support Participants who received psilocybin reported significantly greater improvements in MDD symptoms compared with those who received niacin. MADRS scores — a scale from 0 to 60 where higher scores indicate more severe depression — showed greater reductions with treatment vs placebo at 8 days (mean difference, −12.0; 95% CI, −16.6 to −7.4; P < .001), and at day 43 (mean difference, −12.3; 95% CI, −17.5 to −7.2; P < .001). More participants receiving psilocybin had sustained depressive symptom response (42% vs 11%; P = .002) and more improvement in the Sheehan Disability Scale score, which measures functional disability, 43 days after treatment (P < .001). The effects persisted through the end of the study, although the differences between groups were no longer significant by week 6. "This is another exciting piece of evidence that adds to the current literature regarding the potential efficacy of psilocybin for the treatment of mental health conditions, particularly depression," said Greg Fonzo, MD, co-director of the Center for Psychedelic Research and Therapy at the University of Texas at Austin's Dell Medical School, who commented on the findings for Medscape Medical News. Significantly more people in the psilocybin group reported at least one treatment-related adverse event (82% vs 44%), although most were mild to moderate. Headache and nausea were the most common side effects and most resolved within one day of dosing. While those numbers are high, Fonzo said they're not out of line with AEs reported in other studies. "Particularly with the types of adverse events reported here, like headache and nausea, those are things you would typically expect to see in this treatment," said Fonzo, who was not part of the research. "But it is high, and it underscores that this is not a treatment without certain risks, even though it was good that they were primarily mild in severity," he added. A "Stepping Stone" to FDA Approval? The use of tools to measure disability in addition to symptoms of depression severity is a strength of the study, Fonzo added. The use of an active comparator and the 6-week follow-up also offer something new over previous studies. Despite the longer follow up, questions remain about the durability of response, something only a longer study could answer, Fonzo said. The small and homogenous sample-size are also a concern. Nearly 90% of participants were White and more than half had an income of $75,000 a year or higher. "It's another stepping stone in the process to FDA approval, but the next step in that process would be much larger phase 3 trials that would have much larger samples, a longer follow up, and hopefully have a more inclusive swath of the population," Fonzo said. But perhaps one of the most significant limitations is the use of niacin as an active comparator, said Caleb Alexander, MD, co-director of the Center for Drug Safety and Effectiveness at Johns Hopkins University in Baltimore, Maryland. The use of an agent that doesn't produce effects similar to those expected from a psychedelic introduced the potential for functional unblinding, Alexander told Medscape Medical News. Investigators did not ask participants to guess whether they received psilocybin or niacin, so the quality of the blinding was not assessed in the study. "We'd like to see the use of [an] active comparator that might have a chance of obscuring to people as to whether they've been randomized to the treatment arm or control arm," said Alexander, who wasn't involved in the study. "Why not use a benzodiazepine or another drug that produces a transient euphoria that would better obscure whether or not people were receiving the psilocybin?" The authors of any accompanying editorial shared these concerns, also noting that the study included "a significant number of patients who did not respond to therapy." "It is important to analyze and understand adverse outcomes in psychedelic trials and conduct longitudinal studies to determine how sustained the effects will be and what may initiate a recrudescence of symptoms," write Rachel Yehuda, PhD, and Amy Lehrner, PhD, both of the Peters VA Medical Center and Icahn School of Medicine at Mount Sinai, New York City. "Future studies will help identify who is most likely to benefit from psychedelics, whether booster or repeated treatment is safe and beneficial, and what the optimal dose and therapeutic frameworks are." A long-term follow-up of the current trial was terminated last year because of low enrollment. The spokesperson with Usona Institute did not respond to questions about that study, and the institute's statement only added that preparations are underway to launch another study that "will provide additional safety and efficacy data to support submission of a new drug application to the FDA." Usona published its manufacturing process that it used to synthesize psilocybin in an open-access journal and signed a statement on "open science and open praxis" with psilocybin and similar substances, which appears on their website. That statement was signed by 31 research and service organizations around the world and nearly 150 scientists, scholars, and practitioners. Related Article: Single Psilocybin Dose Again Shows Major Depression Benefit

— One-size-fits-all treatment approaches sometimes fail Methadone Access America's drug overdose crisis has escalated in the past few years due to several factors, including disruptions caused by the COVID-19 pandemic, driving an unprecedented rise overdose fatalities. Fentanyl, stimulants and, more recently, sedatives like xylazine in the unregulated drug supply continue to drive the worst overdose crisis in American history. We cannot effectively address this crisis without updating policies that narrow the persistent addiction treatment gap acknowledge the reality of polysubstance use, and equip addiction specialists with every tool science has to offer. While we saw important policy changes during the pandemic, one essential policy issue still lags behind: broadening access to methadone treatment. Background on Opioid Use Disorder Treatment As an addiction specialist physician, I served on the front line of this overdose crisis during the pandemic. My patients experienced lonely COVID-19 quarantines during inpatient and residential addiction treatment. Staff working in outpatient programs were pushed to deliver care remotely, including medical clinicians learning to initiate lifesaving addiction medications via telehealth. In-person requirements to receive addiction treatment were modified, and addiction treatment systems quickly adapted. We learned that remote delivery of addiction medications could be managed safely and enhanced patient access to care. New policies were enacted, like those facilitating telehealth prescribing of controlled medications. Greater flexibilities with respect to take-home methadone supplies for opioid use disorder (OUD) treatment swept the nation. Last year, federal policymakers further transformed the landscape when they passed a law ensuring that clinicians who prescribe controlled medications receive education on treating patients with substance use disorders, and eliminated antiquated restrictions on the prescribing of buprenorphine for OUD. Buprenorphine will continue to play a critical role in OUD treatment, but in the context of this unprecedented overdose crisis, we need access to additional options. One limitation of buprenorphine is that it can precipitate opioid withdrawal if a patient is actively using other opioids. In a recently published document reviewing clinical considerations surrounding the use of buprenorphine in the age of high-potency, we come to better understand synthetic opioids. As part of an effort to increase successful buprenorphine treatment of OUD, the document's authors describe emerging buprenorphine-related strategies in the age of fentanyl. For example, higher doses of buprenorphine may be required for stabilizing some patients. For other patients, the use of long-acting, injectable buprenorphine may be the best option. Still, for others, initiating buprenorphine at low doses, while continuing full agonist opioids (such as methadone) during buprenorphine escalation may be warranted. However, there's a major catch when it comes to this latter strategy: U.S. federal law is currently understood to prohibit an outpatient prescription of a full agonist opioid for the treatment of OUD. This means that some patients may continue to use illegally obtained opioids while initiating buprenorphine to avoid withdrawal. With such a strategy, it is outdated federal policy, not drug potency, that exacerbates an unnecessary patient risk. This document should prompt every American policymaker to rethink how we can modernize our policies to save more lives. In the age of fentanyl, one-size-fits-all protocols for buprenorphine sometimes fail. Options for Updating Methadone Policy Methadone remains the only full agonist opioid approved in the U.S. for OUD treatment, and current federal law largely restricts outpatient access to methadone for OUD to approximately 2,000 clinics called opioid treatment programs (OTPs). These methadone regulations create an often-insurmountable challenge for many Americans. For example, in rural America, a patient may spend a good part of each day driving to their OTP -- if their county has one, that is. Some health professionals have expressed concerns that a big increase in access to methadone could lead to new safety issues, such as low-quality care or harmful use of methadone itself. However, when methadone is managed by trained physicians who arrange for dispensing by community pharmacies, it can be handled in a medically appropriate manner. Inaction is a much greater threat to patient safety than the risk of responsibly updating decades-old policies to expand patient access to methadone when it is managed by addiction specialist physicians. The U.S. Senate should take up the Modernizing Opioid Treatment Access Act (MOTAA), as the U.S. House advances other legislation to bolster the nation's addiction treatment infrastructure. MOTAA would finally allow addiction specialist physicians, like me, to use our clinical expertise to treat OUD with methadone dispensed by a local pharmacy. MOTAA would mean the chance for more Americans with OUD to reach remission and recovery; at full scale, it could man a giant step forward to ending this human crisis. In honor of Overdose Awareness Day, Congress should pass MOTAA -- an essential policy change needed to save lives.

CASE VIGNETTE “Mr Deuce” is a 22-year-old male with no previous psychiatric history who presents to the emergency department with his family. He is a senior in college. He has not been sleeping well, with complaints of initial insomnia, and has been taking NyQuil for the past 2 weeks with minimal benefit. Per his sister, the patient has exhibited delusional thinking, stating that he thinks he is a superhero and his roommates at college are plotting to get him kicked out of school. He has also had a paranoid ideation that his dorm room is wiretapped. Upon admission to the emergency department, he told the interviewer that he would be meeting the president the next day. The patient also has periods in which his speech is mostly incoherent. His laboratory studies, including a urine drug screen, were unremarkable. He was diagnosed with a first episode of psychosis and stabilized on risperidone, titrated to 3 mg daily, during an inpatient psychiatric hospitalization. Sleep disorders are highly prevalent in patients with psychotic disorders.1 This comorbidity has a significant impact on the clinical course of illness, including worsening psychotic symptoms and cognitive impairment, as well as poorer functioning and decreased quality of life.2-4 However, the nature of the relationship between psychosis and sleep disorders is unclear, as it may be a primary component of the illness itself and/or a secondary consequence of behavioral or iatrogenic factors.5 The Current Study The Physical Health Assistance in Early Psychosis (PHAstER) study was a randomized clinical trial (RCT) of a physical health nurse intervention for patients with first-episode psychosis (FEP).6 Gannon and colleagues7 performed a prospective cohort study nested within this RCT. Patients aged 15 to 24 years with FEP and <4 weeks of exposure to antipsychotic medications attending the Early Psychosis Prevention and Intervention Centre service in Melbourne, Australia, were assessed at baseline and 6 months follow-up. Participants were diagnosed using the Structured Clinical Interview for DSM-5. Insomnia was defined by a score of ≥15 on the Insomnia Severity Index (ISI). Poor sleep quality was determined by a score of >5 on the Pittsburgh Sleep Quality Index (PSQI). Psychopathology was assessed with the Brief Psychiatric Rating Scale (BPRS) and the Schedule for Assessment of Negative Symptoms (SANS). Functioning was assessed with the Social and Occupational Function Assessment Scale (SOFAS), and the Simple Physical Health Questionnaire (SIMPAQ) was used to measure physical activity. The authors used binary logistic regression models to calculate odds ratios for demographic and clinical predictors of either insomnia or poor sleep quality. Seventy-seven individuals participated in the PHAstER trial, of whom 70 (91%) had baseline data on insomnia. The mean age was 19.4 years, 53% of participants were male, and 44% had a diagnosis of schizophreniform disorder. The prevalence of clinical insomnia at study baseline was 43% (n=30). Individuals with insomnia had more severe total psychopathology (mean BPRS total score 63 vs 55) and negative symptoms (mean SANS score 24 vs 14). Positive symptoms, demographic factors, functioning, and physical activity were not associated with baseline clinical insomnia. At 6 months, ISI data was available for 42 individuals, and the prevalence of insomnia decreased to 21%. Those individuals with insomnia at 6 months had more severe total and positive psychopathology, and lower social and occupational functioning. Poor sleep quality at baseline was present in 87% of the cohort, and there were no associated demographic, clinical, or physical health factors. At 6 months, only 43% of the cohort completed the PSQI, of whom 67% had poor sleep quality. Similar to the data for insomnia, individuals with poor sleep quality at 6 months had more severe total and positive psychopathology, and lower social and occupational functioning. Study Conclusions The authors concluded that there was a high prevalence of poor sleep quality and insomnia in patients with FEP. Study strengths included that participants had minimal antipsychotic exposure at baseline and the longitudinal design. The primary study limitation was the appreciable attrition of data on sleep at the 6-month follow-up. There is some evidence supporting sleep hygiene strategies8 and cognitive behavioral therapy for insomnia (CBT-I) in FEP.9 By contrast, there is limited evidence for use of specific psychopharmacological agents for insomnia in this patient population. The Bottom Line Findings provide evidence that sleep problems are common at the onset of psychotic illness. Sleep disorders represent a potential therapeutic target in psychosis to improve psychopathology and functioning. Dr Miller is a professor in the Department of Psychiatry and Health Behavior at Augusta University in Augusta, Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for Psychiatric Times®. The author reports that he receives research support from Augusta University, the National Institute of Mental Health, and the Stanley Medical Research Institute. Related Article: Postpartum Psychosis: Improving the Likelihood of Early Intervention

In a 1943 paper titled "A Theory of Human Motivation," American psychologist Abraham Maslow theorized that human decision-making is undergirded by a hierarchy of psychological needs. In his initial paper and a subsequent 1954 book titled Motivation and Personality, Maslow proposed that five core needs form the basis for human behavioral motivation. Hierarchy of Needs Jump To Section

Mental Health Matters Episode Summary In 2020, suicide was the 12th leading cause of death in the United States, claiming the lives of over 45,000 people. Suicide doesn't discriminate—it impacts people of different ages, races, and genders. In this episode, we talk with Dr. Arielle Sheftall, an associate professor in the Department of Psychiatry at the University of Rochester Medical Center. We learn about who is at increased risk for suicide, how it's impacting the nation's youth, and most importantly, what we're doing about this tragic and preventable issue. Transcript ARIELLE SHEFTALL: So, for our kiddos, 5 to 9 years of age, it's the 10th leading cause of death. Just to think about that, it's quite devastating to be 100% honest, to think that a child that young could even have thoughts about suicide is very devastating, but it does happen. It's the 10th leading cause of death for that age group. JOSHUA A. GORDON: In 2020, suicide was the 12th leading cause of death overall in the United States, claiming the lives of over 45,000 people. And suicide doesn't discriminate. It impacts people of different ages, races, and genders. The death of a loved one by suicide has profound impacts on a person's family, friends, and the larger community. Hello, and welcome to "Mental Health Matters," a National Institute of Mental Health Podcast. I'm Dr. Joshua Gordon, Director of NIMH. And today, we'll talk with Dr. Arielle Sheftall, an associate professor in the Department of Psychiatry at the University of Rochester Medical Center. We'll learn about who is at increased risk for suicide, how it's impacting the nation's youth, and most importantly, what we're doing about this tragic and preventable issue. Arielle, welcome, so glad to have you. ARIELLE SHEFTALL: Thank you for having me. JOSHUA A. GORDON: I'm just curious, suicide, it's a topic that can be challenging to talk about, much less devote one's career to, what made you become interested in studying suicide and suicide prevention? ARIELLE SHEFTALL: To be 100% honest, I kind of stumbled upon suicide and suicide prevention. Originally, I thought I was going to be a medical doctor, but I realized chemistry was not my forte, so I had to change that pretty quickly. I went to Penn State for my undergrad. I studied biobehavioral health and had a minor in psychology. And I really enjoyed looking at problems from a behavioral, biological, psychological perspective. And I continued to just really enjoy that, and went on to Ohio State, and got my master's in Human Development and Family Science, and had all of this combined, and learned how mental health could be associated with different systems depending on where you are and what you're doing, and who you're interacting with. And it really opened my eyes, to be honest, about mental health. That was something that really excited me. And I happened to stumble upon Dr. Jeffery Bridge, at that time, who had just joined Nationwide Children's Hospital, and he was actually studying suicide and suicidal behavior in adolescence. And it really hit a nerve, to be honest. So, when I was 14 years of age, my mother passed away from cancer. And I started living with my grandmother. And during that time, I was starting high school, I was trying to figure out my life. You know, at 14 years old, my mom who was my best friend had passed away, and I was really lost. And I love my grandmother. I mean, I love, love, love her. And still, she's the strongest person I've ever known in my entire life. But, you know, we had a really big age gap. And I think, unfortunately, she just didn't quite understand what I was experiencing. And she was very smart, though, she actually had my older cousins check-in on me very often, because she knew that it would be better coming from my cousins at that time than from her specifically. And I went into this very deep, dark space, and started to have suicidal thoughts myself. JOSHUA A. GORDON: Yeah. ARIELLE SHEFTALL: So, I could relate to this study that Dr. Jeffery Bridge was doing. And I wanted to understand what was it about suicidal behavior during this stage of lifespan? How could we help individuals? How could we get the care for these adolescents so that they don't suffer? And what could we do on our end to help them to get through this space that I had, thank goodness, been able to achieve, and to be able to get through, but I had a lot of family help to get me through that really dark, dark space in my life. And some of those individuals, unfortunately, that I interacted with during that study didn't have that. And we had to be that barrier, so to speak, and getting those kids the help that they needed, and to make sure that the quality of care that they were receiving was high so that they can move on and get better. JOSHUA A. GORDON: So, for you during your training, suicide prevention, it was professional, but also deeply personal. ARIELLE SHEFTALL: Absolutely. JOSHUA A. GORDON: I'd imagine that hasn't changed. ARIELLE SHEFTALL: No, it hasn't. It really hasn't. I am very, very committed to the field. And not only because of my own personal experiences, but all the experiences that I've heard about. I've been in this field for, which is so crazy to believe, 17 years now. And I've been able to actually study suicide from different perspectives. But that's great, but hearing the stories from the families that I work with, that's even more motivation to keep going and keep striving, and keep doing better. And that is something that I take with me every single day. And if I can help one person, then I feel that I've done a good job and that I can actually keep on moving forward to help another one and another one and another one. JOSHUA A. GORDON: Before we go any further, let's talk about language. What do we mean when we use terms like suicidal ideation or self-harm? ARIELLE SHEFTALL: Yeah. So, suicidal ideation is just thoughts about suicide. So, those can range anywhere from something that's very passive, like just wishing you were dead, or all the way up to a thought that has a specific method in mind, with intention to actually act on that method. So, they can range, but it's really just a fancy way of saying suicidal thoughts. And then when talking about self-harm behavior, that is actually different in terms of suicidal behavior, just so everyone is aware. So, self-harm behavior, is when someone actually hurts themselves on purpose, but they do not have the intent to die. And usually, these injuries occur to help someone or a person to actually get the emotions that they're experiencing out, if that makes any sense. And some people actually indicate that they self-harm, because they feel so numb on the inside that they want to see something or feel something. Suicide attempt is when an individual will actually hurt themselves on purpose with the intent to actually die. That intent is what's really important. That intent to actually want to die has to be present for it to be a suicide attempt. And then suicide is what we would call someone that dies by suicide. JOSHUA A. GORDON: We used to say someone committed suicide. ARIELLE SHEFTALL: Yes. JOSHUA A. GORDON: You use died by suicide, just then, and tell me why that's become a more preferred way of saying for either? ARIELLE SHEFTALL: Yeah. So, back in the day, suicide was actually considered a crime. And that stigma continues to be present in our field of mental health and suicidal behavior. Like, so you commit a crime. You don't commit cancer. Like, you don't commit heart disease. People die from those things, and people die from suicide. And so, we actually have changed the language, so that we can get rid of that stigma, and actually start talking about the problem freely. And that takes the onus off of that person dying by a specific method versus them actually committing a crime and making it criminal. JOSHUA A. GORDON: So, this something that happens to you because of an underlying illness. What are those underlying illnesses or risks? What increases the risk for suicide? ARIELLE SHEFTALL: So, there are a ton of risks that are associated with suicide, and they vary from person to person, though some of those can be mental health concerns. So, for instance, depression, bipolar disorder, schizophrenia, and substance use disorders, but some can be chronic health concerns, like diabetes, others can be financial concerns, divorce, relationship problems. So, risks can vary greatly. They can be genetic. So, we've seen that having a familial history of suicide and suicidal behavior has been associated with an individual having a higher risk for suicidal behavior or they can be environmental. Like, experiencing bullying, or being a bully actually puts you at higher risk for having suicidal thoughts and behaviors as well. JOSHUA A. GORDON: What about the link between suicide and depression? We often think about suicide as a potential outcome from depression. But not everyone, right, who dies by suicide is depressed. Tell me about that link. ARIELLE SHEFTALL: So, there are individuals in this world that suffer from depression. And there are individuals that unfortunately, who have depression who died by suicide, but that's not necessarily the case that once you have depression, that is going to be your cause of death. There is a higher association, yes. But individuals that suffer from depression don't necessarily have suicidal thoughts. So, there's different risks for different individuals. But there is a higher risk, unfortunately, for those who do suffer from mental health concerns. So, I focus on youth suicide, primarily. Depression is actually not the disorder that we're seeing that's associated with suicide death. What we're seeing actually is ADHD. So, Attention Deficit Hyperactive disorder. And those are in kids, you know, 5 to 12 years of age. So, it depends again, unfortunately, on what group of youth you're speaking of, or individual that you're speaking about when looking at the association between depression and suicidal behavior. JOSHUA A. GORDON: So, bottom line suicide, suicidal thoughts, these are seen, yes, in individuals who suffer from depression, but also in individuals who suffer from other mental illnesses and other environmental conditions. ARIELLE SHEFTALL: Yes, absolutely. Nobody is immune. And unfortunately, if you were to do a survey from around the world, you would find that a lot of people have had thoughts about suicide. It doesn't see race. It doesn't see age. It doesn't see sex. Anybody can suffer from suicidal thoughts and behaviors. So, I think we need to change our mindset a little bit in terms of thinking about this being a public health problem for anyone. JOSHUA A. GORDON: How many people die by suicide in the US each year? ARIELLE SHEFTALL: Yeah. So, that's a great question. How big is the problem itself? So, in 2020, suicide was the 12th leading cause of death, and it was the cause of death for about 44,000 individuals. JOSHUA A. GORDON: Forty-four thousand? That's a lot of people. ARIELLE SHEFTALL: Yes, it is a lot of people. Absolutely. JOSHUA A. GORDON: How does suicide rates in the United States compare with the rest of the world? ARIELLE SHEFTALL: Yeah. So, when you look at the rest of the world, we are not doing well. So, the World Health Organization collects data on suicide, though, for 184 countries. There's 195 in the world, so they get majority of the countries. When you compare all 184 countries, we are actually the 32nd for adults, which is pretty high. Our rate in 2019 was 14.5 per 100,000. And then when you look at Australia, it was like 11.3, United Kingdom is even lower at 6.9. And then Israel is even lower than that at 5.2 per 100,000. And when you look at youth suicide, it's even more horrifying, to be 100% honest. For the United States, we are actually 19 when you compare all the rates. Yeah, 19. JOSHUA A. GORDON: Nineteen per 184. ARIELLE SHEFTALL: A hundred and eighty-four. JOSHUA A. GORDON: So, compared to the rest of the world, we've got a lot of work to do. ARIELLE SHEFTALL: Absolutely. JOSHUA A. GORDON: Changes in rates that you described, are those changes happening differently for different people, for different demographic groups? ARIELLE SHEFTALL: So, suicide does differ depending on the age group. So, for 25 to 34-year-olds, suicide is actually the second leading cause of death. And then for our 35 to 44-year-old individuals, it's actually the third leading cause of death. And this differs even more when you start looking at youth. So, for children 5 to 19 years of age, that's the primary age group that I focus my energies on, it was actually the third leading cause of death in 2020. And it touches my heart even more now. I have young kids myself. I have a 6-year-old and a 10-year-old. And to think even that those thoughts have been on their mind is devastating. JOSHUA A. GORDON: And it's rising faster in that age group isn't it than in other age groups? Yeah. ARIELLE SHEFTALL: Yes. So, when you look at the breakdown, so over the past 20 years, for our teenagers, 13 and 19 years of age, so we've seen from 2000 to 2020, we've actually seen a 38% increase in that age group. But for our 5 to 12-year-olds, it's actually been 107%. JOSHUA A. GORDON: Wow, that's more than a doubling in the rate of death by suicide in young kids. ARIELLE SHEFTALL: Five to 12. And unfortunately, another area of my research looks at black youth suicide. JOSHUA A. GORDON: Yep. ARIELLE SHEFTALL: And unfortunately, we've seen that rate is even more drastic. For our black youth, 5 to 12 years of age, they're approximately two times more likely to die by suicide than their white counterparts. What's happening in this age group is that suicide seems to be the leading cause of death for black girls 12 to 14 years old. A lot of research to be done, a lot of work to be done. JOSHUA A. GORDON: Do we know why these changes are happening? And in particular, do we know why these changes are happening differently for people from different groups? ARIELLE SHEFTALL: The research, it's still pretty young in terms of where we are when looking at minority, so youth of color, individuals of color, to be 100% honest. Back in the day, suicide was really considered to be a white male problem, because again, the rate was the highest in white middle-aged men. So, a lot of research focused in on white men or white youth. And now we're starting to see, wait a minute, we lost a lot of opportunity here because we didn't focus in on these youth of color. So, we're still in the infancy of this research. We're trying our best. I think we have gotten a lot further than what we did in the past. But we still have a lot of research to do in order to understand what are those specific risks, and how can we actually intervene appropriately for youth of color? JOSHUA A. GORDON: It's really important this research that you are doing to try to get at the causes of suicide, particularly, in young people. Rare, as you pointed out, we know that children as young as five die by suicide, which, to me, it's just truly heartbreaking. ARIELLE SHEFTALL: Yes. JOSHUA A. GORDON: What do we know about suicide in children that young? And in particular, maybe you can tell us, what should parents do if their young child, their 5, 6, 7-year-old child says they're thinking about killing themselves, or they have other thoughts of self-harm? ARIELLE SHEFTALL: Yeah. So, I would definitely say no matter the age, we should absolutely 100% make sure we're taking every disclosure of self-harm or suicide or suicidal thoughts very, very seriously. And I know that can be very hard for parents to do even, you know, at this young age to even fathom that my kid is saying these words, actually speaking these words, and they actually mean these words. Because, you know, we never think. Never, ever would have ever thought that my five-year-old would think that they want to kill themselves or hurt themselves on purpose. We have to do something about it. As a parent, this is gonna be a very scary space that you're gonna be in, but we have to make sure that we get the kids, even at this younger age, the help that they need immediately so that we can make sure that they're okay. And that they can get off of that trajectory towards self-harm behavior, or towards suicidal behavior. So, we have to take it seriously every single time. JOSHUA A. GORDON: Your research has shown that black youth, particularly very young black youth, have a higher rate of suicide than white youth. What do we know about this? What are the circumstances in the black community that might be contributing to this difference? ARIELLE SHEFTALL: So, I will be 100% honest, black youth suicide was something that we kind of stumbled upon with myself and my colleague, Dr. Jeffrey Bridge. He received a phone call from a media outlet that asked him about a suicide death that had occurred in an 8-year-old. When we started to break the data down by race, what we found is that for our black males, they actually had a significant increase in their suicide rate versus white males. So, we started to dig a little bit more. And he did the analysis over and over and over again because couldn't believe what he was seeing. And then he asked me to do it, and it was the same results, unfortunately. And yeah, it was just something that we weren't understanding to be 100% honest, but we knew it was important for us to report. And what we found is that for black youth, specifically, 5 to 12 years of age, they were about two times more likely to die by suicide compared to their white counterparts. So again, why? That's the big question. So, when I started to think about the problem, when I started to sit down and really do some introspective work, so to speak, I started to think, what are those risk factors that black youth may actually experience that white youth don't necessarily? Well, one of them, unfortunately, is racism, discrimination, right? And recently that has been shown to be associated with suicide, death, suicidal behavior, suicidal thoughts. So, I think that is one of the risk factors that may be playing a role when you look at suicide rates and suicidal behavior in black youth. And I think, unfortunately, the environment that we live in right now is not a safe space for black youth, specifically, or youth of color, specifically. JOSHUA A. GORDON: Which the reason why we ask questions about why things are happening because we wanna do something about these disparities, and about suicide deaths in general. Are there ways that we know of now to reduce suicide deaths? ARIELLE SHEFTALL: That is absolutely the reason why we ask these questions, right? JOSHUA A. GORDON: Right. ARIELLE SHEFTALL: We wanna do something. We want to change the trajectories that we're seeing, these trends that we're seeing, and I think unfortunately, the research is still not done to be able to say, "Oh, yeah, use this prevention program, or use that prevention program." But I do think there is hope. And I think that's why I still am in this field to this day is because I think that number one, suicide is preventable. Everybody can prevent suicide no matter who you are, no matter how old you are. But I think also there are some promising avenues for preventing suicide. I think in terms of youth suicide, there have been programs that have shown good promise. So, Signs of Suicide is one of them. And they actually, I believe, are starting to take the Signs of Suicide and bring it down to elementary school age. JOSHUA A. GORDON: Tell us more about Signs of Suicide, what is it? ARIELLE SHEFTALL: So, it's a school-based program, specifically. And you educate everybody from the top to the bottom within that school setting. So, it's the principals, the counselors, the teachers, the cafeteria staff, the environmental services staff, the students. You are telling them all about what are the signs that they should be looking for in any individual that they interact with that is concerning and that they should act upon. So, these things could be, you know, isolating themselves, like not answering your text messages anymore than what they used to. Acting differently, giving away possessions. Things like that that just spark, like, this isn't right, behaviors have changed. So, it educates the entire school on these behaviors. But not only that, it tells them what to do when they see these behaviors present. But it also brings the parents to the table as well. So, it educates the parents of the students also. So, you basically are creating a system of prevention within one school setting that can go outside of the school into the family setting. JOSHUA A. GORDON: Maybe it's the fact that you've been there yourself that helps you understand that reaching out to kids and talking about suicide is a helpful thing rather than a dangerous thing. Many of us are reluctant to talk to anyone, much less children about suicide because it's a scary thing for us to think about. We worry that we're gonna cause them to think about it. We're gonna impact them that way. So, just the fact that you intuitively understand that kids wanna talk about this stuff, and they appreciate learning from you more about suicide, I mean that's powerful. ARIELLE SHEFTALL: Yeah. And there's actually research out there that says that if we talk about suicide, that does not put the thought of suicide in a child's mind. There's research out there that supports that argument. It actually gives an opportunity for a kid to feel like, oh, I can talk about these things with you. And I can actually be very honest and open with you about not only this but other kind of risky behaviors that they might be doing or might be thinking about doing, right? So, we have to break that barrier. We have to understand that this does not put those thoughts in that child's mind. If the thought's there, the thought's already there. And us not knowing that the thought is there is what actually does more damage than good. JOSHUA A. GORDON: You've now mentioned research several times throughout our conversation. NIMH has been supporting research now for 75 years. ARIELLE SHEFTALL: Yes. JOSHUA A. GORDON: A lot of that in the suicide and suicide prevention research field. What has been NIMH's role from your perspective, and how far have we come in terms of understanding or preventing suicide? ARIELLE SHEFTALL: Number one, NIMH is the number one funder in the government world when it comes to suicide prevention and research. So, if NIMH wasn't present number one, my research couldn't be. It couldn't be. So, I'm very grateful for that. And thinking even way back in the day, where suicide was this taboo topic, where we didn't want to talk about it because again, we had all these thoughts about, well, if we talk about it, it's gonna open this big can of worms, and people will become suicidal. Well, no, I think NIMH has actually made that very clear that talking about it is necessary, and that we need to continue to have this conversation. We can't just, you know, brush it under the rug. And I think unfortunately, that's been the case for many years that we've kind of brushed it under the rug, that suicide doesn't really exist, and that we don't really wanna talk about it because it'll bring up other things. So, I think NIMH is absolutely the one that's driving the conversation, and making sure that you are all working with other institutions and other organizations to make sure that people understand that suicide is a public health concern, and we have to do something about it. JOSHUA A. GORDON: Is there anything you think the field could do better when it comes to studying suicide and supporting the work necessary to study it? ARIELLE SHEFTALL: So, I think engaging community, getting community organizations to be at the table to give you input about your own research ideas, to actually listen versus just talking to, and to gain insight from the community because they're the ones that are on the ground and working with these families, and working with these youth, and understand the problem probably a little bit better than what we do. And I think they are the insiders. And having their input, and being able to hear what they have to bring to the table, and to help actually form our research ideas can be extremely beneficial, and I think will play a big role in actually changing the trajectory that we're seeing. The other thing is the youth voice, which is something we haven't done in the research field. We have not done a really good job at listening to youth that have lived experience, and understanding what we can do better. And understanding what that experience was like when they did have suicidal thoughts. What were those experiences that they had prior to suicidal thoughts? What happened when they were hospitalized for a suicide attempt? What was that experience like for them? And gaining perspective from the youth themselves is something I think, again, will help us change the way that we look at the problem, and also give us some insight on where to go in terms of intervention and prevention programming. JOSHUA A. GORDON: Have you been involved, personally, in some of this research in these kinds of evidence-based approaches? ARIELLE SHEFTALL: Yeah. Actually, I have. And that's why I say Signs of Suicide. But there are other ones out there as well. But Signs of Suicide when I was in Columbus, Ohio, at the Abigail Flexner Research Institute, we in the center have a prevention arm, which is actually educating schools in central and southeastern Ohio. So, we actually have a whole team that was dedicated to going into schools, doing the Signs of Suicide training program, and then also implementing the program, and then training the trainer's so that they could keep the program going. So, I was actually involved in that program. And we were also involved with Boys and Girls Club. So, actually taking the Signs of Suicide program and implementing it into the Boys and Girls Club in Columbus. And trying to figure out how can we take that program and make it more community-based. JOSHUA A. GORDON: What was that experience like for you to be involved in an effort to really develop something that can make a difference? ARIELLE SHEFTALL: You know, that was the best feeling. It really was. And don't get me wrong, I love that NIMH funds my research. And I love that, and I love doing what I do. But getting on the ground and actually talking to kids, and talking to individuals that are talking to kids every single day, and giving them those tools to have in their tool belt to actually prevent suicide, that is like one of the best feelings in the world. JOSHUA A. GORDON: I wish that our listeners could see your face right now, and how animated it is, but I'm sure that they can hear it in your voice. Working with kids, talking to them about suicide, it clearly drives you. ARIELLE SHEFTALL: It does. It really does. I've been there. I've been there. And I don't want people to believe that means I know everything. That's not true. I don't know everything. This was my experience. These were my circumstances. But I don't want people to feel like they're alone in those experiences that they're having. And the more that I can do, the more that I can share my own story, the more that I can be present to give individuals ideas about what they can do for their friends and their family members. I feel that goes further than anything else I can do on the research side of the world. JOSHUA A. GORDON: Dr. Sheftall, thank you for joining us today. ARIELLE SHEFTALL: Thank you for having me. I'm very honored. JOSHUA A. GORDON: This concludes this episode of Mental Health Matters. I'd like to thank our guest, Dr. Arielle Sheftall, for joining us today. And I'd like to thank you for listening. If you enjoyed this podcast, please subscribe, and tell a friend to tune in. If you'd like to know more about suicide, please visit nimh.gov. We hope you'll join us for the next podcast. 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— Significant early improvement sustained through day 43 in multicenter study Single Psilocybin Dose Just one dose of psilocybin significantly improved depression symptoms and functional disability in patients with major depressive disorder (MDD), a randomized trial found. Administered with psychological support, a 25-mg dose of synthetic psilocybin resulted in a sustained 12.3-point (95% CI -17.5 to -7.2) greater improvement versus active niacin placebo in Montgomery-Asberg Depression Rating Scale (MADRS) score on day 43, meeting the phase II study's primary endpoint, according to Charles Raison, MD, of the Usona Institute in Fitchburg, Wisconsin, and colleagues in JAMA. As early as day 8, investigators observed a 12.0-point (95% CI -16.6 to -7.4) greater reduction in MADRS score favoring the psilocybin group, meeting a key secondary outcome of the trial. Other secondary outcomes demonstrated improvements with psilocybin in disability and sustained response for depressive symptoms. Treatment was well-tolerated, with the majority of adverse events (AEs) being graded mild or moderate in severity. The most commonly occurring AEs in the psilocybin group were headache (66% vs 24% for niacin), nausea (48% vs 6%), and visual perceptual effects on dosing day (44% vs 6%). Acting as a tryptamine alkaloid, psilocybin is found in Psilocybe mushrooms, commonly known as "magic mushrooms." And this isn't the first trial to demonstrate that psilocybin eases psychiatric conditions, like depression and anorexia. Another phase IIb trial -- sponsored by COMPASS Pathway -- showed benefit in MADRS total score at 3 weeks with a single 25-mg psilocybin dose, and significant improvement was seen as early as the second day. Comparing their two findings, Raison's group noted that "[i]n contrast to prior psilocybin trials for depression, there was not a significant reduction in depressive symptoms or a psilocybin/placebo difference in depressive symptom status at the day 2 assessment." "This may reflect the fact that to maintain central rater blinding, the 7-day recall period used for all other MADRS assessments was maintained at day 2, with the result that the majority of recall period for the day 2 assessment covered the pre-dosing period during which depressive symptoms remained elevated, based on results from the Symptoms of Major Depressive Disorder Scale," they explained. The study authors also pointed out a similar rate of severe adverse events in these two trials -- 8% here and 10% in the COMPASS Pathway trial. A few patients in the COMPASS trial experienced suicidal ideation as an adverse event (all were deemed non-responders), which was not seen in this current trial. Here, 41.7% of participants who received 25-mg of psilocybin experienced a sustained response versus 20.3% of the same dose psilocybin patients in the COMPASS trial. Commenting on this, accompanying editorial authors Rachel Yehuda, PhD, and Amy Lehrner, PhD, both of James J. Peters VA Medical Center in New York City, said "it is clear that despite the enthusiasm, psychedelic therapies do not represent a panacea for every patient. There are no silver bullets in psychiatry." Because a large proportion of patients in these psilocybin trials don't respond to this kind of treatment, future studies should focus on identifying exactly who might benefit most, determine the optimal dose, and figure out if "booster" or repeated treatment might be beneficial, Yehuda and Lehrner suggested. "If psychedelic therapies do prove to have enduring effects after just a single or a few administrations in the context of a few sessions for preparation and integration, they have the potential to offer not just a new approach to mental health care, but an entirely new paradigm of care," the editorialists wrote. A total of 104 participants were involved in the current trial, half of whom were women, and the average age was 41. After randomization, 51 were assigned to psilocybin and 53 to the niacin group. Niacin was used in order to aid in blinding because it produces a flushing response. All were between the ages of 21 to 65 with DSM-5-confirmed MDD of at least 60 days in duration with moderate or higher symptom severity (MADRS score of 28+). Those with a history of psychosis or mania, active substance use disorder, or active suicidal ideation with intent were excluded. If indicated, psychiatric medications were tapered prior to treatment so participants met criteria for moderate to severe MDD at the baseline assessment. Among the secondary outcomes, participants on psilocybin also saw a significant reduction in Sheehan Disability Scale scores compared with niacin at day 43 (-2.31, 95% CI -3.50 to -1.11). This disability improvement was greater for psilocybin recipients at all other timepoints after administration, as well -- days 8, 15, and 29. Significantly more psilocybin patients had a sustained response for depressive symptom improvement compared with niacin too (41.7% vs 11.4%), defined as a 50% or greater reduction from baseline MADRS total score at days 8, 15, 29, and 43. This translated to psilocybin recipients having more than a five times higher likelihood of sustained depressive symptom response than niacin recipients (OR 5.60, 95% CI 1.87-16.74). Psilocybin also trended toward a higher chance of sustained depressive symptom remission as well, defined as a MADRS total score of 10 or less at each post-dose assessment, but this wasn't statistically significant (OR 3.37, 95% CI 0.99-11.47). Participants underwent 6 to 8 hours of preparatory sessions with two facilitators prior to dosing and a 7- to 10-hour dosing session performed in a supervised, comfortable room. Participants were encouraged to wear sunglasses and listen to a curated playlist with headphones during dosing. This was followed by a 4-hour post-dose integration session when participants could discuss their experience with facilitators. Related Articles: What is Depression? A Recent Study Linked Changes in Alcohol Consumption to Changes in Depression Symptoms Can Alternative Medicine Help Depression? Vortioxetine Improves Cognition in Patients With Depression and Early Dementia Depression, Anxiety Do Not Increase Overall Risk for Cancer Does Social Media Use Cause Depression?

— Increase seen particularly in western states and in younger adults Pills Fatal overdoses from counterfeit pharmaceuticals, particularly pills found to contain fentanyls, more than doubled in recent years, the CDC reported. Among more than 100,000 recent overdose deaths in the U.S., the percentage caused by pills disguised as legitimate pharmaceutical products increased from 2.0% in the third quarter of 2019 to 4.7% in the last quarter of 2021. The proportion of those deaths involving illicitly manufactured fentanyls jumped to 93.0% from 72.2%, while illicit benzodiazepines also rose to 5.3% from 1.4%. Fake fentanyl was the sole drug involved in 41.4% of counterfeit pill-related deaths, compared with 19.5% of overdose deaths without evidence of counterfeit pill use. Western states drove the increase in deaths with evidence of counterfeit pill use, with a rise from 4.7% to 14.7% across the study period, whereas percentages remained below 4% elsewhere, reported Julie O'Donnell, PhD, of the CDC, and colleagues in Morbidity and Mortality Weekly Reportopens in a new tab or window. "The proliferation of counterfeit pills, which are not manufactured by pharmaceutical companies, but are typically made to look like legitimate pharmaceutical pills (frequently oxycodone or alprazolam [Xanax]), is complicating the illicit drug market and potentially contributing to [overdose] deaths," O'Donnell and colleagues wrote. And it may unintentionally expose new populations to highly potent drugs. "Counterfeit pills often contain illicitly manufactured fentanyls (IMFs), illicit benzodiazepines (e.g., bromazolam, etizolam, and flualprazolam), or other illicit drugs, and can increase overdose risk because the pills might expose persons to drugs they did not intend to use," they added. The findings come against a backdrop of an overall increase in drug overdose death ratesopens in a new tab or window involving fentanyl, methamphetamine, and cocaine from 2016 through 2021, as previously reported by the CDC without respect to counterfeit status. Prevention and education efforts "that are tailored to persons most at risk, and include outreach to those who do not frequent traditional harm reduction services, might be most successful," they wrote. Effective messaging by public health entities might include highlighting the dangers of pills obtained and taken without a prescription, as well as encouraging drug product testing, O'Donnell and colleagues added. Data examined for the study came from jurisdictions participating in CDC's State Unintentional Drug Overdose Reporting System (SUDORS), which included 29 states and the District of Columbia from July 2019 to December 2021, with an additional five states reporting data during 2021. Jurisdictions entered information about unintentional and undetermined intent overdose deaths from death certificates, post-mortem toxicology reports, and medical examiner and coroner reports. As for means of drug use, smoking was the most common non-ingestion route among deaths with evidence of counterfeit pill use (39.5%) and was highest in western jurisdictions (55.1%). More than half of deaths with evidence of counterfeit pill use involved counterfeit oxycodone, either alone (55.2%) or with counterfeit alprazolam (3.9%), researchers reported. Decedents with evidence of counterfeit pill use were younger than those without such evidence (57.1% vs 28.1% under age 35) and more were Hispanic or Latino (18.7% vs 9.4%, respectively). Additionally, a higher percentage of deaths with evidence of counterfeit pill use were in people with a history of prescription drug misuse compared with those without such evidence (27.0% vs 9.4%). Deaths involving oxycodone and alprazolam combined involved people of the youngest average age (26 years). "Counterfeit pills have been marketed toward younger persons, who might have more recently started using drugs and have lower tolerance," O'Donnell and colleagues wrote. "Younger persons might also exhibit more risk-taking behaviors than do older persons, and engage less with harm reduction services." "The higher percentage of Hispanic decedents could reflect the younger age of this population and the demographics of western states where evidence of counterfeit pill use was more common; nonetheless, it might still have implications for access to and use of prevention messaging materials and harm reduction services," they added, such as tailoring these messages and services to address potential engagement, language, or other barriers. Limitations of the study included that analyses might not be generalizable beyond jurisdictions that were included, and that documentation of counterfeit pill use is likely underestimated, the researchers noted. Furthermore, the definition for evidence of counterfeit pill use included pills found or reported to be at the overdose scene, and some overdose deaths might be included as having evidence of such use even if the decedent did not use the pills. Related Article: Substance Use Disorder Two Thirds Say They or Family Affected by Substance Use

Suicidal Behavior Patients with major depressive disorder (MDD) and suicidal behavior during the depressive period have over double the mortality rate of those without a suicide attempt, new research suggests. Investigators studied close to 143,000 patients, encompassing more than 150,000 MDD episodes. Episodes of depression with suicidal behavior (MDD-SB) were compared to MDD episodes without suicidal behavior (MDD-non-SB). Suicidal behavior was associated with a 2.6-fold higher rate of all-cause mortality, as well as considerably higher healthcare resource utilization (HCRU) and work loss, compared to matched controls. Patients with depression who had attempted suicide were younger and more commonly suffering from other psychiatric comorbidities, such as anxiety and addiction. Important risk factors for suicidal acts within a year after the onset of a depressive episode were previous suicide attempts, substance use disorder, anxiety, and sleeping disorders. "The findings tell us that the care provided for this particular group needs to be developed," lead author Johan Lundberg, MD, PhD, adjunct professor in psychiatry and senior physician in psychiatry, Karolinska Institute, Stockholm, Sweden, told Medscape Medical News. "The take-home message is that, when treating patients with increased risk of suicidal behavior, one should offer treatments with this in mind," said Lundberg, also the head of the section of mood disorders, Northern Stockholm Psychiatry Clinic. "One possible option is lithium augmentation.". Identifying Subgroups Depression is associated with increased all-cause mortality, the authors write. Suicidal behavior and previous suicide attempts are known to increase the risk of suicide-associated mortality, with up to 13% of patients with nonfatal suicide attempts dying of suicide at a later time. Previous studies investigating the association between suicidal behavior and mortality have been limited by nonrandom sampling due to "nonuniversal access to healthcare and/or exclusion of primary care data," they state. For this reason, it's not established to what extent these estimates actually represent patients with MDD as a whole, or to what extent suicidal behavior is a risk factor for all-cause mortality. "We think there is a need to identify subgroups within the very large group of individuals with MDD in order to improve treatment outcomes," Lundberg said. To do so, the researchers turned to data from the Stockholm MDD Cohort (SMC), which comprises all patients diagnosed with MDD in any healthcare setting in the regions of Stockholm from 2010 to 2018. They identified 5 years of recorded MDD episodes (n = 158,169) in patients aged 18 years and older (n = 145,577). A single patient could contribute more than 1 episode. At index, MDD-SB patients (n = 2219, mean age 41 years) were matched with MDD-non-SB patients (9574, mean age 41 years) based on age, sex, year of MDD diagnosis, and socioeconomic status. In total, 2219 episodes (63.2% in women, 36.8% in men) were compared to 11,109 episodes (63.4% in women, 36.6% in men), respectively. Enhanced Monitoring, Optimized Treatment The median time from the start of the episode until the first suicidal behavior was 165 days. The all-cause mortality rate in the MDD-SB and MDD-non-SB groups was 2.5 per 100 person-years vs 1 per 100 person-years, respectively (based on 466 deaths), corresponding to a hazard ratio of 2.62 (95% CI, 2.15 - 3.20). Patients in the MDD-SB group were younger, more frequently diagnosed while in specialized care, and had sustained more work loss than their counterparts in the MDD-non-SB group. They also showed a gradual increase in the prevalence of comorbid conditions from about 12 months before index, with this increase being "most pronounced" for anxiety, stress, substance use, and personality disorders. MDD-SB episodes were associated with higher HCRU and more work loss, compared with MDD-non-SB episodes. The researchers calculated a risk score for factors associated with suicidal behavior within 1 year after the start of an MDD episode (outcome). The two most important risk factors for suicidal behavior were a history of suicidal behavior together with age, which had a "U-shaped association" with the outcome, they write, with individuals younger than age 20 and older than age 70 having the highest risks. The final risk score included additional factors that increased the risk of the outcome (in descending order): history of substance use, history of sleep disorders, healthcare level in which MDD was diagnosed, history of antidepressant use, and history of anxiety disorders. These results "indicate that patients at risk for suicidal behavior can be identified at an early stage to allow for enhanced monitoring and optimized treatment with the goal of preventing suicidal behavior and reducing mortality," the authors state. The specific causes of death weren't analyzed in this particular paper, Lundberg noted. A previous study conducted by the same group found the risk of death was doubled in MDD patients, compared to controls. "We don't speculate about which causes other than suicide might explain the difference," and account for the increased mortality risk, he said. "This should be studied in future projects." Complicated Family of Destructive Behaviors Commenting for Medscape Medical News, Russell Copelan, MD, a former emergency department psychiatrist at the University of Colorado Affiliated Hospital and currently an expert consultant to the American Association of Suicidology, said a take-home message of the study is that suicide is "a complex and complicated family of destructive behaviors." The findings "should not suggest a wait-and-see clinical approach," warned Copelan, who wasn't involved with the study. Underrecognized or misdiagnosed anxiety, agitation, and insomnia may be "barriers to remission and treatment response," he noted. Copelan, who is also the founder and CEO of eMed Logic, which offers assessment tools for suicide and violence, encouraged clinicians "not to minimize the proportion of patients who experience anxiety, agitation, and insomnia in response to what some may consider a personal misfortune, such as interpersonal, employment, or financial crisis." 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Introduction The term self-sabotage enjoys wide usage in psychological, spiritual, and self-help circles. It is often used to explain a variety of behaviors such as addiction, compulsion, perfectionism, procrastination, and bad financial management. In this article I’ll contend that there are several problems with the notion of self-sabotage: It does not accurately describe what it’s attempting to describe. It carries with it an aura of blame and shame. It provides no explanation for why a person is behaving in a particular way and is therefore essentially useless as a concept. I’ll also lay out what I consider a more helpful way of looking at behaviors that are often described as self-sabotage, using the lens of Internal Family Systems (IFS) as a guide. A Question of Intent The first and most glaring problem with the idea of self-sabotage is that it’s not actually “sabotage.” Sabotage implies conscious intent. The Oxford Dictionary, for example, defines sabotage as follows: “to deliberately destroy, damage, or obstruct” something. Self-sabotage, then, would involve intentionally destroying or obstructing oneself, one’s relationships, one’s career, or what have you. As an example, consider someone who tries to get a new job. They apply for it, get an interview, and then proceed to botch the interview in an explicit way – perhaps by behaving bizarrely or showing up late. The theory of self-sabotage would say that this person initially thought to themselves something along the lines of “I want this job, so I’m going to apply for it and hopefully get an interview”, but then before the interview, they changed their thought to “I’m going to intentionally ruin the interview by behaving in a way that the interviewer finds unacceptable.” Needless to say, this isn’t how things usually happen. Other examples may seem to be more intentional at first glance. For example, a person commits to a diet and then a week later binge-eats ice cream and ruins all of his or her progress. It may be tempting here to conclude that the person intentionally ruined the diet, but this viewpoint conflates the intentionality of the action (eating ice cream) with the intentionality of the effect (ruining the diet). While the eating was intentional – insofar as the physical movements required to do it were under the person’s conscious control – ascribing intentionality to the effect assumes that the person ate the ice cream in order to ruin the diet. One would be hard-pressed to find a situation where this scenario was the case. This matter of intent is extremely important when determining how to treat a given behavioral pattern. Blame & Shame As a result of the fact that it implies intentionality, the term self-sabotage carries with it a connotation of blame, shame, and guilt. If people are intentionally engaging in maladaptive behaviors, it must be their own fault. Can’t he simply stop doing this? Can’t she control herself? What’s the matter with him or her? Whether or not these types of questions are communicated explicitly, they’re inherent in the very name of the diagnosis. Muddying the Waters Much like mental health diagnoses, while the term self-sabotage may appear on the surface to be helpful, it doesn’t actually explain anything. In fact, the logic of it turns out to be completely circular. For example, consider a person who is trying to get a new business off the ground, but keeps herself perpetually distracted by spending inordinate amounts of time on social media. One might say she is self-sabotaging as if this view somehow clarifies the issue, but consider the circular logic of such a claim. “Why does Helen spend hours a day on social media instead of working on her new business?” “Because she is self-sabotaging.” “How do we know she is self-sabotaging?” “Because she spends hours a day on social media instead of working on her new business.” “Why does Helen spend hours a day on social media instead of working on her new business?” What becomes clear is that the term self-sabotage is nothing more than a label that describes behavior (or behaviors). This label offers no insight into why the behaviors are occurring and is therefore unhelpful as any kind of explanation or diagnosis. Getting at Why With any kind of repetitive, maladaptive behavior, it’s critical to get to the root cause – rather than offering a surface-level description – if treatment is to succeed. The behaviors that often fall into the realm of self-sabotage are, in my view, virtually always the result of unconscious emotional processes. As such, a bottom-up therapeutic modality that works with the unconscious – such as Internal Family Systems (IFS) – offers a far more comprehensive approach to healing relative to cognitive (top-down) techniques. IFS recognizes that our minds consist of parts, rather than being a single entity. Each person’s parts interact and function in different ways depending on his or her history. We are particularly susceptible to trauma (both overt and covert) early in life, and this susceptibility causes our parts to take on two basic roles: Burdened Parts carry pain and toxic self-beliefs. Protector Parts take on protective roles aimed at preventing more pain from being inflicted on burdened parts. A practitioner of IFS takes a systems-level view of the parts to understand what the parts are doing, why they’re doing it, and how they’re interacting with each other. Only through the IFS lens can we truly get an understanding of the dynamics underlying one’s behavioral patterns. We then can work with our parts rather than against them – in a compassionate and non-confrontational way – to effect change. As parts largely operate in the unconscious, ascribing intentionality (which implies conscious awareness) to the effects of one’s actions is often inappropriate when parts are in the lead. The parts themselves are acting in intentional ways, but the person’s consciousness has no awareness of this scenario. This type of distinction is a good example of what a parts-aware approach brings to the table: a deeper understanding of the internal dynamics at play, which leads to a more informed and holistic plan of action in therapy. Going back now to the example of the person who did poorly in the job interview: If there are indications that a part (or parts) caused this to happen, in an IFS context we guide the client to form relationships with these parts and find out what their fears were about the prospect of getting the new job. This information-gathering will likely lead to other areas in the person’s life that these parts have been influencing. Once the relevant parts in the system have been identified, the process of unloading the trauma that the burdened ones are carrying can begin, at which point the protective parts won’t need to engage in defensive behaviors anymore. While this post is necessarily a brief overview of how the IFS process works, hopefully, it is helpful in providing a baseline understanding of how the IFS approach can be used to dig deeper into symptoms that might appear as self-sabotaging. Conclusion Thus, the term self-sabotage is inaccurate, unhelpful, and full of negative connotations. A deeper look into the behavioral patterns which typically fall under the self-sabotage label reveals a far more complex and subtle picture, an understanding of which is critical in order for healing to occur. Furthermore, the Internal Family Systems approach provides a far more comprehensive method for healing than cognitive (top-down) techniques.

Online Therapy Online psychotherapy has benefits that are hard to ignore. Clients who lack transportation, or those who live in underserved areas can access treatments that were not previously available. During disasters and public crises, such as the COVID-19 pandemic, treatment can be continued with minimal interruption. There’s more good news: Research seems to show that online therapy works for a broad range of problems and interventions. In many cases, internet-based treatments have outcomes comparable to in-person therapy. Although phone, chat, and email therapy have each found support, we have chosen to focus on video-based online therapy because of its prevalence, and its many similarities to in-person therapy. Because treatment is ultimately the same whether practiced online or in-person, we will focus on what’s different. Laws and Ethics There are many laws that limit how and when online therapy can be practiced. For example, if you live in the United States, you may not be permitted to provide services to a person who is in a different state. You might also find that popular video conferencing services such as Skype and FaceTime are not compliant with medical privacy laws, such as HIPAA. Because laws are location- and situation-specific, it is important to understand how they relate to your own unique situation. If you have any questions about legal or ethical issues related to online counseling, reach out to your local licensure board or an attorney who specializes in the area. During the COVID-19 pandemic, many of the usual legal requirements related to online therapy are being loosened, allowing for care to continue throughout the crisis. See the resources below for more information. Building Relationships Some critics fear that it might be difficult, or even impossible, to create an effective therapeutic relationship through the internet. They argue that limited nonverbal cues, differences in setting such as timezones or weather, and even the loss of other senses, such as smell, could have a negative impact on treatment. Although there are some unique challenges to building a working alliance online, research indicates that these relationships can be just as powerful. This can be especially beneficial for clients who have anxiety about travel, crowds, or in-person meetings, by reducing the barriers to starting a therapeutic relationship. To help build relationships online, some experts recommend having initial sessions in-person, whenever possible. If this isn’t possible, they suggest doing so early in the relationship. However, this is not always necessary to form an effective relationship. When it comes down to it, building a relationship online works much like offline. Many of the standard helping skills in a therapist’s toolbox, such as reflections, empathy, and active listening, are powerful whether or not you are behind a screen. Maintaining Focus and Commitment Getting dressed, driving to an office, and sitting face-to-face with another person helps to create a sense of commitment and convey the importance of each therapy session. It can be difficult to build a similar feeling of commitment through a device that’s more often used for social media, Netflix, and chatting with friends. Many people—clients and clinicians alike—will find that they unintentionally de-prioritize online therapy sessions. While parents might find a babysitter for in-person therapy sessions, it might not feel necessary during online therapy. Pets will beg for attention, laundry machines will rumble in the background, and phone notifications will become more difficult to ignore. To combat the mindset that online therapy requires less commitment, and to minimize distractions, set clear expectations about attention and boundaries during online therapy sessions. First and foremost, this means setting a good example. Ask yourself: Would this behavior be acceptable during in-person therapy? Dress as if you were in the office, silence your phone, place children with a caretaker, and fully commit to the therapy session. Similarly, encourage your clients to close other computer programs, close their door, and commit fully to the session. If there are distractions on your client’s side, again, ask the question: Would this be appropriate during in-person therapy? If not, it might be a good candidate for exploration. Client Privacy During in-person therapy, steps are taken by the therapist to ensure privacy. Typically, therapy offices are far from prying friends and family. During online therapy, while you are responsible for using secure technology to maintain privacy, your clients must take steps to create a sense of privacy in their chosen therapy location. If your clients fear that a family member might hear them through the door, or try to snoop on their session, they might be less likely to self-disclose. Encourage your clients to find a private location for each session. If they live with others, suggest closing the door, and using something to create noise (e.g. white noise audio found online, a loud fan). For clients who live in a smaller home, you may need to get creative. Do they have an outdoor location that’s private? Can sessions be scheduled for times when other family members will be out of the house? Can your client come to an agreement with housemates to be out of the house during the scheduled session time? If the expectation of privacy is regularly violated, it may indicate an issue related to boundaries or assertiveness. These issues can be further explored in therapy. Therapy Office Setup Whether you’re working from home or an office, create a designated therapy area that is neat and uncluttered, with a simple background. Test out the lighting to ensure the area doesn’t get too dark at night or too bright during the day. Make sure the area is quiet, with minimal background noise. To create consistency for your clients, use this same area for every session. Ensure the equipment you’re using is conducive to a good therapeutic experience. This means having a computer, microphone, and camera that allow you and your client to see and hear each other clearly. Built-in laptop webcams and microphones are often low quality, making your image blurry, and your voice distorted. This can greatly affect the ability to read non-verbal cues. Try testing with a friend or colleague to see how your image and sound come out on the other end. Take some time to figure out how you want to appear in front of the camera. How much of your body do you want visible to your clients? By sitting close to the camera, as is typical with a webcam, your face will be visible with great detail. This may allow for better reading of facial expressions. However, by sitting far from the camera, you will allow your clients to see more body language, such as crossed arms or a tapping foot. There is no “right” way to go about this, as both options have different advantages. Crisis Intervention It’s reasonable to have concerns about how to handle a crisis during online therapy. However, if the situation arises, you will take the same general steps, and use the same skills, as you would during a crisis that happens in-person. Conduct an initial assessment with each client before beginning online therapy. Be mindful that clients who are suicidal, or who have other significant risks, may need more intensive treatment than can be provided by online therapy. Before each session, make sure you know the client’s current location (e.g. their home address), along with their local emergency phone numbers. You may want to obtain information about personal emergency contacts, such as friends or family, along with a signed release for these contacts. Make sure your client has access to their local emergency numbers at all times. Technology Backup Plan Inevitably, your internet will go down. Video software will crash. Someone’s computer will break. Something will go wrong. Create a technology backup plan with your client. Have phone numbers, email addresses, or other modes of communication handy. If you and your client are in the middle of a difficult session and the connection goes bad, you’ll both be happy that a plan is in place.

As more older adults turn to cannabis to alleviate medical ailments like pain, insomnia, and anxiety, many physicians are hesitant to ask their patients about the topic or advise them about possible health impacts. The lack of questioning is concerning for both doctors and patients: while moderate use of cannabis and cannabidiol (CBD) may be safe on their own when combined with certain medications, the substance can cause serious side effects. Older adults may also be more sensitive to the drug. The problem is magnified by a sharp increase in cannabis consumption among older Americans resulting from its legalization in 38 states across the country. One study found that use of cannabis by adults 65 years and older in the United States jumped sevenfold in the past decade. In states like California, the stark increase has resulted in a 1808% jump in the rate of cannabis-related visits by seniors to the emergency room, according to a study published this past January in the Journal of the American Geriatric Society. As cannabis grows in popularity, doctors need to inform patients about the potential harms and benefits, experts said. Marijuana can have serious interactions with blood-thinning medications like warfarin, resulting in a risk for internal bleeding. Its use may also cause harmful interactions with the anti-epileptic medication clobazam (Sympazan, Onfi). Anesthesia requirements are also greater in those who regularly use cannabis; therefore, if a patient is going into surgery the doctor needs to have an accurate understanding of regular use, said Peter Grinspoon, MD, a primary care physician and instructor at Harvard Medical School in Boston. "If you don't have open communication between a doctor and patient then cannabis use can be dangerous," said Grinspoon, the author of Seeing Through the Smoke: A Cannabis Specialist Untangles the Truth About Marijuana. If doctors are aware of a patient's cannabis use, they can adjust their medications, he said. Many physicians are hesitant to advise their patients on cannabis use because they weren't taught about it in medical school, Grinspoon said. Only about 15% of US medical schools teach about medical marijuana and the endocannabinoid system, through which cannabis works in the body. Cannabinoid receptors are found throughout the body in tissue and organs, and they are most numerous in the brain. When cannabis is in the system it acts on these receptors, which then release brain chemicals that impact appetite, pain, mood, and memory. "We're doing a huge disservice to doctors by not educating them on the basics of how cannabis works," Grinspoon said. Seniors may also turn to cannabis to help with their depression and anxiety, said Thomas Kosten, MD, a professor of psychiatry at Baylor College of Medicine in Houston. The drug also can serve as an appetite stimulant in depressed patients who aren't eating well and are losing weight as a result. An April 2020 study published in the American Journal of Geriatric Psychiatry found that anxiety was among the most common reasons why older patients use cannabis and that patients found it effective for alleviating symptoms. Kosten notes that older patients may sometimes experience anxiety over concerns around aging or loneliness. Although cannabis may reduce symptoms of depression and anxiety, doctors must look below the surface at what's causing the symptoms. "Cannabis may improve your appetite but it won't necessarily make the depression that's causing it any better," Kosten said. "For that, patients may need an antidepressant." Kosten noted that older military veterans may turn to cannabis to help ease "We're doing a huge disservice to doctors by not educating them on the basics of how cannabis works," Grinspoon said. Seniors may also turn to cannabis to help with their depression and anxiety, said Thomas Kosten, MD, a professor of psychiatry at Baylor College of Medicine in Houston. The drug also can serve as an appetite stimulant in depressed patients who aren't eating well and are losing weight as a result. An April 2020 study published in the American Journal of Geriatric Psychiatry found that anxiety was among the most common reasons why older patients use cannabis and that patients found it effective for alleviating symptoms. Kosten notes that older patients may sometimes experience anxiety over concerns around aging or loneliness. Although cannabis may reduce symptoms of depression and anxiety, doctors must look below the surface at what's causing the symptoms. "Cannabis may improve your appetite but it won't necessarily make the depression that's causing it any better," Kosten said. "For that, patients may need an antidepressant." Kosten noted that older military veterans may turn to cannabis to help ease post-traumatic stress disorder (PTSD). Some evidence points to benefits of cannabis for PTSD, including a study published in the journal Psychiatry and Neuroscience in March 2019. Many patients turn to cannabis because the side effects are more tolerable than other medications, Grinspoon said. Even so, doctors need to be aware of these side effects and act accordingly. "There's no free lunch," he said. "All medications have side effects." Sara Novak is a science writer based in South Carolina who has written for a variety of publications, including WebMD, Medscape, Scientific American, and New Scientist.. Some evidence points to benefits of cannabis for PTSD, including a study published in the journal Psychiatry and Neuroscience in March 2019. Many patients turn to cannabis because the side effects are more tolerable than other medications, Grinspoon said. Even so, doctors need to be aware of these side effects and act accordingly. "There's no free lunch," he said. "All medications have side effects." Sara Novak is a science writer based in South Carolina who has written for a variety of publications, including WebMD, Medscape, Scientific American, and New Scientist. Related Article:

In this insightful interview, experts discuss the journey toward a more humanistic approach in psychiatry, the challenges of integrating biological and psychosocial aspects, and the need for comprehensive training for future psychiatrists. CLINICAL CONVERSATIONS Psychiatric Times’ Editor-in-Chief Emeritus Ronald W. Pies, MD, has never shied away from controversial topics and supporting the field of psychiatry and its practitioners. Dr Pies has consistently encouraged the consideration of the ethical, psychosocial, and humanistic aspects of psychiatry, in addition to the biological and pharmacological aspects of the field. His latest book draws from previous commentaries and columns published with Psychiatric Times to reflect on the current status of psychiatry and possible paths for the future. Howard Forman, MD: We have all heard "don't judge a book by its cover," so I want to ask you about the question chosen for the cover of your newest book, Psychiatry at the Crossroads: Can Psychiatry Find the Path to a Truly Humanistic Science? Compared to other eras, how close is our current era to psychiatry achieving this goal? Ronald W. Pies, MD: I think there is both good news and bad news in that regard. Just to put your question in historical context, US psychiatry had its heyday during the 1950s and ’60s when the psychoanalytic era was in full flower, but when biological approaches to mental illness were generally very limited or rudimentary. The 1980s and ’90s saw the great biological turn in psychiatry, which began with a great deal of promise but ended with some disappointment. That’s not to say that our biological treatments were not helpful or that we didn’t learn a great deal about the brain during that period. But despite our best efforts and intentions, the field fell short of integrating basic biological research into clinical practice—so-called translational psychiatry. For example, despite excellent research in the areas of brain imaging and neurochemistry, psychiatry never really developed office-ready biological tests for the major mental illness categories, though we have a few promising contenders. Furthermore, during the so-called Decade of the Brain (ca. 1990-1999), I think psychiatry lost much of its historical connection to psychosocial factors in mental illness and to the rich tradition of psychotherapy. Ever since then, I think the profession has continued to pivot toward mainly biological approaches and treatments, somewhat to the detriment of a full, humanistic understanding of psychiatric illnesses and their treatment. I say this as someone who more or less paid the rent doing psychopharmacology consultation for more than 25 years, and who firmly believes in the benefits of psychiatric medication and somatic treatments. But, during my 40 years in psychiatry, I have always advocated a biopsychosocial approach to psychiatric illness. In fact, my 1994 book Clinical Manual of Psychiatric Diagnosis and Treatment was subtitled, A Biopsychosocial Approach. Psychiatry—to the extent that we can generalize about such a diverse field—now has a golden opportunity to integrate biological with psychosocial knowledge into a single, humanistic science. Now back to your question and to the good and bad news. I think psychiatry—to the extent that we can generalize about such a diverse field—now has a golden opportunity to integrate biological with psychosocial knowledge into a single, humanistic science. We know that a purely biological or purely psychosocial approach to the most serious psychiatric disorders is far from adequate. So, we really must find a way to put it all together. At the same time, market pressures and the general derogation of psychiatric expertise—we are now mere providers—are powerful forces working against us. US psychiatrists are still doing psychotherapy, but substantially less often than in the 1970s and 1980s, and this has played into the hands of third-party payers who want us merely to “write scripts.” I think we, as a profession, need to find the will and the way to resist this kind of pressure. If we do so, we have a shot at becoming a truly humanistic science. Forman: When I attended the 2023 American Psychiatric Association Annual Meeting in San Francisco, I was struck by the contrasting large banners celebrating the success of psychiatry amid a city whose streets are filled with homeless individuals, many of whom are in the throes of active illness. Where has psychiatry failed these individuals? Where has society failed in allowing psychiatry to help? Pies: You are highlighting one of the great tragedies of our American health care system, which is really no system at all! In the US, medical care in general—and psychiatric care in particular—is like a big, tattered patchwork of poorly-integrated, regional fiefdoms. This is especially the case when we look at dual diagnosis treatment, and I would wager that many of the homeless folks you saw on the streets of San Francisco fall into the category of comorbid psychiatric/substance abuse disorders. As our colleague, Allen Frances MD, once commented in Psychiatric Times:1 It is heartbreaking to me that 600,000 of our most severely ill patients are either in jail or homeless and that we have done so little to advocate for the community mental health centers and affordable housing that would have freed them from confinement and ended the shameless neglect. But, I think there is plenty of blame to go around. Society—as represented by our national and state legislatures—never built or financed the kind of community support system needed to deal with the thousands of seriously ill, deinstitutionalized patients with psychiatric disorders who were essentially put out on the streets, during the period of roughly 1955-1980. As a 2007 Kaiser Commission noted:2 Not until 1993 were more state-controlled mental health dollars allocated to community care than to the state institutions… [and] policy in large federal programs was not controlled by those responsible for mental health care… Forman: You have a quote by William Alwyn Lishman, MD, FRCP, FRCPsych (Hon) – PMC: "All psychiatrists should be all types of psychiatrist." Do you see a loss in the movement away from the general psychiatrist to the highly subspecialized psychiatrist? Pies: Yes, indeed I do. I’m glad you cited Dr Lishman’s comment. His classic work, Organic Psychiatry: The Psychological Consequences of Cerebral Disorder (1987) was a very important resource for me over the course of my career. Despite the term organic in the title of his book, the late professor believed that psychiatrists need to take a diversified, pluralistic, biopsychosocial approach to their work, and I certainly agree. I think it’s worth sharing the entire quote you reference:3 You have got to have a finger in every pie in psychiatry, and be ready to turn your hand to whatever is the most important avenue: an EEG one day, a bit of talking about a dream another day. You just follow your nose. All psychiatrists should be all types of psychiatrist. Forman: When I worked for economists, they would joke, "the field of economics advances one funeral at a time." Although I hope psychiatrists will continue to learn and adapt throughout their careers, certainly residency training provides the largest pool of impressionable future psychiatrists. If given the power, what would you change about the training of psychiatrists today? Pies: I doubt this idea will be popular with many residents, but I would like to see psychiatric residency become a 5-year program. After all, surgical residency can last 5 years or more, and we need to know at least as much as surgeons. I would like to see an expansion and deepening of both the neurology and psychotherapy components of residency training, because I see these as being of equal importance. I would like to see our residents become Renaissance clinicians, with a working knowledge of the social, cultural, and spiritual aspects of psychiatric diagnosis and treatment. And, as if I haven’t heaped on enough, I believe our residents need a strong background in the philosophy of psychiatry, as my colleagues Awais Aftab, MD, and Nassir Ghaemi, MD, MPH, have elucidated so well.4 Forman: Where do you see this most recent book fitting into your larger collection of books, which so many of us have enjoyed. Although you indicate it is a sequel of sorts to Psychiatry on the Edge, where do you place it in the larger context of your written works? Pies: Thanks for asking. In a sense, I think Psychiatry at the Crossroads is of a piece with my other writing, in that it contains everything from hard science (for example, articles on serotonin and antidepressants) to psychiatric ethics to philosophical/spiritual pieces,and even to some poetry and fiction. I want to give an appreciative nod to my colleagues who contributed to these features of the book: Cindy Geppert, MD, PhD, MA, MPH, MSBE, DPS, MSJ, Mark S. Komrad, MD, Annette Hanson, MD, Steve Moffic, MD, Alan Blotcky, PhD, James L. Knoll IV, MD, David Osser, MD, Joe Pierre, MD, George Dawson, MD, and Richard Berlin, MD. I also want to tip my hat to Mark L. Ruffalo, MSW, DPsa, for his kind reading of the book. All of which brings to mind the quip by one of my mentors in residency, the late Bob Daly, MD, who used to say, “With psychiatry, you can do biology in the morning and theology in the afternoon!” Indeed, I have found to my deep satisfaction that this is so. Dr Forman is director of the Addiction Consultation Service at Montefiore and assistant professor in the department of psychiatry and behavioral sciences at Albert Einstein College of Medicine. He serves as Psychiatric Times Book Review Editor. Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Professor Emeritus of Psychiatry, Tufts University School of Medicine; and Editor in Chief Emeritus of Psychiatric Times (2007-2010). Dr Pies is the author of several books, including, most recently, the novelette, The Unmoved Mover.