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Keypoint: The behavioral and psychological symptoms of dementia contribute significantly to the greater rates morbidity and mortality among those with dementia. The term behavioral and psychological symptoms of dementia (BPSD) describes a constellation of symptoms and behaviors that occur in >90% of individuals with dementia. Apathy is the most common BPSD seen among individuals with Alzheimer disease (AD) , whereas depression is the most common BPSD observed among individuals with vascular dementia (VD). Anxiety is the most common BPSD noted in individuals with dementia with Lewy bodies (DLB), and agitation and aggression are the most common BPSD identified among individuals with frontotemporal dementia (FTD). BPSD is associated with a faster decline in cognition and function among individuals with dementia. This decline often results in the placement of those with dementia in care facilities. Additionally, BPSD contributes directly and indirectly to one-third of the cost of caring for individuals with dementia because of the greater utilization of health resources and services. Furthermore, BPSD adds significantly to increased distress and depression among caregivers of individuals with dementia . Finally, BPSD contributes significantly to the greater rates morbidity and mortality among those with dementia. Available evidence indicates efficacy for both nonpharmacological and pharmacological treatments for BPSD. The use of pharmacotherapy is usually reserved for those who have not responded adequately to nonpharmacological treatments. Nonpharmacological interventions are the recommended first line treatment recommended for BPSD. Evidence for Nonpharmacological Interventions One meta-analysis by Brodaty and Arasartnam found that interventions like skills training for caregivers, education of caregivers, activity planning and environmental design, enhancing support for caregivers, self-care technique for caregivers, and collaborative care not only reduced the frequency and severity of BPSD (effect size=0.34, P<0.01), but also reduced the caregiver burden (effect size=0.15, P=0.006). Another meta-analysis found that a multidisciplinary care [standardized mean difference (SMD)=-0.5], massage and touch therapy (SMD=-0.75) and music combined with massage and touch therapy (SMD=-0.91) were found to be more efficacious than usual care for the management of agitation and aggression among those with dementia. A third meta-analysis found benefits for massage therapy (SMD=−0.77), animal-assisted intervention (SMD=−0.47), personally tailored intervention (SMD = −0.39), pet robot intervention (SMD=−0.38), massage therapy (SMD=−5.220), light therapy (SMD=−5.25), music therapy (SMD=−3.61), reminiscence therapy (SMD=−4.59), animal-assisted intervention (SMD=−3.14) and personally tailored intervention (SMD=−2.98) for the management of agitation in dementia when compared to the control group. A fourth meta-analysis found that interventions that are tailored to involve activities based on the abilities and interests of individual with BPSD, and education and support that is offered to meet the needs of caregivers are more effective in reducing symptoms of BPSD, when compared with standardized intervention (SMD = -0.24, P=0.04). Pharmacological Interventions Data from the meta-analysis by Trinh et al indicated that individuals with BPSD who received acetylcholinesterase inhibitors did better on the Neuropsychiatric Inventory (NPI) scale by 1.72 points, when compared with individuals who received receiving placebo indicating a small, but statistically significant benefit. Another meta-analysis found that individuals with BPSD who received memantine did better by 1.99 points on the NPI scale, when compared with people receiving placebo (P=0.04). A meta-analysis by Seitz et al found that individuals with BPSD who received sertraline and fluoxetine did better than those individuals who received placebo on the Cohen Mansfield Agitation Inventory [CMAI (mean difference (MD)=-0.89, P<0.001]. A meta-analysis by Bhaji et al indicated benefits for cannabinoids on the CMAI (SMD=−0.80), the NPI total score (SMD=−0.61), the neuropsychiatric inventory-nursing home (NPI-NH)-Agitation/Aggression sub-score (SMD=−0.61), and on nocturnal motor activity (SMD=−1.05) among individuals with BPSD. A meta-analysis by Vacas et alfound benefits for rTMS, among individuals with BPSD (overall effect=−0.58, P=0.01). The Role of Antipsychotics Yunusa et al in their meta-analysis found benefits for aripiprazole among individuals BPSD, when compared with placebo on the NPI (SMD=−0.17), the BPRS (SMD= −0.20), and on the CMAI (SMD=−0.30). The investigators also found benefits for quetiapine on the BPRS (SMD=−0.24) and risperidone on the CMAI (SMD=−0.26), when compared with placebo. In this meta-analysis, the investigators did not find a greater risk of death with any of the antipsychotics compared with placebo. They noted a greater risk for cerebrovascular events (CVAEs) with olanzapine [odds ratio (OR)=4.28] and risperidone (OR=3.85) compared with placebo. Risperidone (OR=2.23) was noted to produce greater risk of extrapyramidal symptoms (EPS) compared with placebo. Somnolence was greater for aripiprazole (OR=3.14), olanzapine (OR=4.08), quetiapine (OR=4.47), and risperidone (OR=2.57), when compared with placebo. Quetiapine (OR=2.11) was associated with increased urinary incontinence or urinary tract infections compared with placebo. Yunusa et al found that when compared with placebo, aripiprazole (SMD=− 0.12) and olanzapine (SMD=−0.17) demonstrated small although nonsignificant numerical improvements in NPI-NH psychosis scores, whereas quetiapine (SMD=0.04) did not show any benefits among individuals with dementia related psychosis. The investigators found that the odds of mortality were higher for aripiprazole (OR=1.58), brexpiprazole (OR=2.22), olanzapine (OR=2.21), quetiapine (OR=1.68), and risperidone (OR=1.63), when compared with placebo. The investigators also noted that the use of risperidone (OR=3.68) and olanzapine (OR=4.47) increased the odds of CVAEs compared with placebo. The odds of all-cause discontinuation were lower for aripiprazole (OR=0.71), but higher for brexpiprazole (OR=1.17), olanzapine (OR=1.14), and quetiapine (OR=1.01). Aripiprazole (OR=0.5) and olanzapine (OR=0.48) had lower odds of discontinuation due to lack of efficacy, when compared with placebo. The odds of discontinuation due to adverse effects were higher for olanzapine (OR=2.62), brexpiprazole (OR=1.80), quetiapine (OR=1.25), aripiprazole (OR=1.38) and risperidone (OR=1.41). The US Food and Drug Administration (FDA) has a boxed warning for increased risk of death for both atypical and typical antipsychotic medications when they are used among older individuals with dementia. Note: This article originally appeared on Psychiatric Times .

Key points: Accurate diagnosis of borderline and bipolar conditions is essential. Borderline personality disorder is marked by primitive defenses and interpersonal hypersensitivity. Mood shifts in borderline personality are reactive; in bipolar disorder, they’re cyclical. How do we distinguish between bipolar mood disorder, cyclothymic temperament, and borderline personality disorder? This may be among the most important questions in clinical psychiatry and psychotherapy. The ability to accurately distinguish between these conditions frequently leads to treatment success; misdiagnosis can result in major failures. For instance, bipolar disorder is often well-treated with medication. Lithium therapy can lead to remission of symptoms and prevention of future episodes in appropriately selected patients (Ghaemi, 2024). In contrast, medication does not treat the core symptoms of borderline personality disorder. Misdiagnosis of borderline personality disorder as a mood disorder often results in multiple failed medication trials and prolonged suffering and impairment. Much diagnostic confusion results from significant symptomatic overlap, particularly in the area of mood symptomatology. Below are two fundamental features of borderline personality disorder that are not present in bipolar spectrum disorders. I teach psychiatry residents to use these pointers to help differentiate the two forms of psychopathology. They are: 1. Borderline personality disorder is marked by a reliance on primitive defense mechanisms: splitting, projection, and projective identification (Kernberg, 1975). These defenses pervade the lives of borderline patients. For instance, splitting refers to the tendency to see self and others as being either "all good" or "all bad," with an inability to see things in "shades of gray." This symptom is captured by DSM-5 criteria for borderline personality disorder ("…alternating between extremes of idealization and devaluation") (American Psychiatric Association, 2013). We do not see this as a prominent symptom in bipolar disorders. 2. Borderline personality disorder is marked by the patient's fundamental interpersonal hypersensitivity (Gunderson & Lyons-Ruth, 2008). Symptoms of borderline personality disorder are mediated by the patient's subjective experience of the major object (sometimes referred to as the patient's "favorite person"). This was Gunderson's (1984) seminal contribution to understanding borderline psychopathology. He wrote, for instance, that "these characteristic disturbances in interpersonal relations uniformly provide the most distinguishing aspect of the borderline syndrome vis-à-vis a variety of other diagnoses" (Gunderson, 1984). Contrary to Linehan's (1993) claim that emotional dysregulation represents the "core" of borderline personality disorder, mood problems in borderline patients are actually secondary to interpersonal hypersensitivity, which is the "engine" that drives all borderline symptoms. Patients with borderline personality disorder are prone to abandonment depression, which Masterson (2000) saw as the primary affective state in the borderline personality. For instance, a person with borderline personality disorder may experience feelings of depression, emptiness, and suicidal despair in response to a minor or imagined distancing by their romantic partner. These symptoms can easily be misdiagnosed as a major mood disorder. Mood symptoms are actually a very poor discriminating feature, and this is the source of much confusion, misdiagnosis, and mistreatment (Ghaemi, 2014). Both borderline personality disorder and bipolar spectrum disorders can present with intense affective shifts, but in borderline patients, these shifts are reactive to interpersonal events rather than driven by endogenous mood cycling. In addition, individuals with cyclothymic temperament exhibit chronic, low-grade mood instability that fluctuates independently of relational dynamics and lacks the identity diffusion, primitive defenses, and object-related dysregulation characteristic of borderline personality disorder. The differential diagnosis of these problems becomes much easier if one keeps these two points in mind. To find a therapist, visit the Psychology Today Therapy Directory .

The secretary of the Department of Health and Human Services (HHS) is charged with overseeing the department’s mission: “to enhance the health and well-being of all Americans by providing for effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, public health, and social services.” Sworn in as HHS secretary on February 13, how well is Robert F. Kennedy Jr upholding this mission? An environmental lawyer, Kennedy has no background in healthcare administration or research, which has become common among those appointed to the role. Over the last 30 years, only one person with an educational or professional background in healthcare administration has held the position. As secretary, Kennedy has taken on chronic disease and autism awareness as his primary health concerns. He is also focusing on food and water safety as part of the government’s Make America Healthy Again initiative. He has encouraged avoiding seed oils in favor of animal fats like beef tallow, suggested removing fluoride from water supplies, and developed policy to eliminate petroleum-based artificial foods dyes from the nation’s food supply. But will these methods make America healthy again? Seed Oils or Beef Tallow? As a sustainability lover, I appreciate the videos on social media where homesteaders boil down beef bones for tallow and bone broth. I keep a bag of veggie scraps in my freezer so I can throw them in a pot with my rotisserie chicken bones for bone broth. Do I think it’s the magical healing potion that some influencers suggest? No. But, it’s a nice way to use up my scraps while I get a tasty, protein-rich broth for my next pot of soup. However, Kennedy’s argument for beef tallow isn’t in the name of sustainability. It’s in the name of health. He argues that seed oils are pro-inflammatory but doesn’t elaborate. I am left to assume he is referring to the pro-inflammatory process that may develop when omega-6 fatty acids, found in large quantities in seed oils, grossly outweigh omega-3 fatty acids in the diet. If this is the case, the obvious solution is to recommend increasing intake of omega-3 fatty acids from fatty fish, mussels, walnuts, flax seed, algae oil, and soybeans. Instead, Kennedy decided to promote beef tallow as an appropriate substitute for seed oils. Beef tallow is about 50% saturated fat. The United State Department of Agriculture’s Dietary Guidelines for Americans recommend that saturated fat intake be kept below 10% of total calorie intake, and the American Heart Association recommends that saturated fat be kept below 6% of total calorie intake to promote cardiovascular health. A medium order of Steak ‘n Shake french fries cooked in beef tallow contains 11 g of saturated fat, or 5% of the average American’s total calorie intake in saturated fat alone. If the fries are the side for another food high in saturated fat, like a cheeseburger or chicken tenders, that dinner has likely already exceeded the daily recommended total intake of saturated fat before they’ve left the table. That doesn’t include a milkshake. Is there some ongoing research that suggests saturated fat may not be the villain that noted physiologist Ancel Keys, PhD, thought it was? Sure. But, until we have adequate research to support such a theory, trading canola oil for beef tallow isn’t going to make American healthier. Fluoridation May Cause Neurological Problems? One of Kennedy’s claims about fluoridated water is it increases the risk for attention deficit/hyperactivity disorder and neurological injuries. Some studies indicate a correlation between early exposure to fluoridated water and ADHD, and a recent cohort study conducted in Los Angeles, California, suggested a link between using fluoridated water for drinking and food preparation while pregnant and development of neurodivergent behavior in toddlers. The study included pregnant women who were predominantly Hispanic and of low socioeconomic status and found that those with elevated urinary fluoride metabolites had children more likely to develop neuroatypical behaviors at or before their third birthday. The researchers noted that many study participants reported regularly cooking dishes like rice at home, which may increase fluoride intake from tap water used in cooking. Most municipal water in the United States is fortified with fluoride, a practice that began in the 1940s to combat dental cavities. Now, most toothpaste is fluoridated, and 65.9% of American adults and 86.9% of children aged 2-17 years have regular access to a dentist for dental cleanings that can hinder the development of cavities. However, 34.1% of American adults remain without regular dental care. Utah and Florida have already passed legislation to remove fluoride from tap water and other states are sure to follow. The government of Calgary, Canada, ceased water fluoridation in 2011 and is currently in the process of refortifying the water supply due to a significant spike in dental caries among children in the years following. Would it be prudent for the administration to simply recommend decreasing recommended fluoride levels in tap water while further research is conducted? Sure. But, that line of thought suggests that funds will be available in the coming years for such research. A recent analysis published in JAMA found that more than $1.2 billion in research grants disbursed by the National Institutes of Health (NIH) were cancelled between February 28, 2025 and April 8, 2025, and the proposed 2026 budget would slash the total budget of the NIH to 56% of its 2025 budget. These proposed cuts are almost certain to handicap future research on everything from fortification of our water and food supply to neurobehavioral disorders. In the meantime, it may be wise for those of us working with patients to take extra steps to promote oral hygiene, connect patients with dental care resources, and to recommend high fluoride foods like potatoes, grapes, raisins, and canned shrimp and/or crab, or to consider fluoride supplements, especially in children. Artificial Dyes Cause Behavioral Problems? Kennedy’s most recent target has been petroleum-based artificial food dyes based on concern that they promote behavioral problems in children. The research is mixed. But of all the items on Kennedy’s agenda, this is the one I am least concerned about. Artificial food dyes have no nutritional value or any known benefits. If there is even a chance that they could be harming Americans, we should work to get them out of the food supply. It won’t hurt us if our sugar-laden breakfast cereals are a slightly duller shade of red, green, or purple. I would argue that limiting artificial dyes in the food supply may encourage manufacturers to use natural dyes that could provide health benefits like beet juice, turmeric, or chlorophyll. This is a non-issue in my eyes. Will We Make America Healthy Again? America has a diet problem. As a dietitian, I appreciate that Secretary Kennedy is promoting health and wellness. But, swapping out beef tallow for seed oils isn’t the answer to the obesity epidemic. Autism spectrum disorder (ASD) affects about 1 in 31 children in the United States, and I’m pleased that the Secretary is so driven to find the cause. But I don’t think that handicapping our research institutions and limiting fluoridation or artificial dyes will get us any closer to discovering what causes ASD. I fear that the Secretary’s agenda is overly focused on sowing mistrust in traditional healthcare, while inadequately focused on the health and wellness of the Americans that the DHHS is charged with caring for. It remains to be seen less than 100 days into his tenure whether his agenda will “enhance the health and well-being of all Americans,” but I can already see that he is not interested in “fostering sound, sustained advances in the sciences,” and that alone frightens me. Note: This article originally appeared on Medscape .

Keypoint: A study assessed the associations between the use of ADHD medications and CVD over the course of 14 years. Here's what the investigators found. Recent decades have seen increased medication use for attention-deficit/hyperactivity disorder (ADHD), including both stimulants and nonstimulants. However, long-term effects of ADHD medications on the cardiovascular system are not fully understood. There is limited evidence on whether long-term use is associated with an increased risk of cardiovascular disease (CVD), with most prior studies having an average follow-up time of no more than 2 years. This study used the nationwide health registers in Sweden to assess the associations between the use of ADHD medications and CVD over the course of 14 years. The Study Zhang L, Li L, Andell P, et al. Attention-deficit/hyperactivity disorder medications and long-term risk of cardiovascular diseases . JAMA Psychiatry. 2024;81(2):178-187. Study Funding L. Zhang: Grants from Swedish Research Council for Health, Working Life, and Welfare H. Larsson: European Union’s Horizon 2020 research and innovation program under grant agreement Study Objectives To assess the association between long-term use of ADHD medication and the risk of CVD. Methodology This was a population-based case-control study looking at all individuals in Sweden aged 6 to 64 years who either had an incident diagnosis of ADHD or had been prescribed ADHD medication between January 1, 2007 and December 31, 2020. Excluded from the study were patients with a previous CVD diagnosis, those who used ADHD medication for other indications, and those who had emigrated or died before the baseline. In this study, the investigators defined baseline (cohort entry) as the date of incident ADHD diagnosis or ADHD medication dispensation, whichever event came earlier. Patient demographics including diagnosis, medication dispensation history, socioeconomic factors, and death information were obtained from multiple Swedish nationwide registries: the Swedish National Inpatient Register, the Swedish Prescribed Drug Register, the Longitudinal Integrated Database for Health Insurance and Labor Market Studies, and the National Cause of Death Register. CVD diagnosis was defined by the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) and included ischemic heart diseases, cerebrovascular diseases, hypertension, heart failure, arrhythmias, thromboembolic disease, arterial disease, and other forms of heart disease. Each patient case—that is, a patient with ADHD who received a CVD diagnosis after initiation of ADHD medication was matched with up to 5 controls who did not receive a CVD diagnosis. Patient cases and controls were matched based on age, sex, and calendar time to ensure similar lengths of follow-up. Each patient was followed for up to 14 years. The primary exposure was cumulative duration of ADHD medication use, and the primary outcome was incident CVD. Conditional logistic regression analyses were used to estimate odds ratios for the associations between cumulative durations of ADHD medication use and incident CVD. The crude odds ratios were adjusted for all matching variables, which included age, sex, and calendar time. The adjusted odds ratios (AORs) were additionally controlled for country of birth (Sweden vs another country), highest educational level, and diagnoses of somatic and psychiatric comorbidities before baseline. Study Results The study’s treatment effect showed that longer use of ADHD medications was associated with increased CVD risk compared with nonuse (1 to ≤ 2 years: AOR, 1.09 [95% CI, 1.01-1.18]; 2 to ≤ 3 years: AOR, 1.15 [95% CI, 1.05-1.25]; 3 to ≤ 5 years: AOR, 1.27 [95% CI, 1.17-1.39]; and > 5 years: AOR, 1.23 [95% CI, 1.12-1.36]). Specifically, there was a significant association of long-term ADHD medication use with hypertension (AOR, 1.72 [95% CI, 1.51-1.97] for 3 to ≤ 5 years) and arterial disease (AOR, 1.65 [95% CI, 1.11-2.45] for 3 to ≤ 5 years). There were no statistically significant associations for arrhythmias, heart failure, ischemic heart disease, thromboembolic disease, or cerebrovascular disease. Throughout the study’s follow-up, each 1-year increase in the use of ADHD medications correlated with a 4% increased association of CVD (95% CI, 1.03-1.05) and an 8% increased association in the first 3 years (95% CI, 1.04-1.11). There was a rapid increase in association for the first 3 cumulative years, but the association stabilized thereafter. The association between CVD and ADHD medications increased with higher average defined daily doses (DDDs; eg, 30 mg methylphenidate or 80 mg atomoxetine), with a statistically significant risk found only among individuals with a mean dose of at least 1.5 times the DDD. Researchers found a 4% increased risk for individuals receiving 1.5 to 2 times the DDD, whereas they found a 5% increased risk for individuals receiving more than 2 times the DDD. Looking at specific classes of ADHD medications , atomoxetine’s association with CVD was significant only for the first year of use, with an AOR of 1.07 (95% CI, 1.01-1.13). For methylphenidate use vs no use, the AOR was 1.20 (95% CI, 1.10-1.31) for 3 to 5 or fewer years. For greater than 5 years, the AOR was 1.19 (95% CI, 1.08-1.31). The data for lisdexamfetamine use vs no use showed an AOR of 1.23 (95% CI, 1.05-1.44) for 2 to 3 or fewer years. Across groups, researchers observed similar associations in females and males. Conclusions The results of this population-based case control study suggest that long-term ADHD medication use was associated with an increased risk of CVD, specifically hypertension and arterial diseases. The observed risk of CVD was greater when stimulant medications were used in comparison with nonstimulant medications to treat ADHD. There was also a significant association between the cumulative duration of ADHD medication use and increased risk of CVD. Practical Applications Long-term use of ADHD medications is associated with CVD. It is important to weigh the risks and benefits of this treatment modality with every patient. It is also important to closely monitor patients for the signs and symptoms of CVD in those who are taking these medications. Bottom Line This nested case-control study followed patients for 14 years and found that long-term ADHD medication use was associated with CVD, specifically hypertension and arterial diseases. Note: This article originally appeared on Psychiatric Times

Tris Pharma Inc has announced a licensing agreement with Braingaze Ltd and the establishment of Tris Digital Health. Tris Digital Health will concentrate on developing and distributing digital diagnostic and therapeutic products for the treatment of attention-deficit/hyperactivity disorder (ADHD) and other neurological health disorders. Under the agreement, Tris Pharma—a biopharmaceutical company specializing in ADHD, pain, addiction, and neurological disorders—has gained exclusive rights to develop and market a digital diagnostic platform for ADHD in the United States and Canada by Braingaze, a digital health firm focusing on technology-driven solutions for cognitive disorders. According to Tris Pharma, the launch of Tris Digital Health and the licensing of Braingaze’s platform are to meet an unmet need for more objective diagnostic tools for ADHD . “Patients, caregivers, and physicians deserve better tools to support accurate ADHD diagnosis beyond the currently available options,” said Ketan Mehta, founder and CEO at Tris Pharma, in a press release. “We have launched Tris Digital Health to deliver on our long-term commitment to advance meaningful and beneficial health care for physicians, ADHD patients, and caregivers. We are delighted to partner with Braingaze to launch this important endeavor and look forward to offering practitioners in the United States and Canada the opportunity to use and evaluate the benefits of this digital ADHD diagnostic platform.” Braingaze's digital diagnostic tool for ADHD, which utilizes artificial intelligence and digital biomarkers, facilitates ADHD diagnosis in both children and adults by employing a computerized game and patented eye-tracking technology to assess attention levels. The results provide clinicians with probability and severity scores for individual patients with ADHD. “Tris analyzed multiple investigational ADHD digital diagnostic technologies and concluded that the Braingaze test substantially outperforms other tools designed to provide objective ADHD assessment and diagnosis,” said James Hackworth, brand division president at Tris Pharma, in a press release. “We look forward to validating this technology in US patients, with the goal of providing patients, their caregivers, and health care providers greater confidence in ADHD diagnoses to support improved outcomes.” The technology has already obtained the European CE Mark as a medical device and will undergo clinical trials in the United States under the guidance of the US Food and Drug Administration (FDA) to validate its efficacy for clinical use in North America. “We’ve received enthusiastic feedback from European physicians who tell us that our novel diagnostic test is an improvement over subjective tools they relied on until now,” said Laszlo Bax, CEO and co-founder of Braingaze, in a press release. “We are thrilled to partner with Tris, another leader in the ADHD space who has an exceptional track record with 4 commercialized medications, to extend the reach of our ADHD diagnostic solutions to patients who might benefit from it in the United States and Canada.” An estimated 129 million children and adolescents worldwide have ADHD. Here are some recent expert updates and discussions on ADHD as seen in Psychiatric Times®

TOPLINE: Combining transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) was associated with a greater reduction in symptoms of major depressive disorder (MDD) than either treatment alone, a new study showed. METHODOLOGY: Researchers conducted a double-blind, sham-controlled randomized clinical trial from 2021 to 2023 at three hospitals in China with 240 participants with MDD (mean age, 32.5 years; 58% women). Participants received active tDCS + active rTMS, sham tDCS + active rTMS, active tDCS + sham rTMS, or sham tDCS + sham rTMS with treatments administered five times per week for 2 weeks. tDCS was administered in 20-minute sessions using a 2-mA direct current stimulator, whereas rTMS involved 1600 pulses of 10-Hz stimulation targeting the left dorsolateral prefrontal cortex. Sham treatments used a pseudostimulation coil and only emitted sound. The primary outcome was change in the 24-item Hamilton Depression Rating Scale (HDRS-24) total score from baseline to week 2. Secondary outcomes included HDRS-24 total score change at week 4, remission rate (HDRS-24 total score ≤ 9), response rate (≥ 50% reduction in HDRS-24 total score), and adverse events. TAKEAWAY: The active tDCS + active rTMS group demonstrated the greatest reduction in mean HDRS-24 score (18.33 ± 5.39) at week 2 compared with sham tDCS + active rTMS, active tDCS + sham rTMS, and sham tDCS + sham rTMS (P < .001). Response rates at week 2 were notably higher in the active tDCS + active rTMS group (85%) than in the active tDCS + sham rTMS (30%) and sham tDCS + sham rTMS groups (32%). The remission rate at week 4 reached 83% in the active tDCS + active rTMS group, which was significantly higher than the remission rates with the other interventions (P < .001). The treatments were well tolerated, with no serious adverse events, seizures, or manic symptoms reported across all intervention groups. IN PRACTICE: This trial “was the first to evaluate the safety, feasibility, and efficacy of combining tDCS and rTMS in treating depression. Future studies should focus on investigating the mechanism of this synergistic effect and improving the stimulation parameters to optimize the therapeutic effect,” the investigators wrote. SOURCE: This study was led by Dongsheng Zhou, MD, Ningbo Kangning Hospital, Ningbo, China. It was published online on November 13 in JAMA Network Open. LIMITATIONS: The brief treatment duration involving 10 sessions may have been insufficient for tDCS and rTMS to demonstrate their full antidepressant potential. The inability to regulate participants’ antidepressant medications throughout the study period presented another limitation. Additionally, the lack of stratified randomization and adjustment for center effects may have introduced variability in the results. DISCLOSURES: This study received support from multiple grants, including from the Natural Science Foundation of Zhejiang Province, Basic Public Welfare Research Project of Zhejiang Province, Ningbo Medical and Health Brand Discipline, Ningbo Clinical Medical Research Centre for Mental Health, Ningbo Top Medical and Health Research Program, and the Zhejiang Medical and Health Science and Technology Plan Project. The authors reported no conflicts of interest. Note: This article originally appeared on Medscape .

Keypoint: Elevated levels of high-density lipoprotein may be protective against psychiatric disorder risk. Carbohydrate and lipid metabolism may play a role in the development of depression, anxiety, and stress-related disorders, according to study results published in JAMA Network Open . Depression, anxiety, and stress-related disorders are highly prevalent mental health issues and have been commonly associated with cardiometabolic dysfunction. However, research on the relationship between glucose or lipid biomarkers and these disorders has yielded inconsistent results and the directionality of this association remains unclear. To this aim, investigators conducted a longitudinal population-based cohort study to assess how carbohydrate, lipid, and apolipoprotein metabolism may affect the risk of developing depression, anxiety, and stress-related disorders. Investigators used data collected in Sweden between January 1, 1985, and December 31, 1996, from the Apolipoprotein-Related Mortality Risk (AMORIS) cohort. The investigators identified participants aged 16 years and older who underwent routine health screenings in an occupational setting, had no psychiatric disorders at baseline, and had at least 1 biomarker measured during the recruitment period. The primary outcomes of interest were incident cases of depression, anxiety, or stress disorders – confirmed via International Classification of Diseases codes – following enrollment in the AMORIS study. The investigators assessed 211,200 participants and matched each case with up to 10 controls based on birth year, sex, and enrollment year. On average, participants were 42.1 (SD, 12.6) years of age at first biomarker measurement and 42% of individuals were women. Over a 21-year follow-up, 16,256 people were diagnosed with depression, anxiety, or stress-related disorders, for an incidence rate of 36.4 per 10,000 person-years. The investigators found that psychiatric disorder risk was higher among those with elevated glucose (hazard ratio [HR], 1.30; 95% CI, 1.20-1.41) and triglyceride levels (HR, 1.15; 95% CI, 1.10-1.20). Conversely, elevated levels of high-density lipoprotein lowered psychiatric disorder risk (HR, 0.88; 95% CI, 0.80-0.97). These results did not differ significantly between men and women and remained robust in sensitivity analyses. These findings indicate that individuals diagnosed with depression, anxiety, or stress-related disorders exhibited elevated levels of glucose, triglycerides, and total cholesterol up to 20 years before their diagnosis. “These results add further evidence of the association between cardiometabolic health and psychiatric disorders and potentially advocate for a closer follow-up of individuals with metabolic dysregulations for prevention and early diagnosis of psychiatric disorders,” the investigators concluded. Study limitations include potential biases due to recruitment through employment-related health screenings, which may restrict the generalizability of findings beyond the study population. Note: This article originally appeared on Psychiatry Advisor

A psychosocial intervention designed to improve depressive symptoms and promote good parenting skills can be an effective way of treating male postpartum depression, according to new research. In a study conducted in Pakistan, about 70% fathers with postpartum depression who received the intervention showed complete remission of their depressive symptoms and experienced enhanced relationships with their children and domestic partners. Called Learning Through Play Plus Dads (LTP + Dads), the intervention, which can be delivered by community health workers, could improve paternal mental health and child development not only in Pakistan but also in other populations, the authors stated. The results of the study were published on October 2 in JAMA Psychiatry . Stigmatized and Understudied "Pakistan is a patriarchal society with strict gender roles, and male mental health, particularly postpartum depression in new fathers, is stigmatized and understudied," lead investigator Ishrat Husain, MD, a senior scientist at the Centre for Addiction and Mental Health and associate professor of psychiatry at the University of Toronto, Toronto, Ontario, Canada, told Medscape Medical News. "Historically, and rightly so, the focus has always been on the mother, but men also experience significant emotional challenges as they adapt to being a parent. Fathers are also in need of support," said Husain. Male postpartum depression is prevalent in all populations. Globally, about 10% fathers have postpartum depression. But in societies like Pakistan, rates of male postpartum depression have been reported to be as high as 23.5%. The study included 357 fathers aged 18 years or older (mean age, 31.44 years) with a Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition, diagnosis of major depressive episode and a child younger than 30 months. They were randomly assigned either to receive treatment as usual (n = 186) or to participate in the LTP + Dads program (n = 171). LTP + Dads is a parenting and mental health initiative adapted from a similar program for Pakistani mothers. It combines parenting skills training, play therapy, and cognitive behavioral therapy. In this study, the initiative was delivered by community health workers in 12 group sessions over 4 months. Sessions took place weekly for the first 2 months and biweekly thereafter. The researchers assessed changes in the 17-item Hamilton Depression Rating Scale (HDRS-17) score at 4 months and at 6 months. They also looked at anxiety symptoms; parenting stress; intimate partner violence; functioning; quality of life; and child social, emotional, and physical health outcomes. Improved Child Development There were significantly greater reductions in HDRS-17 scores in the LTP + Dads group than in the treatment as usual group at 4 months (group difference ratio [GDR], 0.66; P < .001) and at 6 months (GDR, 0.67; P < .001). Similar results were seen for anxiety (GDR, 0.62; P < .001), parenting stress (GDR, −12.5; P < .001), intimate partner violence (GDR, 0.89; P = .05), disability (GDR, 0.77; P = .03), and health-related quality of life (GDR, 12.7; P < .001) at 4 months. The differences in depression and parenting stress were sustained at 6 months. In addition, children of fathers who received the parenting intervention showed significantly greater improvements in social-emotional development scores (mean difference, −20.8; P < .001) at 6 months than children of those who received the treatment as usual. "We believe that this program could also be successful in other countries, including Canada," said Husain. "Canada is multicultural, and similar patterns of male postpartum depression probably exist here. We know that cultural and social pressures create barriers to seeking mental health support for men. Stigma and cultural beliefs often prevent new fathers from seeking the help they need. Programs like LTP + Dads can help men transition to their new role as fathers by giving them support to process their emotions," he said. Husain added that the program will be expanded throughout Pakistan to include about 4000 fathers and their partners. 'Remarkable' Success Rate "Postpartum depression in men is still something that people are trying to understand," John Ogrodniczuk, MD, professor of psychiatry and director of the psychotherapy program at The University of British Columbia in Vancouver, British Columbia, Canada, told Medscape Medical News. He did not participate in the study. "Understandably, most of the literature is around postpartum depression in women, not so much around men. The positive results seen here are interesting, especially in a country that is patriarchal and where there is not a lot of uptake of mental health interventions and services by men," he said. "The success rate of this psychosocial intervention is remarkable, so I am excited to see that the researchers have secured funding to expand the study and validate their results with a larger group of participants," Simon B. Sherry, PhD, professor of psychology and neuroscience at Dalhousie University in Halifax, Nova Scotia, Canada, told Medscape Medical News . "I am also encouraged by the inclusion of play-based activities in addition to cognitive behavioral therapy. Perhaps more than any other role we hold through life, the role of parent comes with copious societal and personal expectations, plus with all that pressure, transitioning into that role is hard for everyone, but especially for those with postpartum depression. Supporting parents and improving their mental well-being goes a long way toward raising mentally healthy kids," said Sherry, who was not part of the study. The study was funded by a grant from Grand Challenges Canada, an Academic Scholars Award from the Department of Psychiatry at the University of Toronto, and a Tier 2 Canada Research Chair from the Canadian Institutes of Health Research. Husain reported receiving grants from COMPASS Pathfinder, stock options from Mindset Pharma, and personal fees from Wake Network, outside the submitted work. He previously served as a trustee for the Pakistan Institute of Living and Learning. Ogrodniczuk and Sherry reported no relevant financial relationships. Note: This article originally appeared on Medscape .

Keypoint: Young people with ADHD experience higher levels of loneliness, which in turn contribute to worse mental health outcomes. Young people with attention-deficit/hyperactivity disorder (ADHD) experience higher levels of loneliness than their peers without ADHD, according to results from a systematic review and meta-analysis published in the Journal of Attention Disorders. These higher levels of loneliness are associated with additional mental health difficulties, emphasizing the need for early interventions in this population. Although individuals with ADHD often experience social difficulties, relatively little is known about the prevalence of loneliness — the subjective experience of perceived social isolation — among young people with ADHD. Because both ADHD and loneliness are separately associated with adverse mental health outcomes, understanding the prevalence and effect of this comorbidity may help researchers and providers develop mental health interventions for individuals with ADHD. To this aim, investigators conducted a systematic review and meta-analysis to determine the 1) prevalence of loneliness among young people (10 to 24 years of age) with and without ADHD and 2) how loneliness affects mental health in individuals with ADHD. The investigators searched publication databases for cross-sectional or longitudinal quantitative studies that evaluated at least 1 measure of loneliness among young people with ADHD. Participants’ ADHD was verified via Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses, International Classification of Disease (ICD) codes, or symptomatic presentation. A total of 20 studies were included, 17 of which included a comparison group in addition to individuals with ADHD. Additionally, 8 studies evaluated mental health difficulties associated with loneliness among young people with ADHD. The pooled sample size was 1253 for participants with ADHD and 5028 for the non-ADHD comparator cohort. The ADHD cohort primarily comprised boys/men while the non-ADHD cohort had more girls/women. The investigators observed that 9 out of the 17 studies found higher levels of loneliness in the ADHD group, while 4 showed no notable differences, 3 did not conduct significance tests, and 1 indicated lower loneliness levels in the ADHD group during adolescence compared to childhood. The meta-analysis results confirmed that younger people with ADHD reported significantly higher levels of loneliness (Hedges g, 0.41; 95% CI, 0.25, 0.58; P <.001) relative to individuals without ADHD. Despite concerns about potential publication bias, moderator analyses indicated no significant influence on the effect size. In the systematic review exploring the association between loneliness and mental health difficulties in young individuals with ADHD, the investigators found significant positive associations between loneliness and externalizing behavior, internalizing behaviors, depression, anxiety, and addiction among individuals with ADHD. Loneliness fully mediated the association between depression and ADHD symptoms , and a diagnosis of ADHD diagnosis was a significant predictor for major depressive disorder onset, even after controlling for confounders. Additionally, social anxiety and internet addiction were correlated with loneliness in young individuals with ADHD. Authors concluded, “This review highlights that loneliness may be an important problem in ADHD and clinicians should be aware of and assess the potential for elevated loneliness in this population.” The investigators noted, “A better understanding of the experience of loneliness in young people with ADHD, including what contributes to their loneliness, may aid in developing loneliness interventions targeted for this population.” Study limitations include a small number of studies, the narrow focus on loneliness, and the use of a dichotomous categorization of ADHD (which may have excluded less severe presentations of ADHD). Note: This article originally appeared on Psychiatry Advisor

Key Point: Almost a quarter of persons with bipolar disorder have a very good outcome. Bipolar I and bipolar II disorder occur in about 2% of the population. About 44% of people with bipolar disorder experience symptom remission; 23% achieve complete mental health. Outcomes should improve when current treatments reach more people and as new treatments become available. Bipolar disorder can be a devastating and disabling psychiatric illness that often begins in young people and then runs an episodic clinical course. Do individuals with bipolar disorder get better? What does "getting better" mean? These questions are addressed in a study recently published in the Journal of Affective Disorders Reports by Melanie Katz, Ishnaa Gulati, and Esme Fuller-Thomson. Individuals with bipolar disorder have “severe mood disturbances and significant shifts in energy, activity levels, quality of life, and the ability to carry out daily tasks, with recurrent episodes of mania and depression.” Those with bipolar I disorder experience more severe and disruptive highs and lows than those with bipolar II disorder. The combined prevalence of bipolar I and bipolar II disorder is about 2 percent of the general population. Katz and colleagues analyzed data from the 2012 Canadian Community Health Survey-Mental Health, a representative sample of over 25,000 individuals. After excluding participants with incomplete data, there were 555 adults (20 years old and above) who reported that they had been diagnosed with either bipolar I or bipolar II disorder during their lifetimes. The authors examined three outcome measures: 1) absence of bipolar disorder during the previous year; 2) absence of bipolar disorder and absence of depressive episodes, anxiety disorders, alcohol or drug dependence, and suicidal ideation during the previous year; 3) complete mental health, which they defined as the absence of psychiatric disorders during the previous year, emotional well-being (high level of happiness or life satisfaction), and social and psychological well-being. Well-being was ascertained by responses on a survey instrument. Characteristics of the Samples The mean age of the 555 people with a lifetime history of bipolar disorder was lower than the group without a history of bipolar disorder (40.3 years vs. 48.0 years). More participants with a history of bipolar disorder had experienced adverse childhood events such as exposure to chronic parental domestic violence, sexual abuse, or physical abuse (56 percent vs. 29 percent). Certain psychiatric conditions were more common in those with a history of bipolar disorder, for example, a lifetime history of generalized anxiety disorder (45 percent vs. 8 percent) and a lifetime history of drug and/or alcohol use disorder (52 percent vs. 21.5 percent). Outcomes About 44 percent of those with a prior history of bipolar disorder no longer had enough symptoms to qualify for a current (preceding year) diagnosis of bipolar disorder. Furthermore, about 34 percent of those with a prior history of bipolar disorder were free of both bipolar disorder and other psychiatric disorders in the preceding year. In comparison, 93 percent of the group without a history of bipolar disorder were free of psychiatric disorders during the previous year. About 23 percent of the individuals with a lifetime diagnosis of bipolar disorder fulfilled the criteria for complete mental health. This compares to 74 percent of the sample without bipolar disorder. Factors that were associated with achieving complete mental health by those with a history of bipolar disorder included “older age, higher household income, being married, having a confidant, utilizing religion or spirituality for coping, and being free from substance abuse or dependence and debilitating chronic pain.” What This Means Bipolar disorder can severely disrupt an individual’s life. Suicide attempts and completed suicides are unfortunately common in those with bipolar disorder. However, as demonstrated by this study, many individuals improve with a combination of appropriate somatic and psychologic therapies. This study reveals that over the course of at least a year, about a quarter of individuals do well in terms of symptom remission, decreases in comorbid psychopathology, and emotional, social, and psychological well-being. Although 23 percent is far less than the 74 percent of those without bipolar disorder who do well, these data demonstrate the very real possibility that individuals can achieve favorable outcomes despite having a diagnosis of bipolar disorder. However, given the episodic course of bipolar illness, more systematic data about longer-term outcomes with these types of analyses are needed. Improved implementation of current treatments, more research to develop new treatments, improved efforts to treat co-morbid alcohol and substance use problems, societal efforts to decrease early childhood trauma, and decreasing stigma and discrimination directed against those with bipolar disorder should all help improve outcomes for people with this serious mental illness. Note: This article originally appeared on Psychology Today .

Key Takeaways 6% of US adults have a current ADHD diagnosis; 8% report past or present diagnosis. Medication shortages impact 70% of adults receiving stimulant pharmacotherapy for ADHD. Over 50% of adults with ADHD were diagnosed in adulthood, with gender discrepancies in diagnosis age. Telehealth enabled 46% of adults with ADHD to receive care during the COVID-19 pandemic. Upcoming APSARD guidelines aim to standardize adult ADHD care in the US, improving patient outcomes. The US Centers for Disease Control and Prevention (CDC) today released new data that highlight issues around attention-deficit/hyperactivity disorder (ADHD) in adults. The October 10, 2024, Morbidity and Mortality Weekly Report (MMWR) provides crucial updates on the burden of adult ADHD, sharing information specifically on prevalence, treatment barriers, and telehealth . Using the National Center for Health Statistics Rapid Survey System (RSS) data collected from October through November 2023, investigators found that 6% of US adults had a current diagnosis of ADHD, with 8% of US adults reporting a past or present diagnosis. About 7 in 10 of those receiving stimulant pharmacotherapy reported trouble obtaining their ADHD medication due to a shortage. The RSS also reports that more than 50% of adults with ADHD were diagnosed in adulthood, with larger discrepancies for woman than men; 45% of men and 25% of women were diagnosed before 11 years of age, whereas 40% of men and 61% of women were diagnosed in adulthood. On the positive side, telehealth during the COVID-19 pandemic allowed a total of 46% of adults with a current ADHD diagnosis to receive care. According to Gregory Mattingly, MD, and Ann Childress, MD, these data demonstrate the need for the upcoming American Professional Society of ADHD and Related Disorders’ (APSARD) Adult ADHD Guidelines. A set of guidelines would help improve patient outcomes by standardizing care among all mental health clinicians who see adult patients with ADHD . “These will be the first US guidelines for the diagnosis and treatment of adults with ADHD and will provide a valuable framework of treatment for clinicians and families. While many unanswered questions remain, these findings bring us one step closer to a deeper understanding of the needs of adults with ADHD,” wrote Mattingly and Childress. “The CDC shakes up things we have taught for years,” Mattingly told Psychiatric Times in an exclusive video. Back in January 2024, Psychiatric Times spoke with David W. Goodman, MD, an adult psychiatrist, assistant professor in the department of psychiatry and behavioral sciences at Johns Hopkins Hospital School of Medicine, and a clinical associate professor at the State University of New York. Goodman hosted a town hall discussion of the adult ADHD guidelines at the APSARD 2024 Conference. “We don't have guidelines for adults with ADHD, like we do for children and adolescents. Now there are international guidelines developed in Canada, Europe, South Africa, Australia, and the UK. We've been slow in the United States to address this because it is an arduous and scientific endeavor that requires a number of experts,” Goodman shared. “We're looking to standardize the care of patients with ADHD in adults in the United States. We want clinicians to come up to speed with the clinical practice guidelines and clinical practice of taking care of patients. It also affects patients and their family and the general public. It is giving a baseline guide of what is to be expected when you are diagnosed and treated.” The guidelines will be available in late 2024 or early 2025.

CAUTIONARY TALES: MISUNDERSTANDING AND MISAPPLICATIONS OF RESILIENCE This second of 5 articles addresses the kinds of therapeutic support needed to foster genuine resilience, the pressures (psychodynamic and economic/institutional) that impede the provision of such support, and the inadequate treatment offered in its place. Resilience Real and Factitious Resilience training is best informed by an understanding of how resilience naturally develops. For example, Abenes1 sees resilience as a buffer of mental fortitude that develops over time and can be modeled and nurtured by parents and other primary caregivers. With children and adolescents who are susceptible to psychiatric illnesses (70% of which manifest by the age of 24 years), an environment of safety, maintenance of healthy routines, and emotional regulation on the part of parents can help children regulate their own emotions. Resilience training in psychiatry, such as the program presented by “health experts” from Benson-Henry Institute for Mind-Body Medicine in 20222 and a lecture series offered by Massachusetts General Hospital,3 has the best chance of success when a therapeutic alliance has been established. Without the attachment and trust formed through a supportive alliance, the patient may not be able to release their defenses and incorporate the resilience-promoting factors that contribute to developing a robust and flexible capacity to maintain emotional stability during and after trauma. This restabilizing response can be understood as positive resilience, to distinguish it from a toxic form of resilience in which an individual recovers from trauma, but reactivates in the direction of a vengeful, hostile, and/or destructive (to themselves or others) goal.4 In clinical settings, patients who do not experience secure attachment and trust during what purports to be resilience training are at risk for developing a feigned or pseudo-resilience. That is, they decide to appear as if they have experienced a positive, resilience-promoting process or what they have been taught to manifest as recovery from psychiatric symptoms. They are observed to be no longer isolating or avoiding contact, but instead engaging well socially, expressing positive affect, eating well, sleeping well (by self-report), denying nightmares or suicidal or homicidal ideation, and engaging in creative activities. They essentially appear as if they have recovered fully and “bounced back” from the trauma or symptoms that led to their seeking or being referred for treatment, whether inpatient, residential, or outpatient. Appearances to the contrary, patients who are experiencing significant psychiatric symptoms usually do not develop the ability to return to the challenges of their lives, unmediated by structured treatment, after a few days of instruction in “cognitive reappraisal.” One of the most deceptive qualities that can underlie or support a superficial, misleading presentation of resilience is stoicism, which has been defined as a form of emotional and behavioral control that reflects an indifference to the vicissitudes of fortune and to pleasure or pain. Such a presentation can easily be mistaken for resilient qualities such as “grit and toughness” (as described in the previous article’s references to Tang et al). Although the concern for one’s appearance, reputation, or image that characterizes stoicism bears an external resemblance to resilience, it can mask what amounts to an unexploded emotional grenade. Sadly, inexperienced clinicians and trainees often have difficulty distinguishing the constricted affect of the stoic from the balanced affect of a genuinely resilient person. Lessons From Clinical Experience Given the complexities inherent in the development and manifestation of resilience, clinicians should be cautious in responding to a patient’s apparent resilience. As analyzed by Simon and Gutheil, a number of factors complicate an accurate assessment of the ongoing status of a patient undergoing psychiatric treatment after an attempted suicide or serious suicidal ideation . Patients who present as cognitively reconstituted still need to be assessed for disordered affective states that can impair their capacity for decision making and self-care. A patient who presents as ready for discharge may simply want to be free from the hospital, may wish to restart drugs, may have decided on a plan to complete suicide after discharge, or may believe mistakenly that he or she has truly improved as a result of the activating effects of medication, the supportive milieu, group therapy, improved sleep, or a “flight into health” (involving denial of ongoing symptoms). A stoic demeanor can contribute to such a misleading presentation. Moreover, some clinicians may avoid difficult questions or explorations because of cultural taboos or unexamined problematic feelings (their own or the patient’s) about suicide. This problem can result from the clinician’s subconscious or conscious discomfort in dealing with the issue of suicide or, not infrequently, from an unfounded concern that raising the issue of suicide with the patient will cause the patient to think more about committing suicide and then act on those thoughts. Such concerns add to pressures, including that created by the utilization review process,7-10 complicating staff reactions to patient presentations. These pressures have brought about a recent national movement among physicians to unionize out of concern that they cannot give their patients proper care in corporate environments (including hospitals, health insurers, and private equity) that now employ more than three-fourths of physicians in the United States.11-12 These pressures, both internal and external, may exert at least a subconscious influence on how staff focus on and process a patient’s presentation. Clinicians who feel pressure to view the patient's appearance, behavior, and interactions as positively as possible may overlook or minimize signs of ongoing illness or emotional instability. They may fail to ask directly about suicidality, fail to question the patient’s self-report of sudden improvement and denial of suicidal ideation, fail to seek communication with the patient’s collateral contacts to take into account relevant family dynamics and interpersonal interactions, or fail to share pertinent concerns. Instead, a misperception spreads among staff and clinicians that the patient’s apparent rapid recovery will be “durable enough to sustain the patient’s safety after discharge.” Meanwhile, the patient may be providing clues which, in the past, experienced clinicians usually have observed and reported, such as poor appetite, continued disheveled appearance, an absence of consistent social interaction with staff or peers, or an inability to trust, attach to, or develop a therapeutic alliance with clinicians. Other warning signs include possible delusions or self-dialoging and inconsistent compliance with medications (including possible “cheeking” of pills). Particularly concerning is the patient’s refusal to allow clinicians to speak with family or other collateral contacts, since “approximately 25% of patients at risk for suicide deny having suicidal ideation to their clinicians but do admit it to their families.” As pressure from the utilization review process grows, clinicians may not ask as often as they should whether the patient is having thoughts about self-harm or suicide. Thus, when the insurance reviewer asks whether the patient has expressed suicidal concerns, the clinician is able to say “no” because the question was not addressed recently, allowing the clinician, perhaps unconsciously, to collude with utilization reviewers and perhaps the patient in a contagion of “magical thinking” in which the patient is misperceived as significantly improved and “resilient.” As it becomes more and more challenging to resist the pressures for a shorter inpatient stay, it is all the more important for clinicians to examine possible urges, both external and internal, to perceive the patient as resilient in response to pressures from the patient, insurance companies, or the administration. As noted by Rufino, et al,14 citing a study by Appleby, et al, “the majority of deaths by suicide post discharge happened within the first week, with most suicides occurring the day after discharge: 186 of those suicides occurred before the initial follow-up appointment. In a comparable study, Bickley, et al, identified risk and protective factors for suicide among 100 psychiatric patients who died within 2 weeks post-discharge. Of these patients, 55% had died by suicide within the first week after discharge and 49% died before their first follow-up appointment.” As we continue to learn what factors can support and what factors can undermine resilience in all its complexity, we must remain alert to the risk of perceiving resilience that may in fact be either fragile or entirely absent, a misperception that can impede proper clinical care. Note: This article originally appeared on Psychiatric Times .