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Keys Findings In 2021, people aged 18–24 were most likely to use e-cigarettes among all adults. The percentage of adults who were current e-cigarette users varied by race and Hispanic origin. The percentage of adults who used e-cigarettes generally decreased as family income increased. Adults aged 18–24 and 25–44 were more likely to be dual users of e-cigarettes and cigarettes compared with adults aged 45 and over. Summary Definitions Data source and methods About the authors References Suggested citation Electronic Cigarette Use of electronic cigarettes (e-cigarettes) has increased among some adults (1–3). Reducing the use of any tobacco product, including e-cigarettes, is a Healthy People 2030 objective (4). E-cigarettes have the potential to benefit some adults who smoke and are not pregnant if they are used as a complete substitute for regular cigarettes or other tobacco products (5). However, concerns exist about dual use of e-cigarettes and cigarettes (6–9). Use of e-cigarettes among young adults is also a concern because nicotine adversely impacts brain development, which continues into the early to mid-20s (5,10). This report uses 2021 National Health Interview Survey data to describe the percentage of adults aged 18 and over who currently use e-cigarettes by selected sociodemographic characteristics and dual use of e-cigarettes and cigarettes. Keywords: smoking, tobacco, vaping, race and Hispanic origin, National Health Interview Survey In 2021, people aged 18–24 were most likely to use e-cigarettes among all adults. Among adults aged 18 and over, 4.5% were current e-cigarette users, and use was higher among men (5.1%) compared with women (4.0%) (Figure 1). Current e-cigarette use was highest among adults aged 18–24 (11.0%). The observed difference between men (11.6%) and women (10.3%) was not statistically significant. Among adults aged 25–44, current e-cigarette use was higher among men (7.9%) compared with women (5.1%). E-cigarette use was lowest among adults 45 and over, and use was similar for men (1.9%) and women (2.0%). Current e-cigarette use decreased with increasing age for both men and women. Figure 1. Percentage of adults aged 18 and over who currently use e-cigarettes, by age group and sex: United States, 2021. 1Significantly different from women (p < 0.05). NOTES: Men, women, and total men and women had a significant linear trend by age (p < 0.05). Current e-cigarette use was based on responses of “every day” or “some days” to the question, “Do you now use e-cigarettes or other electronic vaping products every day, some days, or not at all?” This question was asked of adults who had ever tried an e-cigarette, even one time. Estimates are based on household interviews of a sample of the U.S. civilian noninstitutionalized population. The percentage of adults who were current e-cigarette users varied by race and Hispanic origin. White non-Hispanic (subsequently, White) adults were more likely to be current e-cigarette users (5.2%) than Asian non-Hispanic (subsequently, Asian; 2.9%), Black or African American non-Hispanic (subsequently, Black; 2.4%), and Hispanic or Latino (3.3%) adults (Figure 2). Current use of e-cigarettes was highest among White adults compared with the other race and Hispanic-origin groups for all adults and for age groups 25–44 (7.9%), and 45 and over (2.3%). Among adults aged 18–24, e-cigarette use for White adults was higher than for Black and Hispanic or Latino adults. For Asian, Hispanic or Latino, and White adults, use of e-cigarettes declined with age. Among Black adults aged 45 and over, the percentage currently using e-cigarettes (1.4%) was lower than among those aged 25–44 (3.9%) but did not differ significantly from adults aged 18–24 (2.4%). Figure 2. Percentage of adults aged 18 and over who currently use e-cigarettes, by age group and race and Hispanic origin: United States, 2021 *Percentage does not meet National Center for Health Statistics standards of reliability: confidence interval width is greater than 5 and relative confidence interval is greater than 130% (actual value confidence interval width = 15 and relative confidence interval width = 175.4%). 1Significant linear trend by age (p < 0.05). 2Significant quadratic trend by age (p < 0.05). 3People of Hispanic origin may be of any race. 4Significantly different from White, non-Hispanic adults (p < 0.05). 5Significantly different from Hispanic or Latino adults (p < 0.05). NOTES: Current e-cigarette use was based on responses of “every day” or “some days” to the question, “Do you now use e-cigarettes or other electronic vaping products every day, some days, or not at all?” asked of adults who had ever tried an e-cigarette, even one time. Estimates are based on household interviews of a sample of the U.S. civilian noninstitutionalized population. SOURCE: National Center for Health Statistics, National Health Interview Survey, 2021. The percentage of adults who used e-cigarettes generally decreased as family income increased. Among adults aged 18 and over, those with family incomes of less than 200% federal poverty level (FPL) (5.8%) were more likely to be e-cigarette users than those with family incomes 200% to less than 400% of FPL (4.8%) and those with family incomes of 400% FPL or more (3.6%) (Figure 3). Among adults aged 18–24, the observed difference in e-cigarette use among those with family incomes of less than 200% FPL (12.5%) compared with those with higher family incomes was not significant. Among adults aged 25–44, use decreased with increasing family income (from 8.1% to 5.2%), while use was similar by family income among adults aged 45 and over. At each level of family income, current use of e-cigarettes declined with age. Figure 3. Percentage of adults aged 18 and over who currently use e-cigarettes, by age group and family income as a percentage of the federal poverty level: United States, 2021 1Significantly different from 200% to less than 400% FPL (p < 0.05). 2Significantly different from 400% FPL or more (p < 0.05). 3Significant linear trend by family income as a percentage of FPL (p < 0.05). NOTES: Each family income group had a significant linear trend by age (p < 0.05). FPL is federal poverty level, which is based on a ratio of the family’s income in the previous calendar year to the appropriate poverty threshold defined by the U.S. Census Bureau. Current e-cigarette use was based on responses of “every day” or “some days” to the question, “Do you now use e-cigarettes or other electronic vaping products every day, some days, or not at all?” This question was asked of adults who had ever tried an e-cigarette, even one time. Estimates are based on household interviews of a sample of the U.S. civilian noninstitutionalized population. SOURCE: National Center for Health Statistics, National Health Interview Survey, 2021. Adults aged 18–24 and 25–44 were more likely to be dual users of e-cigarettes and cigarettes compared with adults aged 45 and over. Among all adults aged 18 and over, 1.3% both smoked cigarettes and used e-cigarettes; 10.2% smoked cigarettes only and 3.2% used e-cigarettes only (Figure 4). Among adults aged 18–24, use of e-cigarettes only (9.2%) was higher compared with cigarette smoking only (3.6%) or use of both cigarettes and e-cigarettes (1.8%). Among adults aged 25–44 and 45 and over, use of cigarettes only was highest (10.6% and 11.4%, respectively) compared with e-cigarette use only or both. Adults aged 18–24 were less likely than adults aged 25 and over to smoke cigarettes only but were more likely to use e-cigarettes only. Use of both e-cigarettes and cigarettes was similar for adults aged 18–24 and 25–44 and higher for both groups compared with adults aged 45 and over (0.8%). Figure 4. Percentage of adults aged 18 and over who currently smoke cigarettes and use e-cigarettes, by age group: United States, 2021 1Significant quadratic trend by age (p < 0.05). 2Significant linear trend by age (p < 0.05). 3Significantly different from e-cigarettes only (p < 0.05). 4Significantly different from both cigarettes and e-cigarettes (p < 0.05). 5Significantly different from adults aged 25–44 (p < 0.05). 6Significantly different from adults aged 45 and over (p < 0.05). NOTES: Current e-cigarette use was based on responses of “every day” or “some days” to the question, “Do you now use e-cigarettes or other electronic vaping products every day, some days, or not at all?” This question was asked of adults who had ever tried an e-cigarette, even one time. Adults were asked if they had smoked at least 100 cigarettes in their lifetime and, if yes, whether they currently smoked cigarettes every day, some days, or not at all. Those who smoked every day or some days were classified as current cigarette smokers. The sum of e-cigarettes only and both cigarettes and e-cigarettes may not equal total e-cigarette use due to rounding. Estimates are based on household interviews of a sample of the U.S. civilian noninstitutionalized population. SOURCE: National Center for Health Statistics, National Health Interview Survey, 2021. Summary In 2021, 4.5% of adults aged 18 and over were current e-cigarette users, with people aged 18–24 having the highest levels (11.0%) compared with those aged 25–44 (6.5%) and 45 and over (2.0%). Men had higher percentages of e-cigarette use overall and among adults aged 25–44. E-cigarette use among those aged 18 and over was highest among White adults and those living in families with the lowest level of family income. Differences in current e-cigarette use by family income level among adults aged 18–24 and 45 and over, however, were not significant. Dual use of tobacco products is a health concern because it may result in greater exposure to toxins and worse respiratory outcomes than using either product alone (6–9). In 2021, most e-cigarette users aged 18–24 had never smoked cigarettes (11). Despite this, the percentage of adults aged 18–24 who were dual users of e-cigarettes and cigarettes was similar to the percentage among adults aged 25–44 (1.8% compared with 2.0%). Adults aged 45 and over had the lowest levels of e-cigarette only use (1.1%) and dual use of e-cigarettes and cigarettes (0.8%). Definitions Cigarette smoking status: Adults were asked if they had smoked at least 100 cigarettes in their lifetime and, if yes, whether they currently smoked cigarettes every day, some days, or not at all. Those who smoked every day or some days were classified as current cigarette smokers. Currently use e-cigarettes: Based on a response of “every day” or “some days” to the question, “Do you now use e-cigarettes or other electronic vaping products every day, some days, or not at all?” The question was asked of adults who had ever tried an e-cigarette, even one time. Dual use of tobacco products: Refers to the use of e-cigarettes, smokeless tobacco, or other tobacco products in addition to regular cigarettes, usually in an attempt to cut back on smoking cigarettes (6). In this report, dual use considers regular cigarettes and e-cigarettes only. Family income as a percentage of FPL: Based on FPL, which was calculated from the family’s income in the previous calendar year and family size using the U.S. Census Bureau’s poverty thresholds (12). Family income was imputed when missing (13). Race and Hispanic origin: Adults were categorized as White non-Hispanic, Black or African American non-Hispanic, or Asian non-Hispanic when indicating one race only. Any non-Hispanic or Latino adults indicating multiple or other races are not shown distinctly but are included in the total. Hispanic or Latino respondents can be of any race or combination of races. Estimates for non-Hispanic adults of other races and other single and multiple races are not shown. Data source and methods The National Health Interview Survey is a nationally representative household survey of the civilian noninstitutionalized population. It is conducted continuously throughout the year by the National Center for Health Statistics. Interviews are typically conducted in respondents’ homes, but follow-ups to complete interviews may be conducted over the telephone. Because of the COVID-19 pandemic, interviewing procedures were disrupted, and during 2021, 62.8% of Sample Adult interviews were conducted at least partially by telephone (14). For more information about the survey, visit https://www.cdc.gov/nchs/nhis.htm. Point estimates and corresponding variances for this analysis were calculated using SAS-callable SUDAAN software version 11.0 (15) to account for the complex sample design of the survey. All estimates are based on self-report and meet National Center for Health Statistics data presentation standards for proportions (16). Differences between percentages were evaluated using two-sided significance tests at the 0.05 level. Linear and quadratic trends by age group and family income were evaluated using orthogonal polynomials in logistic regression. About the authors Ellen A. Kramarow and Nazik Elgaddal are with the National Center for Health Statistics, Division of Analysis and Epidemiology.

Vitamin D supplementation is not an aid alone or in combination. HealthDay News — The combination of aerobic and resistance exercises with computerized cognitive training may improve cognition in older adults with mild cognitive impairment (MCI), according to a study published online July 20 in JAMA Network Open. Manuel Montero-Odasso, M.D., Ph.D., from the Gait and Brain Lab at the Parkwood Institute in London, Ontario, Canada, and colleagues assessed whether aerobic-resistance exercises, computerized cognitive training, and vitamin D supplementation can enhance cognition among 175 older adults (aged 65 to 84 years) with MCI. Researchers found that at 6 months, all active intervention arms with aerobic-resistance exercise, regardless of the addition of cognitive training or vitamin D, significantly improved the Alzheimer Disease Assessment Scale Cognitive 13 (ADAS-Cog-13) score vs control (mean difference, −1.79 points). Exercise and cognitive training significantly improved the ADAS-Cog-13 score compared with exercise alone (mean difference, −1.45 points). There was no significant improvement seen with vitamin D supplementation. “In this clinical trial, older adults with MCI receiving aerobic-resistance exercises with sequential computerized cognitive training significantly improved cognition, although some results were inconsistent. Vitamin D supplementation had no effect,” the authors write. “Our findings suggest that this multidomain intervention may improve cognition and potentially delay dementia onset in MCI.” One author disclosed ties to the pharmaceutical industry.

This book asks us to reexamine anxiety… Life Enhancing Anxiety: Key to a Sane World by Kirk J. Schneider In Life-Enhancing Anxiety, Kirk J. Schneider, PhD—a prominent psychologist and a leading spokesperson for contemporary existential-humanistic psychology—seeks to overturn our collective understanding of anxiety. According to Schneider, even though the contemporary world is overwhelmed with negative affect, we do not need less anxiety; we need more anxiety of a certain variety in order to live our best lives. The particular kind of anxiety we need is termed as life-enhancing anxiety, and is contrasted with its opposite, life-destroying anxiety. “What specifically do I mean by life-enhancing anxiety? I mean anxiety that enables us to live with and make the best of the depth and mystery of existence,” Schneider writes. Through a compilation of both original and previously published essays, the book examines this proposal and explores how anxiety is necessary for us to achieve a state of passionate engagement, ethical attunement, and creative enrichment. Schneider’s understanding of anxiety is in stark contrast to our contemporary attitudes. Instead of relying on the default strategy of avoiding and suppressing anxiety, Schneider makes the case that life-enhancing anxiety is a vital catalyst for embracing the profound depths and mysteries of existence. Our relationship with anxiety stands in for something deeper and existential. Are we willing to immerse ourselves fully in the challenges and uncertainties of life to discover the sense of awe that fuels creativity? Throughout the book, Schneider elaborates on this idea, showing its relevance to clinical work, arts and humanities, spirituality and religion, and societal and political challenges. Schneider sees himself as working within the existential tradition and frequently acknowledges his intellectual debt to Rollo May and his classic 1950 work, The Meaning of Anxiety. In many ways, Schneider is trying to do what May did for his generation. May offered a distinction between anxiety characterized by neurotic distortion of reality and anxiety that allows for creative transformation of reality, and this distinction is also at the heart of Schneider’s book. Existential freedom and anxiety are unavoidably and inseparably linked. One cannot exist without the other. The life-enhancing character of anxiety is not something fixed or inbuilt; it emerges from a particular process of engagement. Schneider explains: “… the state of arousal generated by experiences of difference. We call that arousal anxiety, and anxiety can only become “life-enhancing” if we can bolster our ability to assimilate and accommodate it.” Life-enhancing anxiety, therefore, is not something to be passively discovered, either in our ordinary lives or in the clinic, but something to be actively created. Schneider is careful to acknowledge that anxiety as a clinical problem is not a trifling matter. It is often debilitating, paralyzing, and requires treatment. He also does not dismiss the value of medications or psychological interventions such as cognitive behavioral therapy, and views them as essential clinical tools to be utilized appropriately. Schneider’s fundamental goal is that he does not want us to understand anxiety as a phenomenon restricted to the single dimension of discomfort and pathology. Schneider wants us to approach anxiety—even in anxiety disorders—as multidimensional, as possessing elements of excitement and wonder which need to be recovered even as we seek to alleviate it. Perhaps the most memorable sections of the book are those where Schneider shares his personal experience with anxiety and how his anxiety was transformed during the course of psychotherapy. Schneider’s struggles began after the traumatic loss of his younger brother at the age of 2 and a half. This led his family to take him for therapy with a child psychoanalyst when he was 6 years old. Subsequently at age 22, Schneider experienced a frightening encounter with anxiety that threatened to shake his very grip on reality: “I recall some terrifying moments. For many days and weeks, I was beset by panic and anxiety. It seemed as if the slightest association to feeling helpless or being far from home and my girlfriend, or thinking I might be psychotic would set off a racing heart, physical shaking, and relentless feelings of doom. I also experienced perceptual distortions. For example, I would watch one of my professors speak but only hear every individual word he was saying, not the gist or basic idea he was conveying. This started to happen with other professors and even students, which gave me a growing sense of unraveling that just added to my anguish. Thus was my initiation into the throes of panic and anxiety. I could easily have been diagnosed with an “anxiety disorder” accompanied by features of panic and distorted perceptions, but such a diagnosis would hardly illuminate what I was grappling with. This was a coming-of-age battle and a deep gnawing reactivation of “unfinished business” stemming from childhood fears. My therapist–analyst, Ann G., recognized the complexity of my malady. She conveyed a sense of confidence that I was going through a kind of “dark night of the soul,” and that there was more, so much more, that I could discover from this time. Just this perspective alone was helpful to me.” (p 26-27) This psychological work enabled Schneider to find forms of fulfillment in life that he could not have imagined before: “… I learned something else that has bolstered me for over 40 years: how to be bodily present, even in the most dire moments of vulnerability. With this hard-won discovery, I have been able to pursue romantic relationships that I hardly knew were possible at the time of my breakdown. Foremost among these was what turned out to be a 40-year relationship with my wife, Jurate.” (p 27) Schneider describes how he gradually transitioned from a state of debilitating withdrawal to one characterized by curiosity, awe, and a courageous engagement with life. He reflects that today his treatment would likely have been dominated by medications and short-term symptom-focused treatments which would have fallen well-short of offering the existential engagement that he needed. “… in my experience, if that change is essentially biological or intellectual or behavioral, it is not as likely to endure. On the other hand, if the change is holistic, involving one’s whole bodily being, it is likely to be life altering and profoundly ingrained.” (p 28) The pervasive tendencies of modern society to eradicate anxiety goes beyond clinical interventions. We are surrounded by endless opportunities for distraction, from all the legal and illicit substances we consume to all forms of device-mediated communications: “I have the creeping feeling that we are entering a brave new age where statistical and mechanical manipulation is replacing personal discovery and risk.” (p 33) Schneider wants us to rediscover the richness of face-to-face relationships, the immersive contact with nature, and our unfiltered capacity to genuinely experience the world. The advice he has to offer his readers is simple, but reflects this accumulated wisdom: take the time to reflect and to be present, develop a capacity to slow down, develop a capacity to savor the moment, cultivate a practice of meditation, and cultivate an openness to the mystery of life, etc. That such goals are worthwhile is likely evident to most, but what Schneider wants us to appreciate is that none of it is possible without a courageous and creative engagement with anxiety. “Not since the warnings of such existential visionaries as Kierkegaard, Nietzsche, Sartre, and Tillich, or their successors Rank, May, Becker, Laing, and Foucault have we needed more desperately to come to grips with anxiety. For these thinkers, and in my own very personal experience, anxiety is assuredly two-edged. It is both an impediment to and potentially a signal of human flourishing; and its viability now is pivotal. Why? Because, again, unlike any other time in history we are in a position to virtually eradicate anxiety.” (p 5) In conclusion, Life Enhancing Anxiety is a thought-provoking book that forces us to reexamine our assumptions about the nature of anxiety and its relationship to psychological flourishing, and is a valuable work for clinicians and patients alike.

Highly Touted MIND Diet The effect of the highly touted MIND diet with mild calorie restriction offered no greater protection against cognitive decline than a control diet with mild calorie restriction alone in healthy adults at risk for dementia, results of a new randomized trial show. Given the strong base of evidence from observational studies that demonstrate the benefits of the MIND diet on cognitive decline, Alzheimer's disease (AD), and neuropathologic changes such as reduced beta amyloid and tau associated with AD, the study's results were "unexpected," study investigator Lisa L. Barnes, PhD, with the Rush Alzheimer's Disease Center, Chicago, Illinois, told Medscape Medical News. "One possibility is the trial may not have been long enough to see an effect. It's also possible that participants in the control diet group benefited just as much as those in the MIND diet group because they also improved their diets to focus on weight loss," Barnes said. "Although we did not see a specific effect of the MIND diet, people in both groups improved their cognitive function, suggesting that a healthy diet in general is good for cognitive function," she added. The findings were presented at the Alzheimer's Association International Conference (AAIC) 2023 and simultaneously published online July 18 in the New England Journal of Medicine. Randomized Trial A hybrid of the Dietary Approaches to Stop Hypertension (DASH) and Mediterranean diet, the MIND diet includes foods and nutrients that have been putatively associated with a decreased risk of dementia. To further investigate, the researchers conducted a randomized trial that included 604 older adults without cognitive impairment who had a family history of dementia, a body mass index greater than 25, and a suboptimal diet determined via a 14-item questionnaire. For 3 years, 301 were randomly assigned to follow the MIND-diet with mild calorie restriction and 303 to follow a control diet with mild calorie restriction only. All participants received counseling to help them adhere to their assigned diet, plus support to promote weight loss of 3% to 5% by year 3. The primary endpoint was the change from baseline in global cognition and in specific cognitive domains through year 3. Cognition was assessed with an established battery of 12 publicly available cognitive function tests. The secondary endpoint was the change from baseline in MRI-derived measures of brain characteristics in a nonrandom sample of participants. "We had good adherence to the assigned diets and both groups lost weight, on average about 5 kilograms in both groups," Barnes noted in her presentation. From baseline through 3 years, small improvements in global cognition scores were observed in both groups, with increases of 0.205 standardized units in the MIND-diet group vs 0.170 standardized units in the control-diet group. However, in intention-to-treat analysis, the mean change in score did not differ significantly between groups, with an estimated mean difference at the end of the trial of 0.035 standardized units (P = .23). At the trial's conclusion, there were also no between-group differences in change in white-matter hyperintensities, hippocampal volumes, and total gray- and white-matter volumes on MRI. Barnes noted that the trial was limited to well-educated, older adults, mostly of European descent. Other limitations include the small sample size of those who received MRI and follow-up that was shorter than a typical observational study. Barnes noted that this is a single study and that there needs to be more randomized trials of the MIND diet that, as with the observational research, follow participants for a longer period of time. More to Brain Health Than Diet Reached for comment, Majid Fotuhi, MD, PhD, adjunct professor of neuroscience at George Washington University, Washington, DC, noted that participants who enroll in clinical trials that focus on diet become more aware of their eating habits and shift toward a healthier diet. "This may explain the reason why both groups of participants in this study improved," said Fotuhi, medical director of NeuroGrow Brain Fitness Center, McLean, Virginia. However, he believes better brain health requires a multipronged approach. "In order to see significant results, people need to improve their diet, become physically fit, sleep well, reduce their stress, engage in cognitively challenging activities, and develop a positive mind set," said Fotuhi. "Interventions that target only one of these goals may not produce results that are as remarkable as multimodal programs, which target all of these goals," Fotuhi said. Fotuhi developed a multidimensional "brain fitness program" that has shown to provide multiple benefits for individuals with memory loss, attention deficit hyperactivity disorder (ADHD) and post-concussion syndrome (PCS). "Having provided our 12-week program for thousands of patients in the past 10 years, I have noticed a synergistic effect in patients who incorporate all of these changes in their day-to-day life and maintain it over time. They often become sharper and feel better overall," Fotuhi told Medscape Medical News. The study was supported by the National Institute on Aging. Disclosures for study authors are listed with the original article. Fotuhi has disclosed no relevant financial relationships. Alzheimer's Association International Conference (AAIC) 2023. Presented July 18, 2023.

Transcranial magnetic stimulation treatment appeared to lessen some neuropsychiatric symptoms of long COVID in an open-label pilot study. Transcranial magnetic stimulation (TMS) treatment of neuropsychiatric symptoms in patients with post-COVID condition, or long COVID, appeared to provide some improvement in depressive symptoms and in cognitive function, but not in chronic fatigue, in an open-label pilot study1 conducted in Japan. The treated population with long COVID was a subset from a TMS consortium research project2 to elucidate treatment mechanisms and identify predictors of therapeutic response to TMS. The initial stage of the project is the development of a centralized registry database of TMS treatment in refractory psychiatric disorders in Japan. The epidemiological, clinical, and biological data collected will be used, the investigators indicated, “to promote cross-sectional and longitudinal exploratory observational studies.” The results from this open-label, pilot study of TMS in patients with long COVID warrant additional investigation, lead author Yoshihiro Noda, MD, PhD, MBA, of the Department of Neuropsychiatry at Keio University School of Medicine in Tokyo, Japan, told Psychiatric Times®. “Our future plan is to conduct a full-scale clinical study in patients with long COVID who complain of psychiatric symptoms, using a similar TMS treatment protocol and [a randomized controlled trial] (RCT) design that includes sham stimulation,” Noda said. “We would also like to conduct [electroencephalogram] (EEG) testing before and after the intervention to investigate the neurophysiological therapeutic mechanism of the [repetitive TMS] (rTMS) treatment.” The current study was conducted in May through September 2022, with patients whose COVID-19 diagnosis had been confirmed with polymerase chain reaction testing as early as January 2020. The 23 study participants, aged 20 to 70 years, were identified from among clinic outpatients presenting with neuropsychiatric symptoms that had manifested after contracting COVID-19. None of the participants had received psychiatric medications at the time of entering the study or during the TMS regimen. At baseline, participants exhibited moderate depression, with a mean Montgomery-Asberg Depression Rating Scale (MADRS) score of 21.2 (± 7.0) and a mean Patient Health Questionnaire-9 (PHQ-9) score of 12.9 (±4.7). The mean performance status (PS) measure of difficulty with activities of daily living as an indicator of chronic fatigue and lethargy was 5.4 (±1.6). The mean score of the Perceived Deficits Questionnaire-Depression 5 item (PDQ-D-5) to assess cognitive function was 10.0 (±5.2). TMS treatment was administered 3 times weekly for a total of 20 sessions. Each session consisted of intermittent theta burst stimulation (iTBS) to the left dorsolateral prefrontal cortex (DLPFC) followed by low-frequency rTMS to the right lateral orbitofrontal cortex (LOPC). “The rationale for combining low-frequency rTMS for the right LOPC in addition to the usual iTBS for the left DLPFC was inspired by the TMS treatment protocol for refractory depression invented by Feffer and colleagues,”3 Noda and colleagues acknowledged. “This TMS treatment protocol also showed ameliorative effects on cognitive impairment represented by ‘brain fog,’” the investigators noted. “The reason behind the improvement in cognitive function with this TMS treatment protocol may be that the TMS treatment targeted the left DLPPC, the most common target site of TMS treatment for depression, resulting in significant improvement in cognitive impairment, including executive dysfunction. “Furthermore, administration of iTBS, which has afacilitatory effect on the DLPFC, may strengthen neural rhythms, including theta-phase and gamma-amplitude coupling, which is also related to cognitive function and may even lead to enhanced neuroplasticity in the same region, thereby improving cognitive function.” In this study, the investigators found a significant improvement in mean MADRS score to 9.8 (±7.8). Approximately 65% of participants (15/23) improved their baseline score by ≥50% and approximately 70% (16/23), with a post-treatment score of ≤ 10 marking remission of depressive symptoms. The investigators indicated that most participants were subjectively aware of improvement, which was reflected in the statistically significant mean improvement in the self-administered PHQ-9. The investigators reported that improvement of the mean PDQ-D-5 score to 6.3 (±4.7) was evidence of “significant improvement in cognitive function,” and they noted that no participant showed deterioration in cognitive function following the TMS sessions. Although there was also improvement to 4.2 (±1.8) in the mean self-administered PS score, used as a measure of fatigue, the investigators found that any subjective improvement in fatigue appeared to be “at a minor level.” “rTMS treatment was only partially effective with respect to chronic fatigue due to long COVID,” Noda commented. “The impression was that many patients with chronic fatigue only partially improved, and their symptoms gradually retuned after the TMS treatment was completed.” Although larger trials, ideally with sham control and additional follow-up assessments, have yet to be conducted, Noda anticipates that TMS treatment could prove helpful for the neuropsychiatric symptoms of long COVID. “Considering that effective treatment for long COVID has not yet been established, rTMS therapy is a possible option,” Noda said. “However, since rTMS therapy imposes a certain burden on both therapist and patient, I believe that it should be implemented only when a TMS specialist judges its appropriateness and the patient is willing to undergo rTMS therapy.” Dr Bender reports on medical innovations and advances in practice and edits presentations for news and professional education publications. He previously taught and mentored pharmacy and medical students, and provided and managed pharmacy care and drug information services.

Oral monotherapy for major depressive disorder entering phase 3 trials ‘Trial and error’ treatment approach for major depressive disorder has pros and cons, experts say A phase 3 clinical program has been initiated for a potential monotherapy for the treatment of major depressive disorder (MDD). The monotherapy treatment is navacaprant (NMRA-140), an oral, once-daily, 80 mg, novel kappa opioid receptor (KOR) antagonist designed to modulate the dopamine and reward processing pathways. Navacaprant showed statistically significant and clinically meaningful reductions in symptoms of anhedonia and depression among patients with moderate to severe MDD in its phase 2 studies.1 Following a positive end-of-phase 2 meeting between navacaprant developer Neumora Therapeutics and the US Food & Drug Administration (FDA) in June 2023, navacaprant has been approved for study in the KOASTAL Program, a phase 3 pivotal clinical program that will further evaluate the safety and efficacy of the drug.1 The KOASTAL Program will consist of KOASTAL-1, KOASTAL-2, and KOASTAL-3—3 randomized, placebo-controlled, double-blind studies that will assess navacaprant monotherapy in adult patients with moderate to severe MDD who have a Montgomery-Åsberg Depression Rating Scale (MADRS) total score of ≥ 25 at baseline. The primary endpoint for each study will be a change from baseline MADRS total score at week 6. The key secondary endpoints will be a change from baseline on the Snaith-Hamilton Pleasure Scale (SHAPS) at week 6.1 The KOASTAL-1, KOASTAL-2, and KOASTAL-3 studies will be initiated in the third quarter of 2023, the fourth quarter of 2023, and the first quarter of 2024, respectively.1 “The planned initiation of the KOASTAL program represents an important step toward our goal of bringing a truly novel treatment to people living with MDD,” said Paul L. Berns, co-founder and executive chairman of Neumora, in a press release. “The data from our phase 2 study with navacaprant demonstrate its potential as a differentiated antidepressant that may help to manage anhedonia in addition to other core symptoms of depression with a favorable safety profile.”

From Insider: “The first Adderall ad appeared in my Instagram feed during the height of pandemic isolation. I thought the slick 30-second video promising me a ‘super easy’ way to get ADHD medication was another gimmick. But after the algorithm pushed a few more plugs my way, I started to get curious. The drugs, to my surprise, were real. Unlike countless sketchy ads for black-market supplements, Cerebral, the then-hot telehealth startup behind the ads, offered a legal path to prescription medications. Looming Addiction Crisis. It was indeed a ‘super easy’ path — too easy. My intake process to get prescribed a potentially addictive amphetamine turned out to be easier than getting Taylor Swift tickets or an appointment with my primary-care physician. Even as I doubted that I met the clinical criteria for ADHD, I could honestly answer the vague, brief self-assessment (e.g., ‘How often do you have difficulty paying attention when you are doing boring or repetitive work?’) and receive the same result as tens of thousands of AI-targeted customers: ‘You have some symptoms consistent with ADHD. We suggest further evaluation.’ When I spoke to a Cerebral nurse practitioner for all of 13 minutes, the experience was much the same. Answering that, yes, my concentration was strained in the middle of a once-in-a-century pandemic got me an official diagnosis and prescription. Like its many telehealth competitors, including Done, Klarity, adhdonline.com, and Circle Medical, Cerebral could peddle, prescribe, and postmark a package of Adderall for me while I never left the couch. A new breed of direct-to-consumer services is aggressively using targeted ads to sell habit-forming medications. Not only do these companies make it easier for those seeking recreational drugs to access them, they’re also poised to inundate and threaten the sobriety of people in recovery. And unlike a typical prescriber who might interrogate answers to assess genuine need, some of these firms appear to be designed to remove every possible barrier. In short, AI and surveillance capitalism, which empower today’s targeted ads, have joined forces with the deadly OxyContin playbook. But unlike the opioid crisis of the early 2000s, advertisers today have much more data and far more precise tools to push prescriptions, and our privacy laws haven’t even tried to keep up. Without intervention, another public-health catastrophe looms.” The looming addiction crisis fueled by AI Online pill services are using the same aggressive marketing tactics that drove the opioid epidemic.

No evidence seen for link between childhood stimulant treatment and substance use during adolescence and young adulthood. HealthDay News — For children with attention-deficit/hyperactivity disorder (ADHD), stimulant treatment is not associated with later frequent substance use by adolescents and young adults, according to a study published online July 5 in JAMA Psychiatry. Brooke S.G. Molina, Ph.D., from the University of Pittsburgh, and colleagues examined the association of ADHD stimulant treatment in childhood with later adolescent or adult substance use using the Multimodal Treatment Study of ADHD, a multisite study initiated at six sites in the United States and one site in Canada. A total of 567 participants were analyzed. The child participants were recruited between 1994 and 1996 (mean age, 8.5 years) and were assessed repeatedly until a mean age of 25 years for heavy drinking, marijuana use, daily cigarette smoking, and other substance use. The researchers found that after adjustment for developmental trends in substance use and age, there was no evidence that current or prior stimulant treatment or their interaction were associated with substance use. There was no evidence that more years of stimulant treatment or continuous, uninterrupted stimulant treatment were associated with adulthood substance use in marginal structural models adjusting for dynamic confounding by demographic, clinical, and familial factors. Findings were the same with an outcome of substance use disorder. “Although these results contrast with recent conclusions of protection found in other data sets, across all studies the findings lend a measure of comfort in the consistent lack of evidence that stimulant treatment predisposes children with ADHD to later substance use,” the authors write. Stimulant treatment for ADHD not associated with substance use in adolescence, adulthood Several authors disclosed ties to the pharmaceutical industry.

Two thirds of Americans responding to a Kaiser Family Foundation poll said that either they or a family member has been addicted to alcohol or drugs, experienced homelessness due to addiction, or experienced a drug overdose leading to an emergency room visit, hospitalization, or death. Alcohol is still the substance misused most often, with more than half of adults (54%) responding to the online and telephone survey stating that someone in their family has ever been addicted to alcohol. About a quarter said they or a family member had been addicted to any illegal drug, and another quarter said they or a family member was addicted to prescription painkillers. Almost a fifth of adults (18%) reported that they had (a) personally been addicted to drugs or alcohol, (b) had a drug overdose requiring an ER visit or hospitalization, or (c) had experienced homelessness because of addiction. The substance misuse affects all income levels, almost equally. For adults with a household income of less than $40,000 a year, some 25% said they had been addicted. That compares to 18% of those with an income of $40,000-to-$90,000 annually, and 16% of those who make $90,000 or more a year. White Americans reported more addiction and overdose; the difference is driven largely by alcohol and prescription painkiller addiction, the Kaiser poll found. Sixty percent of White adults, compared with 50% of Black and 47% of Hispanic adults, said someone in their family had been addicted to alcohol. For prescription opioids, 28% of White adults, 18% of Black adults and 20% of Hispanic adults reported addiction in their family. Substance Use Opioid addiction was especially high among White adults and rural adults, with 42% of those in rural areas reporting they or a family member was addicted to opioids, compared with 30% of suburban residents and 23% of urban residents. Substance use disorders have a big impact on families and mental health, Kaiser reported. Among those who have an addiction or a family member with addiction, 75% said the disorder had an impact on their relationship with their family. At least half of adults are worried that someone in their family will experience a substance use disorder, with 39% worried that someone in their family might unintentionally consume fentanyl. Fentanyl is a potent synthetic opioid drug approved by the Food and Drug Administration for use as an analgesic (pain relief) and anesthetic. Almost two thirds of adults said they were "very" or "somewhat worried" that someone in their family will experience a serious mental health crisis. Thirty-six percent said they were worried someone in their family will attempt suicide. Concerns about homelessness were highest among Hispanic adults, with 75% saying they were worried about a family member becoming homeless, compared with 60% of Black adults, and 23% of White adults. These worries were highest among those with incomes of less than $40,000 a year. Few Receiving Treatment Only about 46% of adults reporting personal or family addiction said that they or their family member had received treatment. White adults (51%) were more likely to have received treatment; slightly more than a third of Black and Hispanic adults reported they or a family member had been treated. Poll respondents cited multiple barriers to treatment, including that the person did not want or refused help; stopped on their own; denied that they had an addiction; could not afford care; or felt shame or stigma. Some reported that a family member died before they could get help. Kaiser included some of what respondents said in their own words. "We are not raised that way," said a 22-year-old Black woman from Georgia. "Brother quit on his own and been sober for 2 years; my dad was addicted to cocaine [and] quit on his own," said a 37-year-old Hispanic man from Texas. Only a quarter of people said they or a family member received medication-assisted treatment for opioid use disorder. People reported an openness to having addiction treatment centers in their community, with 91% expressing support. A large majority also supported making naloxone (Narcan) freely available in places like bars, health clinics, and fire stations. Democrats (61%) strongly or somewhat supported the establishment of safe consumption sites, while Independents (49%) were less supportive; just 23% of Republicans were supportive. The Kaiser survey was conducted July 11-19 among a nationally representative sample of 1327 US adults in English (1246) and in Spanish (81). The majority were part of a probability-based panel where panel members are recruited randomly. The margin of error is plus or minus 3 percentage points.

Cognitive distortions are irrational thoughts that can influence your emotions. Everyone experiences cognitive distortions to some degree, but in their more extreme forms they can be harmful. These distortions are the fundamental principle behind Cognitive Behavioral Therapy developed by Dr. Aaron Beck. Cognitive Distortions List of Types of Cognitive Disorders Magnification and Minimization: Exaggerating or minimizing the importance of events. One might believe their own achievements are unimportant, or that their mistakes are excessively important. Catastrophizing: Seeing only the worst possible outcomes of a situation. Overgeneralization: Making broad interpretations from a single or few events. "I felt awkward during my job interview. I am always so awkward." Magical Thinking: The belief that acts will influence unrelated situations. "I am a good person-bad things shouldn't happen to me." Personalization: The belief that one is responsible for events outside of their own control. "My mom is always upset. She would be fine if did more to help her." Jumping to Conclusions: Interpreting the meaning of a situation with little or no evidence. Mind Reading: Interpreting the thoughts and beliefs of others without adequate evidence. 'She would not go on a date with me. She probably thinks I'm ugly." Fortune Telling: The expectation that a situation will turn out badly without adequate evidence. Emotional Reasoning: The assumption that emotions reflect the way things really are. "I feel like a bad friend, therefore I must be a bad friend." Disqualifying the Positive: Recognizing only the negative aspects of a situation while ignoring the positive. One might receive many compliments on an evaluation, but focus on the single piece of negative feedback. "Should" Statements: The belief that things should be a certain way. "I should always be friendly." All-or-Nothing Thinking: Thinking in absolutes such as "always", "never", or "every". "I never do a good enough job on anything."

Steps in Healing After a Loss 1. Tell the story. Telling the story of what happened, from beginning to end, is healing step in itself. Follow the guidelines in the packet, take your time, and tell it in detail. Often there will be things you've kept to yourself since the loss happened, and this is a chance to get those thoughts, feelings, and memories outside of yourself. In this setting, no one will try to "fix" it for you or tell you what to feel or not feel. Your listeners will simply sit with you and hear you. 2. Explore the meanings of loss. Each loss has multiple layers of meaning in your life, and facing those meanings is crucial to your ability to move forward. For instance, the death of a parent will have an impact on you for years into the future, even if it happened years in the past. If you can acknowledge the many things a loss means in your life, you can address them on many levels, and prepare in advance for taking care of yourself in painful situations ahead. 3. Explore what feels un-finished. Feeling that things are unfinished keeps us stuck in the pain of the loss and gets in the way of letting go of that pain (NOT of the person or the happy memories) and moving forward. When you identify what feels unfinished, you can take steps toward closure. 4. Honor what was and take steps toward closure. These are the steps you take to release the pain - letters to (or from) the other person, collages or other artwork, rituals for anniversary dates, carrying symbolic objects, times/places ways to periodically revisit the loss. Do several, including the ones you want to avoid because the sound is too painful. The relief afterwards is worth the pain of the processing. 5. Celebrate what you get to keep. After every loss, there are things you get to keep -what you learned about yourself, what you learned from the other person, happy memories, the time and experiences you had before the loss, and the strength you gained from surviving the loss. Identifying these things can help you set down the burden of your grief and heal from the pain and intensity of the loss.

In my role as director of policy and advocacy at Mental Health America, I have ongoing opportunities to lead annual policy meetings on prevention and early intervention of mental health conditions – some of which I have dealt with firsthand since middle school. Since the COVID-19 public health emergency, we have spent a great deal of time advocating for the public health response to include addressing mental health concerns – which are routinely excluded even though data shows schizophrenia was the number one co-occurring condition in people who died from COVID-19, higher than asthma, obesity, and cardio conditions. At our 2023 National Policy Institute (held right before the start of our Annual Conference in early June), we went back to youth-focused discussions. Mental health condition signs manifest by age 14 in 50% of people who end up developing them, yet, on average, 12 years go by before individuals connect to services. With Gen Z in the middle of a pandemic, ongoing violence, and digital connectivity, this year was all about Tweens, Teens, and Technology. We discussed the internet and technology's impact on youth mental health and substance use based on research by the National Institute on Drug Abuse director Dr. Nora Volkow and several psychologists who conduct annual studies on youth and media, including Dr. Yalda Tehranian-Uhls of Scholars and Storytellers and Monica Anderson of the Pew Research Center. We highlighted which technology policies currently in front of Congress will help address harms. While 1 in 3 internet users is under age 18, California is the only state to enact an Age Appropriate Design Code Law (similar to the United Kingdom law by 5Rights Foundation) to ensure youth are not exploited and targeted online. No congressional action in the U.S. has been taken to hold technology companies accountable for social media harms even though youth report spending over eight hours a day on social media. In fact, much of the over $70 billion in revenue generated by Meta in 2020 can be attributed to advertisements to youth. The Senate Commerce Committee has previously taken up the Kids Online Safety Act, the closest bill we have to a national framework alongside the Children and Teens' Online Privacy Protection Act, but has not yet done so in the 118th Congress. Recently, the Federal Trade Commission renewed and expanded its order to provide for “Blanket Prohibition Preventing Facebook from Monetizing Youth Data.” And, last year Congress funded a Center of Excellence for Adolescent Social Media Use. We greatly appreciate having its co-director Dr. Megan Moreno join the policy institute as a speaker alongside Haley Hinkle, policy counsel of Fairplay, and Alison Rice the youth initiatives campaign manager at Accountable Tech. MHA was honored to also highlight the work of Amelia Vance, chief counsel for The School Superintendents Association, Fred Dillion, head of advisory services at Hopelab, Dr. Erlanger Turner of Pepperdine University, and Mitch Prinstein, chief science officer of American Psychological Association. We applaud the decades of work by these researchers and advocates in child online safety and privacy and call on Congress to heed the U.S. Surgeon General's recommendations on Social Media and Youth Mental Health and enact a national standard to ensure online media protects youth from harm and encourages healthy exploration of topics and help-seeking behavior. Read the many reports by these leaders in the policy institute meeting agenda and watch the program here.