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.

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.

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.

Hospital visits for mental health care increased among children and teens in the second year of the COVID-19 pandemic, according to a study supported by the National Institute of Mental Health. Analyses of insurance claims data for more than 4.1 million children showed an especially notable increase in acute mental health care visits—including emergency department visits—among teen girls. The study was led by Lindsay Overhage , an M.D.-Ph.D. student at Harvard Medical School, and Haiden Huskamp, Ph.D. , the Henry J. Kaiser Professor of Health Policy at Harvard Medical School. Overhage, Huskamp, and colleagues examined national, deidentified commercial health insurance claims for youth aged 5 to 17 years over the following periods: Baseline year: March 2019 to February 2020 First year of the pandemic: March 2020 to February 2021 Second year of the pandemic: March 2021 to February 2022 The researchers defined mental health-related emergency department visits as visits in which a mental health condition was recorded as the primary diagnosis for the visit. They then sorted the diagnoses into categories, which included depression; suicidal ideation, suicide attempt, or self-injury; anxiety disorder; and eating disorder. Visits with a primary diagnosis of substance use disorder were not included. From these data, the researchers identified 88,665 mental health-related emergency department visits. Relative to the pre-pandemic baseline year, the proportion of youth with at least one mental health visit decreased by 17.3% in the first year of the pandemic. In contrast, the proportion of youth with a mental health visit increased by 6.7% in the second pandemic year relative to the baseline year. The proportion of youth with multiple visits in the same year remained similar over time. Further analyses revealed notable differences according to age and sex. Relative to baseline, mental health-related emergency visits in the second year of the pandemic increased by 22.1% among teen girls (aged 13 to 17), while these visits decreased by 15.0% among boys aged 5 to 12 and 9.0% among teen boys (aged 13 to 17). The data also showed that girls’ visits increased considerably for specific diagnostic categories. For example, among girls, there was a 43.6% increase in visits for suicidal ideation, suicide attempt, or self-injury and a 120.4% increase in visits for eating disorders in the second year of the pandemic. Among boys, mental health-related visits decreased or stayed the same across diagnostic categories in both pandemic years. The researchers note that these findings are consistent with other studies indicating that the pandemic has taken a greater toll on girls’ mental health. Inpatient psychiatry admissions also increased during the pandemic. After a mental health-related emergency department visit, youth were more likely to be admitted for inpatient psychiatric care and stayed in inpatient psychiatric care longer in both pandemic years compared to the baseline year. Importantly, during both years of the pandemic, youth were more likely to spend two or more nights in a medical unit waiting to be admitted to a psychiatric unit, a practice the researchers call “prolonged boarding.” Relative to the baseline year, prolonged boarding increased by 27.1% in the first year of the pandemic and 76.4% in the second year of the pandemic. The increase in the second year of the pandemic was especially high (87.2%) among teens aged 13 to 17. According to the researchers, the increase in prolonged boarding could be due to two factors: increased demand and reduced capacity. In other words, more children needed urgent mental health care, but there were also fewer inpatient psychiatric beds and fewer qualified staff to meet those needs. The researchers note that this underscores the importance of expanding the capacity of psychiatric services for youth. Although the study focused only on youth with commercial insurance, the findings shed light on the broad need for appropriate, responsive mental health care for children and teens. The researchers suggest that educating and supporting primary care providers in delivering mental health care could help address youth mental health concerns before they require more acute, hospital-based care. At the same time, they note that supporting existing mental health care providers and increasing the pipeline of qualified staff are critical steps in addressing the provider shortage.

Is forgiveness healing? PSYCHIATRIC VIEWS ON THE DAILY NEWS We have entered the third sentencing stage of the Pittsburgh Synagogue Mass Shooter trial. It will be an opportunity of sorts for the family and loved ones of those killed or injured to present how they felt they were affected psychologically. They will continue the important psychological work of witnessing that has occurred in Holocaust survivors. Inevitably, the anguishing possibility of forgiveness of the perpetrator will emerge. A statement by a leader of 1 of the 3 synagogues located in the building attacked, the New Light Congregation, was made right after the jury decision to consider the death penalty1: “These can be no forgiveness. Forgiveness requires 2 components: that it is offered by the person who commits the wrong and it is accepted by the person who was wronged. The shooter has not asked—and the dead cannot accept.” In a psychological sense, forgiveness can be unilaterally considered by anybody who felt wronged. Historically, a somewhat similar challenge occurred in the mass shooting in the Mother Emanuel Charleston Church on June 17, 2015. The perpetrator also lived, was sentenced to death, has not asked for forgiveness, and maintains that “there is nothing wrong with me psychologically.” Many, but not all, of the family members almost immediately during the bond hearing expressed forgiveness of the shooter. Forgiveness was described by one family member as a “superpower” of “spiritual resistance.”2 Such forgiveness is culturally congruent, and there is also the possibility of empathy and compassion with the troubling backgrounds of any given perpetrator. There also seem to be similarities with other white supremacist shootings in El Paso and Christchurch New Zealand. Moreover, there was another synagogue mass shooting, that of a Poway synagogue north of San Diego on April 27, 2019. The perpetrator also believed in anti-Semitic conspiracy theories. He was caught and sentenced to life in prison. I asked a psychologist who has helped the families of that synagogue about forgiveness. It seems like there was nobody known who actually forgave the perpetrator. The day after the shooting, their Rabbi, Yisroel Goldstein, who was injured in the shooting, called to “battle darkness with light.” Can the light include forgiveness? Even if there is some tendency for religions to differ in their views on forgiveness, usually there are always some offenses that are viewed as unforgivable.3 There certainly is also individual variation in what is involved in forgiveness. It might be too sensitive to conduct long-term studies on how loved ones do after such tragedies in comparing those who forgive early on and those who do not, and I do not know any such research. One important consideration is whether such forgiveness helps prevent future posttraumatic stress disorders (PTSD) and related problems, or not. What clearly voluminous recent research results tell us is that forgiving in general is beneficial for physical health, mental health, and overall functioning. A pioneer in such research, the psychologist Everett Worthington, whose own mother was murdered in 1996 in the midst of his studies, confirmed that in a recent study across 5 countries. He offers specific tools to do so in the REACH method involving Recall, Empathy, Altruism, Commit, and Hold.4 When forgiveness is considered, it is important to separate it from justice and remembering. One can forgive a perpetrator, but still desire them to face any appropriate legal justice and to not forget the trauma. In our clinical work, my own experience is that forgiveness was often the last challenge in a patient recovering from PTSD. Sometimes that was possible at the time and sometimes not. Although it is controversial whether groups of people can forgive, there certainly are groups that are targeted. The Church and Synagogue represented racism and anti-Semitism, and the ongoing goal of the perpetrator was further escalation of violence against those groups. That is when individual psychopathology overlaps with social group psychopathologies. However, the individual is subject to legal processing, but how to address the associated offending social group is much more uncertain, but ultimately necessary. Dr Moffic is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of Psychiatric Times.

Pittsburgh synagogue shooter’s beliefs are shared, not delusions, says psychiatrist In this courtroom sketch, Robert Bowers, the suspect in the 2018 synagogue massacre, sits in court Tuesday, May 30, 2023, in Pittsburgh. A prosecution expert witness in the Pittsburgh synagogue shooting trial said Monday he believes convicted gunman Robert Bowers was able to form the intent to kill required for the jury to consider imposing the death penalty. Bowers was found guilty in June of killing 11 Jewish worshipers and injuring six other people at the Tree of Life synagogue in 2018. In this phase of Bowers’ trial, jurors must determine if he is eligible for a death sentence. In order to consider the death penalty, jurors must first determine that Bowers had the ability to form an intent to kill, as defined by the court. Forensic psychiatrist Dr. Park Dietz, who spent more than 14 hours in May interviewing Bowers, began testifying last Thursday. Dietz has consulted on several high-profile criminal cases; he evaluated John Hinkley Jr., interviewed serial killer Jeffrey Dahmer and testified in numerous other trials. WESA Inbox Edition Newsletter https://www.wesa.fm/courts-justice/2023-07-10/pittsburgh-synagogue-shooters-beliefs PSYCHIATRIC VIEWS ON THE DAILY NEWS Today, the third and last phase of the Pittsburgh trial begins. Last Thursday, the jury quickly decided that it can move forward to consider the death penalty. Diagnostic Expertise So far, the main witnesses have been psychiatrists and other related medical specialists. As usual, experts that were chosen by either side gave different options about the perpetrator’s mental health and how that may have influenced his crime. Much focused on whether a given psychiatric diagnosis included delusional thinking, which could have impaired his “intent.” All combined, several diagnoses were presented: -Schizophrenia -Schizoid personality disorder -Epilepsy -Adjustment disorder In addition, sub threshold symptoms and a history of other disorders became apparent: major trauma, substance abuse, and clinical depression, among them. The depth of any treatment was not apparent to me. While someone could conclude from these diverse opinions that those in clinical psychiatry are not reliable enough in our assessment ability, they would fail to understand the difference between evaluating an individual patient for treatment versus a forensic evaluation for the purpose of answering questions by the prosecution or defense. The Role of Cults and Cultish Thinking Besides the individual assessment of the accused, and any contribution of his personal history, the case also focused on his most recent preoccupation, which was online anti-Semitism conspiracy theories, specifically about one of the synagogues he attacked bringing in immigrants to replace white individuals. Discussion ensued about whether all his beliefs were just like those of others online that he viewed over and over, or that he had his own unique delusional disease. Nothing I found, however, discusses these online tropes as being parts of cults or cultish influence. Cults have never been a prominent focus for psychiatrists, but there is one diagnosis that was never brought up that could reflect cultish thinking: “Other specific Dissociative Disorder, 300.15.” Resolving a Dialectic One resolution of the differing testimonies might lie in a more complex interaction and causation of both the individual and the social. Perhaps the perpetrator had psychiatric dysfunction that made him uniquely vulnerable to undue influence, but that dysfunction did not reach the DSM diagnostic level. The undue influence would lie in the social anti-Semitic conspiracy theories which he believed—and still does—were true, and that his mass shooting would make him a hero like our country’s Founding fathers. Serendipitously, perhaps, a new book on delusions came out last Wednesday that may help our understanding.1 Right from the beginning of the book, the question of how to define delusions is conveyed. On page 3, the DSM-5-TR definition is quoted: “Delusions are deemed bizarre if they are clearly implausible and not understandable to same-culture peers and do not derive from ordinary life experiences.” The confusion from this definition in regard to the perpetrator is that his subculture affirmed his conspiracy theories, but most of the general public apparently did not. Alternatively, in the Preface, there is this current caution: “Importantly, it is established that delusional beliefs cannot be distinguished from popular unsupported beliefs on the basis of their content alone: rather, one must consider the role of social factors in acquiring and potentially spreading the belief.” Certainly, anti-Semitism conspiracy theories spread to the perpetrator. Right after the verdict of eligibility for the death penalty, a community leader, exclaimed: “It is clear that this is hatred of Jews. This is anti-Semitism. This is not a mental health issue.” I continue to wonder whether hatred is a mental health issue, however. What else is it when it is an inappropriate individual or collective psychologically-based response to a group of others? No, that does not necessarily usually fit an official DSM-5 disorder, but it would fit being a social psychopathology if only we had such a classification. As we will continue to discuss, there are treatments and interventions that can address these social psychopathologies if only we use them. Dr Moffic is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of Psychiatric Times. Reference 1. Hardy K, Turkington D, eds. Decoding Delusions: A Clinician's Guide to Working With Delusions and Other Extreme Beliefs. American Psychiatric Association Publishing; 2023.

My father was such an inspirational man that showed me the values that were the core of his existence. In my wildest dreams, I could not imagine how my dad overcome such hardest obstacles in life to achieve what he achieved on a personal and professional level. He touched many hearts, as he genuinely did mine. Each day I hope to mirror and refine those values that I have been taught. I am sad that my father is not around in flesh, but I do feel his presence in spirit and memories. I know that I am thinker, by the ways in which he helped me to see a better world, one that he wanted me to help out in. I am only a mere product of such an amazing, inspiring human being, who is forever by missed by his family. My Father and I Back when I was young and 17. My dad taught me a lot about how to treat his patient as I have some amazing memories of his patients saying such kind words about how much my dad helped him/her. He was my role model and I wanted to help people just like him. Half the time I have a frank and candid conversation with parents about how to alter their parenting style to be more authoritative. Discipline is important, so is love and nurturing as it is paramount in building self-esteem and confidence. So many adults had rough childhoods because their parents didn't tools necessary to shape, inspire and model them. My parents weren't perfect they were a product of poverty and limiting nurturing in their lives. But they tried their best and im grateful through the ups and downs. Here is a interesting piece that may help enlightenment the teamwork that is necessary for both parents in the eyes of a child! One who loves till her eyes close, is a *Mother*. One who loves without an expression in the eyes, is a *Father*. ____________________________ *Mother* - Introduces you to the world. *Father* - Introduces the world to you. ___________________________ *Mother* : Gives you life *Father* : Gives you living __________________________ *Mother* : Makes sure you are not starving. *Father* : Makes sure you know the value of starving __________________________ *Mother* : Personifies Care *Father*: Personifies Responsibility __________________________ *Mother* : Protects you from a fall *Father* : Teaches you to get up from a fall. __________________________ *Mother* : Teaches you walking. *Father* : Teaches you walk of life __________________________ *Mother* : Teaches from her own experiences. *Father* : Teaches you to learn from your own experiences. __________________________ *Mother* : Reflects Ideology *Father* : Reflects Reality ___________________________ *Mother's* love is known to you since birth. *Father's* love is known when you become a Father. ___________________________ Enjoy what your father says. Keep loving your mother. ___________________________ Just feeling blessed and grateful for what I have, as many people don't have love or guidance in life. Despite my battles, I have always had such kindness and caring people in my life.

The Art of Happiness is a book that I would highly recommend to read. It was co-written by the Dalai Lama and a psychiatrist Howard Cutler. Dr. Cutler poses questions to the Dalai Lama about various elements of happiness, through his knowledge and wisdom about life. It helps to put into perspective what are the most important aspects that can lead to a happy life. It is based on the foundation and tenets of Buddhism, however described through real-life examples. The book explores how training the human outlook on life can alter one's perception. It illustrates that one's state of mind is much more heavily influenced by internal peace than external factors, conditions, circumstances, or events. One of the factors that is consistent discussed through the book is the importance of human contact and connection. This is one factor that I believe is on a decline as we live within isolated bubbles "pseudo-connected" through technology. However, reduction in face-to-face contact seems to be a rare occurrence at time. One of the aspects of life that I observe is how disconnected we can be from one another. I think that any type of technology has its pros and cons, however it is humans that can alter how such technology would influence one's life. I find myself often enjoying a random conversation with a stranger, which I believe is very important. I had an interesting conversation with an older gentleman that other day that had various questions about my race, ethnicity, and culture. It was nice to share aspects of myself with a complete stranger who appeared to desire contacting with another human being. It was interesting to learn about his life and various chapters that existed within his sense of happiness. Source: Vilash Reddy, MD

I came across a post earlier today that stood out today. It made me think about a human spirit, drive, and adversity. I was really surprised when I read about the life of a very well-known actor Keanu Reeves. I was amazed at the course of his life and it makes you realize how much we often don't know what someone has been through or experience in life. Early Life Keanu was only three years old when his father left their family. He did keep in contact with his father, till 6 years of age. However, due to financial issues stemming from his parents' divorce, he moved from city to city during his childhood, later attending 4 various high school. He struggled academically due to diagnosed dyslexia, which made his school years challenging, until leading him to drop out of high school. Death of Loved Ones In 1993, early in his career as an actor, he lost his best friend River Phoenix, from a drug overdose at the age of 23. This was a very devastating point in his life, made him realize the fragility of life. In 1998, Keanu met Jennifer Syme. She ended up becoming pregnant 1 year following. At 8 months pregnant their child was born stillborn. It was suspected that the death of their daughter was a driving force to the end of his relationship. 18 months following the separation, Syme died in a car accident. Triumph While dealing with the aftermath of tragedies and loss, he channeled his energy toward his craft. In 1999, he released the blockbuster movie hit The Matrix, which has historically been one of high grossing movies, which later lead to subsequent sequels. Unlike like scenes in the Matrix, where he dodged bullets, personally he learned to deal with the pain and suffering of being "hit" at various points in life. River Phoenix was one of his best friends that died from a drug overdose tragically at a young point in his career Generosity/Philanthropy Keanu is a charitable human being. It is estimated that he has given 2/3rd of his income to the Matrix and subsequent sequels to his staff who was involved in specials effects and building of the sets. In addition, he became the caretaker for his sister Kim, who was diagnosed with leukemia. His sister battled leukemia for approximately a decade, later her cancer was found to be in remission. He donated a substantial portion of his money to cancer charities, research center, and treating hospitals. Some of charities that he has supported include Stand Up to Cancer and the SickKids Foundation. Humility Humility. Even though Keanu is worth well over $100 million, he does not walk around with bodyguards. He is not chauffeured, as he rides the subway. Possibly hoping to reduce or decrease his carbon footprint or increase his ability to connect with other people. He has been photographed truly desiring to get understand life through other people's perspective. He is a very mindful and intentional human being. He chose to make his suffering his leverage to overcome hurdles. I really admire that money never went to his dead and he tries each day to be a good human being and treat people kindly with his action and not his words. Source: Vilash Reddy, MD