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Somatic symptom disorder is diagnosed when a person has a significant focus on physical symptoms, such as pain, weakness or shortness of breath, to a level that results in major distress and/or problems functioning. The individual has excessive thoughts, feelings and behaviors relating to the physical symptoms. The physical symptoms may or may not be associated with a diagnosed medical condition, but the person is experiencing symptoms and believes they are sick (that is, not faking the illness). A person is not diagnosed with somatic symptom disorder solely because a medical cause can’t be identified for a physical symptom. The emphasis is on the extent to which the thoughts, feelings and behaviors related to the illness are excessive or out of proportion. Somatic Symptom Disorder Diagnosis One or more physical symptoms that are distressing or cause disruption in daily life Excessive thoughts, feelings or behaviors related to the physical symptoms or health concerns with at least one of the following: Ongoing thoughts that are out of proportion with the seriousness of symptoms Ongoing high level of anxiety about health or symptoms Excessive time and energy spent on the symptoms or health concerns At least one symptom is constantly present, although there may be different symptoms and symptoms may come and go People with somatic symptom disorder typically go to a primary care physician rather than a psychiatrist or other mental health professional. Individuals with somatic symptom disorder may experience difficulty accepting that their concerns about their symptoms are excessive. They may continue to be fearful and worried even when they are shown evidence that they do not have a serious condition. Some people have only pain as their dominant symptom. Somatic symptom disorder usually begins by age 30. Treatment Treatment for somatic symptom disorder is intended to help control symptoms and to allow the person to function as normally as possible. Treatment for somatic symptom disorder typically involves the person having regular visits with a trusted health care professional. The physician can offer support and reassurance, monitor heath and symptoms and avoid unnecessary tests and treatments. Psychotherapy (talk therapy) can help the individual change their thinking and behavior, and learn ways to cope with pain or other symptoms, deal with stress and improve functioning. Antidepressant or anti-anxiety medications can be useful if the person is also experiencing significant depression or anxiety. Related Disorders Illness anxiety disorder Illness anxiety disorder was previously referred to as "hypochondriasis." The person is preoccupied with having an illness or getting an illness – constantly worrying about their health. They may frequently check themselves for signs of illness and take extreme precautions to avoid health risks. Unlike somatic symptom disorder, a person with illness anxiety disorder generally does not experience symptoms. Conversion disorder Conversion disorder(functional neurological symptom disorder) is a condition in which the symptoms affect a person’s perception, sensation or movement with no evidence of a physical cause. A person may have numbness, blindness or trouble walking. The symptoms tend to come on suddenly. The symptoms may last for a long time or may go away quickly. People with conversion disorder also frequently experience depression or anxiety disorders. Factitious disorder Factitious disorder involves people producing or faking physical or mental illness when they are not really sick, or intentionally making a minor illness worse. A person with factitious disorder may also create an illness or injury in another person (factitious disorder imposed on another), such as faking the symptoms of a child in their care. The person may or may not seem to benefit (such as getting out of school or work) from the situation they create. Reference Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). American Psychiatric Association. (2013).

Every human being has flaws. Every human has insecurities. Every human has vulnerabilities. Forgiveness /Self-Compassion Every human has micro-trauma, sometimes even macro-trauma. Micro-trauma — events in our life that seem insignificant, however remain buried in our subconscious, which alter the way we perceive the world. Ex. breakup with girlfriend/boyfriend, lose of friendship, etc. Macro-trauma is my opinion is abuse, neglect, death, loss of job, loss of identity, etc. Sometimes humans go through their own life…holding on to this trauma…completely altering how they perceive life. Forgiveness /Self-Compassion. Imagine a beautiful sunny day and you are a boat on the water. We are all boats (some yachts, some speed boats, some trolling boats, some kayaks, etc.). We are beautiful in our own way, with our own characteristics or purposes. We have different functions, meanings, and abilities. However, I feel that many are truly yachts on the inside, and depict that are fishing boats on the outside. Vica Versa (to those that are narcissistic and boastful). Ultimately, we all have our anchors to this boat that we call life. Sometimes people with such heavy macro trauma are unable to move much despite a beautiful day, as their toxic experiences are so deeply anchored in their subconscious (sand at the bottom of the ocean floor). One of the most important thing in life is to think about why you act and behave the way that you do. In my humble opinion, our actions are 10–20% conscious, the remaining amount is subconscious. Ex. you meet someone for the first time and they create a deep impression on you….why is that? Baggage or your anchor displaced onto a stranger. I have a pretty decent understanding of subconscious effects and defense mechanisms based on my profession. I like to operate from a very holistic perspective, which is why I truly believe that psychology influences our mood, behavior, exponentially. I dont think that adults are hopeless, I think their need to work on pruning their mind, as neuroplasticity is alive and well. People need to see out doctors that are holistic in nature, helping to coach and develop a tailored lifestyle for someone dealing with mental illness. I truly believe that mental illness is the anchor to many people achieving their dreams and living an abundant life. Limiting beliefs squash anything positive that we could potentially accomplish, as subconscious non-sense got impeded into our mind…As a human, we can achieve many things…we just need a sound mind and life is work its way out. Itruly believe as I dedicated my life to help those going through that journey. Source: Medium: Author: Vilash Reddy, MD

Learning to appreciate life Self Reflection. One of the most important things that I am learning, is to appreciate and reflect on a current moment in life. I feel that throughout the course of my life I have always focused on getting to the next step or chapter in my life, particularly after starting medical school. I feel that over the past 2–3 years, I have become more mindful, something that I was taught during my 4th year of medical school, which I think its very important to help enrich our lives and our existence. I hope to apply that philosophy to all aspects of my life, learning to embrace each and every moment to the fullest with complete awareness. I hope to make make an effort to reflect on a lesson(s) that I may have learned within that day, which could potentially help me be a better person. Source: Medium - Vilash Reddy, MD

Sleep disorders (or sleep-wake disorders) involve problems with the quality, timing, and amount of sleep, which result in daytime distress and impairment in functioning. Sleep-wake disorders often occur along with medical conditions or other mental health conditions, such as depression, anxiety, or cognitive disorders. There are several different types of sleep-wake disorders, of which insomnia is the most common. Other sleep-wake disorders include obstructive sleep apnea, parasomnias, narcolepsy, and restless leg syndrome. Sleep difficulties are linked to both physical and emotional problems. Sleep problems can both contribute to or exacerbate mental health conditions and can be a symptom of other mental health conditions. About one-third of adults report insomnia symptoms and 6-10 percent meet the criteria for insomnia disorder.1 Importance of Sleep Sleep is a basic human need and is critical to both physical and mental health. There are two types of sleep that generally occur in a pattern of three-to-five cycles per night: Rapid eye movement (REM) – when most dreaming occurs Non-REM – has three phases, including the deepest sleep When you sleep is also important. Your body typically works on a 24-hour cycle (circadian rhythm) that helps you know when to sleep. How much sleep we need varies depending on age and varies from person to person. According to the National Sleep Foundation most adults need about seven to nine hours of restful sleep each night. The Foundation revised its sleep recommendations in 2015 based on a rigorous review of the scientific literature. Many of us do not get enough sleep. Nearly 30 percent of adults get less than six hours of sleep each night and only about 30 percent of high school students get at least eight hours of sleep on an average school night.2 An estimated 35 percent of Americans report their sleep quality as “poor” or “only fair.”3. More than 50 million Americans have chronic sleep disorders.2 Consequences of Lack of Sleep and Coexisting Conditions Sleep helps your brain function properly. Not getting enough sleep or poor quality sleep has many potential consequences. The most obvious concerns are fatigue and decreased energy, irritability and problems focusing. The ability to make decisions and your mood can also be affected. Sleep problems often coexist with symptoms of depression or anxiety. Sleep problems can exacerbate depression or anxiety, and depression or anxiety can lead to sleep problems. Lack of sleep and too much sleep are linked to many chronic health problems, such as heart disease and diabetes. Sleep disturbances can also be a warning sign for medical and neurological problems, such as congestive heart failure, osteoarthritis and Parkinson’s disease. Insomnia Disorder Insomnia, the most common sleep disorder, involves problems getting to sleep or staying asleep. About one-third of adults report some insomnia symptoms, 10-15 percent report problems with functioning during the daytime and 6-10 percent have symptoms severe enough to meet criteria for insomnia disorder. An estimated 40-50 percent of individuals with insomnia also have another mental disorder.1 Symptoms and Diagnosis To be diagnosed with insomnia disorder, the sleep difficulties must occur at least three nights a week for at least three months and cause significant distress or problems at work, school or other important areas of a person's daily functioning. Not all individuals with sleep disturbances are distressed or have problems functioning. To diagnose insomnia, a physician will rule out other sleep disorders (see Related Conditions below), medication side-effects, substance misuse, depression and other physical and mental illnesses. Some medications and medical conditions can affect sleep. A comprehensive assessment for insomnia or other sleep problems may involve a patient history, a physical exam, a sleep diary and clinical testing (a sleep study). A sleep study allows the physician to identify how long and how well you’re sleeping and to detect specific sleep problems. A sleep diary is a record of your sleep habits to discuss with your physician. It includes information such as when you go to bed, get to sleep, wake up, get out of bed, take naps, exercise, eat and consume alcohol and caffeinated beverages. Sleep problems can occur at any age but most commonly start in young adulthood. The type of insomnia often varies with age. Problems getting to sleep are more common among young adults. Problems staying asleep are more common among middle-age and older adults. Symptoms of insomnia can be: Episodic (with an episode of symptoms lasting one to three months) Persistent (with symptoms lasting three months or more) Recurrent (with two or more episodes within a year) Symptoms of insomnia can also be brought on by a specific life event or situation. Treatment and Self-help Sleep problems can often be improved with regular sleep habits. (See Sleep Hygiene section for tips.) If your sleep problems persist or if they interfere with how you feel or function during the day, you should seek evaluation and treatment by a physician. Sleep disorders should be specifically addressed regardless of mental or other medical problems that may be present. Chronic insomnia is typically treated with a combination of sleep medications and behavioral techniques, such as cognitive behavior therapy. Several types of medications can be used to treat insomnia and to help you fall asleep or stay asleep. Most of these can become habit-forming and should only be used for short periods and under the care of a doctor. Some antidepressants are also used to treat insomnia. Most over-the-counter sleep medicines contain antihistamines, which are commonly used to treat allergies. They are not addictive, but they can become less effective over time. They may also contribute to confusion, blurred vision, urinary retention, and falls in the elderly and should be used with caution in this population. Many people turn to complementary health approaches to help with sleep problems. According to the National Institutes of Health some may be safe and effective, others lack evidence to support their effectiveness or raise safety concerns. Relaxation techniques, used before bedtime, can be helpful for insomnia. Melatonin supplements may be helpful for people with some types of insomnia. Long-term safety has not been investigated. Mind and body approaches, such as mindfulness, meditation, yoga, massage therapy and acupuncture lack evidence to show their usefulness, but are generally considered safe. Herbs and dietary supplements have not been shown to be effective for insomnia. There are safety concerns about some, including L-tryptophan and Kava. Let your health care provider know about any alternative medicines or supplements you are taking. Sleep Hygiene: Healthy sleep tips to address sleep problems. Stick to a sleep schedule – same bed time and wake up time even on the weekends Allow your body to wind down with a calming activity, such as reading away from bright lights; avoid electronic devices Avoid naps especially in the afternoon Exercise daily Pay attention to bedroom environment (quiet, cool and dark is best) and your mattress and pillow (should be comfortable and supportive) Avoid alcohol, caffeine and heavy meals in the evening Associated Conditions: Sleep Apnea Obstructive sleep apnea involves breathing interruptions during sleep. A person with sleep apnea will have repeated episodes of airway obstruction during sleep causing snoring, snorting/gasping or breathing pauses. This interrupted sleep causes daytime sleepiness and fatigue. Sleep apnea is diagnosed with a clinical sleep study. The sleep study (polysomnography) involves monitoring the number of obstructive apneas (absence of airflow) or hypopneas (reduction in airflow) during sleep. Sleep apnea affects an estimated 2 to 15 percent of middle-age adults and more than 20 percent of older adults.1 Major risk factors for sleep apnea are obesity, male gender and family history of sleep apnea. Lifestyle changes, such as losing weight if needed or sleeping on your side, can improve sleep apnea. In some cases a custom-fit plastic mouthpiece can help keep airways open during sleep. The mouthpiece can be made by a dentist or orthodontist. For moderate to severe sleep apnea, a doctor can prescribe a CPAP (continuous positive airway pressure) device. The CPAP works to keep airways open by gently blowing air through a tube and face mask covering your mouth and nose. Central Sleep Apnea In central sleep apnea, the brain does not properly control breathing during sleep, causing breathing to start and stop. It is diagnosed when a sleep study identifies five or more central apneas (pauses in breathing) per hour of sleep. Central sleep apnea is rare and less prevalent than obstructive sleep apnea. It is more common in older adults, in people with heart disorders or stroke, and in people using opioid pain medications. It can be treated using a CPAP or other device during sleep. Sleep-Related Hypoventilation People with sleep-related hypoventilation have episodes of shallow breathing, elevated blood carbon dioxide levels, and low oxygen levels during sleep. It frequently occurs along with medical conditions, such as chronic obstructive pulmonary disease (COPD), or medication or substance use. Those with sleep-related hypoventilation often have trouble with insomnia or excessive daytime sleepiness. Risk factors for sleep-related hypoventilation include medical conditions, such as obesity and hypothyroidism, and use of certain medications, such as benzodiazepines and opiates. Other Sleep Disorders Non-Rapid Eye Movement Sleep Arousal Disorders Non-rapid eye movement (NREM) sleep arousal disorders involve episodes of incomplete awakening from sleep, usually occurring during the first third of a major sleep episode, and are accompanied by either sleepwalking or sleep terrors. The episodes cause significant distress or problems functioning. NREM sleep arousal disorders are most common among children and become less common with increasing age. Sleepwalking involves repeated episodes of rising from bed and walking around during sleep. While sleepwalking, the individual has a blank, staring face; is relatively unresponsive to others; and is difficult to wake up. Nearly 30% of people have experienced sleepwalking at some time in their lives. Sleepwalking disorder, with repeated episodes and distress or problems functioning, affects an estimated 1% to 5% of people. Sleep terrors (also called night terrors) are episodes of waking abruptly from sleep, usually beginning with a panicky scream. During each episode, the person experiences intense fear and associated physical signs such as rapid breathing, accelerated heart rate and sweating. The person typically does not remember much of the dream and is unresponsive to efforts of others to comfort them. Sleep terrors are common among very young children—at 18 months of age about 37% of children experience night terrors and at 30 months about 20% experience them. Only about 2% of adults experience night terrors. Nightmare Disorder Nightmare disorder involves repeated occurrences of lengthy, distressing, and well-remembered dreams that usually involve efforts to avoid threats or danger. They generally occur in the second half of a major sleep episode. The nightmares are typically lengthy, elaborate, story-like sequences of dream imagery that seem real and cause anxiety, fear or distress. After waking up, people experiencing nightmares are quickly alert and generally remember the dream and can describe it in detail. The nightmares cause significant distress or problems functioning. Nightmares often begin between ages 3 and 6 years but are most prevalent and severe in late adolescence or early adulthood. Rapid Eye Movement Sleep Behavior Disorder Rapid eye movement (REM) sleep behavior disorder involves episodes of arousal during sleep associated with speaking and/or movement. The person’s actions are often responses to events in the dream, such as being attacked or trying to escape a threatening situation. Speech is often loud, emotion-filled, and profane. These behaviors may be a significant problem for the individual and their bed partner and may result in significant injury (such as falling, jumping, or flying out of bed; running, hitting, or kicking). Upon awakening, the person is immediately alert and can often recall the dream. These behaviors arise during REM sleep and usually occur more than 90 minutes after falling asleep. The behaviors cause significant distress and problems functioning and may include injury to self or the bed partner. Embarrassment about the episodes can cause problems in social relationships and can lead to social isolation or work-related problems. The prevalence of REM sleep behavior disorder is less than 1% in the general population and it overwhelmingly affects males older than 50. Hypersomnolence Disorder People with hypersomnolence disorder are excessively sleepy even when getting at least 7 hours sleep. They have at least one of the following symptoms: Recurrent periods of sleep or lapses into sleep within the same day (such as unintentional naps while attending a lecture or watching TV) Sleeping more than nine hours per day and not feeling rested Difficulty being fully awake after abruptly waking up The extreme sleepiness occurs at least three times per week, for at least three months. Individuals with this disorder may have difficulty waking up in the morning, sometimes appearing groggy, confused or combative (often referred to as sleep inertia). The sleepiness causes significant distress and can lead to problems with functioning, such as issues with concentration and memory. The condition typically begins in late teens or early twenties but may not diagnosed until many years later. Among individuals who consult in sleep disorders clinics for complaints of daytime sleepiness, approximately 5%–10% are diagnosed with hypersomnolence disorder. Narcolepsy People with narcolepsy experience periods of an irrepressible need to sleep or lapsing into sleep multiple times within the same day. Sleepiness typically occurs daily but must occur at least three times a week for at least three months for a diagnosis of narcolepsy. People with narcolepsy have episodes of cataplexy, brief sudden loss of muscle tone triggered by laughter or joking. This can result in head bobbing, jaw dropping, or falls. Individuals are awake and aware during cataplexy. Narcolepsy nearly always results from the loss of hypothalamic hypocretin (orexin)-producing cells. This deficiency in hypocretin can be tested through cerebrospinal fluid via a lumbar puncture (spinal tap). Narcolepsy is rare, affecting and estimated 0.02%–0.04% of the general population. It typically begins in childhood, adolescence or young adulthood. Restless Legs Syndrome Restless legs syndrome involves an urge to move one’s legs, usually accompanied by uncomfortable sensations in the legs, typically described as creeping, crawling, tingling, burning, or itching. The urge to move the legs: begins or worsens during periods of rest or inactivity; is partially or totally relieved by movement; and is worse in the evening or at night than during the day or occurs only in the evening or at night. The symptoms occur at least three times per week, continue for at least three months, and cause significant distress or problems in daily functioning. The symptoms of restless legs syndrome can cause difficulty getting to sleep and can frequently awaken the individual from sleep, leading, in turn, to daytime sleepiness. Restless legs syndrome typically begins in a person’s teens or twenties and it affects an estimated 2% to 7.2% of the population. Circadian Rhythm Sleep-Wake Disorders With circadian rhythm sleep-wake disorders, a person’s sleep-wake rhythms (body clock) and the external light-darkness cycle become misaligned. This misalignment causes significant ongoing sleep problems and extreme sleepiness during the day leading to significant distress or problems with functioning. Circadian rhythm disorders can be caused by internal factors (a person’s body clock is different than the light-dark cycle) or external factors (such as shift work or jet lag). Prevalence of delayed sleep phase type (staying up late and getting up late) in the general population is approximately 0.17% but estimated to be greater than 7% in adolescents. The estimated prevalence of advanced sleep phase type (going to sleep early and waking early) is approximately 1% in middle-age adults and it is more common in older adults. References American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth edition. 2013. Centers for Disease Control and Prevention. Insufficient Sleep is a Public Health Problem. Accessed July 2017. National Sleep Foundation. Sleep Health Index. 2014.

Excoriation (Skin-Picking) Disorder A person with excoriation (skin-picking) disorder, also known as dermatillomania, repeatedly picks at one’s own skin enough to cause lesions. The skin-picking behavior causes significant distress or problems in work, social interactions, or other activities. It can cause feelings of a loss of control, embarrassment, and shame and can lead to avoiding social situations. Individuals with excoriation disorder have usually made repeated attempts to decrease or stop skin picking. The behavior may be triggered by feelings of anxiety or boredom. It may be preceded by an increasing sense of tension and may lead to a sense of relief after, or it may be a more automatic behavior. It sometimes involves a compulsion to try to fix perceived “blemishes.” In the general population, the lifetime prevalence of excoriation disorder in adults is estimated at less than 2% and it is much more common among women than men. It most often begins in adolescence, and it may come and go over time Treatment for skin picking disorder typically involves cognitive behavioral therapy, including a technique called habit reversal therapy, which can help identify stressors and triggers, tolerate and reduce urges, and replace the behavior with one that is less harmful. People with excoriation disorder often have other psychiatric disorders, such as depression or obsessive-compulsive disorder. Source: International OCD Foundation

“She would never hurt her baby.” These are words commonly uttered by the partners and family members of women presenting to our facilities with postpartum psychosis (PPP) symptoms. In their reluctance to accept the presence of a mental illness and its related risks, and in their desire to get their loved one out of a psychiatric facility and back home with her baby, partners and family members of patients with PPP often minimize the severity of symptoms they have observed and place themselves at odds with the inpatient psychiatric team seeking to hold and treat the patient. Their reasons for doing so are myriad, but often rooted in a lack of understanding of the course of PPP episodes and the potential for devastating outcomes of not providing treatment. At Connections Health Solutions psychiatric crisis centers in Arizona, where I serve as medical director, we typically have at least 1 patient with PPP. By contrast, many psychiatrists in the community encounter PPP rarely, or not at all. Despite this, it is vital that we are all prepared to recognize the risk factors and early signs of a developing episode, and to provide education and guidance to patients and their supports. Given the co-occurrence of massive hormone fluctuations, sleep deprivation, and the acute psychological stress of being wholly responsible for keeping a newborn alive, it is no wonder that the postpartum period is fraught with vulnerability for the development of mood disturbances, anxiety disorders, and psychosis. Findings from some studies have shown that a woman’s risk of hospitalization for psychosis is higher in the first postpartum month than it is at any other time in her life. Helping expectant mothers and their supports prepare for these possibilities, whether it is as common and relatively benign as the so-called “baby blues” or as rare and potentially life-threatening as PPP, is the first step to improving clinical outcomes. As with most psychiatric disorders, early intervention is key to improving clinical outcomes for PPP, and this becomes more feasible when mental health clinicians, patients, and their supports are familiar with risk factors and early warning signs. A Brief Summary of the Clinical Aspects of PPP Table. Identified Risk Factors for Developing PPP3-5 PPP is relatively rare, occurring in 1 to 2 per 1000 live births, with at least half of sufferers having no psychiatric history.1,2 Identified risk factors for developing PPP are listed in the Table.3-5 Psychiatrists should take careful family histories when caring for pregnant and postpartum patients, inquiring about any history of psychiatric hospitalization, mania, psychosis, depression, and suicide. The onset of PPP is rapid and severe, with hallucinations, delusions, emotional distress, and bizarre behaviors seen as early as 2 days after, and typically within 2 weeks of, delivery.2,6 The patients whom I have encountered, presenting with their first episodes of psychosis during the postpartum period, have typically exhibited delusions that are persecutory, religious, and/or grandiose in nature and usually involve the baby (for example, believing that something “evil” is happening to the baby). This differs from patients with a history of psychosis presenting with relapse of symptoms during the postpartum period, who tend to present with psychotic symptoms similar to those exhibited during their previous episodes. Episodes of PPP can last for months, and subsequent psychotic episodes outside of the postpartum period are common.7 The association between PPP and bipolar I disorder is well established, with onset of psychosis in the immediate postpartum period being a significant predictor of a later diagnosis of bipolar I disorder, although some women do present with an isolated episode of PPP that does not develop into a chronic psychiatric disorder following the postpartum period.6,8,9 There is a significant risk of death by suicide in patients presenting with first-episode PPP, with study data demonstrating rates as high as 4% to 11%, as well as a risk of homicide, with 4% of women with PPP committing infanticide.7,10 PPP should be considered a medical emergency that necessitates rapid identification and intervention, which should always begin by ensuring the safety of the patient and her child(ren). It is recommended that patients with PPP be psychiatrically hospitalized and that they not be left alone with their child(ren) prior to stabilization. With appropriate pharmacotherapy and support, patients can make a full recovery. Tragic Outcomes of Untreated PPP Andrea Yates. Kimberlynn Bolanos. Carol Coronado. We are likely all familiar with at least 1 of these names. All 3 women live in infamy after having murdered their children while in the throes of PPP. All 3 also had romantic partners who had observed signs of mental illness in them but were not able to prevent the murder of their children. And of course, all 3 women have faced the vitriol of the US public and criminal justice system. If you have not viewed the 2019 documentary Not Carol, I suggest you do so. It tells the story of Carol Coronado, a loving and devoted mother who murdered her 3 young children and then stabbed herself in the chest during a PPP episode in 2014. Prosecutors sought the death penalty, but she ultimately received 3 life sentences. The documentary features psychiatrist Torie Sepah, MD, who treated Carol at the Twin Towers Correctional Facility in Los Angeles, California, following her arrest and testified in her criminal trial. Sepah speaks and writes passionately about the tragic loss of life that can result from untreated PPP—a tragedy that is too often compounded by a justice system that often seeks to punish rather than to treat these patients, each of whom will suffer until her last breath knowing that her child(ren) died at her hands. But the greatest tragedy of all is that PPP is treatable and these horrific outcomes are preventable when intervention is swift. Concluding Thoughts PPP is a serious psychiatric disorder with a significant risk of morbidity and mortality for the patient and her child(ren). Early and aggressive treatment is vital to improving outcomes, and we must find ways to reduce the barriers to achieving them. This starts with psychiatrists gaining expertise on PPP and sharing that knowledge with others. When it comes to the woman experiencing PPP, it may be true that she would never hurt her baby, but she is not herself. Fortunately, there is treatment and there is hope. Dr Costales serves as Arizona medical director at Connections Health Solutions, overseeing all clinical operations for Connections crisis response centers in Phoenix and Tucson. Prior to joining Connections, she spent time working with individuals designated as being seriously mentally ill in outpatient settings. References 1. Terp IM, Mortensen PB. Post-partum psychoses: clinical diagnoses and relative risk of admission after parturition. Br J Psychiatry. 1998;172:521-526. 2. Blackmore ER, Rubinow DR, O’Connor TG, et al. Reproductive outcomes and risk of subsequent illness in women diagnosed with postpartum psychosis. Bipolar Disord. 2013;15(4):394-404. 3. Videbech P, Gouliaev G. First admission with puerperal psychosis: 7-14 years of follow-up. Acta Psychiatr Scand. 1995;91(3):167-173. 4. Nonacs R, Cohen LS. Postpartum mood disorders: diagnosis and treatment guidelines. J Clin Psychiatry. 1998;59(suppl 2):34-40. 5. Jones I, Craddock N. Familiality of the puerperal trigger in bipolar disorder: results of a family study. Am J Psychiatry. 2001;158(6):913-917. 6. Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet. 2014;384(9956):1789-1799. 7. Gilden J, Kamperman AM, Munk-Olsen T, et al. Long-term outcomes of postpartum psychosis: a systematic review and meta-analysis. J Clin Psychiatry. 2020;81(2):19r12906. 8. Munk-Olsen T, Laursen TM, Meltzer-Brody S, et al. Psychiatric disorders with postpartum onset: possible early manifestations of bipolar affective disorders. Arch Gen Psychiatry. 2012;69(4):428-434. 9. Wesseloo R, Kamperman AM, Munk-Olsen T, et al. Risk of postpartum relapse in bipolar disorder and postpartum psychosis: a systematic review and meta-analysis. Am J Psychiatry. 2016;173(2):117-127. 10. Parry BL. Postpartum psychiatric syndromes. In: Kaplan HI, Sadock BJ, eds. Comprehensive Textbook of Psychiatry. 6th ed. Williams & Wilkins; 1995 Source: Psychiatric Times: Volume 40, Issue 7; Theresa Costales, MD

Self-Reflection of my life It is an amazing experience to recognize how much your growth and development is influenced by a stable, loving environment. I use to think in my teens and early 20’s that I was nothing like my parents. I would describe the contrast, as though they were born in Mercury and I was born in Pluto. But, during my late 20’s and early 30’s, I realize that I am nothing more than a reflection of the values, beliefs, and ideals that were taught to me by my parents, my extended family, mentors, etc. I think its interesting to see that I am a hybrid of these influential people, who showed me true, unconditional love through their actions and not just their words. I view children as sponges, who are very capable of absorbing positive and negative experiences based on the influence of their environment. This is a concept that I consistently discuss with my patients’ parents, to help them recognize how much of an positive influence they can be on their children. After working with children for over the years, I realize how much instability children can be exposed to. I think my mom is sometimes surprised when I give her random compliments about how great of a parent I think she is. Both of my parents sacrificed so much for the betterment of my sister and I, forgoing their happiness at times. I truly learned about sacrifice through their actions, because they believed that my sister and I would be reflections of their love and dedication. As a child, I use to recognize how much effort my parents would put into being a part of my life. They always wanted me to be well-rounded, which is why they would let me try new things. I think I was enrolled in at least 4 different sports, each year, in which my parents would try to attend each event. In addition, they emphasized pretty consistently that I needed to do well in school, otherwise I would lose a lot of such privileges. I still laugh at how they let me get 3 earrings when I was in high school/college, which I thought at the time was “super cool”. I think that’s what I love the most is they never restricted me from exploring aspects of life, within a certain limit. I still laugh about the time that I was “super into” playing the clarinet, had my mom purchase a brand new one. Then I slowly started showing interest playing the saxophone, as the clarinet was “not cool enough”. I imagine my mom might have been annoyed, but she did not get mad, based on my shift in interest. My new music interest in playing the tabla, which I have not played in a while, however I need to start practicing again. I took lessons for approximately 1.5 years, which was amazing. I think its the coolest instrument, reflecting the richness of the Indian culture, which I love. As an first generation Indian-American, my parents submerged me into the Indian culture and Hindu religion as a youth, which I did not appreciate at the time. I was more interested in running around and playing games with friends that I would met. I guess I am only a reflection of the incredible people that I was blessed with. I will always miss my father, who was an amazing human being. I can notice things that I say or do that replicate his prior actions, which I find fascinating. Source: Medium - Author Dr. Vilash Reddy

Grass isn’t greener on the other side The grass isn’t always greener on the other side. It is a false perception of reality. No grass is “perfect”. Sometimes the most important aspect that we sometimes forget is to appreciate the patch of a grass we were blessed with. In order for growth and beauty to manifest we should cultivate and add nutrients to the areas that deficient and have realistic expectations for the rates of progression. It is important to be honest about areas that we need to improve, though it can challenging. We should focus on each isolated moment that a strand of grass is green and vibrant, eventually these changes will manifest overall. At some point, take the time to reflect and appreciate how beautiful the changes in your patch of grass are, due to the foundation of honesty, effort, and cultivation.

One movie that I think was very fascinating is a movie called Happy, which is available on Netflix. It is documentary film directed, written, and co-produced by Academy Award nominated film-make Roko Belic. It discusses principles of happiness, particularly through the perspective of positive psychology, through a series of interviews of people from 14 different countries, with varying cultural, socioeconomic differences. This was created based on Belic’s interest in trying to understand the fundamental aspects of happiness, which stem from a article he read “A New Measure of Well Being From Happy Little Kingdom”, which indicated that the US was the 23rd happiest country in the world. I am not sure how this ranking was measured. Belic spent several years, meeting hundreds of people, to explore his own curiosity of what factors lead to someone being happy. The film helps deconstruct happiness from an abstract concept to a possible formula based on the principles of human psychology. It was interesting because many of the aspects of happiness that were discussed coincide with concepts that were discussed by Abraham Maslow’s hierarchy of needs illustrated below. Maslow’s theory suggests that the most basic level of needs must be met before the individual will strongly desire (or focus motivation upon) the secondary or higher level needs. Maslow also coined the term “metamotivation” to describe the motivation of people who go beyond the scope of the basic needs and strive for constant betterment. The movie reflects, that regardless of socioeconomic factors and wealth, a individual was capable of feeling happy if he/she were capable advancing their life according the hierarchy that had been stated by Maslow. I thought this was an interest parallel which was not discussed in the movie, however coincided. I think in many ways I believe that Maslow’s hierarchy applies to my life, where I try to focus on my health first and foremost. Source: Medium, Author Vilash Reddy, MD

Children and adults with attention-deficit/hyperactivity disorder (ADHD) show greater improvement in symptoms with viloxazine extended release (ER) compared with treatment with atomoxetine, new research suggests. Investigators studied patients who started out taking atomoxetine and, after a washout period, initiated treatment with viloxazine. Participants' ADHD symptoms were assessed prior to initiation of each treatment and after 4 weeks. Children and adults showed significantly larger improvement in inattentiveness and hyperactivity/impulsivity when taking viloxazine vs atomoxetine, with almost all patients preferring the former to the latter. ADHD In addition, close to one half of the study participants were taking a prior stimulant, and 85% were able to taper off stimulant treatment. Viloxazine's effects were also more rapid than were those of atomoxetine. "It is timely to have a rapidly acting, and highly effective non-stimulant option across the full spectrum of ADHD symptoms, for both children and adults, in light of recent stimulant shortages and the new FDA [US Food and Drug Administration] boxed warnings regarding increased mortality associated with overuse of stimulants" study investigator Maxwell Z. Price, a medical student at Hackensack Meridian School of Medicine, told Medscape Medical News. Nonstimulant Treatment Options Study co-author Richard L. Price, MD, told Medscape Medical News that the study was conducted to find a more acceptable alternative to psychostimulant treatments for ADHD, which are currently considered the "gold standard." Although they are effective, said Price, they are fraught with adverse effects, including appetite suppression, insomnia, exacerbation of mood disorders, anxiety, tics, or misuse. Atomoxetine, a nonstimulant option, has been around for a few decades and is often used in combination with a stimulant medication. However, he said, the drug has a mild effect, requires frequent dosage adjustment, takes a long time to work, and people have "soured" on its utility, Price added. Like atomoxetine, viloxazine is a selective norepinephrine inhibitor that has been used an antidepressant in Europe for 30 years. It was recently reformulated as an extended-release medication and approved by the FDA for pediatric and adult ADHD. However, unlike atomoxetine, viloxazine is associated with increased prefrontal cortex 5-hydroxytrytamine, norepinephrine, and dopamine levels in vivo.There have been no head-to-head trials comparing the two agents. However, even in head-to-head ADHD medication trials, the agents that are under investigation are typically compared in matched patients. The current investigators wanted to compare the two agents in the same patients whose insurers mandate a trial of generic atomoxetine prior to covering branded viloxazine. "We wanted to find out whether patients taking atomoxetine for ADHD combined type would experience improvement in ADHD symptoms following voluntary, open-label switch to viloxazine," said Price The researchers studied 50 patients who presented with ADHD combined type and had no other psychiatric, medical, or substance-related comorbidities or prior exposure to atomoxetine or viloxazine. The study included 35 children (mean age, 11.9 ± 2.9 years; 94.3% male) and 15 adults (mean age, 29.3 ± 9.0 years; 73.3% male). Of these, 42.9% and 73.3%, respectively, were taking concurrent stimulants. Patients received mean doses of atomoxetine once daily followed by viloxazine once daily after a 5-day washout period between the two drugs. Participants were seen weekly for titration and monitoring. At baseline, the pediatric ADHD-Rating Scale 5 (ADHD-RS-5) and the Adult Investigator Symptoms Rating Scale (AISRS) were completed, then again after 4 weeks of treatment with atomoxetine (or upon earlier response or discontinuation due to side effects, whichever came first), and 5 days after discontinuing atomoxetine, which "re-established the baseline score." The same protocol was then repeated with viloxazine. 'Paradigm Shift' At baseline, the total ADHD-RS-5 mean score was 40.3 ± 10.3. Improvements at 4 weeks were greater in viloxazine vs atomoxetine, with scores of 13.9 ± 10.2 vs 33.1 ± 12.1, respectively (t = -10.12, P < .00001). In inattention and hyperactivity/impulsivity, the t values were -8.57 and -9.87, respectively (both Ps < .0001). Similarly, from the baseline total, AISRS mean score of 37.3 ± 11.8, improvements were greater on viloxazine vs atomoxetine, with scores of 11.9 ± 9.4 vs 28.8 ± 14.9, respectively (t = −4.18, P = .0009 overall; for inattention, t = −3.50, P > .004 and for hyperactivity/impulsivity, t = 3.90, P > .002). By 2 weeks, 86% of patients taking viloxazine reported a positive response vs 14% when taking atomoxetine. Side effects were lower in viloxazine vs atomoxetine, with a total of 36% of patients discontinuing treatment with atomoxetine due to side effects that included gastrointestinal upset, irritability, fatigue, and insomnia vs 4% who discontinued viloxazine due to fatigue. Almost all participants (96%) preferred viloxazine over atomoxetine and 85% were able to taper off stimulant treatment following stabilization on viloxazine. "These were not small differences," commented Richard Price. "These were clinically and statistically meaningful differences." The findings could represent "a paradigm shift for the field" because "we always think of starting ADHD treatment with stimulants, but perhaps treatment with viloxazine could help patients to avoid stimulants entirely," he suggested. Real-World Study Commenting for Medscape Medical News, Greg Mattingly, MD, associate Clinical Professor, Washington University, St. Louis, Missouri, called it "a timely addition to the clinical literature where for the first time ever we have 2 non-stimulant options approved for adults with ADHD." This real-world clinic study "yields many answers," said Mattingly, who is also the president-elect of the American Professional Society of ADHD and Related Disorders (APSARD) and was not involved with the study. "Simply put, this real-world study of 50 clinic patients found that viloxazine ER had faster onset, was significantly more effective, and was preferred by 96% of patients as compared to atomoxetine," he said. "Another intriguing part of the study that will be of high interest to both patients and providers was that, of those initially treated concurrently with stimulant and viloxazine ER, 85% were able to discontinue their stimulant medication," Mattingly added. Source: Medscape Medical News; Batya Swift Yasgur, MA, LSW; July 21, 2023

How does schizophrenia differ between men and women, and what does this mean for developing treatment strategies Several aspects of schizophrenia differ considerably between men and women and influence treatment strategies. The most important differentiating factors are the age of onset, symptom differences, response to antipsychotic medications, parenting responsibilities, and care during the menopausal transition. Age of Onset and Differences in Symptoms The first occurrence of the symptoms and behaviors that conform with the currently accepted definition of schizophrenia occur, on average, several years earlier in men than they do in women.1 The older age of onset found in women is partially explained by the fact that many large studies include a wide range of ages, sometimes extending into older age. In women, a second peak of schizophrenia onset occurs around the time of menopause,2 which has been attributed to the decline of estrogen levels as menopause approaches.3 This hypothesis is consistent with the observation that schizophrenia symptoms can be exacerbated during other times of estrogen withdrawal not only at perimenopause,4 but also postpartum5 and during the premenstrual phase of the menstrual cycle.6 It has been suggested that the onset of psychotic symptoms in middle-aged women may have a different etiology than onset that occurs in young adulthood. One hypothesis is that a first episode in middle age predominantly relates to the social stressors that women experience at this time (Table).7 Women with schizophrenia tend to be more socially adept than their male peers, perhaps because they socially mature earlier than men and because their psychotic symptoms often begin at a later age.8 Thus, the adolescent presentation of schizophrenia in women may be less clinically obvious because women can mask early schizophrenia with appropriate affect and relatively easy therapeutic engagement. The flat affect and negative symptoms that characterize men with schizophrenia may not be present in women.9 Moreover, women with schizophrenia usually have fewer cognitive symptoms than men.10 For these reasons, it is easier to attribute symptoms such as delusions and hallucinations in these young women to depression, anxiety, post-traumatic stress disorder, dissociation, and even eating disorders. Thus, women with schizophrenia are often misdiagnosed early in the course of their illness. In contrast, the main differential diagnosis in young men presenting with psychotic symptoms is substance use.11 This means that adolescent schizophrenia is often diagnosed late in women, both because it is not expected and because the first presentation may not meet textbook specifications. Finally, a distinguishing presentation in women with schizophrenia is that symptoms often fluctuate, corresponding to the ups and downs of estrogen levels across the menstrual cycle.12,13 Response to Antipsychotic Medications Women with schizophrenia find it easier than their male peers to form therapeutic alliances with their clinicians,14 and, perhaps for this reason, tend to respond to cognitive-behavioral, psychotherapeutic, and pharmacologic treatments more robustly than men.15 Differences in antipsychotic medication effects between men and women are frequently reported for several reasons. Body build usually differs in height and in lipid storage, both of which are important for drug distribution.16 The amount of therapeutic drug that reaches the relevant neurotransmitter receptors in the brain depends on a number of factors (absorption, distribution, metabolism, elimination, protein binding, blood flow to the brain), but, in sum, at comparable oral doses, more of the drug reaches targets in the brain in women than it does in men.15 This varies somewhat depending on the specific drug and whether the enzymes responsible for the drug’s breakdown are affected by estrogen levels.17 The overall effect of differences between men and women in body habitus and metabolism is that women respond to lower doses of anti-psychotic medications. On the other hand, when receiving the same doses as men, women develop more adverse effects. Metabolic effects (leading to type 2 diabetes), cardiac effects (torsade de pointes), hyperprolactinemia effects (hirsutism and acne, osteoporosis, breast cancer), and tardive dyskinesia are important potential adverse effects that are seen more commonly in women than in men.18 Parenting Responsibilities Many women with schizophrenia want to be mothers, but many do not. Discussions about this issue are important because those who do not want children need contraceptive advice and reminders, while those who want children need psycho-education, social skills training, and preparation for pregnancy and motherhood.19 Clinicians can help female patients with schizophrenia to plan pregnancy in a few different ways. They need to address smoking and substance abuse, advising their patients to gradually wean themselves off prior to conception.20 Discussions with patients and their partners should also include the pros and cons of anti-psychotic medication use during pregnancy, as well as the risks of untreated psychiatric illness to the mother, the pregnancy, and the exposed infant. Clinicians need also to refer their patients to obstetrics/gynecology, monitor their prenatal care, and carefully titrate all medications over the course of the stages of pregnancy in order to maintain the patient’s psychiatric well-being.21 Family support is essential at this time. When the patient is in a relationship, meeting with the couple is essential. Domestic abuse is sometimes triggered by pregnancy.22 When patients are living in supported housing, new and child-appropriate living and financial arrangements are often necessary, and, because the postpartum period is a time of risk for psychotic relapse in schizophrenia,23 home visits by members of the therapeutic team are necessary. Antipsychotic doses are usually kept low during late pregnancy, but they need to be increased after delivery when estrogen levels sharply fall and when symptoms can increase in severity. Breastfeeding may or may not be the best course for mother and child, depending on the mother’s wishes and their support system, so this decision should be made with careful consideration.24 Although fewer than a third of men with schizophrenia become fathers (this varies according to country and culture), approximately 50% of women with schizophrenia are mothers, which is roughly the same percentage as in the general population.25 In many cases, women raise their children on their own, and, even when women are partnered, the responsibilities of parenthood lie primarily with mothers. Because of disability, women with schizophrenia are too often economically disadvantaged, live in poor neighborhoods, eat poorly, sleep poorly, have no childcare, and enjoy relatively little family support. Some women with this disorder believe that, due to their diagnosis, they risk losing custody of their children. Because of this belief, they mistakenly think that if they stop taking medication, they will no longer be viewed as psychiatrically ill—a decision that can prove disastrous.26 Mothers with schizophrenia need therapeutic support at home when young children make mental health visits difficult. Inexperienced mothers need support, parental education, and financial assistance. Family therapy to maintain as much familial engagement as possible is also needed. The well-being of children should come first, which means that childcare workers are ideally included in the therapeutic team. Should mothers require hospitalization, temporary surrogate parenting plans should be in place.26 The Menopausal Transition Women’s transition to menopause—known as perimenopause, which tends to begin approximately at age 40 years—can occur early in women with schizophrenia because most antipsychotic medications raise prolactin levels and, consequently, suppress ovarian production of estrogen. Low estrogen levels can be associated with acne, hirsutism, and weight gain, affecting physical appearance; cause vaginal dryness and lower sexual libido; and predispose to osteoporosis. Perimenopause is also associated with hot flashes, night sweats, and insomnia. At the same time, women at this stage of life often experience psychological concerns and psychosocial stressors, which can trigger symptomatic relapse.27 In addition, antipsychotic medications that are metabolized by enzymes that are sensitive to estrogen levels may lose their effectivenessat this time.6 In turn, if the dosage of an antipsychotic is increased, adverse effects can increase. A switch to intramuscular long-acting medication has been recommended; a series of family meetings in order to reduce stress levels is advisable as well. Medical issues such as sleep apnea, breast cancer, cardiovascular and respiratory problems, osteoporosis, and osteoarthritis may emerge at this age and ideally should be addressed early.28 A Note About Suicide As in the general population, women with schizophrenia, as a group, suffer more from depression than do men with the same diagnosis, but men with schizophrenia commit suicide much more frequently. However, it must be remembered that, when it comes to schizophrenia, the proportion of women vs men who complete suicide is significantly larger than that ratio in the general population. Women as well as men with schizophrenia are at considerable risk for suicide. Suicidal thoughts should be identified and monitored, and patients must be reassured that, should they feel desperate, a team member will always be available.29 Concluding Thoughts To summarize this report on treatment needs in women with schizophrenia, the emphasis has been on strategic approaches for women patients and how these may differ from the ones routinely used with men. It must be remembered, however, that women are individuals, each of whom has her own history and her own needs. As Sir William Osler taught, “It is important to care more particularly for the individual patient than for the special features of the disease.”30 Dr Seeman is professor emerita in the Department of Psychiatry at the University of Toronto in Toronto, Ontario, Canada. References 1. Häfner H. From onset and prodromal stage to a life-long course of schizophrenia and its symptom dimensions: how sex, age, and other risk factors influence incidence and course of illness. Psychiatry J. 2019;2019:9804836. 2. Selvendra A, Toh WL, Neill E, et al. Age of onset by sex in schizophrenia: proximal and distal characteristics. J Psychiatr Res. 2022;151:454-460. 3. Brand BA, de Boer JN, Sommer IEC. Estrogens in schizophrenia: progress, current challenges and opportunities. Curr Opin Psychiatry. 2021;34(3):228-237. 4. Sommer IE, Brand BA, Gangadin S, et al. Women with schizophrenia-spectrum disorders after menopause: a vulnerable group for relapse. Schizophr Bull. 2023;49(1):136-143. 5. Perry A, Gordon-Smith K, Jones L, Jones I. Phenomenology, epidemiology and aetiology of postpartum psychosis: a review. Brain Sci. 2021;11(1):47. 6. Reilly TJ, Sagnay de la Bastida VC, Joyce DW, et al. Exacerbation of psychosis during the perimenstrual phase of the menstrual cycle: systematic review and meta-analysis. Schizophr Bull. 2020;46(1):78-90. 7. González-Rodríguez A, Guàrdia A, Monreal JA. Peri- and post-menopausal women with schizophrenia and related disorders are a population with specific needs: a narrative review of current theories. J Pers Med. 2021;11(9):849. 8. Rochat MJ. Sex and gender differences in the development of empathy. J Neurosci Res. 2023;101(5):718-729. 9. Malaspina D, Walsh-Messinger J, Gaebel W, et al. Negative symptoms, past and present: a historical perspective and moving to DSM-5. Eur Neuropsychopharmacol. 2014;24(5):710-724. 10. Zhao N, Wang XH, Kang CY, et al. Sex differences in association between cognitive impairment and clinical correlates in Chinese patients with first-episode drug-naïve schizophrenia. Ann Gen Psychiatry. 2021;20(1):26. 11. Irving J, Colling C, Shetty H, et al. Gender differences in clinical presentation and illicit substance use during first episode psychosis: a natural language processing, electronic case register study. BMJ Open. 2021;11(4):e042949. 12. Brzezinski-Sinai NA, Brzezinski A. Schizophrenia and sex hormones: what is the link? Front Psychiatry. 2020;11:693. 13. Seeman MV. Menstrual exacerbation of schizophrenia symptoms. Acta Psychiatr Scand. 2012;125(5):363-371. 14. Browne J, Bass E, Mueser KT, et al. Client predictors of the therapeutic alliance in individual resiliency training for first episode psychosis. Schizophr Res. 2019;204:375-380. 15. Li R, Ma X, Wang G, Yang J, Wang C. Why sex differences in schizophrenia? J Transl Neurosci (Beijing). 2016;1(1):37-42. 16. Seeman MV. Antipsychotic-induced somnolence in mothers with schizophrenia. Psychiatr Q. 2012;83(1):83-89. 17. Seeman MV. The pharmacodynamics of antipsychotic drugs in women and men. Front Psychiatry. 2021;12:650904. 18. Brand BA, Haveman YRA, de Beer F, et al . Antipsychotic medication for women with schizophrenia spectrum disorders. Psychol Med. 2022;52(4):649-663. 19. Schonewille NN, van den Eijnden MJM, Jonkman NH, et al. Experiences with family planning amongst persons with mental health problems: a nationwide patient survey. Int J Environ Res Public Health. 2023;20(4):3070. 20. Azenkot T, Dove MS, Fan C, et al. Tobacco and cannabis use during and after pregnancy in California. Matern Child Health J. 2023;27(1):21-28. 21. Seeman MV. Clinical interventions for women with schizophrenia: pregnancy. Acta Psychiatr Scand. 2013;127(1):12-22. 22. Wilson CA. Mitigating the increased risk of domestic abuse among people with mental illness: challenges and opportunities of the COVID-19 pandemic. BJPsych Advances. 2022;28(5):328-329. 23. Taylor CL, Stewart RJ, Howard LM. Relapse in the first three months postpartum in women with history of serious mental illness. Schizophr Res. 2019;204:46-54. 24. Breadon C, Kulkarni J. An update on medication management of women with schizophrenia in pregnancy. Expert Opin Pharmacother. 2019;20(11):1365-1376. 25. Radley J, Barlow J, Johns LC. Sociodemographic characteristics associated with parenthood amongst patients with a psychotic diagnosis: a cross-sectional study using patient clinical records. Soc Psychiatry Psychiatr Epidemiol. 2022;57(9):1897-1906. 26. Seeman MV. Intervention to prevent child custody loss in mothers with schizophrenia. Schizophr Res Treatment. 2012;2012:796763. 27. González-Rodríguez A, Monreal JA, Seeman MV. The effect of menopause on antipsychotic response. Brain Sci. 2022;12(10):1342. 28. Solomon HV, Sinopoli M, DeLisi LE. Ageing with schizophrenia: an update. Curr Opin Psychiatry. 2021;34(3):266-274. 29. Sommer IE, Tiihonen J, van Mourik A, et al. The clinical course of schizophrenia in women and men - a nation-wide cohort study. NPJ Schizophr. 2020;6(1):12. 30. Osler W. Aequanimitas, With Other Addresses to Medical Students, Nurses and Practitioners of Medicine. Blakiston’s Son & Co; 1905. Source: Psychiatric Times: Jul 21, 2023; Mary V. Seeman, MD

Nutraceuticals are a special class of supplements that have been found by the FDA to be safe enough for sale over the counter in the US without a prescription. However it is an unregulated industry, where consumers are pretty unaware of what they are buying as the industry is filled with false advertisements. It is estimated that US citizens spend millions of dollars on supplements that they commonly find at local drug stores, which are commonly have addictive, fillers, etc. The bio-availability is limited for consumers may find limited or no benefits. It is important to find quality products that consumers have found beneficial. I will provide a list of various products that could be potentially beneficial based on bio-availability, quality of ingredients, source of product, and positive feedback by consumers. Remember, costs does not necessarily make it a better quality of product. SAM-E (S-adenosylmethionine) has been the first line, mainstream antidepressants mostly used in Europe over the past 20 years. SAMe is the essentially the same molecule that participates in hundreds of biochemical reactions. It donates molecules for the production of DNA, phosholipids, three key neurotransmitters (Serotonin, Norephriphrine, and Dopamine). In approximately 50 clinical trials it was found to be safe and effective. It has a very low side profile and has a rapid onset of action (compared to antidepressants which take 4-6 weeks, minimum). No adverse reactions have been reported with other medications. Bonus, it protects the liver from the toxic effects of other medications. It is a great augmenting agent, for antidepressant or when the medication seems to wear off. SAMe can be activating and can worsening underlying anxiety so should be closely monitored under the care of a licensed physician. This supplement has a low side effect profile compared to other antidepressants. One of the benefits is it causes no weight gain or sexual side effects (which are frequently caused by an SSRI or SNRI). Avoid taking this supplement without the guidance of physician as it could potentially (in rare cases) induce Bipolar Disorder (which can be caused by any antidepressant, if there is any genetic predisposition). Many physicians believe that depression and bipolar disorder lie on a spectrum and are not individual diagnosis, contrary to common belief. This symptoms should be taken on a empty stomach before breakfast. If experience anxiety or agitation, it would be transient, however mild anxiety medications used temporarily can help the transition. Like any medication, the start dose is between 200mg to 400mg, as tolerated. Based on level of depression, you should consult with your dose to see how much supplement you may need which is strongly correlated with the severity of underlying depression. You may augment this medication with a B-complex. B-vitamins tend to be deficit in patients struggling with depression, which can helpful reduce mental fatigue, improve levels of energy, and improve overall well-being as these molecules are used in a majority of metabolic process, particular to induce natural body energy. One of the fascinating aspects of SAMe, based on various double-blind studies is that it can help conditions arthritis, fibromyalgia, reduce the effect of cirrhosis (chronic liver disease), mood improvements in patients struggling with HIV/AIDS, and Parkinson's Disorder (one commonly used medication Levodopa reduces the natural SAMe produced in the body). There is ongoing research of its children (which are not responding to medication, or refuse to take medication). Given their age, they would need much smaller doses with a faster response. SAMe is minimal reactive with other medications, in fact can protect the liver, can be combined or augment typical antidepressants to reduce typical side effects issues. Source: How to Use Herbs, Nutrients, & Yoga in Mental Health