Search Results

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

Keypoint: Sleep disordered breathing and ADHD are highly cross-prevalent, particularly among children and adolescents. A targeted review published in the Journal of Attention Disorders found that the relationship between sleep disordered breathing (SDB) and attention-deficit/hyperactivity disorder (ADHD) was well-supported. In particular, SDB may contribute to the development and worsening of ADHD symptoms . Disordered sleep has been associated with impaired cognition and ADHD and SDB appears to be highly prevalent among children with ADHD. However, the relationship between ADHD and SDB may be under-recognized and relatively understudied. To provide a more comprehensive understanding of the effect of SDB on ADHD, investigators searched publication databases through September 2022 for studies of SDB and/or obstructive sleep apnea (OSA) in ADHD in their focused review. In evaluating the prevalence and co-occurrence of SDB/OSA and ADHD, the investigators found that the existing evidence indicates a high cross-prevalence between sleep disorders and ADHD (or ADHD symptoms), particularly among children and adolescents. One study found that among 3019 children aged 5 years, 25% had SDB. The children with SDB had a higher prevalence of hyperactivity (odds ratio [OR], 2.5; 95% CI, 2.0-3.0), inattention (OR, 2.1; 95% CI, 1.7-2.6), and aggressiveness (OR, 2.1; 95% CI, 1.6-2.6) than the children without SDB. Similarly, a review found that children with OSA had a high rate of attentional deficits (95%), and up to 20% to 30% of children with ADHD had OSA. Furthermore, a meta-analysis reported that youth with SDB were at higher risk of presenting with ADHD and that ADHD symptoms improved after adenotonsillectomy. The investigators found that several studies reported on the proposed mechanisms of the association between SDB and ADHD. Study authors posit that fluctuating levels of hypoxia and hypercapnia during sleep may affect brain function relating to working memory and attention. Another proposed mechanism is that SDB causes sleep fragmentation and micro-awakenings, which leads to fatigue, exhaustion, and excessive daytime sleepiness. Based on the published evidence, the review authors found a preponderance of evidence that supported the relationship between SBD and physiological processes, such as the activation of stress hormones and immunological activities. The activation of stress hormones and immunologic responses that affect blood oxygenation during sleep affects the brain regions associated with attention and executive function. These effects can, in turn, cause cognitive deficits consistent with symptoms of ADHD . The investigators stated, “Accumulating evidence on possible neurophysiological mechanisms that may link SDB to the development of ADHD-like symptoms further supports the recommendation that SDB should be considered in the initial assessment of young children exhibiting inattention, daytime fatigue and distractibility.” Review authors concluded, “While SDB and ADHD are not mutually exclusive, their comorbidity can influence the severity of each condition. Consequently, there is a need for more targeted assessment of possible sleep disturbances in children evaluated for ADHD.” Note: This article originally appeared on Psychiatry Advisor

Key Takeaways Low-dose lithium shows promise in preventing dementia and reducing suicide risk, with evidence supporting its neuroprotective effects. Microdoses of lithium may address a potential deficiency, improving mood, irritability, and cognitive function. Lithium's role in addiction recovery includes reducing medication use and improving treatment outcomes. Research supports lithium's efficacy in treating resistant depression, with benefits observed even at lower doses. As a treatment, low-dose lithium can act like a bridge between medications and integrative approaches, supporting well-being with reduced adverse effects. Rethinking Lithium Lithium has long remained at the forefront of effective treatments for bipolar disorder. However, due to safety concerns, a stigma often hangs over its use. For decades, data have slowly been building that lithium has a much wider dose-response curve with potential utility at lower doses. With my own patients, low and microdose lithium has been invaluable for helping with irritability, anger, and addiction. As a treatment, low-dose lithium can act like a bridge between medications and integrative approaches, supporting well-being with reduced adverse effects. While not generally accepted as a nutrient, some authors have made strong arguments—based on animal research and ecological studies—that lithium may fit the definition of a mineral. This may help explain why microdoses of lithium are often helpful: patients may actually be struggling with a lithium deficiency. Arguably, the strongest evidence for low-dose or even nutritional doses of lithium is for the prevention of dementia and suicide. Recent research and my own clinical experience have demonstrated additional clinical applications, including for depression, substance use disorder, and irritability. Defying Cognitive Decline: How Low-Dose Lithium May Prevent Dementia Initial evidence for the effects of lithium on cognitive decline and dementia were uncovered in patients with bipolar disorder. Bipolar is well known to increase the risk of developing dementia. An analysis from 2020 found that a diagnosis of bipolar disorder tripled the risk. In contrast, studies on patients with bipolar disorder who were on lithium as a mood stabilizer found that lithium treatment significantly reduced the risk of dementia. Based on the findings, clinical trials started exploring the use of lithium as a direct treatment for Alzheimer disease. While some of the initial studies were mixed, further clinical trials have found benefits for slowing or halting the progression of cognitive decline with lithium treatment. A trial by Nunes et al even found potential benefits with 300 µg of lithium per day. At this microdose, patients with Alzheimer disease remained stable over 15 months as patients on placebo continued to decline. At the end of the study, Mini-Mental State Examination (MMSE) scores had dropped to 14 in the placebo group, whereas the lithium group held steady at just below 20. In 2011, a trial of low-dose lithium for cognitive decline also found benefits. Treatment included 12 months of low-dose lithium, with blood levels between 0.25-0.5 mmol/L. As compared with placebo, lithium-treated subjects had a decrease in phosphorylated tau in cerebrospinal fluid (CSF) and better cognitive function. After additional data was collected on the same subjects over the next 2 years, outcomes were further improved. Placebo patients worsened, whereas the patients on low-dose lithium remained mostly stable. Memory and attention were significantly better with lithium. Lithium also increased levels of amyloid-beta peptide in the CSF at 3 years. The increase was hypothesized to be due to an increased clearance of amyloid plaques with long-term lithium treatment. The final analysis of these patients was published in 2024. While a significant subset of patients had died, the patients who had received lithium had higher MMSE scores vs those who were given placebo: 25.5 vs 18.3, respectively. Verbal fluency testing also showed marked advantages with lithium treatment with scores of 34.7 vs 11.6. One of the most recent meta-analyses for patients with bipolar disorder found that pharmaceutical lithium reduces dementia risk by half. A separate meta-analysis of both the preclinical and clinical research found that lithium displays neuroprotective effects with clinical data showing positive results in patients with Alzheimer disease. Increasing cases of Alzheimer disease and dementia are one of the more sobering realities we face in medicine, as cases are projected to increase precipitously over the coming decades. Considering the challenges of our aging population, lithium may be a cost-effective augmentation strategy to fill treatment gaps for dementia prevention initiatives. A Life-Saver in Microdoses: The Potential of Lithium in Suicide Prevention Beyond the potential benefits for cognitive health, lithium may also be useful for another significant unmet need: suicide prevention . Suicide rates have been mostly on the increase in the United States since 2001. Suicide is the second leading cause of death among individuals aged 10 to 34. And while there is controversy around the research, in total, it strongly suggests that lithium has antisuicidal properties. Evidence for microdoses reducing suicide risks comes from a large and growing number of ecological studies exploring suicide rates and lithium levels in tap water. Lithium is naturally found in the environment, with tap water being a significant component of the lithium present in the diet. Tap water levels can vary dramatically from locality to locality providing natural variations in exposure. Lithium levels in drinking water are usually measured in micrograms per liter, suggesting that lithium may have relevant neurological effects even at these low levels. In 1970, the first report about lithium concentrations in tap water and local state mental health hospital admissions found an inverse correlation. As lithium exposure from groundwater increased, local hospital admissions were reduced. Over the ensuing decades, numerous research groups analyzed local water supplies and mental health outcomes, most often as suicide rates. A meta-analysis of this data was published in 2021, including 113 million individuals from 2678 regions around the world. The study found that higher groundwater lithium was correlated with reduced suicide and mental hospital admissions. Since the meta-analysis, most of the additional studies have continued to confirm the relationship. For patients with bipolar disorder, standard pharmaceutical doses of lithium have also shown consistent effects for lowering suicide risk. Tentatively, the results of the research suggest that lithium’s antisuicidal effects occur through a broad range of dosage levels. Considering the rising tide of suicides in this country and the safety of lithium when utilized in lower doses, lithium may deserve additional consideration as one component in a multiprong approach for suicide prevention . A Subtle Shift: The Promise of Low-Dose Lithium for Resistant Depression While the data shows that doses close to and including standard pharmaceutical levels are more effective for treating mania and depressive episodes in bipolar disorder , the research also has shown that lower doses are well-tolerated and may provide benefits in some cases of major depressive disorder. An open-label study in severely depressed patients who were unresponsive to an initial trial of venlafaxine found significant benefits with low-dose lithium augmentation. Lithium, at doses between 300 and 450 mg, does not require blood monitoring and was well tolerated. The authors argue that low-dose lithium may be a preferable first choice in “non-emergent situations'' due to its ease of use and higher tolerability. A separate, small, dose-response trial using lithium augmentation for treatment-resistant depression that was unresponsive to sertraline found that both 400 mg and 800 mg of lithium were equivalent in their clinical response. In patients with severe depression, a subset of patients on citalopram plus 300 mg of lithium carbonate achieved therapeutic blood levels and had significantly higher remission rates of suicidal thoughts. In patients with multiple sclerosis, low-dose lithium (between 150 and 300 mg) improved depression symptoms better than an observation period without lithium. However, not all research findings on low-dose lithium treatment for depression have found benefits. In patients on tricyclic antidepressants who were resistant to treatment, lithium at 750 mg provided significant benefits whereas doses of 250 mg did not. Breaking Chains: Lithium’s Role in Addiction Recovery Substance use and addiction are typically difficult to treat. Clinical trials are often plagued with high dropout rates, a predictor of relapse. As such, interpreting the data can be difficult. While the results are mixed, some research and my own clinical experience suggests that low-dose lithium may have a role for helping to treat addiction. An early study using an integrative medicine approach for treatment using 6 mg of lithium (as 150 mg of lithium orotate), combined with other supplements and dietary recommendations, found benefits for patients with alcohol use disorder. Of the treated patients who stayed on lithium, 36 of 42 had a history of hospitalization due to severe alcohol use. With lithium treatment, almost a quarter of patients remained alcohol free for up to 3 to 10 years. None of the patients needed additional hospitalizations. However, the study had numerous limitations, including a high drop-out rate and only included patients who managed to continue lithium treatment. In patients recently detoxed from alcohol, low-dose lithium (defined as blood levels between 0.3 and 0.5 mmol/L) or a vitamin placebo were administered. Due to a previous study noting that patients who detoxified from alcohol often displayed manic-type symptoms, the study was implemented to see if lithium could address these symptoms. For the detoxed patients on lithium, manic symptoms significantly decreased, fully normalizing over a 2-week period. For controls, manic symptoms did not significantly change and remained elevated. The most recent study of interest utilized 150 mg of lithium carbonate for patients at a residential addiction center as a replacement for antidepressants or benzodiazepine medications. With the implementation of low-dose lithium, opiate doses dropped by 50%, benzodiazepine use was almost eliminated, and atypical antipsychotics were reduced by more than two-thirds. Polypharmacy, or the use of 5 or more psychiatric medications in a treatment regimen, was reduced by almost 80%. For patients on lithium, program completion rates increased by almost 100%. In total, low-dose lithium effectively reduced medication use and improved residential addiction treatment outcomes. Cooling the Fire: Microdose Lithium for Anger and Irritability Irritability and anger are not official diagnoses in the DSM. As such, they are often considered as secondary to other conditions like depression or bipolar disorder and not treated directly. In children, disruptive mood dysregulation disorder (DMDD) encompasses problems with anger and irritability. From my own clinical experience, irritability often has roots in metabolic, environmental, and nutritional factors. While older studies on prison inmates suggest that lithium may have utility for decreasing anger and aggressive behaviors,30-32 in my experience, irritability is one of the most powerful indicators that a patient will benefit from low-dose or microdoses of lithium. For any patient struggling with irritability, especially when there is a family history of addiction, bipolar disorder , or depression, elemental lithium between 2 and 10 mg, typically as lithium orotate, has often provided significant relief. For children with DMDD, lithium can sometimes provide profound benefits, helping to safely decrease symptoms when used in such low doses. The Untapped Potential of Low-Dose Lithium Lithium has long had a starring role in standard medicine as a therapeutic option for bipolar disorder and as an adjunctive treatment for depression. Nonetheless, research and my own clinical practice with thousands of patients have found that lithium’s efficacy is still very relevant at lower doses. From an integrative medicine perspective, microdoses of lithium may act more like a nutrient,improving mood, reducing irritability, and supporting cognitive function. These low-dose benefits of lithium extend from hundreds of micrograms up through the standard dosage range of lithium used for bipolar disorder treatment . Note: This article originally appeared on Psychiatric Times .

Depression is a medical problem where feelings of sadness, distress, and other physical and emotional symptoms are long-lasting and interfere your day-to-day life. Other symptoms of depression can include a loss of interest in favorite activities, fatigue, and thinking and memory problems. After a cancer diagnosis and during cancer treatment, it is common to feel emotions like sadness, grief, anxiety, and fear at times. These feelings can come and go throughout your cancer treatment. But when these feelings are persistent most of the day, most days of the week for more than 2 weeks, and interfere with your daily routines and pleasures, it may be a sign of clinical depression . Even if you think your feelings are normal, it is important to talk to your health care team about how you are feeling. Some cancer treatments can make people feel depressed or fatigued. Diagnosing and treating depression is an important part of cancer care. If untreated, depression can affect your quality of life and it can make it harder to cope with or finish your cancer treatment. The American Society of Clinical Oncology (ASCO) recommends screening for depression at the time of a cancer diagnosis, and again during and after treatment. The symptoms of depression may appear at any of these times. Depression and cancer According to research, around 25% of people with cancer have depression . This means the symptoms (see below) go beyond distress after a cancer diagnosis or during cancer treatment . A cancer diagnosis can trigger these feelings: Fear of cancer treatment or treatment-related side effects, such as pain Changes to your body, affecting your self-image Concerns about money and finances Uncertainty Spiritual questions about life's meaning Fear of recurrence after treatment Fear of suffering Fear of death Talk with your health care team about your concerns. They will ask you to describe how you are feeling, including any specific symptoms. They have special training, expertise, and knowledge to help you cope with these strong feelings and get additional treatment if needed. What are the symptoms of depression? Depression is a type of mood disorder. The symptoms range from mild to severe. When they are severe, persistent, and include many of the mood-related symptoms listed below, they are a major depressive disorder. You can receive treatment for depression whether you have mild, moderate, or severe symptoms. Talk with your doctor if you have any of these symptoms, especially if they last 2 weeks or longer: Mood-related symptoms. People with depression can feel a range of feelings. You may feel sad or down, but anxiety, irritation and anger can also be signs of depression. Mood-related symptoms of depression include: Feeling sad, down, or hopeless most of the time Feeling irritable and angry, often without a reason you can point to Feeling numb, like nothing matters Feeling worthless Feeling guilt Thoughts of suicide Always tell your family and your doctor immediately if you are experiencing suicidal thoughts. Suicidal thoughts are when you feel like life is not worth living and you are thinking about or planning to harm or kill yourself. If you feel you’re in crisis and cannot reach your doctor or a loved one, call the National Suicide Prevention Lifeline at 1-800-273-8255 or dial the code "988" (available in the United States). Learn more about depression, suicide, and cancer. Behavioral symptoms. Often, people with depression have a hard time finding joy in the activities they used to love. Behavioral symptoms of depression include: Loss of motivation to do daily activities, including taking care of yourself Loss of interest in activities you used to enjoy Withdrawal from friends or family Frequent crying Cognitive symptoms. Depression can cause attention, thinking, and memory problems. These include: Trouble focusing Difficulty making decisions Memory problems Negative thoughts, including thoughts that life is not worth living or thoughts of hurting yourself Physical symptoms. Depression can also cause many physical symptoms. Physical symptoms of depression include: Fatigue Appetite loss Insomnia, a disorder that interferes with your ability to fall and stay asleep Hypersomnia, a disorder that makes you sleep too much or feel very sleepy during the day Sexual problems, such as a lower sexual desire Having feelings of sadness, worthlessness, emptiness, and/or numbness that last longer than 2 weeks can indicate that your symptoms are a result of clinical depression. Emotional, behavioral, physical, and cognitive symptoms can all have other causes that are not caused by depression. For example, feeling sad and not engaging in usual activities can be caused by pain, fatigue, or some medications. Because of this, your health care team will focus on finding the cause of your symptoms. Other causes of depression symptoms Common physical symptoms of depression can have causes that are not depression. For example, high levels of calcium in your body can cause fatigue, depressed mood, and even confusion. If you are experiencing symptoms of depression, be sure to tell your doctor so the exact cause can be found. Some common medical or physical causes of these symptoms include: High calcium levels or hypercalcemia Anemia Vitamin deficiency Fever Thyroid problems Sleep problems, such as insomnia and hypersomnia Uncontrolled pain Some medications, such as steroids, some antibiotics, some chemotherapy treatments, and hormone therapy treatment What are risk factors for depression? People with cancer are more likely to have depression if they have these risk factors: Previous diagnosis of depression or anxiety A history of suicide attempts or suicide in the family Family history of depression or anxiety Lack of support from friends or family Financial burdens Substance abuse However, it is important to note that depression can be experienced by anyone, especially after a cancer diagnosis. Should people with cancer be screened for depression? Yes. The American Society of Clinical Oncology (ASCO) recommends screening for anxiety and depression. Screenings should start at the time of a cancer diagnosis and be repeated regularly during your treatment and recovery. These screenings can help catch problems related to depression. Treatment for depression will depend on your specific symptoms and how often you have them. As explained above, some symptoms of depression can also be related to other problems, including side effects of cancer and cancer treatment. For example, fatigue and trouble sleeping or concentrating are common side effects of cancer and cancer treatment. Although it can be challenging, try to talk openly with your health care team about your experiences, feelings, and the topic of depression. This will help them understand your concerns and recommend a treatment plan. ASCO recommends the following techniques to help manage depression symptoms during treatment: Deep breathing. Slow, deep breathing helps lower stress in the body. It sends calming signals from your brain to the rest of your body, slowing your heart rate and how fast you are breathing. Progressive muscle relaxation. This is a technique that involves tightening and then relaxing groups of muscles. You begin at the toes or head and then slowly tense and relax the muscles across the body. Guided imagery. This is the use of words and sounds to help you imagine calming, peaceful settings, experiences, and feelings. Meditation. Meditation is a practice of focusing attention or awareness on your breath, a verbal phrase, or a part of the body. This can help you achieve a sense of well-being in the present moment and reduce stress. It can also help you to acknowledge uncomfortable emotions and prevent them from building up. One type of meditation that may be helpful in managing depression symptoms during and after treatment is called “mindfulness- based stress reduction meditation. ” When practicing mindfulness, you focus on bringing your attention to the present moment and becoming aware of your feelings, thoughts, and surroundings within that moment with an attitude of openness, kindness, and acceptance. Mindfulness practices may be helpful for depression symptoms during and after cancer treatment. Music therapy. This artistic expression can help relieve anxiety. Learn more about music therapists. Reflexology. During reflexology, a specialist uses their hands to apply pressure to specific points on the body to help relieve tension. For people diagnosed with breast cancer, ASCO recommendations include the following additional guidance for reducing symptoms of depression during and/or after treatment. These techniques may be helpful for people with other types of cancer as well, but there is not yet enough research for this level of recommendation. Research is ongoing in these areas. Yoga . Yoga combines breathing and posture exercises to promote relaxation. This can be helpful during or after treatment. Tai chi and qigong. Tai chi and qigong are both types of meditation that focus on gentle movements and postures and controlled breathing. There are other techniques or practices that may help reduce symptoms of depression during or after cancer. However, there are no specific recommendations for them, so be sure to talk with your health care team about whether any additional techniques may be helpful for you. Seeking the help of a mental health professional can help you with your depression. Mental health professionals include social workers, licensed counselors, psychologists, and psychiatrists. Psychiatrists are mental health professionals who can prescribe medication. Counselors and other mental health professionals can provide tools to improve your coping skills, develop a support system, and reshape negative thoughts. You can work with a counselor on your own, through couples or family therapy, and in group therapy. Today, options exist for mental health tele-medicine so you may not need to leave your home to get help. Counselors can also lead or direct you to a peer support group. Based on ASCO guidelines: Questions to ask the mental health team - to battle depression due to cancer You may want to ask your health care team the following questions about depression: Who can I talk to if I am feeling depression, anxiety, or other mental distress? What symptoms and side effects of cancer treatment could affect my mental health? Are there counseling services at this medical center for patients? Who can I talk with if I need free or lower-cost counseling services? Do you recommend any relaxation techniques or other ways to manage my depression? Would you recommend medication for my depression? Who should I contact if my depression symptoms continue or worsen? What do I do if I feel suicidal or that life is not worth living anymore? Source: Cancer.net

What is ADHD and Adults Care with a Specialist Psychiatrist ? Attention-deficit/hyperactivity disorder (ADHD) is one of the most common mental disorders affecting children. Symptoms of ADHD include inattention (not being able to keep focus), hyperactivity (excess movement that is not fitting to the setting) and impulsivity (hasty acts that occur in the moment without thought). ADHD is considered a chronic and debilitating disorder and is known to impact the individual in many aspects of their life including academic and professional achievements, interpersonal relationships, and daily functioning (Harpin, 2005). ADHD can lead to poor self-esteem and social function in children when not appropriately treated (Harpin et al., 2016). Adults with ADHD may experience poor self-worth, sensitivity towards criticism, and increased self-criticism possibly stemming from higher levels of criticism throughout life (Beaton, et al., 2022). Of note, ADHD presentation and assessment in adults differs; this page focuses on children. An estimated 8.4% of children and 2.5% of adults have ADHD (Danielson, 2018; Simon, et al., 2009). ADHD is often first identified in school-aged children when it leads to disruption in the classroom or problems with schoolwork. It is more commonly diagnosed among boys than girls given differences in how the symptoms present. However, this does not mean that boys are more likely to have ADHD. Boys tend to present with hyperactivity and other externalizing symptoms whereas girls tend to have inactivity. Symptoms and Diagnosis Many children may have difficulties sitting still, waiting their turn, paying attention, being fidgety, and acting impulsively. However, children who meet diagnostic criteria for ADHD, differ in that their symptoms of hyperactivity, impulsivity, organization, and/or inattention are noticeably greater than expected for their age or developmental level. These symptoms lead to significant suffering and cause problems at home, at school or work, and in relationships. The observed symptoms are not the result of an individual being defiant or not being able to understand tasks or instructions. There are three main types of ADHD: Predominantly inattentive presentation. Predominantly hyperactive/impulsive presentation. Combined presentation. A diagnosis is based on the presence of persistent symptoms that have occurred over a period of time and are noticeable over the past six months. While ADHD can be diagnosed at any age, this disorder begins in childhood. When considering the diagnosis, the symptoms must be present before the individual is 12 years old and must have caused difficulties in more than one setting. For instance, the symptoms can not only occur at home. Inattentive type Inattentive refers to challenges with staying on task, focusing, and organization. For a diagnosis of this type of ADHD, six (or five for individuals who are 17 years old or older) of the following symptoms occur frequently: Doesn’t pay close attention to details or makes careless mistakes in school or job tasks. Has problems staying focused on tasks or activities, such as during lectures, conversations or long reading. Does not seem to listen when spoken to (i.e., seems to be elsewhere). Does not follow through on instructions and doesn’t complete schoolwork, chores or job duties (may start tasks but quickly loses focus). Has problems organizing tasks and work (for instance, does not manage time well; has messy, disorganized work; misses deadlines). Avoids or dislikes tasks that require sustained mental effort, such as preparing reports and completing forms. Often loses things needed for tasks or daily life, such as school papers, books, keys, wallet, cell phone and eyeglasses. Is easily distracted. Forgets daily tasks, such as doing chores and running errands. Older teens and adults may forget to return phone calls, pay bills and keep appointments. Hyperactive/impulsive type Hyperactivity refers to excessive movement such as fidgeting, excessive energy, not sitting still, and being talkative. Impulsivity refers to decisions or actions taken without thinking through the consequences. For a diagnosis of this type of ADHD , six (or five for individuals who are 17 years old or older) of the following symptoms occur frequently: Fidgets with or taps hands or feet, or squirms in seat. Not able to stay seated (in classroom, workplace). Runs about or climbs where it is inappropriate. Unable to play or do leisure activities quietly. Always “on the go,” as if driven by a motor. Talks too much. Blurts out an answer before a question has been finished (for instance may finish people’s sentences, can’t wait to speak in conversations). Has difficulty waiting for his or her turn, such as while waiting in line. Interrupts or intrudes on others (for instance, cuts into conversations, games or activities, or starts using other people’s things without permission). Older teens and adults may take over what others are doing. Combined type This type of ADHD is diagnosed when both criteria for both inattentive and hyperactive/impulse types are met. ADHD is typically diagnosed by mental health providers or primary care providers. A psychiatric evaluation will include a description of symptoms from the patient and caregivers, completion of scales and questionnaires by patient, caregivers and teachers, complete psychiatric and medical history, family history, and information regarding education, environment, and upbringing. It may also include a referral for medical evaluation to rule out other medical conditions. It is important to note that several conditions can mimic ADHD such as learning disorders, mood disorders, anxiety, substance use, head injuries, thyroid conditions, and use of some medications such as steroids (Austerman, 2015). ADHD may also co-exist with other mental health conditions, such as oppositional defiant disorder or conduct disorder, anxiety disorders, and learning disorders (Austerman, 2015). Thus, a full psychiatric evaluation is very important. There are no specific blood tests or routine imaging for ADHD diagnosis. Sometimes, patients may be referred for additional psychological testing (such as neuropsychological or psychoeducational testing) or may undergo computer-based tests to assess the severity of symptoms. The Causes of ADHD Scientists have not yet identified the specific causes of ADHD. While there is growing evidence that genetics contribute to ADHD and several genes have been linked to the disorder, no specific gene or gene combination has been identified as the cause of the disorder. However, it is important to note that relatives of individuals with ADHD are often also affected. There is evidence of anatomical differences in the brains of children with ADHD in comparison to other children without the condition. For instance, children with ADHD have reduced grey and white brain matter volume and demonstrate different brain region activation during certain tasks (Pliszka, 2007). Further studies have indicated that the frontal lobes, caudate nucleus, and cerebellar vermis of the brain are affected in ADHD (Tripp & Wickens, 2009). Several non-genetic factors have also been linked to the disorder such as low birth weight, premature birth, exposure to toxins (alcohol, smoking, lead, etc.) during pregnancy, and extreme stress during pregnancy. ADHD Treatment ADHD treatment usually encompasses a combination of therapy and medication intervention. In preschool-age and younger children, the recommended first-line approach includes behavioral strategies in the form of parent management training and school intervention. Parent-Child Interaction Therapy (PCIT) is an evidence-based therapy modality to help young children with ADHD and oppositional defiant disorder. According to current guidelines, psychostimulants (amphetamines and methylphenidate) are first-line pharmacological treatments for the management of ADHD (Pliszka, 2007). In preschool-aged patients with ADHD, amphetamines are the only FDA-approved medication, although guidelines suggest that methylphenidate rather than amphetamines may be helpful if behavioral interventions prove insufficient. Alpha agonists (clonidine and guanfacine) and the selective norepinephrine reuptake inhibitor, atomoxetine, are the other FDA-approved options for treating ADHD. There are newer FDA-approved medications for ADHD treatment, including Jornay (methylphenidate extended-release) which is taken at night and starts the medication effect the next morning, Xelstrym (dextroamphetamine) which is an amphetamine patch, Qelbree (viloxazine) which is a non-stimulant, Adhansia (methylphenidate hydrochloride), Dyanavel (amphetamine extended-release oral suspension), Mydayis (mixed salts amphetamine product), and Cotempla (methylphenidate extended-release orally disintegrating tablets). Many children and families can alternate between various medication options depending on the efficacy of treatment and tolerability of the medication. The goal of treatment is to improve symptoms to restore functioning at home and at school. ADHD and School-Aged Children Teachers and school staff can provide parents and doctors with information to help evaluate behavior and learning problems and can assist with behavioral training. However, school staff cannot diagnose ADHD, make decisions about treatment or require that a student take medication to attend school. Only parents and guardians can make those decisions with the child’s health care clinician. Students whose ADHD impairs their learning may qualify for special education under the Individuals with Disabilities Education Act or for a Section 504 plan (for children who do not require special education) under the Rehabilitation Act of 1973 . Children with ADHD can benefit from study skills instruction, changes to the classroom setup, alternative teaching techniques and a modified curriculum Source: Comprehensive Guide for Advocating for 504 vs IDEA ADHD and Adults Many children diagnosed with ADHD will continue to meet criteria for the disorder later in life and may show impairments requiring ongoing treatment (Pliszka, 2007). However, sometimes a diagnosis of ADHD is missed during childhood. Many adults with ADHD do not realize they have the disorder. A comprehensive evaluation typically includes a review of past and current symptoms, a medical exam and history, and use of adult rating scales or checklists. Adults with ADHD are treated with medication, psychotherapy or a combination. Behavior management strategies, such as ways to minimize distractions and increase structure and organization, and support from immediate family members can also be helpful. ADHD is a protected disability under the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA). This means that institutions receiving federal funding cannot discriminate against those with disabilities. Individuals whose symptoms of ADHD cause impairment in the work setting may qualify for reasonable work accommodations under ADA. Related Conditions Autism spectrum disorder Disruptive, impulse control and conduct disorders Social communication disorder Specific learning disorder Source: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) . 2013.

Grief is universal. People often describe grief as passing through 5 or 7 stages. The 5 stages are denial, anger, bargaining, depression, and acceptance. The 7 stages elaborate on these and aim to address the complexities of grief more effectively. They include feelings of guilt. Grief is universal. At some point, everyone will have at least one encounter with grief. It may be from the death of a loved one, the loss of a job, the end of a relationship, or any other change that alters life as you know it. Dr. Kubler Rosss Dr. Kubler Ross Grief is also very personal. It’s not very neat or linear. It doesn’t follow any timelines or schedules. You may cry, become angry, withdraw, or feel empty. None of these things are unusual or wrong. Elizabeth Kübler Ross wrote in her book “On Death and Dying” that grief could be divided into five stages. While everyone can grieve differently, there are some commonalities in these stages and the order of feelings experienced during grief. Are there 5 or 7 stages of grief? In 1969, a Swiss-American psychiatrist named Elizabeth Kübler-Ross wrote in her book “On Death and Dying” that grief could be divided into five stages. Her observations came from years of working with terminally ill individuals. In time, two more stages were added to make seven stages. This expanded model aims to better reflect the complexities of grief. Neither model will necessarily reflect an individual’s experience, however, as emotions tend to come and go. You may miss a stage or come back to it later, and that’s OK. The 5 stages of grief Kübler-Ross’s five stages were originally devised for people who were ill but have been adapted for coping with grief. Her theory of grief became known as the Kübler-Ross model. While it was originally devised for people who were ill, these stages of grief have been adapted for other experiences with loss, too. According to Kübler-Ross, the five stages of grief are: denial anger bargaining depression acceptance Here’s what to know about each one. Stage 1: Denial Grief is an overwhelming emotion. It’s not unusual to respond to the strong and often sudden feelings by pretending the loss or change isn’t happening. Denying it gives you time to more gradually absorb the news and begin to process it. This is a common defense mechanism and helps numb you to the intensity of the situation. As you move out of the denial stage, however, the emotions you’ve been hiding will begin to rise. You’ll be confronted with a lot of sorrow you’ve denied. That is also part of the journey of grief, but it can be difficult. Examples of the denial stage Breakup or divorce: “They’re just upset. This will be over tomorrow.” Job loss: “They were mistaken. They’ll call tomorrow to say they need me.” Death of a loved one: “She’s not gone. She’ll come around the corner any second.” Terminal illness diagnosis: “This isn’t happening to me. The results are wrong.” Stage 2: Anger Where denial may be considered a coping mechanism, anger is a masking effect. Anger is hiding many of the emotions and pain that you carry. This anger may be redirected at other people, such as the person who died, your ex, or your old boss. You may even aim your anger at inanimate objects. While your rational brain knows the object of your anger isn’t to blame, your feelings in that moment are too intense to act according to that. Anger may mask itself in feelings like bitterness or resentment. It may not be clear-cut fury or rage. Not everyone will experience this stage of grief. Others may linger here. As the anger subsides, however, you may begin to think more rationally about what’s happening and feel the emotions you’ve been pushing aside. Examples of the anger stage Breakup or divorce: “I hate him! He’ll regret leaving me!” Job loss: “They’re terrible bosses. I hope they fail.” Death of a loved one: “If she cared for herself more, this wouldn’t have happened.” Terminal illness diagnosis: “Where is God in this? How dare God let this happen! Stage 3: Bargaining During grief, you may feel vulnerable and helpless. In those moments of intense emotions , it’s not uncommon to look for ways to regain control or to want to feel like you can affect the outcome of an event. In the bargaining stage of grief, you may find yourself creating a lot of “what if” and “if only” statements. It’s also not uncommon for religious individuals to try to make a deal or promise to God or a higher power in return for healing or relief from the grief and pain. Bargaining is a line of defense against the emotions of grief. It helps you postpone the sadness, confusion, or hurt. Examples of the bargaining stage Breakup or divorce: “If only I had spent more time with her, she would have stayed.” Job loss: “If only I worked more weekends, they would have seen how valuable I am.” Death of a loved one: “If only I had called her that night, she wouldn’t be gone.” Terminal illness diagnosis: “If only we had gone to the doctor sooner, we could have stopped this.” Stage 4: Depression Whereas anger and bargaining can feel very active, depression disorders may feel like a quiet stage of grief. In the early stages of loss, you may be running from the emotions, trying to stay a step ahead of them. By this point, however, you may be able to embrace and work through them in a more healthful manner. You may also choose to isolate yourself from others in order to fully cope with the loss. That doesn’t mean, however, that depression is easy or well defined. Like the other stages of grief, depression can be difficult and messy. It can feel overwhelming. You may feel foggy, heavy, and confused. Depression may feel like the inevitable landing point of any loss. However, if you feel stuck here or can’t seem to move past this stage of grief, you can talk with a mental health expert . A therapist can help you work through this period of coping. Examples of the depression stage Breakup or divorce: “Why go on at all?” Job loss: “I don’t know how to go forward from here.” Death of a loved one: “What am I without her?” Terminal illness diagnosis: “My whole life comes to this terrible end.” Stage 5: Acceptance Acceptance is not necessarily a happy or uplifting stage of grief. It doesn’t mean you’ve moved past the grief or loss. It does, however, mean that you’ve accepted it and have come to understand what it means in your life now. You may feel very different in this stage. That’s entirely expected. You’ve had a major change in your life, and that upends the way you feel about many things. Look to acceptance as a way to see that there may be more good days than bad. There may still be bad — and that’s OK. Examples of the acceptance stage Breakup or divorce: “Ultimately, this was a healthy choice for me.” Job loss: “I’ll be able to find a way forward from here and can start a new path.” Death of a loved one: “I am so fortunate to have had so many wonderful years with him, and he will always be in my memories.” Terminal illness diagnosis: “I have the opportunity to tie things up and make sure I get to do what I want in these final weeks and months.” The 7 stages of grief The seven stages of grief are another popular model for explaining the many complicated experiences of loss. These seven stages include: Shock and denial: This is a state of disbelief and numbed feelings. Pain and guilt: You may feel that the loss is unbearable and that you’re making other people’s lives harder because of your feelings and needs. Anger and bargaining: You may lash out, telling God or a higher power that you’ll do anything they ask if they’ll only grant you relief from these feelings or this situation. Depression: This may be a period of isolation and loneliness during which you process and reflect on the loss. The upward turn: At this point, the stages of grief like anger and pain have died down, and you’re left in a more calm and relaxed state. Reconstruction and working through: You can begin to put pieces of your life back together and move forward. Acceptance and hope: This is a very gradual acceptance of the new way of life and a feeling of possibility for the future. As an example, this may be the presentation of stages from a breakup or divorce: Shock and denial: “She absolutely wouldn’t do this to me. She’ll realize she’s wrong and be back here tomorrow.” Pain and guilt: “How could she do this to me? How selfish is she? How did I mess this up?” Anger and bargaining: “If she’ll give me another chance, I’ll be a better boyfriend. I’ll dote on her and give her everything she asks.” Depression: “I’ll never have another relationship. I’m doomed to fail everyone.” The upward turn: “The end was hard, but there could be a place in the future where I could see myself in another relationship.” Reconstruction and working through: “I need to evaluate that relationship and learn from my mistakes.” Acceptance and hope: “I have a lot to offer another person. I just have to meet them.” What is the hardest stage of grief to go through? There’s no one stage that’s universally considered to be the hardest to endure. Grief is a very individual experience. The toughest stage of grief varies from person to person and even from situation to situation. How long does each stage of grief last? Grief is different for every person. There’s no exact time frame to adhere to. You may remain in one of the stages of grief for months but skip other stages entirely. This is typical. It takes time to go through the grieving process. Is it possible to repeat the stages of grief? Not everyone goes through the stages of grief in a linear way. You may have ups and downs and go from one stage to another, then circle back. Additionally, not everyone will experience all stages of grief, and you may not go through them in order. I didn’t go through the stages of grief — how will this affect me? Avoiding, ignoring, or denying yourself the ability to express your grief may help you dissociate from the pain of the loss you’re going through. But holding it in won’t make it disappear. And you can’t avoid grief forever. Over time, unresolved grief can turn into physical or emotional manifestations that affect your health. In order to heal from a loss and move on, you have to address it. If you’re having trouble processing grief, consider seeking out counseling to help you through it . Why is it important to understand the stages of grief? Grief is a natural emotion to experience when going through a loss. While everyone experiences grief differently, identifying the various stages of grief can help you anticipate and comprehend some of the reactions you may experience throughout the grieving process. It can also help you understand your needs when grieving and find ways to have them met. Understanding the grieving process can ultimately help you work toward acceptance and healing. Frequently asked questions What are the 5 stages of grief in order? The 5 stages of grief, in order, are: denial anger bargaining depression acceptance What are the 7 steps of grief? The 7 stages are: shock and denial pain and guilt anger and bargaining depression the upward turn reconstruction and working through acceptance and hope Are there 7 or 5 stages of grief? It depends which description you use. The 7 stages aim to address the complexity of grief more effectively. They include guilt as a second stage and divide the recovery stages into three parts. What is the hardest stage of grief? This will depend on the individual. There is no way to define the hardest stage. How long do stages of grief last? This varies widely between individuals and depends on many factors. How do you know what stage of grief you are in? The stages are not a prescribed pattern, more like a description to help you understand what you are feeling and why you might be feeling it. They can also help you accept that your feelings are not unusual or wrong. You may recognize feelings that a stage describes, and this will help you know which stage you are in. However, there is no fixed way of recognizing a stage. Stages can also come and go, and and earlier stage can return later. The takeaway The key to understanding grief is realizing that no one experiences the same thing. Grief is very personal, and you may feel something different every time. You may need several weeks, or grief may be years long. If you decide you need help coping with the feelings and changes, a mental health professional is a good resource for vetting your feelings and finding a sense of assurance in these very heavy and weighty emotions. If you need help finding a mental health professional, the click here.

Our easy-to-read fact sheets provide clinicians with reliable information to share with patients and their caregivers. Biomedical therapy for autism spectrum disorder (ASD) is becoming increasingly popular as a complementary treatment option to traditional medication regimes, yet many patients are still unclear about what biomedical therapy entails. Therefore, the following fact sheet provides a helpful overview of biomedical therapy for ASD and answers commonly asked questions. Autism Spectrum Disorder Autism spectrum disorder (ASD) is a neurodevelopmental disorder associated with impairment in social communication and interactions as well as the presence of restricted, repetitive behaviors.1 It is influenced by both genetic and environmental factors, though the direct cause is still unknown. The Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition, Text Revision (DSM-5-TR) is considered the gold standard for ASD diagnosis. The diagnostic criteria for ASD are graded on a severity scale by the level of support needed, in which Level 1 requires support, Level 2 requires substantial support, and Level 3 requires very substantial support. Common Treatment Options for Autism Because ASD occurs on a spectrum, treatment options can vary with each patient depending on their unique set of symptoms. There is no curative treatment for ASD, but the management of ASD takes on a multifaceted approach that includes occupational, behavioral, speech, and play therapies. Psychosocial interventions can also help improve specific behaviors, such as language and social engagement. Although there are no medications directly indicated for the treatment of ASD specifically, many individuals receive medication for comorbidities associated with their diagnosis. Patients with ASD may take medication for irritability, aggression, hyperactivity, and seizures that may co-present with the condition.2 Some examples of the common medications used to manage these other symptoms and disorders may include: Psychostimulants, such as methylphenidate and dextroamphetamine Antidepressants, such as sertraline and fluoxetine Antipsychotic medications, such as risperidone and aripiprazole Antiepileptic medications, such as carbamazepine, levetiracetam, and ethosuximide Alpha-2 adrenergic receptor agonists, such as clonidine and guanfacine Biomedical Therapy for Autism Biomedical therapy is a specific treatment approach that considers the underlying biological basis of a condition and targets physiological impairment.5 The goal of biomedical therapy for autism is to optimize physiological factors impacting brain function and development to treat symptoms and improve patient functioning. Research indicates that ASD is associated with deficits in mitochondrial metabolism and oxidative stress as well as abnormalities in the regulation of the following essential metabolites: Folate Tetrahydrobiopterin Glutathione Cholesterol Carnitine Branch chain amino acids Biomedical therapy can be categorized based on the pathophysiological process they target. Mitochondrial Dysfunction The mitochondria generate energy for cellular processes. When the mitochondria is impaired, it can lead to developmental delays, muscle weakness, and neurological problems.6 Individuals with ASD who have mitochondrial dysfunction often have more severe behavioral and cognitive deficits, relative to those with typical mitochondrial function. Treatments may include: Antioxidants, such as vitamin C and N-acetyl-L-cysteine L-carnitine Multivitamins containing vitamin B, vitamin E, co-enzyme Q10 Folate Metabolism Folate is naturally found in the human body and helps to regulate the absorption of vitamin B. However, individuals with ASD may have genetic modifications in the folate pathway which leads to a decrease in available folate in the brain, known as cerebral folate deficiency. Lack of folate causes symptoms such as fatigue and muscle weakness. Patients with folate irregularity are treated with folinic acid for neurological, behavioral, and cognitive improvements. Redox Metabolism Redox reactions are necessary for many biological functions. Evidence has shown that individuals with ASD may have abnormal redox metabolism which could lead to oxidative damage in areas of the brain responsible for speech, emotion, and social behavior. Several treatments for oxidative stress are available, including: Vitamin or mineral supplements containing antioxidants, co-enzyme Q10, and vitamin B Subcutaneous injections of methylcobalamin (a form of vitamin B12) Oral folinic acid Tetrahydrobiopterin supplementation N-acetyl-L-cysteine These treatment options can help improve many common ASD symptoms, including hyperactivity, tantrums, sensory-motor skills, irritability, and even sleep and gastrointestinal symptoms. Tetrahydrobiopterin Metabolism Tetrahydrobiopterin (BH4) is naturally found in the body and is necessary for multiple important metabolic pathways. Abnormalities in BH4 are prominent in ASD, as the disorder is associated with a lack of oxidative stress needed for BH4 pathways. Treatment for BH4 metabolic dysfunction is primarily the use of sapropterin, a synthetic form of BH4. Sapropretin has been shown to improve cognitive ability, communication, adaptability, verbal expression, and social function in patients with ASD. Frequently Asked Patient Questions At what stage should I consider biomedical therapy for autism? Because ASD is a lifelong condition that occurs on a spectrum, there is no standard timeline for when a treatment should be started.7 Interventions are tailored to the patient’s specific needs. Although supplements are generally safe and well tolerated, they can have interactions with certain medications. Speak with your healthcare provider when making decisions on treatment options as it is important to keep track of your medications to monitor improvement and prevent adverse medication interactions. How long does it take to see improvement? When evaluating treatment success, it is important to consider what symptoms or conditions are being targeted. For example, some patients may be seeking treatment to sleep better or decrease their repetitive behaviors. Tracking progress by logging symptoms and improvements can help you and your provider gain an accurate measure of your treatment response. Improvements may not be seen immediately, especially as certain medications can take time to show measurable effects. Your symptoms may fluctuate over time, so consistent medication adherence is necessary to improve your chances of overall improvement. Are there side effects associated with these treatments? All of the biomedical treatments mentioned throughout this fact sheet are generally considered safe and well-tolerated. However, there are minor side effects for some of these treatments, as detailed below: Patients taking L-carnitine have expressed slight gastrointestinal issues. Symptoms such as nausea, vomiting, and abdominal cramps are usually experienced when the supplement is taken at night on an empty stomach. To minimize these symptoms, these supplements can be taken after a meal and your time of dosing can be adjusted. Some patients taking high-dose folinic acid may experience increased irritability, insomnia, or gastroesophageal reflux when co-administered with other medications, such as antipsychotics. Individuals taking N-acetyl-L-cysteine may experience mild side effects such as constipation, fatigue, daytime drowsiness, or increased appetite. Not all patients respond to treatment options in the same way. Patients should speak with their providers to discuss their treatment plan and any potential side effects they may experience.

The Royal College of Psychiatrists (RCPsych) has urged mental health employers in England to adopt 15 measures to reduce disability discrimination in the NHS workforce. NHS England data show that staff with disabilities are twice as likely to report discrimination from a colleague or manager compared with their nondisabled peers 12.2% vs 5.8%. The College said that almost a quarter of employers still fail to provide consistent adjustments for staff with disabilities, highlighting a gap between legislation and practice. Its new campaign, Delivering for Disability, is supported by new guidance, Providing Reasonable Adjustments Essential Guidance for Mental Health Employers. The initiative is designed to empower NHS services to offer practical support for staff with disabilities and long-term health conditions. The guidance “bridges the gap between policy and lived experience” to enable all staff to thrive, said the college. Disability in the NHS Workforce More than 52,000 NHS staff (3.7%) declared a disability through the NHS Electronic Staff Record in 2021, an increase of 6870compared with 2020. “Disability discrimination comes at an immense cost to individuals, teams, and ultimately impacts our ability to retain experienced professionals and thereby look after patients,” said RCPsych president Dr Lade Smith. The guidance sets out 15 recommendations covering four key areas for mental health employers to implement. These include developing a co-produced disability workforce strategy and implementation plan, providing an independent and confidential point of contact for staff to raise concerns, ensuring leaders andsgfsdrghcvjhgiudrt6yhvjkgy d managers are aware of reasonable adjustments and mitigations and providing reasonable adjustments within a defined, agreed timeframe. Supporting NHS Staff Smith said that reasonable adjustments help staff feel valued, reduce sickness absence, improve retention, and strengthen teamwork. Examples include safe access to buildings, reduced or compressed hours, exemption from on-call duties, and additional breaks to manage health conditions or sensory needs. Work is underway across NHS services in all four UK nations to tackle disability discrimination, but a unified framework is needed to accelerate progress, the college noted. “Tackling the barriers that interfere with people with disabilities being able to give their best at work is imperative to improving productivity,” said Smith. Note: This article originally appeared on Medscape .

TOPLINE: Both Mindfulness-Based Cancer Recovery (MBCR) and Tai Chi/Qigong (TCQ) significantly improved mood in survivors of cancer, whether participants selected their preferred program or were randomly assigned to either type of program. MBCR had greater benefits in reducing tension and anger, while TCQ was particularly effective in reducing depression and boosting vigor. METHODOLOGY: Prior studies have shown that MBCR and TCQ can reduce distress and psychosocial symptoms in patients with cancer, but comparisons have largely been with usual care rather than active control individuals. Researchers conducted a pragmatic, preference-based, multisite randomized controlled design trial to compare these mind-body therapies. A total of 587 distressed survivors of cancer (average age, 60.7 years; 75% women), irrespective of the stage and type of cancer, were enrolled. Participants with a preference for either MBCR or TCQ received their preferred intervention (n = 376) and were then randomly assigned to either the immediate or waitlisted group in a 2:1 ratio. Those without a preference were randomly assigned (1:1) to either intervention (n = 211) and then to the immediate or waitlist group in a 2:1 ratio. Participants received MBCR as a standard 9-week program of weekly in-person group meetings of 1 hour 45 minutes, along with a 6-hour weekend retreat on a Saturday between weeks 6 and 7. TCQ was offered as an 11-week program consisting of a 1.5-hour weekly group meeting and a 4-hour weekend retreat. The primary outcome was change in total mood disturbance, measured by the Profile of Mood States, which included tension-anxiety, depression, anger-hostility, and vigor-activity subscales. TAKEAWAY: In the random assignment group, total mood disturbance scores decreased significantly in both the immediate MBCR (19.9 at baseline to 12.5 after treatment) and immediate TCQ (17.7 at baseline to 12.0 after treatment) groups compared with that in the waitlist control group (P for interaction = .03 and.07, respectively). In the preference group, although total mood disturbance scores decreased in both the immediate MBCR and TCQ groups, the interaction effect relative to the waitlist control group was not significant (P = .57 and P = .09, respectively). Participants who received MBCR showed greatest improvements in tension, anger, and vigor scores, whereas those who received TCQ showed greatest improvements in anger, depression, and vigor scores. A combined analysis of the immediate vs waitlist groups showed substantial reductions in total mood disturbance scores with MBCR (estimate, -4.15; P = .10) and significant reductions in the scores with TCQ (estimate, -5.13; P = .01). IN PRACTICE: “Both MBCR and TCQ proved beneficial for improving overall mood in a broad swath of people living with cancer of different types and stages after treatment completion who were experiencing significant distress,” the authors wrote. SOURCE: The study, led by Linda E. Carlson, PhD, University of Calgary in Calgary, Alberta, Canada, was published online in Journal of Clinical Oncology. LIMITATIONS: Potential baseline imbalances existed between participants who chose MBCR vs TCQ or who chose to be randomly assigned. The study design required participants to have sufficient mobility, time, and energy to travel to program venues, which may have excluded some eligible candidates. Additionally, some discrepancies in dropout rates were observed across groups, although these did not violate missing at random data analytic assumptions. DISCLOSURES: This study was funded by grants from the Lotte & John Hecht Memorial Foundation and Enbridge Research Chair for Psychosocial Oncology. Three authors reported having ties with various sources. Note: This article originally appeared on Medscape .

People imagine that the lives of celebrities is amazing with wealth, prestige, status, however many celebrities suffer from various mental health issues, that can be compounded with stress life choices, little time to decompress, and mental health stigage. Here is a list of some of the celebrities that have been well recognized over the course of their lives. Actors, musicians, DJs, Athletes. There is no amount of money that can make someone happy when they are suffering with any underlying mental health, which can be disabiling. Truthfully, you can be rich and acquire wealth, however your wants (luxury) will never surpass your needs (quality health) mentally and physically. There is a multitude of risk factors that lead to suicide, however the end result can never be predicted. If you are in a crisis or concerned about your safety, dial 988. National suicide and crisis hotline.Reach out to those that can help you escape your inner demon, to avoid being the next potential victim. Celebrities Robin Williams A great American comedian and actor, Williams was widely recognized for the variety of characters he created and portrayed in films, comedies, and dramas. Williams is regarded as one of the greatest comedians of all time, having won various awards throughout his career, including five Grammy Awards and an Academy Award. In 2009 he started having a health problem and was diagnosed with Parkinson’s disease. Later his wife disclosed he had a spike in anxiety, stress, insomnia, memory loss, paranoia, and delusions. Unfortunately, on August 11, 2014, he was founded dead in his home in Paradise Cay, California. An autopsy report concluded his death was suicide by hanging. Stuart Adamson William Adamson was a Scottish rock guitarist and singer who started his music career as a founding member of the punk rock band Skids. One of his successful singles was Into the Valley, which reached 10 on the UK Singles Chart. On December 16, 2001, Adamson was found dead in a hotel room. His death was caused by hanging with an electric cord from a pole in a wardrobe. By the time of his death, a very substantial amount of alcohol was found by Coroner’s Office report at the time of his death. Marilyn Monroe Marilyn Monroe was an American singer, actress, and model who became a popular sex symbol in the 1950s and early 1960s. She remains a significant pop culture icon, and in 1999, the American Film Institute ranked her sixth on their list of the greatest female screen legends from the Golden Age of Hollywood. Monroe was found dead in her home in Los Angeles, California, on August 5, 1962. Her death was caused by an overdose of barbiturates (a drug used to treat anxiety and sleep disorders). Her death was perceived as suicide because she had a history of depression and had attempted suicide several times in the past. Avicii Born as Tim Bergling, he was a Swedish DJ, music producer, and remixer who rose to fame in 2011 for his single Levels . His debut album True in 2013 had the lead single Wake Me Up , which topped most in Europe and reached number four in the United States. In January 2012, Avicii was hospitalized with acute pancreatitis caused by excessive alcohol use, and his health continued to worsen, forcing him to retire from tours in 2016. On April 20, 2018, he died in Muscat; later, it was reported he committed suicide using a glass shard to cut himself. David Foster Wallace He was an American novelist, essayist, short story writer, and university professor of English and creative writing. He is best known for his 1996 novel Infinite Jest which was cited as one of the 100 best English-language novels from 1923 to 2005 by Time Magazine. Wallace had suffered from major depressive disorder for many years, but antidepressant medication allowed him to be productive. Unfortunately, on September 12, 2008, he committed suicide by hanging on the back porch of his house in Claremont, California. He had written a private two-page suicide note to his wife and arranged part of the manuscript for The Pale King. Junior Seau Junior Seau was an American footballer who was a linebacker in the National Football League (NFL), mostly with the San Diego Chargers. He was widely known for his passionate play, was named to the NFL 1990s All-Decade Team, and in 2015 inducted into the Pro Football Hall of Fame 2015. On May 2, 2012, he was found dead of a gunshot wound to the chest at his home in Oceanside, California. His death was ruled out as suicide. Don Cornelius Don was an American television show host and producer known as the creator and host of the music show Soul Train . In 2008 he sold the show to MadVision Entertainment. Through the show, he helped to launch the career of many R&B and soul artists. On February 1, 2012, he was found dead in his home in Los Angeles with a self-inflicted gunshot wound. Ekaterina Alexandrovskaya Ekaterina Alexandrovskaya was a Russian-Australian pair skater. At the junior level, she was the 2017 World Junior champion, the 2017 Junior Grand Prix Final champion, and the 2017 JGP Poland champion. Ekaterina and Harley Windsor began skating together, winning the 2017 CS Tallinn Trophy champion, the 2017 CS Nebelhorn Trophy bronze medalist, and the two-time Australian national champion. On July 18, 2020, she died after jumping out of the 6th-floor window of her Moscow home in a suspected suicide. Chris Benoit Chris Benoit was a Canadian professional wrestler with a wrestling career spanning 22 years. He worked for several pro-wrestling promotions such as World Wrestling Federation/ World Wrestling Entertainment (WWF/WWE), Extreme Championship Wrestling (ECW), Stampede Wrestling in Canada, World Championship Wrestling (WCW), and New Japan Pro-Wrestling (NJPW) in Japan. He held 30 championships between ECW, WWF/WWE, NJPW, WCW, and Stampede and was a two-time world champion. Chris had a long battle with depression, and chronic traumatic encephalopathy (CTE) caused by concussions he sustained during his wrestling led to him committing suicide. In a three-day double murder and suicide, he murdered his wife on June 22, 2007, murdered his 7-year-old son on June 23, 2007, and committed suicide on June 24, 2007. Source: 100 Most Famous People who Committed Suicide

Telepsychiatry, a branch of telemedicine focused to mental health care, has expanded rapidly in recent years. Especially since the pandemic, many people prefer to see a psychiatrist online rather than in person. But this shift raises an important question: Is telepsychiatry truly safe? We'll look at the safety, privacy, and effectiveness of telepsychiatry so you can make an informed decision about your mental health treatment. What is Telepsychiatry? Telepsychiatry involves conducting psychiatric evaluations, therapy sessions, medication management, and consultations over secure video or phone communication. It allows patients to communicate with licensed mental health professionals from the comfort of their own homes. Telepsychiatry is as effective as in-person therapy for a variety of mental health issues, according to research. How Safe Is Telepsychiatry? Very safe, and it's changing the way we get mental health care . Here's why you should trust it: 1. Licensed Professionals Only. Telepsychiatry is provided by qualified and licensed psychiatrists or psychiatric nurse practitioners. These professionals are subject to the same medical standards and ethical guidelines as in-person care. 2. HIPAA and Data Privacy. Telepsychiatry platforms are legally required to adhere to strict HIPAA (Health Insurance Portability and Accountability Act) guidelines in order to maintain patient confidentiality. This means that your conversations, medical records, and mental health information are encrypted and stored securely. 3. Confidential and Secure Technology. Most telehealth services use end-to-end encrypted platforms to prevent unauthorized access. To increase safety, avoid using public Wi-Fi and make sure your provider is using a verified telemedicine platform. Safe from Home. No commuting and no waiting rooms. Simply care in your own space often with easier access to assistance. Advantages of Telepsychiatry Safety Reduced risk of exposure to illnesses, such as COVID-19 and other viral infection. Reduced anxiety among patients in their familiar environment. In the event of a crisis, professionals have safety plans in place to connect patients with local emergency resources. When Telepsychiatry May Be Inappropriate While telepsychiatry is generally safe, it may not be appropriate in specific cases, such as: Severe psychosis or suicidal ideation in absence of local crisis support. Lack of access to a private or quiet space at home. Limited internet connectivity. In such cases, a hybrid approach or in-person care may be recommended. Tips for Maximum Safety in Telepsychiatry Ensure that the psychiatrist is licensed and has experience providing online care. Inquire about the telehealth platform they use and how they protect your data. Make sure your sessions are held in a quiet, private location. In the event of a crisis during a virtual session, inquire with your provider about the steps they will take. Conclusion So, is telepsychiatry safe? The answer is yes, when done correctly. Telepsychiatry is a safe and effective option for the majority of people, thanks to licensed professionals, secure platforms, and patient-centered protocols. Always check the credibility of your provider, stay informed about your rights, and take simple precautions to protect your privacy. With the proper precautions, you can safely and confidently receive mental health care from any location.

Substance use disorder (SUD) is a complex condition in which there is uncontrolled use of a substance despite harmful consequences. People with SUD have an intense focus on using a certain substance(s) such as alcohol, tobacco, or illicit drugs, to the point where the person's ability to function in day-to-day life becomes impaired. People keep using the substance even when they know it is causing or will cause problems. The most severe SUDs are sometimes called addictions. People with a substance use disorder may have distorted thinking and behaviors. Changes in the brain's structure and function are what cause people to have intense cravings, changes in personality, abnormal movements, and other behaviors. Brain imaging studies show changes in the areas of the brain that relate to judgment, decision making, learning, memory, and behavioral control. People can develop an addiction to: Alcohol Marijuana PCP, LSD and other hallucinogens Inhalants, such as, paint thinners and glue Opioid pain killers, such as codeine and oxycodone, heroin Sedatives, hypnotics and anxiolytics (medicines for anxiety such as tranquilizers) Cocaine, methamphetamine and other stimulants Tobacco/nicotine Repeated substance use can cause changes in how the brain functions. These changes can last long after the immediate effects of the substance wears off, or in other words, after the period of intoxication. Intoxication is the intense pleasure, euphoria, calm, increased perception and sense, and other feelings that are caused by the substance. Intoxication symptoms are different for each substance. When someone has a substance use disorder, they usually build up a tolerance to the substance, meaning they need larger amounts to feel the effects. According to the National Institute on Drug Abuse, people begin taking drugs for a variety of reasons, including: To feel good — feeling of pleasure, “high” or "intoxication." To feel better — relieve stress, forget problems, or feel numb. To do better — improve performance or thinking. Curiosity and peer pressure or experimenting. People with substance use and behavioral addictions may be aware of their problem but not be able to stop even if they want and try to. The addiction may cause physical and psychological problems as well as interpersonal problems such as with family members and friends or at work. Alcohol and drug use is one of the leading causes of preventable illnesses and premature death nationwide. Symptoms of substance use disorder are grouped into four categories: Impaired control: a craving or strong urge to use the substance; desire or failed attempts to cut down or control substance use. Social problems: substance use causes failure to complete major tasks at work, school or home; social, work or leisure activities are given up or cut back because of substance use. Risky use: substance is used in risky settings; continued use despite known problems. Drug effects: tolerance (need for larger amounts to get the same effect); withdrawal symptoms (different for each substance). Many people experience substance use disorder along with another psychiatric disorder. Oftentimes another psychiatric disorder precedes substance use disorder, or the use of a substance may trigger or worsen another psychiatric disorder. How Is Substance Use Disorder Treated? Effective treatments for substance use disorders are available. The first step is recognition of the problem. The recovery process can be delayed when a person lacks awareness of problematic substance use. Although interventions by concerned friends and family often prompt treatment, self-referrals are always welcome and encouraged. A medical professional should conduct a formal assessment of symptoms to identify if a substance use disorder is present. All patients can benefit from treatment, regardless of whether the disorder is mild, moderate, or severe. Unfortunately, many people who meet criteria for a substance use disorder and could benefit from treatment don’t receive help. Because SUDs affect many aspects of a person’s life, multiple types of treatment are often required. For most, a combination of medication and individual or group therapy is most effective. Treatment approaches that address an individual’s specific situation and any co-occurring medical, psychiatric, and social problems is optimal for leading to sustained recovery. Medications are used to control drug cravings, relieve symptoms of withdrawal, and to prevent relapses. Psychotherapy can help individuals with SUD better understand their behavior and motivations, develop higher self-esteem, cope with stress, and address other psychiatric problems. A person's recovery plan is unique to the person's specific needs and may include strategies outside of formal treatment. These may include: Hospitalization for medical withdrawal management (detoxification). Therapeutic communities (highly controlled, drug-free environments) or sober houses. Outpatient medication management and psychotherapy. Intensive outpatient programs. Residential treatment ("rehab"). Many people find mutual-aid groups helpful (Alcoholics Anonymous, Narcotics Anonymous, SMART Recovery). Self-help groups that include family members (Al-Anon or Nar-Anon Family Groups). 13 principles of effective drug addiction treatment These 13 principles of effective drug addiction treatment were developed based on three decades of scientific research. Research shows that treatment can help drug-addicted individuals stop drug use, avoid relapse and successfully recover their lives. Addiction is a complex, but treatable, disease that affects brain function and behavior. No single treatment is appropriate for everyone. Treatment needs to be readily available. Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. Remaining in treatment for an adequate period of time is critical. Counseling— individual and/or group —and other behavioral therapies are the most commonly used forms of drug abuse treatment. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure it meets his or her changing needs. Many drug-addicted individuals also have other mental disorders. Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. Treatment does not need to be voluntary to be effective. Drug use during treatment must be monitored continuously, as lapses during treatment do occur. Treatment programs should assess patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, as well as provide targeted risk-reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases. Source: National Institute on Drug Abuse. These principles are detailed in NIDA's Principles of Drug Addiction Treatment: A Research-Based Guide . How to Help a Friend or Family Member Some suggestions to get started: Learn all you can about alcohol and drug misuse and addiction. Speak up and offer your support: talk to the person about your concerns, and offer your help and support, including your willingness to go with them and get help. Like other chronic diseases, the earlier addiction is treated, the better. Express love and concern: don't wait for your loved one to "hit bottom."; You may be met with excuses, denial or anger. Be prepared to respond with specific examples of behavior that has you worried. Don't expect the person to stop without help: you have heard it before - promises to cut down, stop - but, it doesn't work. Treatment, support, and new coping skills are needed to overcome addiction to alcohol and drugs. Support recovery as an ongoing process: once your friend or family member is receiving treatment, or going to meetings, remain involved. Continue to show that you are concerned about his/her successful long-term recovery. Some things you don't want to do: Don't preach: Don't lecture, threaten, bribe, preach or moralize. Don't be a martyr: Avoid emotional appeals that may only increase feelings of guilt and the compulsion to drink or use other drugs. Don't cover up, lie or make excuses for his/her behavior. Don't assume their responsibilities: taking over their responsibilities protects them from the consequences of their behavior. Don't argue when using: avoid arguing with the person when they are using alcohol or drugs; at that point he/she can't have a rational conversation. Don't feel guilty or responsible for their behavior; it's not your fault. Don't join them: don't try to keep up with them by drinking or using. Adapted from: National Council on Alcoholism and Drug Dependence Source: American Psychiatric Association Related Article: Five Key Findings on Mental Health and Substance Use Disorders by Race/Ethnicity The Implications of COVID-19 for Mental Health and Substance Use Two Thirds Say They or Family Affected by Substance Use Stimulant Treatment for Childhood ADHD Not Linked to Adolescent, Young Adult Substance Use Boundary Problems Associated with PTSD and Substance Abuse