Key-point: Although diagnostic criteria for a depressive episode are the same for unipolar major depression and bipolar depression, these episodes differ in their natural history. BIPOLAR UPDATE Although the DSM-5-TR diagnostic criteria for a depressive episode are the same for unipolar major depression and bipolar depression, these episodes differ in their natural history (ie, patients with bipolar disorder have mania and/or hypomania), age of onset, suicide risk, associated comorbidities, and biological correlates. Most importantly, they differ dramatically in the effective medications. Thus, it is critical to diagnose these depressions correctly. To do so, you must take a good history for hypomania or mania. This is where diagnostic errors commonly occur. Start by informing the patient how important it is to have the correct diagnosis for effective treatment and that being wrong about the diagnosis can lead to wrong treatment that, at best, is ineffective and, at worst, very harmful (eg, antidepressants can cause a malignant transformation of bipolar disorder to a rapid cycling and treatment-resistant condition).1-3 This warning to the patient hopefully undermines possible reluctance to disclose manic symptoms because of the stigma of the diagnosis, because they enjoy the experience, or because they believe that it represents their normal mood and energy that they would like to return to and maintain. Start by describing an episode of mania or hypomania: how the episodes start, what symptoms occur at the outset, how individuals react when encountering a patient in a fresh mania, how it progresses over the next several days, and how it ends—typically with a crash into depression when they rapidly develop the opposite of all the symptoms they just had. The patient should first be asked to identify and then focus on periods when they were not significantly using any substances that might produce manic-like symptoms, such as amphetamines, cocaine, and alcohol. Here is how I describe the episodes: I note that typically, there are no precipitants to the onset of manias. This distinguishes them from the common comorbidity (in the patients I see, veterans) of posttraumatic stress disorder (PTSD), in which agitated, hyperactive states are precipitated when some trigger, interaction, or memory leads to a rush of adrenaline and the “fight or flight” response occurs. This agitation and irritability, which is generally an unpleasant experience, may continue for hours or even part of a day. However, if the patient can get away from the triggering stimulus, the symptoms will subside, and they will return to their baseline state. But with manias, the typical onset is when the patient wakes up, and the experience lasts much longer—at least some of the time. They note racing thoughts with many plans for things they would like to do that day and an unusual amount of energy, motivation, and self-confidence that they can do any and all of these things. They may feel invincible. They want to start new projects and ventures, clean and organize the house, add to their possessions, and contact neglected friends. The first person they meet, who might be a spouse or family member they are living with, notices that their speech is faster than usual. They may find it hard to understand as manic individuals (without realizing it) may be dropping syllables or whole words because the speech muscles cannot keep up with the speed of the thoughts. The listener will typically respond by asking the person to repeat what they said, urging them to take a breath or slow down, or maybe questioning how much coffee they had that morning. Ask the patient whether they have had feedback like that from listeners at the start of what might be manias. Next, the individual experiencing mania may tell the person about their plans. And they have a lot to say—they are talking much more than usual, chattier, and even disinhibited in speech, bringing up controversial topics they may regret later. Often, the listener may not agree that these are great plans and may worry that they are unrealistic, impossible, could strain painful medical or orthopedic problems that they have, or maybe the listener may feel there are more important things that the manic person should be doing with this new energy. This could lead to an irritable, if not violent, argument (depending on how insistent the disagreeing person is) because it is usually impossible to dissuade a person experiencing mania from doing what they want to do. They have supreme confidence that it will be easy, and the expenditures will not be a problem (even if they obviously will be a problem). Next, the person experiencing mania sets out to do those projects in “go-go-go” mode, feeling much less need for sleep and maybe skipping sleep completely for a night or 2. As noted, spending money almost invariably occurs to fund the ventures or add to things they collect; clothes are very common purchases, but there can be big-ticket items like vehicles, expensive lawn equipment, or foolish investments, including scams. The person will later recognize these decisions as foolish, but they seemed like perfect opportunities at the time. At night, the person experiencing mania wants to continue their projects, but their loved ones may urge them to come to bed, or they may have enough insight to realize they should at least try to sleep. But it is difficult because their brain is still racing with thoughts of plans, making new ones and modifying previous ones. Again, the contrast with what keeps patients with PTSD awake is important—the individual with PTSD has racing thoughts about past and present traumas, current worries, fears of sounds in the house, and disturbed awakenings and nightmares followed by the inability to return to sleep due to these negative thoughts. Patients with comorbid PTSD and bipolar disorder will have some nights when it is the mania keeping them up and others when the PTSD is the cause. Typically, PTSD is the cause of insomnia during bipolar depressions when they have this comorbidity. After several days or more, the event terminates, usually over a day or less, and there is the crash, as noted before. The victim can feel the energy draining from their body and brain as they lose interest in whatever they were doing and stop working on their projects, leaving them unfinished. They withdraw, do not want to talk to others, and slow down in all respects. Their mood becomes depressed, and suicidality may set in quickly. Patients experiencing mania may have living spaces littered with tools and supplies for unfinished projects. When the next mania comes along, they usually start entirely different projects and cannot be persuaded to finish the previous ones, which is another source of irritability and conflict with the spouse or family. Describing mania in this manner takes 5 to 10 minutes. Then, ask the patient whether they have had experiences like this. It counts for the diagnosis if it happened some years ago, but lately, they have been predominantly depressed. Very often, you will get a strong reaction to the effect that “this is exactly what happens to me; how could you know it so accurately?” They never knew this was mania. Or you may get a reaction that, no, this never happened—and it may be that all the hyperactivity thought to be mania was due to PTSD-triggered events or some other cause related to conflicts with people. The third possibility is that they had some of what you said, but other details were absent. In that case, you flesh out what they claim they did not have in your narrative and see whether it meets the criteria for mania or hypomania. Once you have determined that they have had manic episodes, the next step is to identify how long the spells last, whether they are rapid cyclers with 4 or more episodes per year (2 manias and 2 depressions would qualify), and whether it is bipolar I or II. This is important because, particularly with bipolar I and with rapid cycling, it is essential to avoid antidepressants. I will discuss treatment in later columns. Bipolar I is easily diagnosed if they have a history of psychosis with their manias or if they have been hospitalized because of the manias. The more difficult way to meet the criteria for bipolar I is if they have the third criterion in DSM-5-TR, which is “marked impairment in social or occupational functioning” due to behaviors in the manias. Marked impairment in relationships can come from promiscuity, infidelity to their partner, excessive demands of their partner, or employment of pornography that distresses their partner, all due to the hypersexuality typically associated with manias. I usually wait until now to bring up this symptom. Patients can be ashamed to admit that these things have happened, but by this point in the discussion, they may be ready to discuss it with the clinician. Also, there can be extreme arguments, domestic violence, and intense conflict with significant others, family, and friends about the projects and ideas that the person experiencing mania wants to do. That would also make it bipolar I. Marked impairment at work typically results from the person experiencing mania being very sure of how things should go at work and wanting to argue with bosses/others to have things done their way. In the process of such arguments, they can be fired, or they may impulsively quit good jobs, thinking that everyone at work is stupid compared with them and that they should seek employment elsewhere, only to regret quitting later when the mania subsides. Patients with bipolar I often have a history of many jobs in a short time due, on close inquiry, to their behavior during their manias. If the patient does not report criteria-meeting manic or hypomanic episodes, it is still possible that they are having prebipolar depressions and could have a mania in the future. Initial manias have occurred in older adults after decades of depressions. Predictors of when a unipolar depression diagnosis could change to bipolar include the following: family history of bipolar disorder; a younger age of onset; panic anxiety; a family history of completed suicide; past poor response to antidepressants (even 1 failed trial of an antidepressant should make one pause and wonder whether you missed the diagnosis of bipolar; do not wait until there have been 5 to 10 failed trials); a history of treatment-emergent irritability, agitation, or suicidality after antidepressants; psychotic features; and postpartum depression or psychosis. If enough of these predictors are present, including failure on previous antidepressant trials, consider treating the depression as a bipolar depression . Note: This article originally appeared on Psychiatric Times .

Mental health in the United Kingdom has worsened significantly since COVID-19 pandemic restrictions were imposed, according to a new report by the Institute for Fiscal Studies (IFS). The study confirmed previous findings, showing a “steady increase in reported mental health problems.” Eduin Latimer, a research economist at IFS, warned that rising mental health issues not only affect individuals but also contribute to an increase in the cost of paying benefits. Key Findings The report highlighted several concerning trends. These include: The percentage of working-age people who reported a long-term mental health condition has risen to 13-15%, up from 8%-10% in the mid-2010s. “Deaths of despair” — those caused by alcohol, drugs, or suicide — rose by 24% among 15- to 64-year-olds in 2023 compared with pre-pandemic levels. This contributed to a 5.5% rise in overall working-age mortality. NHS mental health service contacts increased by 36% between 2019 and 2024. Antidepressant prescriptions have risen by 12% since 2019. The number of 16- to 64-year-olds in England and Wales on disability benefits has climbed to 2.9 million (7.5% of this age group), a rise of 900,000 since the pandemic. Over half of new claims cite mental health as the primary condition. A Department for Work and Pensions survey found that 86% of incapacity and disability benefit claimants have a mental health condition, whether primary or secondary. The cost of working-age health-related benefits in 2023-2024 reached £48 billion, £12 billion more in real terms than in 2019-2020, representing 1.7% of GDP. The Office for Budget Responsibility forecasts this will rise to £67 billion by 2029–-2030. Sickness absence days per worker increased by 37% in 2022 compared with 2019. Public sector workers saw significant rises, including 14% in the NHS. Rise in Deaths of Despair Iain Porter, senior policy adviser at the Joseph Rowntree Foundation, which campaigns to end poverty, said there was “clear evidence of a deterioration in mental health in the population” and the trend was “real and growing.” Although greater openness has helped reduce stigma, the increase in deaths of despair underscores the severe impact of worsening mental health, he added. Disability benefit claimants report a range of mental health and behavioural conditions , with anxiety, depression, mood disorders, psychotic disorders, learning disabilities, and autism spectrum disorders being the most common. The report noted particularly fast growth in new disability claims for learning disabilities and autism since 2019. Long Wait Times Dr Subodh Dave, dean of the Royal College of Psychiatrists, called the report’s findings “worrying yet unsurprising.” He told Medscape News UK that 350,000 people with mental illness have waited more than a year for their first NHS appointment, with some waiting more than 2 years. He noted a 29% increase in the waiting list over the past 2 years — a trend he described as “worrying.” Mental illnesses can be treated effectively, particularly when they are identified early, Dave stressed. However, delays increase the risk for more complex conditions that can harm long-term health and prevent people leading fulfilling lives. Patients Struggle to Access Care Dave highlighted the well-known challenges facing NHS mental health services. “Community provision isn’t meeting patients’ needs, adult acute bed occupancy has remained above 95% since May 2022, and patients face unacceptable waits,” he said. “This is hurting individuals and the economy.” Saffron Cordery, interim chief executive of NHS Providers, warned that demand for mental health services has surged. Referrals reached “a record high” of 2 million in December 2024 and were 39% higher than before the pandemic. “The knock-on effects of this are worrying and far-reaching, with poor mental health the leading driver of ill-health related economic inactivity,” she said in a press release. Mental health charities are also struggling to meet demand. Dr Jaime Craig, a consultant clinical psychologist and director of policy and governance at the Association of Clinical Psychologists (ACP), told Medscape News UK that since the pandemic, those at the front lines of healthcare, particularly GPs, have seen an increasing number of patients with poor mental health. This was accompanied by a rise in the number of patients with complex combinations of psychological and physical health difficulties. For both groups, options to help them access effective specialist support can be limited. The ACP’s recent work on the lack of appropriate mental health support for immunocompromised people and their families is a good example of the growing need for specialist clinical health psychology support, and the impact of this being unavailable, Craig said. Craig also warned that healthcare workers are often left advising patients with few available options. “Those on the frontline of healthcare can be placed in the unenviable position of having little to help them advise their patients,” he said. They may also struggle to guide patients on how to safely navigate unregulated therapy services outside the NHS. Note: This article originally appeared on Medscape .

Anxiety is a normal human emotion that everyone experiences from time to time. However, when anxiety becomes excessive or debilitating, it can become a mental health disorder. Anxiety disorders are the most common mental illness in the United States, affecting 40 million adults age 18 and older, or 18.1% of the population every year. There are many different types of anxiety disorders , including generalized anxiety disorder (GAD), panic disorder, social anxiety disorder, and specific phobias. GAD is characterized by excessive worry and anxiety that is difficult to control. Panic disorder is characterized by sudden, intense episodes of fear and anxiety that can lead to physical symptoms such as shortness of breath, chest pain, and dizziness. Social anxiety disorder is characterized by a fear of social situations that can lead to avoidance of social interactions. Specific phobias are characterized by a fear of a specific object or situation that can lead to avoidance of the feared object or situation. Source: Anxiety and Depression Association of America Anxiety disorders can have a significant impact on a person's life. They can interfere with work, school, relationships, and overall quality of life. In some cases, anxiety disorders can lead to suicide . Suicide is the 10th leading cause of death in the United States, and it is the second leading cause of death among young people ages 15-24. Anxiety disorders are a major risk factor for suicide. In fact, people with anxiety disorders are up to six times more likely to attempt suicide than people without anxiety disorders. There are a number of reasons why anxiety can lead to suicide: First, anxiety can make people feel hopeless and helpless. Second, anxiety can make people feel isolated and alone. Third, anxiety can make people feel like they're a burden to others. There are a number of things that can be done to prevent suicide in people with anxiety. These include early identification and treatment of anxiety disorders , providing support and education to families and friends of people with anxiety, and reducing access to lethal means of suicide. 7 Tips on How to Deal with Anxiety Mental health wellness is the state of being mentally healthy and well-functioning. It includes having a positive sense of self, being able to cope with stress, and having the ability to maintain healthy relationships. There are a number of things that you can do to promote mental health wellness. These include: Getting enough sleep Eating a healthy diet Exercising regularly Spending time in nature Connecting with loved ones Practicing relaxation techniques Seeking professional help if needed If you are struggling with anxiety or other mental health challenges, it is important to seek help. There are a number of resources available to you, including therapists, counselors, and support groups. You are not alone, and there is help available.

Key Takeaways Disasters cause widespread disruption, exceeding community coping capacities, and necessitate external assistance for recovery. Disaster psychiatry addresses psychological impacts, focusing on symptom-targeted interventions and promoting community well-being. Key interventions include promoting safety, calming, efficacy, connectedness, and hope to mitigate psychological effects. Clinicians play a crucial role in disaster management, from preparation to long-term recovery, emphasizing resilience-building. Challenges include rapid mobilization of resources, insurance access, and role conflicts, highlighting the need for predisaster planning. Disasters are events that result in serious widespread disruption to the functioning of a society or community, whether on a local or larger scale, due to hazardous events. These events can be either natural or human made. According to the World Health Organization, disasters are severe disruptions, ecological and psychosocial, which greatly exceed the coping capacity of the affected community. What Are the Impacts of Disaster? Disasters’ impacts can be localized, but they are typically widespread and may persist for extended periods. The effects often challenge or exceed the resources available to a community and generally require assistance from external sources. Disaster causes loss of human lives, physical illnesses, and property damage. Beyond the socioeconomic and physical toll, disasters also cause significant emotional and mental distress for the communities they affect. These effects may precipitate an increase in psychiatric disorders such as posttraumatic stress disorder (PTSD) , anxiety, and depression. What Is Disaster Psychiatry? Disaster psychiatry is defined as the understanding and treatment of the psychological impacts resulting from disaster, often using an epidemiological approach. It emphasizes the normality of acute stress responses following disaster event and strives to avoid psychopathologizing individuals. A key goal of disaster psychiatry is to provide interventions targeted at symptoms rather than focusing on syndromes. It aims to promote the overall health status and well-being of an affected community. This approach involves integration outside of traditional office settings, involving many organizations to ensure effective preparation and response. Although there are several important milestones in the development of disaster psychiatry, the 1942 Cocoanut Grove nightclub fire, which claimed nearly 500 lives, stands as a defining moment in the field’s development, particularly due to Erich Lindemann, MD, PsyD’s observations of survivors’ experiences. Psychological Effects of Disasters Disasters differ in nature, each with unique characteristics that impact the psychological responses of survivors and communities. These elements can shape the type, intensity, and duration of stress experienced after the disaster. Disasters can have both short-term and long-term effects on mental health, despite a wide range of individual responses. While some individuals may develop chronic disorders such as PTSD, depression, or anxiety, the majority will experience stress responses that do not reach clinical levels. For many, these are appropriate responses to extreme circumstances. A survivor’s response to and recovery from a disaster is shaped by various factors, some of which can be influenced or developed, while others are inherent traits. Genetic factors play a significant role in how individuals respond. Stress response is complex and regulated by multiple systems, including the sympathetic nervous system (SNS), the hypothalamic-pituitary-adrenal axis (HPA axis), neuropeptide Y, and serotonin, all of which vary genetically between individuals. Interestingly, neuropeptide Y, which is secreted from the hypothalamus and other areas of the brain, may serve as a protective factor from the effects of trauma. The body’s stress response involves 2 main components: an acute response mediated by the sympathetic-adreno-medullar system (SAM) and a long-term response mediated by the HPA axis. SAM activation triggers the adrenal medulla to release norepinephrine and epinephrine, which in turn activate a cascade of cellular responses such as vasoconstriction, increased blood pressure, heart rate, and many others. There is also behavioral activation such as enhanced vigilance, attention, and arousal. Long-term stress leads to sustained activation of the SNS and HPA axis. The hypothalamus releases corticotropin-releasing hormone, stimulating the anterior pituitary gland to release adrenocorticotropic hormone, which prompts the adrenal cortex to secrete glucocorticoid hormones like cortisol, further activating the stress response. Chronic elevation of stress hormones can have detrimental effects on health, including hypertension, immune suppression, insulin resistance, and cardiovascular disease. Clinicians Role in Disaster Psychiatry and Disaster Management Disaster psychiatry is unique from most practice settings as it is not office or hospital based. Clinicians typically work on-site. Clinicians' roles include planning and coordination during the predisaster, immediate response, and long-term care and support stages. Taking a stepwise approach to the phases of a disaster can help clinicians prepare for and respond more effectively to these events. Phases of disaster management include: readiness (predisaster), response (immediate action), relief (sustained rescue work), rehabilitation (long-term remedial measures using community resources), recovery (returning to normalcy), and resilience (fostering). Predisaster: Preparation and Planning Effective disaster preparation and planning are essential for communities to manage potential crises. Clinicians can work as liaisons between disaster response agencies and health care facilities, assisting with hospital and clinic disaster planning. Mental health clinicians in particular can advocate for the inclusion of mental health considerations in disaster preparedness, addressing the psychological impact on affected populations. Preparing for disasters has become increasingly important due to the growing frequency and intensity of disasters related to changes in climate, technology use, and geopolitical situations. Immediate Response: Psychological First Aid An immediate response is crucial in mitigating long-term psychological effects and fostering resilience. This early response typically occurs at the disaster site, beginning as soon as possible and potentially lasting several days to weeks. Psychological first aid (PFA) is a key approach for reducing initial distress and supporting adaptive functioning and coping in both the short and long term. The primary goals of PFA are to improve mental health and functional responses by tending to basic needs, ensuring safety, promoting a sense of control, and fostering social connections. Key components of PFA include engaging with individuals, promoting safety, assessing needs, providing calming and stabilization, and encouraging connectedness. Clinicians should engage survivors with respect and empathy, assess their medical and psychiatric needs to identify those requiring immediate care, and offer information and support to help stabilize emotions. Creating opportunities for social connection helps build a support network promoting resilience, problem-solving, and long-term recovery. Key Interventions: The 5 Elements of Mass Trauma Response There are 5 principles of intervention that serve as guidance for developing practices after disasters and mass violence.15 These principles are: Promote a sense of safety. Promote calming. Promote sense of self and collective efficacy. Promote connectedness. Promote hope. Promote a sense of safety: Disasters force people to respond to events that threaten their lives or the individuals and things they care most about. As a result, it is common to see large percentages of disaster-affected populations with negative posttraumatic reactions. When threat or danger conditions are ongoing, these negative posttrauma responses persist. However, these reactions show a gradual reduction over time once safety is introduced, even when the threat continues. Promote calming: Calming interventions help to counteract the heightened emotionality often seen after mass trauma exposure. While an initial arousal response can be adaptive, heightened emotional responses when prolonged can result in mental health issues such as depression and PTSD. Promote sense of self and collective efficacy: Self-efficacy is the belief that one's actions are likely to lead to positive outcomes, while collective efficacy is the confidence that a group can achieve positive outcomes together. This sense of control over positive outcomes is especially important when coping with trauma-related challenges. Promote connectedness: Social connectedness is important in combating stress and trauma. It supports resilience by encouraging knowledge sharing and increasing opportunities for social support activities. Examples of such activities are discussing traumatic experiences in safe environments with adequate support. Moreover, this can lead to a sense of community efficacy. Promote hope: Disaster tends to be an experience individuals are not trained for and do not have the learned coping strategies to combat. As a result, disaster is often followed with a “shattered worldview,” which undermines hope and leads to despair. However, those who retain hope and remain optimistic about their future after experiencing disaster are likely to have more favorable outcomes. Fostering hope is essential for recovery in disaster situations. Long Term Care and Support Following PFA, long-term care and support are essential to sustained recovery. Key objectives include effective triage and screening, restoration of daily functioning, development of self-regulation techniques for managing emotional responses, and improvement of problem-solving abilities to manage ongoing challenges. Long-term care and support also focuses on strategies for risk reduction, resilience-building to withstand stressors caused by disasters, and long-term recovery to support mental well-being. Challenges in Disaster Psychiatry Disaster psychiatry encounters several significant challenges. Rapid mobilization of mental health resources is essential for effective intervention, yet time constraints pose a challenge. Limited access to insurance or inadequate coverage can prevent individuals from receiving necessary care. The complexity of disaster response also brings role conflicts, particularly regarding leadership and decision-making. Additionally, many lack preparedness for handling disasters, highlighting the need for predisaster training and planning. Even disaster workers are at risk of acute stress disorder, PTSD , and depression. Concluding Thoughts Disaster psychiatry plays a crucial role in mitigating the impact of disaster, promoting an environment where survivors can move forward with resilience. Clinicians who are interested in learning more about disaster psychiatry can find more resources through the American Psychiatric Association’s Disaster Mental Health webpage. This page provides position statements, literature, and resources related to the field. Additionally, it provides information regarding volunteer opportunities. Clinicians can also find resources through the Substance Abuse and Mental Health Services Administration’s webpage on Disaster Behavioral Health Resources. This page provides literature and guides which are designed for both responders and survivors. Note: This article originally appeared on Psychiatric Times .

Medications demonstrated effectiveness for core symptoms of attention-deficit/hyperactivity disorder (ADHD) in adults without evidence of whether quality of life (QOL) is improved, and nonpharmacologic interventions could be rated effective by clinicians but not by patients, in findings from the first component network meta-analysis (CNMA) of the array of treatments offered to adults with ADHD. "Given the concerns around the safety of ADHD medications, there is a pressing need to better understand the comparative efficacy and tolerability or safety of medications and nonpharmacological interventions for the management of ADHD in adults," observed Edoardo Ostinelli, MD, and colleagues. The investigators conducted the CNMA to compare benefits and harms of available interventions from 113 randomized controlled trials (RCTs) identified from multiple data bases, from inception through September 2023. The trials evaluated pharmacologic treatments (63 trials with 6875 participants); psychological therapies (28 trials with 1116 participants); neurostimulatory therapy and neurofeedback (10 trials with 194 participants); and control conditions (97 trials with 5770 participants). The trial controls could be either active or placebo, and were double-blinded if evaluating medication, cognitive training, or neurostimulation alone. Medication trials also had to have maximum planned doses correspond to international guidelines, and duration of at least 1 week. Trials with psychological therapies had to provide at least 4 sessions and trials of neurostimulation had to apply the regimens established in originating studies. The primary outcomes of the CNMA were severity of ADHD core symptoms at time points close to 12 weeks, as measured on clinician-rated scales and/or patient self-rating, and acceptability of the intervention, inferred from discontinuation rates. Secondary outcomes included these measures at longer term, as well as emotional dysregulation, executive dysfunction, and quality of life. A unique aspect of the CNMA study was to include individuals with lived experience in its planning and implementation; Ostinelli et al found this particularly helpful in formulating study questions and selecting outcomes. "Collaborating with individuals with lived experience of ADHD has been a crucial aspect of our work, ensuring their voices are heard and meaningfully influence our research," Ostinelli told Psychiatric Times. "Given the abundance of available findings, we first asked a panel of people with lived experience of ADHD to select which outcomes they wished to visualize based on what matter to them, and data availability—without knowledge of the results," Ostinelli explained. "We then presented the findings to them without disclosing the treatment names. Their insights and feedback provided significant value and helped shape our manuscript." In the primary outcome of ADHD core symptoms at 12 weeks, Ostinelli et al reported that atomoxetine and stimulant medications were statistically significantly superior to placebo on both clinician rating and patient self-report. Relaxation therapy was less effective than placebo on self-reported scales. Cognitive behavioral therapy, cognitive remediation, mindfulness, psychoeducation, and transcranial direct current stimulation were superior to placebo on clinician ratings but not self-reported scales. "There are several potential explanations for the misalignment between clinician and patient ratings," Ostinelli commented. "Further research is needed to determine whether this discrepancy is due to outcome reporting bias or if different types of raters simply measure distinct aspects of the condition." Acceptability of interventions were generally similar for adults, with stimulants rated more acceptable than placebo; however, both atomoxetine and stimulants were less tolerated than placebo. In a secondary efficacy outcome of reducing emotional dysregulation, atomoxetine and stimulants were superior to placebo at 12 weeks, but not at 26 weeks. No other active intervention was found efficacious for emotional dysregulation, albeit with only 3 RCTs identified. The investigators highlighted this area for future research. "As difficulty with regulation of emotions is often a highly impairing symptoms that some argue should be regarded as part of the core symptoms of ADHD, additional evidence to support its management is a pressing need," Ostinelli et al urge. On another secondary outcome of executive function, the CNMA found that active interventions, apart from mindfulness, did not differ from placebo on processing speed at 12 weeks. They noted that their findings differed from studies in children with ADHD, with neither medication nor cognitive training demonstrating efficacy for improving executive function in adults. "Given the high frequency and impairing nature of executive dysfunction associated with ADHD in adults, effective interventions and support are urgently needed," the investigators declared. Although Ostinelli et al found little evidence of any active intervention improving QOL at 12 weeks for adults, they acknowledge that a longer timeframe is probably necessary to measure this outcome and point out that there are few data at longer time points. The lack of evidence for improvement in QOL in adults differs from findings in children, they note, with another meta-analysis finding evidence that medication for ADHD improved QOL in children in short to medium term. "With the similar effects of continuing and discontinuing medications on reported quality of life in a few randomized discontinuation trials, available evidence does not support medications as standalone treatments in providing satisfactory benefits on the quality of life of adults with ADHD," Ostinelli et al indicated. To the question of whether this CNMA will influence clinician's choice of treatment modality for adults with ADHD, Ostinelli acknowledged the hesitancy of some clinicians to prescribe treatments with which they are not fully confident. He emphasized, however, the importance of providing personalized medicine grounded in the available evidence and anticipates that this CNMA will inform clinical decision making. "This underscores the need to enhance education and provide ongoing professional development on ADHD treatments ," Ostinelli said. "Initiatives such as establishing a network of dedicated research clinics and hubs should be promoted to improve access to treatment while also leveraging their contributions to advance future health care." Note: This article originally appeared on Psychiatric Times .

Key Takeaways Children with higher cognitive abilities and social skills often face delayed or missed ADHD diagnoses, especially females, indicating potential sex bias in diagnosis. Emotional and behavioral difficulties, emotional dysregulation, lower cognitive ability, and poorer prosocial skills increase the likelihood of earlier ADHD diagnosis. Emotional dysregulation is gaining recognition as a key ADHD symptom, despite not being included in current diagnostic criteria. Undiagnosed ADHD can undermine development, highlighting the need for assessments if symptoms and functional impacts are present, regardless of academic and social abilities. SPECIAL REPORT: CHILD AND ADOLESCENT PSYCHIATRY Symptoms of attention-deficit/hyperactivity disorder (ADHD) are more often overlooked or diagnosed later in children with higher cognitive ability, physical activity, or social skills, according to findings of a large population cohort study of factors that contribute to diagnosis timing.1 Delayed or missed diagnosis of ADHD was also more likely in youth with fewer behavioral, emotional, peer, and conduct issues. In addition, sex-stratified analysis suggests that the higher prevalence of ADHD in male patients partly reflects sex bias in diagnosis, with higher rates of missed and late diagnoses in female patients. “Overall, our findings suggest that children may have their ADHD missed, or diagnosed later if they are not particularly disruptive, are more cognitively able, and have better prosocial skills,” said Isabella Barclay, PhD candidate, Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, and colleagues. Detecting ADHD Symptoms in an Undiagnosed Cohort Barclay et al identified a cohort of 9991 individuals (43.69% female) from the Millennium Cohort Study,2 a United Kingdom–based population study that defined clinician-diagnosed ADHD by parent report and the presence of undiagnosed symptoms consistent with ADHD by parent-reported questionnaires. The investigators compared characteristics of individuals with ADHD who were diagnosed earlier in childhood (5 or 7 years) with those diagnosed later (11 or 14 years), as well as of those who received a diagnosis at any age, compared with those with probable but unrecognized ADHD. In addition to parent-reported clinician diagnosis, the presence of probable but undiagnosed ADHD symptoms was drawn from the Strengths and Difficulties Questionnaire (SDQ)-hyperactivity subscale, which includes hyperactive-impulsive and inattentive symptoms, completed by parents at the child’s age of 5, 7, 11, and 14 years. An SDQ Impact (Supplement) score of 2 to 10 was considered consistent with experiencing impact from ADHD symptoms. Children with high SDQ-hyperactivity scores reflecting impact at either age 5 or 7 years were considered to have probable ADHD regardless of whether a clinical diagnosis had been made. Children were considered not to have ADHD if they had no or low symptoms (score < 7) on the SDQ-hyperactivity scale and their parents confirmed an absence of clinician diagnosis at all time points. Individual characteristics were drawn from a range of parent-reported instruments, including the SDQ for conduct and emotional problems, peer relationships, and prosocial skills, at ages 5 and 7 years. The Child Social and Behavioral Questionnaire, adapted from the Adaptive Social Behavior Inventory, provided a measure of emotional dysregulation at ages 5 and 7 years. Physical activity was gauged from parent report of the number of days per week of involvement with a club, class, sport, or other physical activity. Cognitive ability was drawn from the British Ability Scale measure at age 5 years. Unrecognized, Undiagnosed, Untreated Barclay et al report finding children are more likely to receive an earlier diagnosis if they experience more emotional and behavioral difficulties, greater emotional dysregulation, lower cognitive ability, and poorer prosocial skills. They also cite previous studies that suggest that the impact of difficulties on others around the child, as well as comorbidity, predict referral to specialist services. “Indeed, in our study, the final comparison comparing recognized ADHD to unrecognized ADHD with higher reported levels of impact, the only differing factor was an increased likelihood of an autism diagnosis in the recognized group,” Barclay and colleagues reported. “Evidently, children with symptoms and impact might benefit from an ADHD assessment, and this finding suggests that the burden of multiple difficulties may increase likelihood of contact with specialist services,” they said. The investigators found the ratio of unrecognized ADHD to be higher in female patients in both the earlier (4.2:1) and later (3.7:1) recognized groups compared with the unrecognized group (1.6:1). The only factor indicating a sex difference was emotional dysregulation, with male patients with an ADHD diagnosis more likely to have a higher score of emotional dysregulation than male patients with unrecognized ADHD, but without that difference in female patients. “Emotional dysregulation is gaining recognition as a key aspect of ADHD symptomatology, despite not being included in diagnostic criteria,” the investigators observed. “If included in the criteria, females may be more likely to be recognized, as post hoc analysis revealed that females with both recognized and unrecognized ADHD were more likely to have higher levels of emotional dysregulation than females with no ADHD.” Undiagnosed ADHD is untreated ADHD, the investigators emphasize, and is likely to undermine development, particularly in the academic and social domains. “This highlights the need to assess for the possibility of ADHD, regardless of academic and social abilities, if children are displaying symptoms, especially if they also have functional impact,” said Barclay et al. Note: This article originally appeared on Psychiatric Times .

When the 42-year-old patient came to see Yarickza Lopez, MSN, FNP-C, the 5-ft woman weighed 260 lb and had severe depression and anxiety, type 2 diabetes, high blood pressure, polycystic ovary syndrome, and high cholesterol. At the time, she was on a plethora of medications, including metformin and Januvia, an atorvastatin, a hypertension drug, and two depression medications, said Lopez, a nurse practitioner who specializes in obesity medicine and is founder and CEO of LB Rejuven8 Aesthetics and Wellness, a med spa based in College Station, Texas. While the patient’s physical conditions were being treated with medication, the root causes of her anxiety and depression had been overlooked for years, Lopez said. As she treated the patient’s obesity, Lopez dug into her mental health issues and learned she used food as a coping mechanism for anxiety and stress. The patient regularly ate fast food when feeling down or stressed, and her diet at home was extremely carb- and rice-based, Lopez said. To address this, Lopez incorporated cognitive behavioral therapy into the patient’s treatment plan and started working with her on positive self-talk and habit optimization. The treatment included lots of regular reminders and reassurances about the patient’s self-worth, she said. “Between the therapy and the medication reducing her food noise, that really helped her to wean off of her cravings,” Lopez said. “We did struggle with self-worth when she would fall back into an old habit, but after a while, old habits made her sick, which was a positive reinforcement to continue eating healthy. She began creating healthy boundaries, and slowly, she started believing in herself again.” Integrating behavioral therapy made all the difference in the patient’s obesity recovery, Lopez said. Today, the patient has lost 110 lb, she feels better mentally and physically, and she no longer needs her depression medication. Studies have long shown a strong association between obesity and poor mental health. Patients who are obese, for example, are 18%-55% more likely to develop depression, while about 45% of adults with depression are obese, according to data from the Centers for Disease Control and Prevention. Patients with obesity are also more likely to experience anxiety, dysregulated eating behaviors, and eating disorders than the general population. The odds of developing a mental health disorder in adolescence , meanwhile, are 7 times higher among children with obesity than among normal-weight children, according to an August 2023 analysis in Psychiatry Research. “Obesity and mental health are deeply interconnected,” said Sasidhar Gunturu, MD, vice chair and medical director for psychiatric integrated services for the BronxCare Health System. “There is a bidirectional relationship between obesity and mental health, meaning not only can obesity contribute to mental and physical health problems but it can be the opposite as well.” With the rise of obesity clinics and the use of glucagon-like peptide 1 agonists for weight loss, integrating mental health support into obesity care treatment is critical, said Gunturu, whose research includes a May 2024 STATPearls article on psychological issues associated with obesity. Long-term health outcomes for patients are generally much better when mental and/or behavioral health is integrated into obesity care, he said. Gunturu is concerned, however, that not enough screenings or mental health interventions are being conducted during obesity treatment. Obesity management specialist Catherine (Cate) Varney, DO, said mental health is one of the most overlooked aspects in the treatment of obesity. Too frequently, clinicians prescribe obesity medications without considering potential, underlying psychological issues, said Varney, an assistant professor in the department of family medicine at the University of Virginia School of Medicine and obesity medicine director for UVA Health in Charlottesville, Virginia. “Newer obesity medications have been shown to help patients manage what they describe as ‘food noise’ — the persistent, intrusive, and sometimes obsessive preoccupation with food,” she said. “While these medications provide relief from this aspect, they cannot address the underlying psychological and behavioral factors driving the condition.” If clinicians fail to directly address or refer patients to mental health professionals who can help with these issues, the risk for negative setbacks and long-term challenges increases significantly, Varney said. Incorporating Mental Health Into Obesity Care Integrating mental health support into obesity treatment plans starts with screening for depression, anxiety, and eating disorders like binge eating disorder, Varney said. Screening tools such as the Patient Health Questionnaire-9, General Anxiety Disorder-7, and Binge Eating Disorder Screener can be helpful, she said. If clinicians are considering treating patients with an anti-obesity medication, it’s essential to assess for these conditions prior to treatment, she said. “These conditions wouldn’t necessarily restrict the use of anti-obesity medications, but treatment for the psychological component can be simultaneously treated,” she said. Treatment generally includes first-line cognitive behavioral therapy but can also include medication therapy, Varney adds. If clinicians aren’t capable of managing this aspect, due to restrictions in time, clinic resources, or expertise, they should refer the patient to a licensed clinical social worker, psychologist, or psychiatrist, she said. Registered dieticians can also help patients develop an individualized and sustainable eating plan that supports both physical health and emotional well-being, she said. Communication and collaborative care among all clinicians treating the patient is key, said Gunturu. At BronxCare Health System, behavioral health is integrated into 11 primary care practices, and clinicians conduct routine mental health screenings on all obesity care patients, he said. An interdisciplinary case management team, which includes primary care physicians, mental health specialists, family practitioners, pharmacists, and social workers, treats patients as a team and regularly discusses cases. Multiple specialists thinking and assessing patients together help fill treatment gaps and often determine more answers when patients aren’t improving, Gunturu said. In one recent case, a 42-year-old woman with depression was being treated with semaglutide injections for 2 months, but her obesity levels were not improving, and her depression continued to worsen, he said. A team of specialists sat down with social workers, a clinical care coordinator, and a member of the managed care team to brainstorm. The care coordinator suggested making a home visit, where she ultimately found the patient had a broken refrigerator and no safe storage area to store her medications. Within a week, the team obtained vouchers for the patient that helped fix her refrigerator, Gunturu said. She was able to store and take her medications, and within 12 weeks, the patient had lost about 15 lb, and her depression improved. “Sometimes we don't think about small things, but they can make a big difference,” he said. “A lot of these problems you see, the social determinants of health, can play an important factor.” Recognizing the Role of Trauma Another often overlooked aspect in obesity care is the role of trauma, said Zerimar Ramírez López, MD, a psychiatry resident at BronxCare Health System. Many patients with obesity, especially those who have binge eating disorder, have a history of adverse childhood experiences or posttraumatic stress disorder, and also emotional trauma, she said. A growing body of research demonstrates a significant relationship between childhood abuse and adult obesity. “These experiences can shape eating behaviors, emotional regulation, and metabolic health in profound ways,” Ramírez López said. “If we don't address trauma in obesity treatment, we're missing a key piece of the puzzle.” Clinicians should shift away from defining patients’ success purely by weight loss numbers and focus on broader markers, such as sleep habits and improved self-control, she said. As patients move through treatment, for example, ask whether their sleeping habits have improved, whether they feel more in control of their eating behaviors, and if they are engaging more in their daily lives. Even when patients experience obvious health benefits from weight loss, they may struggle with body dysmorphia, lingering concerns about their appearance, or feelings of inadequacy, Varney adds. Issues like loose skin or other physical changes can fuel the belief that they are "not good enough" or that they haven’t achieved the ideal body image, Varney said. Post-weight loss, many patients may also face a paralyzing fear of regaining weight, which can lead to increased anxiety, stress, and obsession with maintaining their weight loss, she said. The fear can be exacerbated by concerns about accessing, affording, or continuing anti-obesity medications. “The mental health support should not stop when the patient reaches their goal or maintenance weight,” she said. In Varney’s practice, she has seen another issue pop up after weight loss that can cause mental distress for patients: family tensions. A patient’s weight loss can sometimes trigger food-related tensions within the family due to changes in the patient’s eating habits or interests or cause jealousy and resentment among family and friends. “While the patient may achieve new confidence and health benefits, it can also introduce emotional and psychological complexities that can strain relationships if not addressed,” Varney said. In these cases, Varney’s practice offers a monthly support group for those who have undergone bariatric surgery. For patients without a surgical history, she recommends or refers patients for couple or family counseling through local clinics and religious organizations. Effect of Medications on Mental Health A particularly pressing issue in the realm of obesity and mental health care is the impact of GLP agonists on mental health, Ramírez López said. Recent reports have described the so-called “Ozempic Blues,” a phenomenon where patients can experience mood changes, anhedonia, or emotional blunting, she said. There have also been instances of behavioral activation effects, such as increased anxiety or impulsivity after using such medications. The side effects are not yet well understood, and more research is needed on their association, Ramírez López said. Gunturu adds it’s important to talk to patients about these potential side effects when considering or starting new anti-obesity medications. “When you distort the reward pathway in the brain, it can have some consequences,” he said. “The best way we can approach this is to talk to patients and let them know this can happen in the first 2 months. Be aware of it. You can do some behavioral techniques that can help motivate yourself.” Note: This article originally appeared on Medscape .

Mark Viner, MD, is a psychiatrist based in Reno, Nevada and has extensive experience in schizophrenia, Clozapine, psychopharmacology, and suicide research. He is an active member of organizations focused on cannabis medicine, including the Clinical Society of Cannabis Clinicians and the International Alliance of Medicinal Cannabinoids. In a video interview with Psychiatric Times, Viner said 1 of the most debated topics in psychiatry is the relationship between cannabis and schizophrenia. Both conditions peak in prevalence around the same age—between ages 22 and 25. This simultaneous onset makes it difficult to establish a clear cause-and-effect relationship. He also noted that both cannabis use disorder and schizophrenia share chromosomal loci, suggesting a deeper genetic link that warrants further investigation. Unlike hallucinogens, which do not share this genetic or temporal overlap with schizophrenia, cannabis has unique interactions with psychiatric disorders. Viner believes that further research should focus on the role of cannabis in dissociative disorders, particularly in relation to PTSD and trauma. Since cannabis can induce mild dissociation, understanding its potential therapeutic applications for trauma-related conditions could be valuable. Beyond PTSD, he emphasized that cannabis interacts with key brain regions, such as the hypothalamus and basal ganglia, which are heavily involved in regulating sleep, appetite, and motor functions. As a result, he sees potential for cannabis-based treatments in a wide range of psychiatric and neurological disorders, including sleep disorders, feeding and eating disorders, sexual dysfunction, and elimination disorders. He shared research on cannabis and motor disorders, particularly tic disorders and catatonia. He stressed that the motor-related effects of cannabis are not widely recognized but could offer new treatment pathways for conditions with significant movement-related symptoms. Note: This article originally appeared on Psychiatric Times .

AFFIRMING PSYCHIATRY In the early morning hours of December 4, 2024, United Healthcare CEO Brian Thompson was gunned down on the streets of New York. Although the motives of the murderer are not certain, there are indications that he carried out a vigilante-style execution as an act of terror against the insurance company itself. Unsurprisingly, his death sparked a national outpouring of opinions on the subject of health insurance and health care generally. Much of that opinion was unsparing. Rather than sympathy toward Thompson or United, most immediate social media responses ranged from ironic jokes about denied coverage to outright celebration. The schadenfreude and public rage both continued as United Group’s CEO (Andrew Witty) took to the editorial pages of The New York Times to defend his own. “Healthcare,” he opined, “is both intensely personal and very complicated, and the reasons behind coverage decisions are not well understood. We share some of the responsibility for that.” Readers do not appear to have been convinced. They called the essay “sanctimonious” and “self-serving.” “More gaslighting from an industry that has zero need to exist except to siphon profits from a non-discretionary sector,” said commentator “J M” to the tune of 4488 recommends. While I personally do not agree with Witty’s opinion, I do have to admire his courage in speaking out just days after the assassination. And I can respect the courage of other commentators who went on record to speak up for insurance companies, paddling against the riptide of public emotion that was churning forth. For instance, the editorial board of the Wall Street Journal was sympathetic to insurance companies’ efforts to “control costs,” blaming government for “policies that distort the markets and force rationed care.” Matthew Yglesias, a nationally prominent blogger, has long maintained that the major problem with America’s health care system is that providers charge too much. Economist and blogger Noah Smith has been even more forthright: I think the outpouring of schadenfreude at Thompson’s killing reflects some deep-seated popular misconceptions about the US health care industry. A whole lot of people—maybe most people—seem to regard health insurance companies as the main villains in the system, when in fact they’re only a very minor source of the problems. The insurance companies are simply hired to play the bad guy—and they’re paid a relatively modest fee for that service. Who is the real “bad guy” in our health care system? Well doctors and nurses, of course! Sure, doctors and nurses take good care of patients during the treatment process, but yet they charge “excessive prices.” According to Smith, doctors and nurses know that insurance is not going to pay a lot of those costs. The “smiling doctor” and the “gentle nurse” know full well that insurance is going to fight expensive procedures and drugs, and yet they never mention it. They offer all sorts of treatments knowing and apparently not caring that patients will get stuck with the bill. It is the providers that are the problem, you see. Insurance companies are just the poorly paid fall guy who cut costs so that doctors, nurses, and hospitals can play the ‘good guy.’ Rage Against the Insurance Companies Not surprisingly, I as a physician have a different idea about all this. My idea is that the costs of treatment are only a secondary factor in the titanic rage against the insurance companies. I truly believe that while the expense of medical care is a serious problem for our system, the rage has to do with something else: The experience of being repeatedly and systematically hoodwinked. Hoodwinked? Exactly, at least according to 1 definition of the word: “To conceal one’s true motives from, especially by elaborately feigning good intentions so as to gain an end.” That is a precise description of what many of us experience with insurance companies. We feel repeatedly deceived by protestations of the best intentions followed by cold, calculating, and duplicitous treatment. And that is why so many New York Times readers responded so negatively to Witty’s bland pronouncements of goodwill on behalf of the insurance industry. Although I have no hard evidence for this idea, I do have 20 years of experience with it in private practice. Whenever I treated individuals who paid for treatment directly out of pocket, I noticed the same pattern: They did not like the high price of treatment, but handled it calmly and kindly as long as they knew the costs in advance and could plan for them. On the other hand, individuals became absolutely livid if they had any sense of being deceived about the nature of our arrangement. For instance, people who felt deceived about being charged for no-shows, or ill-informed about whether I was an in-network provider, would turn against me instantly and literally curse me to my face. Whenever individuals did not clearly understand the deal in advance, whenever they felt ambushed by hidden costs after committing themselves to treatment, learning of some new loophole or obligatory expense felt like a stab in the back. I have never seen anyone take kindly to a stab in the back. And so, I submit that the rage against the insurance companies comes from a sense of being duped, not simply from high costs or limits of coverage. It is not the fact that insurance does not cover everything that makes people so angry. It is the impression that they pretend to cover so much, take your money for years in the form of high monthly premiums, and then in your hour of desperation and need, they refuse to pay up. Instead, they seem to find loopholes, make excuses, refuse to help, hide behind rules that no one can understand, and make it excessively difficult even to get a person on the telephone who can address the situation. It is not that insurance seems costly. It is that insurance seems duplicitous. What We Want From Insurance What do we want from insurance companies? We simply want a fair deal, a deal that we can understand in advance, a deal that they will faithfully honor. What we want is an end to the befuddling obfuscation of a secret system that resembles Kafka’s The Trial more than something designed to facilitate health care. What we want is an end to insurance feeling like a lotto card as you scratch off the next panel desperately hoping to win some actual coverage when you get sick. What we want is an end to the infuriating game of ‘heads I win, tails you lose’ routinely played in the insurance business. What we want is a straightforward transaction, not bland promises of ‘your health is in good hands with us,’ followed by callous disregard of our well-being. What we want is an end to the systematic use of delays, knee-jerk denials, inefficiencies, time-wasting, and double-talk to numb us into passive acceptance of such ethical criminality. Dearest Insurance Companies: Just offer us a deal that is straightforward and transparent, and live up to that deal. Then we can all decide if it is worth the cost, rather than going into apoplectic rage the next time that you manipulate the system against us—the very system that you design, administrate, and change at will. And then, perhaps, all the rest of us might really feel that we are on the same side, all trying our best to balance cost vs care, all trying to make the best of a very difficult situation. And then no one will have to be the “bad guy” in health care anymore. Note: This article originally appeared on Psychiatric Times .

Key Takeaways Major depressive disorder and anxiety rates have increased, with media saturation and negativity contributing significantly to mental health issues. The 24-hour news cycle and social media amplify negative content, impacting mental health through stress and anxiety. Political negativity and media bias exacerbate issues, fostering tribalism and ideological conflict, leading to increased hostility. Social media poses risks like body image dissatisfaction and cyberbullying, especially among youth, despite its potential benefits. Encouraging self-reflection and media consumption awareness, alongside psychiatric support, may help mitigate these effects. CLINICAL REFLECTIONS Major depressive disorder is the most common mental health problem in the United States, with prevalence rates increasing over the last 20 years. Anxiety rates have also increased, especially in young adults. The reasons behind these trends are complex and multifactorial, but our unlimited access to mass media is worth considering. One specific example is the media’s coverage of news and current events. Historically this was isolated to newspapers, radio, and local television networks, but the emergence of the 24-hour news cycle on cable news networks and the internet has made access virtually unlimited. Negativity in news coverage is common and nothing new, but the trend has been increasing in recent decades. Researchers have tried to explain this trend and have found viewers show an increase in physiological activation (measured by normalized skin-conductance levels and heart rate variability) when exposed to negative news coverage. A 2023 study found negative words in news headlines increased user consumption rates online, especially in topics like government and the economy. Others have shown high valence emotions (such as fear and anger) are related to increased online sharing behavior.5 This supports the “if it bleeds, it leads” concept that negative headlines increase viewer engagement and that media organizations respond accordingly, giving their customers what they want. It is reasonable to consider how much this negativity impacts the mental health of the consumers. Don Grant, PhD, president of American Psychological Association’s Society for Media Psychology and Technology, refers to the constant accessibility of negative news content as media saturation overload, while others have coined the terms doomscrolling, headline anxiety, and headline stress disorder when referring to the associated psychological strain of this near constant exposure. The American Psychological Association’s Stress in America survey showed that 83% of Americans reported stress over the nation’s future (contributing themes included the COVID-19 pandemic, the economy, and racial injustice) in 2020, and 73% of Americans felt overwhelmed by the number of crises facing the world in 2023. Politics are a source of overwhelmingly negative news coverage. Politicians routinely engage in negative campaigning, going beyond policy disagreements by personally criticizing others and, more recently, insulting and demonizing their opponents. Why this happens is up for debate. Some feel the public’s negativity bias makes it an effective tool at reducing an opponent’s support and mobilizing one’s own voters. Others feel they are responding to the media’s willingness to give more coverage to this type of content. It is unclear how strategically effective this is; the resulting boomerang effect shows potential voters who dislike the negativity become politically disengaged and less likely to vote. This also has a probable effect on our mental health. In 2019, researchers surveyed 800 respondents about the impact of politics on their lives: 40% reported stress; 20% reported poor sleep, feeling depressed, and problems with friends/family; and 10% to 30% reported an emotional toll by triggering feelings of anger and hate. This problem is made worse by media bias, as different outlets may cover topics differently depending on their ideology, leading to distrust among viewers. Researchers at the University of Rochester, New York, found increasing media bias in coverage of domestic and social issues when examining 1.8 million headlines from 2014 to 2022. With increased access, consumers can select news content that confirms their existing beliefs and insulate themselves from anything that contradicts these views. As a result, they are no longer exposed to balanced and unbiased information and their own beliefs are further solidified. Complex issues are oversimplified as consumers regress to black-and-white thinking; those who agree with us are “good,” and those who disagree are “bad.” Some of this can be explained by social identity theory, which suggests some of our personal identity is based on our group membership. While important and necessary, it can also lead to problems when we are confronted with those who appear different. Examples of the negative impact of tribalism include groups avoiding, using stereotypes about, and developing negative attitudes toward other groups who feel differently. No one group appears more or less guilty, as research on the ideological-conflict hypothesis has found liberals and conservatives equally intolerant of those who are ideologically dissimilar. As a result, substantive debates become increasingly hostile and vulgar, occasionally leading to physical confrontation and political violence. Social media is another trend worth considering. The potential benefits include social connection, peer support, and access to educational resources and entertainment. But there are also important risks associated, including body image dissatisfaction, cyberbullying, internet addiction, loneliness, and negative impact on mood. Youth appear particularly vulnerable to these risks. A longitudinal cohort study of 6595 participants aged 12 to 15 years found that those who spent more than 3 hours per day on social media were at higher risk for poor mental health outcomes, including anxiety and depression. The US surgeon general issued a Social Media and Youth Mental Health Advisory in 2023 and called for a surgeon general warning label on social media platforms in 2024. The onset of the COVID-19 pandemic seemed to exacerbate these problems. Suddenly, many were unable to work or go to school. We were spending less time in person with friends, family, and coworkers, and spending more time online and watching TV, increasing our exposure to negative content and social media, and retreating further into media echo chambers that reinforce our views. Of course, the pandemic worsened our mental health in other ways, bringing considerable stresses around health, isolation, education, employment, and finances. Concluding Thoughts Although we are out of the worst of the pandemic, these problems remain. Media excess, negative headlines, political hostility, network bias, social media, and tribalism are not going anywhere. Most of these problems are beyond our immediate control, but maybe we can shift our collective attitude from judgment and close-mindedness to tolerance and respect. Richard A. Friedman, MD, said, “If we have learned anything about the nature of tribalism and bias, it is that humans can be easily encouraged and acculturated to fear—or tolerate—the Other. Perhaps there is hope for us.” On a more individual and pragmatic level, self-reflection might help. Taking an inventory of our media exposure, specifically considering content, quantity, and emotional impact, could increase insight and lead to a more informed decision about our consumption patterns. Although this task may be relatively straightforward for autonomous decision-making adults, it is more complicated for younger patients and their parents. Perhaps this is where psychiatry can—and should—provide support and guidance. Note: This article originally appeared on Psychiatric Times .

Key Takeaways Aggression is not a diagnostic feature of psychiatric disorders but is often linked to mental illness and emergency presentations. The dopamine D4 receptor, particularly its polymorphisms, is associated with aggression, suggesting a potential target for treatment. Clozapine is the most effective antiaggression agent, outperforming risperidone, olanzapine, and haloperidol in studies. Asenapine and loxapine also demonstrate efficacy in reducing aggression, independent of their antipsychotic effects. Targeting aggression directly, rather than solely treating the underlying disorder, may improve treatment outcomes for patients. CLINICAL REFLECTIONS Violence and aggression are not diagnostic features of any psychiatric disorder. Nonetheless, many individuals associate these symptoms with mental illness , and they are often the precipitant for emergency presentations and hospitalization. Additionally, society associates severe mental illness with both aggression and violence, a belief that is reinforced by media, politicians, and others. Yet, excluding substance use, the rates of aggression and violence by patients with psychiatric disorders are similar to those occurring in the general population. Despite the fact that aggression has not been identified as a symptom of any specific psychiatric disorder , it is still seen as a consequence of associated disorders. Treatment of aggression is currently constrained within treatment of the associated disorder. However, there are sufficient data to suggest that it is reasonable to view aggression itself as a potential target for treatment. Pathophysiology of Aggression Several studies have attempted to discern the physiologic congenators of aggression. Although there are many findings, most are probably associations rather than causative. The most reproducible and important of these studies have been associations of polymorphisms of the dopamine D4 receptor with aggression. DRD4 is the gene that codes for the dopamine D4 receptor. It is found on the short arm of the 11th chromosome. Stimulation of D4 activates the inhibitory G protein second messenger system (Gai) and inhibits cyclic adenosine monophosphate formation. D4 is expressed in the frontal cortex, where it is much more common than the D2 receptor, as well as in the thalamus, hypothalamus, and olfactory bulb. The DRD4 gene has a polymorphic third exon. This part of the gene codes for the third cytoplasmic loop of the protein, which interacts with the Gai second messenger. The polymorphism presents as a variable number of repeats within this 48–base pair section. In the population, the number of repeats varies between 2 and 11 times. A common variant is the 7-repeat allele, which is best known for its association with attention-deficit/hyperactivity disorder. But it has also been associated with novelty seeking, impulsivity, anger, and aggression. This association gains importance when one becomes aware that D4 antagonists with high affinity that exceeds affinity for D2 by the same drug have significant antiaggression properties. The Table summarizes the affinities, expressed as dissociation constants (Ki), of several antipsychotics. In general, while second-generation antipsychotics have been described to have greater affinity for D4 than D2, that is generally not true. Antiaggression Agents The most effective antiaggression agent available is clozapine. This has been repeatedly demonstrated in open studies as well as in randomized trials. In the blinded, randomized studies, clozapine was superior to risperidone, olanzapine, and haloperidol. Specifically, the likelihood for aggressive behaviors after study entry was significantly lower for clozapine (17.5%) vs olanzapine (23.1%), risperidone 24.4%, and haloperidol (45.9%). Measured aggression was significantly less likely to happen with clozapine than haloperidol (physical aggression: OR, 2.04; P < .001; aggression against property: OR, 1.85; P < .001; and verbal aggression: OR, 1.35; P < .001) and olanzapine (physical aggression: OR, 1.33; P < .001; and verbal aggression: OR, 1.32; P < .001, but not aggression against property: OR, 1.10; P = .78). (Risperidone was not examined in this study). In this same study, olanzapine was also superior to haloperidol (physical aggression: OR, 1.54; P < .001; aggression against property: OR, 1.67; P < .001, but not verbal aggression: OR, 1.03; P = .57). In a comparative study that examined the hostility items of the Positive and Negative Syndrome Scale, clozapine was the only agent that significantly reduced measured hostility vs baseline (P = .019) and was superior to risperidone (P = .012) and haloperidol (P = .021) but not olanzapine. More importantly, this effect occurred at therapeutic dosage and was independent of clozapine’s antipsychotic effect or the occurrence of sedation. Clozapine is also effective in a genetic animal model of a developmental disorder (immediate early gene transcription factor, Egr3, knockout) in which the animals become aggressive. Similarly, asenapine has also demonstrated antiaggression effects in a prospective study comparing asenapine with treatment as usual (TAU) for 48 patients who were admitted with significant aggression. Asenapine was superior to TAU as measured by the Modified Overt Aggression Scale (MOAS). There was a significant reduction in physical aggression (–8.0 ±5.06 vs –0.78 ± 2.40; P < .0001) and total aggression (–14.7 ± 11.59 vs –5.4 ± 10.12; P = .045) as measured by the MOAS. More recently, a post hoc analysis of hostility in 442 patients with schizophrenia treated with a transdermal formulation of asenapine found that hostility improved independent of antipsychotic effect and after correcting for covariates, indicating that the antihostility effect is independent of the antipsychotic effect. Sublingual asenapine has also demonstrated significant reductions in hostility, irritability, and disruptive behavior vs placebo in participants experiencing acute mania. Asenapine may be effective quickly, and in a randomized, placebo-controlled study of agitation in a mixed diagnosis sample (schizophrenia, bipolar disorder, major depressive disorder, anxiety, and posttraumatic stress disorder) it significantly reduced the Excited Component of the Positive and Negative Syndrome Scale. Adequate D4 blockade and the antiaggression effect is likely achieved at 5 mg daily, whereas the minimum antipsychotic dose is 10 mg daily, and it is believed that aggression should improve at 5 mg. Loxapine is a second-generation antipsychotic agent that was not identified as such prior to the introduction of clozapine. It has a long history of treating aggression, hostility, and agitation in patients with bipolar disorder and schizophrenia experiencing acute mania and psychosis with both injectable and inhalable formulations. Significantly, the effect on reducing aggression in agitated patients appears to occur independent of diagnosis. Receptor occupancy is generally poorly studied in older medications, but the antipsychotic effect (ie, D2 receptor occupancy of 60% to 80%) probably occurs at 15 to 30 mg daily, and since the affinity at D4 is 3 times greater than at D2, one would expect that doses as low as 10 mg daily may be effective for aggression control. Olanzapine and risperidone also have D4 affinities that exceed D2 affinities. The difference is small but similar to that in asenapine. For all 3 agents, it is likely that both receptors are blocked at doses that are frequently used. All these agents are frequently used in treating aggression because the drugs are approved for use in a wide range of psychiatric disorders. While asenapine has not been compared with clozapine, clozapine appears to be superior to both olanzapine and risperidone. Furthermore, reduction in aggression with olanzapine and risperidone appears to be related to their antipsychotic effect, which does not appear to be the case for clozapine. Some of these agents have affinity to D4 that exceeds the affinity for D2 (ie, affinity D4 to affinity D2 > 1).5 Clozapine clearly has the best data and is likely superior to other agents. It is superior to risperidone, olanzapine, and haloperidol. It would appear that when a patient presents with aggression as an important symptom, targeting that symptom may have a greater impact than treating the underlying disease. Note: This article originally appeared on Psychiatric Times .

Keypoint: In the psychiatric care continuum, insurance companies encourage a broader conversation about what constitutes best treatment practices. COMMENTARY The insurance industry is subject to consistent criticism and blame for deficiencies in our health care system, and insurance companies are often despised by stakeholders in the continuum of care. Patients dislike insurance companies for refusing to pay for their care. Providers dislike insurance companies for denying reimbursement for their treatment. Hospital administrators dislike insurance companies as an unnecessary cost that lowers profit margins. Politicians frequently tout insurance reforms to satisfy the stakeholders listed previously. Yet it is important to recognize the value that insurance companies add in providing coverage for psychiatric care. Some Americans unrealistically expect insurance to cover all desired treatments without question and without oversight, an expectation that includes choosing any provider and having whatever tests or treatment prescribed by that provider covered in full regardless of the cost or documented effectiveness. They want all of this, all while keeping insurance costs affordable for everyone in a society where obesity and inactivity is prevalent, and tobacco, alcohol, and other substances are often abused. The murder of United Healthcare CEO, Brian Thompson, is an example of the public’s frustrations. As a testament to the motive, the words “delay,” “deny,” and “depose,” were engraved into the deadly cartridges. Yet rather than condemning the murder of this man, some of the public and media justified the murder as a testament to the vilification of insurance companies and the individuals who work for them. Articles mentioned the “public outrage at the health care system in the wake of the killing,” rather than outrage at the killer. Headlines included “Brian Thompson's death has elicited little sympathy. I don't need to spell out why” and “Why so many people celebrated the death of Brian Thompson.” US health care is far from perfect. There are certainly opportunities for our health care insurers to improve their customer service and enhance their coverage. That said, the inappropriate response to Thompson's death provides an opportunity to reflect on some of the attributes of our health care insurance companies. Psychiatric Treatment Is Not Always the Solution A 2023 study by Harvey et al looking at the universal use of dialectical behavioral therapy in teenagers at Australian high schools found that students exposed to the intervention “reported significantly increased total difficulties.” A 2023 meta-analysis by Li et al found that exercise, in particular team sports, was an effective treatment for youth with depression. These studies are examples that patients may be harmed by treatment or may be appropriately served by nonmedicalized interventions; a healthy insurance system can be an entity to advocate for appropriate interventions in the right scenarios. Psychiatric Diagnoses and Assessment Can Be Subjective There are areas of subjectivity in psychiatry that require oversight, which insurance companies can provide. As demonstrated in the DSM-5 field trials, the intraclass kappa (the likelihood of 2 raters having the same diagnosis) was 28% for depression, 56% for bipolar disorder, and 46% for schizophrenia. As described by Allen Frances, MD, “the results it produced were an embarrassment… barely better than two monkeys throwing darts at a diagnostic board.” Under that consideration and problems with overdiagnosing, a healthy insurance system can serve as a restraint in overzealous diagnosing. Providers May Misuse the System Insurance reviewers may evaluate the individual's reported symptoms, exam findings, and test results to determine whether they are consistent with the reported diagnoses and the recommended treatment. During their assessment, a reviewer may request copies of test results needed to confirm a diagnosis or level of impairment. For example, if an individual is claiming disability because of a nonunion fracture, copies of the x-ray reports may be requested to document the nonhealing bone fracture. It has been our experience that in psychiatry, mental status exams often change radically after an insurance denial or in response to specific questions from the insurance carrier. Additionally, while it is extremely unlikely for a thought process to shift from "linear and logical" to "incoherent and disorganized" after a claim is denied or challenged, this is not uncommon in our reviews. Harmful Overprescribing and Polypharmacy Overprescribing can take many forms. Overdose deaths of celebrities are the most mediatized examples, and while most are thought to be due to opioids, many involve benzodiazepines: Aaron Carter with alprazolam in combination with huffing; Tom Petty with fentanyl, oxycodone, emazepam, alprazolam, citalopram, acetyl fentanyl, and despropionyl fentanyl; Prince with fentanyl; etc. More recently, the case of Matthew Perry’s death involving the use of ketamine led to significant media attention. Adding to the problem of overprescribing are the online prescription companies that have little oversight or interaction with their patients. For instance, online psychiatry company Cerebral heavily relied on the accessible prescribing of ADHD medications , and as a result entered into a nonprosecution agreement of $3.6 million dollars for encouraging the unauthorized distribution of controlled substances. It is these authors’ opinion that insurance companies have the ability to provide an important oversight to limit the reckless prescribing of medications that can be dangerous when used in a way that is not intended. Unnecessary Involuntary Treatment Involuntary treatment is an essential tool of the psychiatric clinician. While assessing the value of involuntary treatment in a randomized controlled manner is practically impossible due to legal regulations and responsibilities, courts have acknowledged that states have a legitimate interest in providing care to individuals “who are unable, because of emotional disorders, to care for themselves.” As granted by the Supreme Court in the case of O'Connor v Donaldson (1975), the state can confine dangerous individuals who are incapable of surviving safely. Courts have compared involuntary treatment with incarceration, describing its effect as “no different than the burdens associated with criminal prosecutions.” Yet inherent to any power dynamic, abuse will happen. Eight decades ago, Albert Maisel famously described the horrific treatment of psychiatric patients in state mental hospitals in an article that jump-started deinstitutionalization. Although conditions have undoubtedly improved, significant concern remains. A recent article by the New York Times exposed a private company, Acadia, reportedly exploited involuntary treatment for financial gain. In scenarios like these, patients can be saved by the oversight of insurance companies that check the necessity of care. Cases of Inadequate Care Issues surrounding quality of care are complicated and often fraught with differing opinions. However, there are many interventions that are inadequate or at least deserve significant explanation. For example, the prescription of controlled substances to an individual with substance use disorder generally requires an explanation, and it may be appropriate for an insurance company to question a clinician. Insurance companies should be commended when, after appropriate questioning, it is recognized that an insured individual is not receiving appropriate care. In our practice, insurance reviewers frequently engage with providers, raising critical points about patient care. They often ask whether the prescribing clinician has (1) considered potential contraindications due to interactions with the cytochrome P450 enzyme system, (2) explored all FDA-approved options for treating specific conditions, like suggesting quetiapine for patients with bipolar depression, (3) considered whether other types of treatments like intensive outpatient programs are viable alternatives. Not All Treatments Should Be Reimbursable An insured individual with a musculoskeletal condition that would improve with physical therapy should have their therapy covered by their insurance carrier. It is, however, reasonable for an insurance carrier to deny reimbursement for physical therapy that has not been shown to improve the underlying condition or if a patient does not have a disorder that warrants therapy. Patients may present to a behavioral health provider to “explore themselves,” or vent, or to validate their beliefs. In such situations, it is reasonable for an insurance carrier to question the underlying diagnosis and the value of any interventions before approving reimbursement for therapy, much like frivolous plastic surgery. The belief that all care should be reimbursed without meeting a certain necessity threshold is unreasonable and cost prohibitive in any system of care, as there are limited resources. (Although there is something to be said about preventive or mental health wellness care.) Concluding Thoughts Although insurance companies are often vilified within the American health care narrative, their role in psychiatry can offer a counterbalance to potential overuse and misuse of psychiatric interventions. They serve as a necessary check against the potential for overprescription, inadequate care, and the misuse of involuntary treatments. By demanding evidence of medical necessity, insurance providers ensure that psychiatric care remains both effective and justified, protecting patients from unnecessary treatments and the system from exploitation. This oversight, though sometimes contentious, contributes to a more ethical and efficient use of psychiatric resources. Moreover, the presence of insurance companies in the psychiatric care continuum encourages a broader conversation about what constitutes necessary treatment. It prompts clinicians, patients, and policymakers to critically evaluate the appropriateness of medical vs nonmedical interventions, promoting a holistic approach to mental health . Although no system is without its flaws, the critical role of insurance in psychiatry underscores the need for a balanced perspective where oversight is not just about cost containment but also about ensuring the quality and necessity of care. This nuanced role of insurance might not make them beloved, but it certainly makes their function in the health care system indispensable. Note: This article originally appeared on Psychiatric Times .