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Self-awareness is the ability to see yourself clearly and objectively through reflection and introspection. While it may not be possible to attain total objectivity about oneself (that’s a debate that has continued to rage throughout the history of philosophy), there are certainly degrees of self-awareness. It exists on a spectrum. Although everyone has a fundamental idea of what self-awareness is, we don’t know exactly where it comes from, what its precursors are, or why some of us seem to have more or less than others. This is where the self-awareness theory comes in, offering some potential answers to questions like these. These detailed, science-based exercises will not only help you increase the compassion and kindness you show yourself but will also give you the tools to help your clients, students, or employees show more compassion to themselves. What Is Self-Awareness Theory? Self-awareness theory is based on the idea that you are not your thoughts, but the entity observing your thoughts; you are the thinker, separate and apart from your thoughts (Duval & Wicklund, 1972). We can go about our day without giving our inner self any extra thought, merely thinking and feeling and acting as we will; however, we also can focus our attention on that inner self, an ability that Duval and Wicklund (1972) termed “self-evaluation.” When we engage in self-evaluation, we can give some thought to whether we are thinking and feeling and acting as we “should” or following our standards and values. This is referred to as comparing against our standards of correctness. We do this daily, using these standards as a way to judge the rightness of our thoughts and behaviors. Using these standards is a major component of practicing self-control, as we evaluate and determine whether we are making the right choices to achieve our goals. Research on the Topic This theory has been around for several decades, giving researchers plenty of time to test its soundness. The depth of knowledge on self-awareness, its correlates, and its benefits can provide us with a healthy foundation for enhancing self-awareness in ourselves and others. According to the theory, there are two primary outcomes of comparing ourselves against our standards of correctness: We “pass,” or find alignment between ourselves and our standards. We “fail,” or find a discrepancy between ourselves and our standards (Silvia & Duval, 2001). When we find a discrepancy between the two, we find ourselves with two choices: to work toward reducing the discrepancy or avoid it entirely. Self-awareness theory (and subsequent research) suggests that there are a couple of different factors that influence how we choose to respond. Basically, it comes down to how we think it will turn out. If we believe there’s little chance of actually changing this discrepancy, we tend to avoid it. If we believe it’s likely that we can improve our alignment with our standards of correctness, we take action. Our actions will also depend on how much time and effort we believe that realignment will take; the slower progress will be, the less likely we are to take on the realignment efforts, especially if the perceived discrepancy between ourselves and our standards is large (Silvia & Duval, 2001). Essentially, this means that when faced with a significant discrepancy that will take a lot of consistent and focused work, we often simply don’t bother and stick to avoiding self-evaluation on this particular discrepancy. Further, our level of self-awareness interacts with the likelihood of success in realigning ourselves and our standards to determine how we think about the outcome. When we are self-aware and believe there is a high chance of success, we are generally quick to attribute that success or failure to our efforts. Conversely, when we are self-aware but believe there is a low chance of success, we tend to think that the outcome is more influenced by external factors than our efforts (Silvia & Duval, 2001). Of course, sometimes our success in realignment with our standards is driven in part by external factors, but we always have a role to play in our successes and failures. Interestingly, we also have some control over our standards, such that we may alter our standards if we find that we don’t measure up to them (Dana, Lalwani, & Duval, 1997). This is more likely to happen if we’re focused more on the standards than on ourselves; if we fail when we are focused on the standards more than our performance, we are more likely to blame the standards and alter them to fit our performance (Dana et al., 1997). Although it may sound like merely shifting the blame to standards and, therefore, letting yourself off the hook for a real discrepancy, there are many situations in which the standards are overly strict. Therapists’ offices are filled with people who hold themselves to impossibly high standards, effectively giving themselves no chance of success when comparing themselves to their internal standards. It’s clear from the research on self-awareness that it is an important factor in how we think, feel, act, and react to our thoughts, feelings, and actions. 4 Proven Benefits of Self-Awareness Now, let’s shift our attention to research on the outcomes of being self-aware. As you might imagine, there are many benefits to practicing self-awareness: It can make us more proactive, boost our acceptance, and encourage positive self-development (Sutton, 2016). Self-awareness allows us to see things from the perspective of others, practice self-control , work creatively and productively, and experience pride in ourselves and our work as well as general self-esteem (Silvia & O’Brien, 2004). It leads to better decision making (Ridley, Schutz, Glanz, & Weinstein, 1992). It can make us better at our jobs, better communicators in the workplace, and enhance our self-confidence and job-related wellbeing (Sutton, Williams, & Allinson, 2015). These benefits are reason enough to work on improving self-awareness, but this list is by no means exhaustive. Self-awareness has the potential to enhance virtually every experience you have, as it’s a tool and a practice that can be used anywhere, anytime, to ground yourself in the moment, realistically evaluate yourself and the situation, and help you make good choices. 3 Examples of Self-Awareness Skills So we know that self-awareness is good, but what does it look like? How does one practice self-awareness? Below are three examples of someone practicing self-awareness skills: Bob at work Bob struggles with creating a quarterly report at work, and he frequently produces subpar results. He notices the discrepancy between his standards and performance and engages in self-evaluation to determine where it comes from and how to improve. He asks himself what makes the task so hard for him, and he realizes that he never seems to have trouble doing the work that goes into the report, but rather, writing it up cohesively and clearly. Bob decides to fix the discrepancy by taking a course to improve his writing ability, having a colleague review his report before submitting it, and creating a reusable template for future reports so he is sure to include all relevant information. Monique at home Monique is having relationship problems with her boyfriend, Luis. She thinks Luis takes her for granted and doesn’t tell her he loves her or share affection enough. They fight about this frequently. Suddenly, she realizes that she may be contributing to the problem. She looks inward and sees that she doesn’t show Luis appreciation very often, overlooking the nice things he does around the house for her and little physical touches that show his affection. Monique considers her thought processes when Luis misses an opportunity to make her feel loved and notes that she assumes he purposely avoids doing things that she likes. She spends time thinking and talking with Luis about how they want to show and receive love, and they begin to work on improving their relationship. Bridget on her own Bridget struggles with low self-esteem , which causes depressive symptoms. She doesn’t feel good enough, and she doesn’t accept opportunities that come her way because of it. She begins working with a therapist to help her build self-awareness. The next time an opportunity comes her way, she thinks she doesn’t want to do it and initially decides to turn it down. Later, with the help of some self-awareness techniques, Bridget realizes that she is only telling herself she doesn’t want to do it because of her fear that she won’t be good enough. Bridget reminds herself that she is good enough and redirects her thoughts to “what if I succeed?” instead of “what if I fail?” She accepts the opportunity and continues to use self-awareness and self-love to improve her chances of success. These three stories exemplify what self-awareness can look like and what it can do for you when you tap into it. Without self-awareness, Bob would have kept turning in bad reports, Monique would have continued in an unsatisfying relationship or broken things off, and Bridget would never have taken the opportunity that helped her grow. If you look for them, you can find these stories everywhere. 5 Ways to Increase Your Self-Awareness Now we have some clearcut examples of self-awareness in mind. We know what it looks like to embrace self-awareness and grow. But how do you do it? What did our leading characters do to practice self-awareness? There are many ways to build and practice self-awareness, but here are some of the most effective: 1. Practice mindfulness and meditation Mindfulness refers to being present in the moment and paying attention to yourself and your surroundings rather than getting lost in thought or ruminating or daydreaming. Meditation is the practice of focusing your attention on one thing, such as your breath, a mantra, or a feeling, and letting your thoughts drift by instead of holding on to them. Both practices can help you become more aware of your internal state and your reactions to things. They can also help you identify your thoughts and feelings and keep from getting so caught up in them that you lose your hold on your “self.” 2. Practice yoga Yoga is a physical practice, but it’s just as much a mental practice. While your body is stretching and bending and flexing, your mind is learning discipline, self-acceptance, and awareness. You become more aware of your body and all the feelings that manifest, and you become more aware of your mind and the thoughts that crop up. You can even pair yoga with mindfulness or meditation to boost your self-awareness. 3. Make time to reflect Reflecting can be done in multiple ways (including journaling; see the next tip) and is customizable to the person reflecting, but the important thing is to go over your thoughts, feelings, and behaviors to see where you met your standards, where you failed them, and where you could improve. You can also reflect on your standards themselves to see if they are good ones for you to hold yourself to. You can try writing in a journal, talking out loud, or simply sitting quietly and thinking, whatever helps you to reflect on yourself. 4. Journal The benefit of journaling is that it allows you to identify, clarify, and accept your thoughts and feelings. It helps you discover what you want, what you value, and what works for you. It can also help you find out what you don’t want, what is not important to you, and what doesn’t work for you. Both are equally important to learn. Whether you like to write free-flowing entries, bulleted lists, or poems, writing down your thoughts and feelings helps you to become more aware and intentional. 5. Ask the people you love It’s vital to feel we know ourselves from the inside, but external feedback helps too. Ask your family and close friends about what they think about you. Have them describe you and see what rings true with you and what surprises you. Carefully consider what they say and think about it when you journal or otherwise reflect. Of course, don’t take any one person’s word as gospel; you need to talk to a variety of people to get a comprehensive view of yourself. And remember that at the end of the day, it’s your self-beliefs and feelings that matter the most to you! Importance in Counseling and Coaching Self-awareness is a powerful tool that, when practiced regularly, can do more good for coachees and clients than anything else a professional can share with them. To make real, impactful, and lasting change, people need to be able to look inward and become familiar with that internal environment. Building self-awareness should be a top priority for virtually all clients, after which the more traditional coaching and counseling work can begin. For example, you can counsel someone on their bad habits and give 1,000 ways to break their habits. Still, if they don’t understand why they tend toward these bad habits in the first place, it’s almost a guarantee that they will either never break those habits or will quit for a while and simply pick up where they left off when things get tough. Self-awareness is not only vital for the coachee or client; it is also important for the coach or counselor. In fact, self-awareness is prioritized as a core standard in the Council for Accreditation of Counseling and Related Educational Programs Standards (2017) for the profession, as both a requirement for counselors and a necessary skill to build in clients. It takes a good amount of self-awareness to give competent counsel and provide actionable advice. Plus, self-awareness will help the caring counselor from getting too wrapped up in their client’s problems or seeing the issues through their own skewed lens. To truly help someone, it’s essential to see things from their perspective, and that requires being self-aware enough to put our thoughts and feelings aside sometimes. Meditation, Mindfulness, and Self-Awareness The link between meditation, mindfulness, and self-awareness is clear, meaning it’s no surprise that practicing the first two will naturally lead to more of the third. When we meditate or practice mindfulness, we are paying attention to the things that can often get ignored in our busy day-to-day: the present moment and our own internal experience. Those who get to know their thought processes and patterns are more able to adapt and improve them, both by simply being aware of their processes and patterns and by giving themselves a mechanism for practicing and improving. Indeed, a program intended to enhance self-awareness (among other things) through yoga and meditation resulted in a range of improvements, including more positive affect, less stress, greater mindfulness, enhanced resilience, and even greater job satisfaction (Trent et al., 2019). Self-Awareness & Emotional Intelligence Emotional intelligence can be defined as the cluster of abilities that allow us to recognize and regulate emotions in ourselves and others (Goleman, 2001). According to the most popular theory of emotional intelligence from psychologist and author Daniel Goleman (2001), self-awareness is not only crucial for emotional intelligence; it’s one of the five components. These five components are: Self-awareness Self-regulation Social skills Empathy Motivation Other popular theories of emotional intelligence also include self-awareness as a core component, making it one of the factors that virtually all researchers and experts agree on (Goleman, 2001). Self-awareness is a necessary building block of emotional intelligence; it is the building block upon which the rest of the components are built. One must have self-awareness to self-regulate, and social skills will be weak and of little use if you are not aware enough about when and how to use them. If you’re looking to build your emotional intelligence, self-awareness is the first step. Make sure you have developed strong skills in self-awareness before giving the other elements your all. ONION METAPHOR OF IDENTITIES Individuals do not want to be too similar or too dissimilar to others. They search for optimal distinctiveness (Brewer, 1991). Being too different and unaccepted can lead to stigmatization, prejudice, and isolation (Lynn & Snyder, 2002). But being too similar can make you lose your sense of self. All humans have these competing needs to belong (Baumeister & Leary, 1995) yet stand out from others. People may vary in their need for uniqueness. Still, most people adjust their behaviors to set them apart when they feel too similar to others (Mengers, 2014). In that respect, you can compare a person to an onion. Personal identities are at the core, with social identities building the different outward layers. Imagine, for example, you are traveling and asked where you are from. Answering the specific district you are from won’t relate to a person from a different continent, but telling your home country won’t differentiate you from others of the same nationality. Other common social identities are race, ethnicity, religion, gender, sexual orientation, or age. Given the context, people can call their social identity to action, depending on their need to belong to or differ from a group (Brewer, 1991). Individuals can fulfill their needs simultaneously by activating social identities associated with distinct groups, resulting in greater levels of wellbeing (Mengers, 2014). Apart from benefits for personal wellbeing and life satisfaction, societies can benefit from encouraging distinctiveness (Lynn & Snyder, 2002). Open and accepting environments allow people to assert their uniqueness, engage in their interests and pursuits and fear negative consequences less (Mengers, 2014). To know who you are and live authentically, you must also understand what you are not. Distinctiveness is an essential tool to help differentiate you from others. Openness and approval must be encouraged to enable individuals, especially teenagers, to thrive. 4 Tips for Improving Self-Awareness in Relationships If you want to be more like post-reflection Monique than pre-reflection Monique (referring to examples of self-awareness skills in action above), or if you’re going to help your clients with their relationship woes, here are some excellent tips for introducing more self-awareness within the context of a relationship: 1. Be mindful Practice mindfulness, especially when interacting with your loved ones. Pay attention to the words they say, their tone, their body language, and their facial expressions. We often communicate far more information with the latter three than we do with our words alone. Give your loved ones your full attention. 2. Talk Have regular discussions about the relationship. It’s important to keep things in perspective and ensure that nothing is falling between the cracks. When you have regular conversations about your relationship with your loved ones, it’s much harder to avoid or ignore things that can turn into problems. It also helps you reflect on your part and come prepared to discuss your thoughts, feelings, and behaviors with your loved ones. 3. Quality time Spend quality time together and apart. This is especially important for romantic relationships, as we often find ourselves spending most or even all of our free time with our spouse or partner. However much you love and enjoy spending time with your partner, everyone needs some quality time alone. Make sure you and your partner are both getting some quality “me” time to think about what you want, what you need, and what your goals are. This will help you keep yourself from merging too much into your partner and maintaining your independence and stability. Then, since there will be two independent, stable, and healthy adults in the relationship, it will be even more fulfilling and satisfying to both partners when they spend quality time together. 4. Be considerate Share your perspective and consider theirs. It’s easy to get too caught up in our own perspective on things; however, healthy relationships require that we consider others’ needs in addition to our own. To know what our loved ones need and to deliver on those needs, we must first identify and understand them. We do this by practicing our self-awareness and sharing that awareness with our friends and family. If you never check in with your loved ones on their views or feelings, it can cause you to drift apart and inhibit real, satisfying intimacy. Ask your loved ones for their perspective on things and share your perspective with them. Role in the Workplace and Leadership As noted earlier, self-awareness improves our communication, confidence, and job performance (Sutton et al., 2015). It’s easy to see how self-awareness can lead to these outcomes in the workplace, as better self-evaluation naturally leads to improving the alignment between our actions and our standards, resulting in better performance. According to Tasha Eurich (2018), self-awareness can be divided into two categories or types: internal self-awareness and external self-awareness. Internal self-awareness is about how well we see ourselves and our strengths, weaknesses, values, etc., while external self-awareness is understanding how others view us with those same factors (Eurich, 2018). Good managers and leaders need both to perform well in their roles. Although you might think that more experience as a leader and greater power in one’s role lead to better self-awareness, that may not be the case. Experience can be positive or negative in terms of learning and improving the self. Even positive experiences can lead one to attribute success to themselves when it may have had more to do with the circumstances, leading to false confidence. In fact, only 10–15% of those in Eurich’s (2018) study displayed self-awareness, although most of us believe we are self-aware. To improve self-awareness, Eurich (2018) recommends introspection , but with a focus on asking oneself the right questions. She notes that asking “why” might not always be effective, as many of our internal processes remain shrouded in our subconscious or unconscious minds; insteadFor example, instead of asking, “ Why do I fail at this task so often? ” you might ask yourself, “ What are the circumstances in which I fail at this task, and what can I do to change them? ” It’s not a foolproof method, but it can aid you in improving your self-awareness and increasing your alignment with your standards on certain activities., asking “what” may lead to better introspection. Self-Awareness in Students and Children Self-awareness isn’t just for managers and employees; it can also substantially benefit students, children, and adolescents. The same benefits that make us more productive in the workplace can make students more productive in the classroom and at home: better communication with teachers and peers, more confidence, and more satisfaction with performance can all lead to happier, healthier students. These benefits also apply to advanced students. Increased self-awareness leads to more self-care in medical students (Saunders et al., 2007) and a better understanding of one’s strengths and capabilities along with a boost to emotional intelligence in law students (James, 2011). A Take-Home Message In short, a little extra self-awareness can be of great benefit to anyone with the will to improve. This piece includes a description of self-awareness, an exploration of the theory of self-awareness, examples, and tips and tools you can use to boost your self-awareness. We hope you find this information helpful in increasing your self-awareness or that of your clients. What exercises do you use to help build self-awareness? What are some other benefits you’ve noticed? Let us know in the comments section below. If you liked this post, head on over to our post about self-awareness books to further help you increase reflection. We hope you enjoyed reading this article. Don’t forget to download our three Self Compassion Exercises for free.

Despite most strokes being preventable, someone in the US experiences a stroke every 40 seconds. Could a new risk score focused on the brain help change that? The McCance Brain Care Score (BCS) aims to empower patients and practitioners to better care for their brains. We already have the American Heart Association’s (AHA) PREVENT online calculator for predicting the 10- and 30-year risk for heart attack, stroke, and heart failure, as well as the Framingham Risk Calculator that estimates 10-year risk for atherosclerotic cardiovascular disease, including strokes and heart attacks. While they incorporate variations of the known modifiable risk factors, the BCS takes a more holistic, patient-forward approach and addresses dementia and late-life depression. Here are some aspects that make it stand out to me. 1. Intuitive scoring system. The BCS incorporates well-known modifiable risk factors (eg, hypertension, hyperlipidemia, smoking, alcohol use) into a 21-point score rather than a risk percentage. Each risk factor gets a number. For hypertension, the biggest modifiable contributor to stroke risk, this ranges from 0 to 3, with more points for better blood pressure control. 2. Gamification of health. Adding the points across several modifiable risk factors yields a score of up to 21, with higher scores linked to better neurologic outcomes. A 5-point higher BCS was associated with an approximate 50% lower risk for stroke in those under 60 years of age. This scoring system capitalizes on the gamification of health, a concept that is increasingly popular because of health apps and wearables such as the Apple Watch and FitBit. Nearly 1 in 3 US adults use health wearables that may nudge them toward health-promoting behaviors such as hitting benchmarks for daily steps or weekly physical activity. Gamification tactics have been shown to improve medication adherence; whether they can lead to sustained behavioral changes remains to be seen. I like the idea of improving people’s health while making it a fun challenge to get a “high” score. 3. Practicality. The BCS presents the modifiable risk factors as opportunities for change and capitalizes on this by giving people goals. For example, the score provides multiple ways to get points for a healthier diet, such as eating 4.5 servings of fruit and vegetables per day or less than 36 oz of sweetened beverages (such as juice and soda) per week. The targets are specific, measurable, and realistic. 4. Widespread applicability and generalizability. Another highlight of the BCS is that it can be used by anyone, even those who have already had a stroke. The score also incorporates risk factors tied to dementia and late-life depression. Given that dementia cases are expected to double by 2060, this has broad application. The BCS shares risk factors with cardiovascular disease and multiple cancers, allowing people to use it to reduce their chances of multiple diseases. For example, in UK adults aged 40-69 years, a 5-point higher BCS was associated with a 43% lower risk of developing cardiovascular disease and a 31% lower risk for leading cancers (specifically, a 66% lower risk for lung cancer, 21% lower risk for colorectal cancer, and 16% lower risk for breast cancer). 5. Increasing popularity. The score is very new. The first validation study was published less than 2 years ago. But since then, there have been at least five other papers on the score’s utility, and the questionnaire has even been adapted by The New York Times. Have you or any of your patients taken the BCS? It might be a fun poster to have in your doctor’s office or waiting room, and it could serve as a focal point to discuss positive habits and opportunities for change. With these strategies, we can empower our patients to proactively reduce their risk for stroke, heart disease, and cancer, and help them live longer, healthier lives. Note: This article originally appeared on Medscape .

Key points Outside of its major symptoms—impulsivity, distractibility, hyperactivity—ADHD comes with surprising traits. Rather than waking them up, people with ADHD may find that coffee makes them sleepy. People with ADHD often concentrate better when loud music is playing. Many people with ADHD find that they are calm in times of crisis. Attention-deficit/hyperactivity disorder (ADHD) is primarily known for its inattentive, hyperactive, and impulsive symptoms. However, recent research and lived experience show that this is not the whole story. There are many traits of ADHD that most people don’t know about yet that are also often part of life with this neurotype. If you relate to these, it might be worth looking into ADHD. 1. Coffee makes you sleepy. In neurology, there is a concept called optimal arousal. It is the idea that there is a certain amount of stimulus that helps you move and do things. Not enough stimulation and you’re bored and sleepy; too much stimulation and you’re nervous and overwhelmed. People with ADHD tend to have a higher threshold for optimal arousal because that system works on dopamine. Stimulants, well, stimulate the brain and central nervous system. For some ADHD people at some doses, caffeine stimulates the brain enough that they can sit still, focus on boring tasks, or even fall asleep promptly instead of literally or figuratively pacing. Where most people drink coffee to wake up, because it brings their brains slightly above optimal arousal levels, people with ADHD may instead find that after drinking coffee, they are ready for a nap. 2. You need loud music to concentrate. Something that also helps ADHD brains reach optimal arousal is music. Having loud music when doing homework or while working is a way for ADHD brains to self-regulate and keep the dopamine flowing. One study even showed that adolescents with ADHD see their reading comprehension increase with music, while teens without ADHD struggle to keep up when there isn’t silence. This is also to show that different brains have different needs to keep working optimally. 3. You’re calm in times of crisis. ADHD brains are usually understimulated, hence the hyperactivity and the nervous energy. When a crisis hits, the associated adrenaline may restore your brain to optimal arousal levels—so suddenly, while everyone else is freaking out, you feel calm and composed. These periods of stress are often associated with a decrease in ADHD symptoms , but can be followed by a crash. After a sprint, you will need to rest. So if you find yourself being the only calm person in times of crisis, remaining calm while everyone freaks out, it may mean that your brain is constantly understimulated—which may, in turn, indicate that it’s worth looking into ADHD. 4. You have a low tolerance for noisy spaces. If you have ADHD, you may need loud music to concentrate, but noisy spaces make you nervous and angry. It may seem contradictory, but the key element that differentiates those situations is control. In moments where you use loud music to concentrate, you may not need to use your senses, and thus there’s no conflict between the task at hand and the stimulation received. But loud spaces are a whole other story. People with ADHD often have sensory processing issues, which can make those spaces quickly overwhelming. If someone is talking to you, the conversation will be drowned out by the thousands of stimuli that your brain struggles to filter. This may help explain why many people with ADHD are also diagnosed with auditory processing disorder. If you need people to repeat what they say all the time, and can’t manage to follow a conversation even when you give it your all, it may be a sign of ADHD ! 5. You hyperfocus. ADHD isn’t a lack of attention; it is a lack of regulation. The other side of ADHD is called hyperfocus: a state of such intense concentration that nothing else seems to matter for several hours. You may even forget to drink, eat, or go to the bathroom. These intense focusing periods come when you’re interested in something. You may even spend days hyperfixating on a new hobby, on a new friend, or even on a new food. But when that thing starts feeling repetitive, boring, or like an obligation, you find yourself being unable to come back to it, and look for the next new thing. Hyperfocus can be a powerful tool for people with ADHD; the catch is that you don’t always control when it hits. If you periodically lose yourself in a new hobby or interest, learning everything there is to learn—while the rest of the time, you’re unable to keep your attention on something for more than five minutes—it may be a sign that you have ADHD . While this article is not a diagnostic tool, if you recognize yourself in some of these traits, it may be worth diving a bit deeper into what ADHD is—and if you’re already diagnosed, you may have learned something about yourself. Perhaps your next hyperfixation can be ADHD itself. Note: This article originally appeared on Psychology Today .

Key Takeaways TD is often underreported and misdiagnosed, despite being a well-known adverse effect of antipsychotic medications, leading to inadequate treatment. VMAT2 inhibitors, approved in 2017, represent a significant advancement in the treatment of TD, offering evidence-based options for managing symptoms. The AIMS exam is essential for monitoring TD, but individual experiences and functional impacts vary, requiring personalized treatment approaches. The Impact-TD scale assesses TD's functional impact across social, psychological, physical, and vocational domains, highlighting the need for comprehensive assessments. According to a new study published in BMC Psychiatry, only 4.9% of patients who were prescribed antipsychotics for their psychiatric illness and had evidence of tardive dyskinesia (TD) had TD recorded properly in their electronic health records, supporting the idea that TD is often underreported and misdiagnosed and, therefore, not treated appropriately.1 Yet, TD is a well-established adverse effect of antipsychotic medications and is often irreversible. The well-described hyperkinetic and often dramatic involuntary movements can involve any of the estimated 650 skeletal muscles of the human body, including the diaphragm and pharynx. As well as causing noticeable and often dramatic involuntary movements, these movements often cause significant functional impairment, which varies significantly from patient to patient. Sometimes the patient is unaware of these movements, and it is not uncommon for a patient’s friend, family member, coworker, or even a stranger to bring these movements to the patient’s attention. TD was first described in the medical literature in 1957,2,3 just a few years after the very first antipsychotic medication, chlorpromazine, was introduced in the United States. Despite tireless medical research, it wasn’t until 2017 that 2 vesicular monoamine transporter 2 (VMAT2) inhibitors—deutetrabenazine4 and valbenazine5—were approved by the US Food and Drug Administration as the first evidence-based effective treatments. This 60-year gap likely contributed to the progressive decrease in screening, documenting, and discussing the cause and course of TD with patients. The presumed pathophysiological mechanism of TD by antipsychotics is the antagonism of dopamine-2 receptors (D2Rs) in the dorsal striatum of the human brain, whereas antagonism of these same receptors in the ventral striatum is believed to improve psychotic symptoms, hence the term antipsychotic. Nonpsychiatric medications such as metoclopramide (Reglan; used for the treatment of gastroesophageal reflux disease, gastroparesis, and as an antiemetic) and prochlorperazine (Compazine; used as an antiemetic) share this property of D2R antagonism and exhibit similar risks for TD. The VMAT2 Inhibitors It was a big deal when VMAT2 inhibitors were approved for the treatment of TD. The American Psychiatric Association updated their practice guidelines for the treatment of schizophrenia in 2020 and recommended “that patients who have moderate to severe or disabling tardive dyskinesia associated with antipsychotic therapy be treated with a reversible inhibitor of the vesicular monoamine transporter 2.” There has been much to learn about TD and its subtleties since its approval. To complicate matters, the field of medicine, the FDA lumped at least 24 different movement disorders into the category of extrapyramidal symptoms (EPS) with no differentiation regarding etiology and diverse treatments. Even today, the term EPS is ubiquitously used to define the presence of any medication-induced movement disorder. (I suggested the term EPS is antiquated and needs to be retired in a previous editorial, but it remains very much entrenched in our nosology.) Curiously, anticholinergic medications, including benztropine, diphenhydramine, and trihexyphenidyl, are commonly used to treat all antipsychotic-induced movement disorders despite the fact that they make TD worse and have no benefit for akathisia. Similarly, the VMAT2 inhibitors can bring out a vulnerability to Parkinson disease (PD) , or if PD is already present, they can make it worse. The AIMS Exam Establishing a pre-antipsychotic motor system baseline, ongoing screening for TD, and monitoring TD once it appears are essential components of good evidence-based practice. The Abnormal Involuntary Movement Scale (AIMS) exam is currently the gold standard monitoring scale that is used to establish a baseline before initiating an antipsychotic medication, as well as to detect the onset of any TD and track its worsening or improvement. Initially developed by the National Institute of Mental Health for use in research, clinicians rapidly adopted the AIMS, and it is the most utilized scale for evaluating and managing TD in the US as well as in clinical trials and research.8 The AIMS includes 12 items, but only the first 7 questions rate movement severity in various muscle groups. Each of these groups is rated from 0 (no movements) to 4 (severe movements), giving a total numeric range from 0 (no movements) to 28 (severe movements in all 7 muscle areas). The collective rating of these 7 items is the AIMS dyskinesia total score (AIMS DTS). Importantly, an individual may have an AIMS DTS of 5 yet meet the standard for treatment with a VMAT2 inhibitor, whereas another individual’s score may be 10, yet no treatment is indicated. How can this be? Let’s review a few case examples. Case 1 “Ms Robbins” is 49 years old and works as a bank teller. She has been on an antipsychotic medication to treat her bipolar disorder for 10 years, resulting in stability of mood symptoms that were previously poorly controlled. Ms Robbins presents to your office for a follow-up visit. She had a recent encounter with her supervisor after several bank customers reported that they observed frequent eye blinking and some lip movements during their bank transactions with her. Later at home, she asked her husband and adult children whether they noticed any movements. They confirmed these types of movements, noting they seemed to be increasing over the past several months. After performing an AIMS exam, Ms Robbins scores a 3 (moderate) on the item for muscles of facial expression due to notable eye blinking, and a 2 (mild) on the item for lip movements, giving her an AIMS DTS of 5. Upon further discussion, Ms Robbins reports increased anxiety and sadness about these movements, and she is worried about her job. Additionally, she reports she is attending fewer social events out of embarrassment. She becomes tearful and is visibly distressed during the conversation. She does not want to change any of her current medications and asks what treatment options are available. Case 2 “Mr Jones” is 45 years old and works the night shift as a security guard at a large office complex. He has been on an antipsychotic medication to treat schizoaffective disorder, bipolar type , for 12 years. He had multiple hospitalizations for psychotic and manic decompensations in his 20s, but he has done well over the past 10 years, which you attribute both to his medication adherence and minimal psychosocial stressors. Mr Jones is in a long-term relationship and enjoys the quietude and financial stability of his job. You perform his annual AIMS exam, and Mr Jones scores a 2 (mild) on tongue, lips, jaw, fingers, and feet, resulting in an AIMS DTS of 10. Upon further discussion, Mr Jones denies distress from these movements. Although both he and his partner have noticed some of these movements, he prefers to leave treatment as is and simply increase monitoring with more frequent AIMS exams. Impact of Movements These 2 cases highlight the importance of balancing the relative objective AIMS DTS score with the individual’s experience and how movements impact their day-to-day life. Looking at AIMS DTS, Mr Jones’ score was twice as high as Ms Robbins’ score on the objective scale, suggesting he should receive treatment with a VMAT2. However, all 5 of Mr Jones’ scores were 2s, putting them all in the mild range. In addition, he expressed no distress or concerns about the movements. After reviewing the possible impact of the current movements on various aspects of his daily functioning, he preferred to simply increase monitoring. On the other hand, Ms Robbins had a much lower score. Yet, she expressed that the moderate eye blinking and mild lip movements were impacting her job, emotions, self-esteem, and social functioning, causing significant distress, so she readily agreed to initiate VMAT2 inhibitor treatment to minimize these movements to the greatest degree possible. Domains of Impairment These past 8 years have shown us that TD is a much larger bucket of symptoms than we originally thought. Although patients with severe TD are readily recognizable, our challenge is identifying patients with moderate to mild impairment. This requires the vigilance of a systematic AIMS exam. The clinician should ensure the patient is relaxed and should be aware of various activating maneuvers, such as tapping each finger to the thumb of one hand while looking for movements everywhere else. Once movements are identified, the real detective work begins. Because each person is unique, movements that bother one person may be hardly noticeable in another, as in the cases of Ms Robbins and Mr Jones. Thus, as clinicians, we should ask questions to uncover any degree of functional impairment. Spouses, partners, family, friends, and care providers can be imperative to capturing the full range of impairments. Importantly, some patients with anosognosia will innocently deny any movements despite dramatic TD with significant impairments. In 2022, a panel of TD experts developed a standardized tool that could be utilized easily in a clinical setting to assess TD’s impact on functioning in various domains. The resulting Impact-TD scale measures the degree of functional impact on 4 categories: social, psychological/psychiatric, physical, vocational/educational/recreational.9 Through my years of assessing and treating TD, I developed an acronym—MEASO—that has been helpful in reminding me to ask the many questions to capture functional impairment resulting from TD, regardless of the AIMS score or my impression of the likely consequences of the dyskinetic movements. Concluding Thoughts Antipsychotic medications have proven to be worthy tools in addressing psychiatric illness, yet they put our patients at risk for developing TD. In retrospect, it is not surprising that psychiatry has overlooked, or even become complacent, in completing motor assessments, functional assessments, informed consent discussions, psychoeducation, and comprehensive treatment of TD. The first task is to master the differential diagnoses of any movement-related symptom, then assess functional impact. When facing uncertainty, consider consulting with a psychiatric colleague or a neurologist to aid in the differential diagnosis and treatment. Importantly, once the diagnosis of TD has been made, perform a thorough assessment of the resulting functional impairment and work with your patient to find the outcomes that are most appropriate for them. Note: This article originally appeared on Psychiatric Times .

LOS ANGELES — Artificial intelligence (AI) falls short of human therapists when it comes to empathy and emotional connection in the delivery of cognitive behavioral therapy (CBT) , initial results of a new pilot study suggested. However, the results showed that AI performed well in providing a structured therapeutic approach. “While AI may offer structured CBT components and serve as a supplementary or triage tool, it lacks the nuance and flexibility to serve as a stand-alone therapy,” study investigator Esha Aneja, a fourth-year medical student at California Northstate College of Medicine, Elk Grove, California, told Medscape Medical News. “Physicians and therapists should view AI as a potential adjunct, not an alternative.” “Human oversight, ethical safeguards, and empathy remain essential to safe and effective mental health care.” The findings were presented on May 17 at the American Psychiatric Association (APA) 2025 Annual Meeting . Demand for CBT Outstripping Supply Currently, there aren’t enough psychiatric professionals in the United States — or globally — to meet the growing demand for CBT. Patients frequently face delays in accessing care, so more are turning to AI tools like ChatGPT to address their mental health needs, said Aneja. However, she noted in her presentation that large language model (LLM)–based AI chatbots for text-based therapy are still largely theoretical in psychiatric literature. While LLMs have been integrated into electronic health records for diagnostic purposes, the ability of AI to execute CBT remains understudied. The goal of the study was to compare the effectiveness of therapy delivered by humans with AI. Experts familiar with CBT principles using the Cognitive Therapy Rating Scale (CTRS) compared a human therapist with an AI model (ChatGPT-3.5) in responding to a third-party patient presenting with a specific mental health concern. CTRS is a gold-standard observational tool for assessing the quality and fidelity of CBT sessions. It evaluates multiple domains, each rated on a 0-6 scale, with higher scores reflecting more skilled therapeutic delivery. Both the human therapist, who conducted the session over Zoom, and the AI therapist, ChatGPT-3.5 (the most current version at the time), interacted with the patient solely via text chat. Reviewers received transcripts of each session but were blinded to whether the responses came from a human or AI. The study surveyed 75 reviewers to compare the quality of human-based and ChatGPT-3.5-based interactions with patients. Participants included medical students, social work students, psychiatric residents, and board-certified psychiatrists. Humans Win the Day The human therapist outperformed ChatGPT-3.5 across all domains. Areas where the differences in mean CTRS scores were statistically significant included feedback (4.48 vs 3.03), collaboration (4.91 vs 3.84), pacing (4.60 vs 3.67), and guided discovery (0.35 vs 3.45), as well as “focus on key cognitive behaviors” and “application of CBT techniques” (P = .001 for all). Areas where the ratings were similar between the two groups included agenda setting, understanding, interpersonal effectiveness, and strategies for change. When it came to therapeutic approach and empathy, respondents disagreed on whether the human therapist demonstrated enough empathy, Aneja reported. “Some praised their warmth and responsiveness, while others felt the therapist focused too much on technique and missed emotional cues,” she said. “In contrast, AI was more uniformly described as ‘robotic’ or ‘surface-level’ in its empathy, with little variation.” While AI may become “cognitively empathetic” in the future and therefore able to respond more appropriately, “emotional or embodied empathy, the kind that comes from shared human experience, is beyond its current capabilities,” said Aneja. And, even in the areas that were more compatible with AI such as structure and agenda, respondents felt AI was “too wordy” and “robotic” and included “a lot of lecturing,” she added. They also noted AI lacked personalized recommendations with respect to patient understanding and tailored approaches. While the researchers suspected AI might fall short, this new study “quantifies and contextualizes those limitations in a real-world CBT framework,” said Aneja. AI could “definitely” be used as a screening tool in psychiatry, particularly when patients can’t get to see a provider in a timely manner, she said. It could “look for things like suicidality or situations where urgent attention is important.” However, therapists should keep the tool’s limitations in mind, especially the empathy component, she added. Weighing in on these results, Howard Liu, MD, chair of the Department of Psychiatry at the University of Nebraska Medical Center, Omaha, Nebraska, and chair of the APA Council on Communications, Washington, DC, called the study “fascinating,” especially with the backdrop of psychiatrist shortages across the country. However, he stressed the importance of informing patients when using AI. “Different health systems have different policies about whether you can, in fact, feed in protected health information into these systems,” he pointed out. Philip R. Muskin, MD, professor of psychiatry at the Columbia University Irving Medical Center, New York City, said he was not surprised by the findings overall or the comments about the “lecture-like quality” of the AI “therapist.” “Human responses vary, even when rigidly following a CBT agenda,” he told Medscape Medical News. “Reading about therapy, which is essentially what the AI software does, isn’t comparable to a therapist who has read training materials but has incorporated the information through human interaction.” Note: This article originally appeared on Medscape .

The secretary of the Department of Health and Human Services (HHS) is charged with overseeing the department’s mission: “to enhance the health and well-being of all Americans by providing for effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, public health, and social services.” Sworn in as HHS secretary on February 13, how well is Robert F. Kennedy Jr upholding this mission? An environmental lawyer, Kennedy has no background in healthcare administration or research, which has become common among those appointed to the role. Over the last 30 years, only one person with an educational or professional background in healthcare administration has held the position. As secretary, Kennedy has taken on chronic disease and autism awareness as his primary health concerns. He is also focusing on food and water safety as part of the government’s Make America Healthy Again initiative. He has encouraged avoiding seed oils in favor of animal fats like beef tallow, suggested removing fluoride from water supplies, and developed policy to eliminate petroleum-based artificial foods dyes from the nation’s food supply. But will these methods make America healthy again? Seed Oils or Beef Tallow? As a sustainability lover, I appreciate the videos on social media where homesteaders boil down beef bones for tallow and bone broth. I keep a bag of veggie scraps in my freezer so I can throw them in a pot with my rotisserie chicken bones for bone broth. Do I think it’s the magical healing potion that some influencers suggest? No. But, it’s a nice way to use up my scraps while I get a tasty, protein-rich broth for my next pot of soup. However, Kennedy’s argument for beef tallow isn’t in the name of sustainability. It’s in the name of health. He argues that seed oils are pro-inflammatory but doesn’t elaborate. I am left to assume he is referring to the pro-inflammatory process that may develop when omega-6 fatty acids, found in large quantities in seed oils, grossly outweigh omega-3 fatty acids in the diet. If this is the case, the obvious solution is to recommend increasing intake of omega-3 fatty acids from fatty fish, mussels, walnuts, flax seed, algae oil, and soybeans. Instead, Kennedy decided to promote beef tallow as an appropriate substitute for seed oils. Beef tallow is about 50% saturated fat. The United State Department of Agriculture’s Dietary Guidelines for Americans recommend that saturated fat intake be kept below 10% of total calorie intake, and the American Heart Association recommends that saturated fat be kept below 6% of total calorie intake to promote cardiovascular health. A medium order of Steak ‘n Shake french fries cooked in beef tallow contains 11 g of saturated fat, or 5% of the average American’s total calorie intake in saturated fat alone. If the fries are the side for another food high in saturated fat, like a cheeseburger or chicken tenders, that dinner has likely already exceeded the daily recommended total intake of saturated fat before they’ve left the table. That doesn’t include a milkshake. Is there some ongoing research that suggests saturated fat may not be the villain that noted physiologist Ancel Keys, PhD, thought it was? Sure. But, until we have adequate research to support such a theory, trading canola oil for beef tallow isn’t going to make American healthier. Fluoridation May Cause Neurological Problems? One of Kennedy’s claims about fluoridated water is it increases the risk for attention deficit/hyperactivity disorder and neurological injuries. Some studies indicate a correlation between early exposure to fluoridated water and ADHD, and a recent cohort study conducted in Los Angeles, California, suggested a link between using fluoridated water for drinking and food preparation while pregnant and development of neurodivergent behavior in toddlers. The study included pregnant women who were predominantly Hispanic and of low socioeconomic status and found that those with elevated urinary fluoride metabolites had children more likely to develop neuroatypical behaviors at or before their third birthday. The researchers noted that many study participants reported regularly cooking dishes like rice at home, which may increase fluoride intake from tap water used in cooking. Most municipal water in the United States is fortified with fluoride, a practice that began in the 1940s to combat dental cavities. Now, most toothpaste is fluoridated, and 65.9% of American adults and 86.9% of children aged 2-17 years have regular access to a dentist for dental cleanings that can hinder the development of cavities. However, 34.1% of American adults remain without regular dental care. Utah and Florida have already passed legislation to remove fluoride from tap water and other states are sure to follow. The government of Calgary, Canada, ceased water fluoridation in 2011 and is currently in the process of refortifying the water supply due to a significant spike in dental caries among children in the years following. Would it be prudent for the administration to simply recommend decreasing recommended fluoride levels in tap water while further research is conducted? Sure. But, that line of thought suggests that funds will be available in the coming years for such research. A recent analysis published in JAMA found that more than $1.2 billion in research grants disbursed by the National Institutes of Health (NIH) were cancelled between February 28, 2025 and April 8, 2025, and the proposed 2026 budget would slash the total budget of the NIH to 56% of its 2025 budget. These proposed cuts are almost certain to handicap future research on everything from fortification of our water and food supply to neurobehavioral disorders. In the meantime, it may be wise for those of us working with patients to take extra steps to promote oral hygiene, connect patients with dental care resources, and to recommend high fluoride foods like potatoes, grapes, raisins, and canned shrimp and/or crab, or to consider fluoride supplements, especially in children. Artificial Dyes Cause Behavioral Problems? Kennedy’s most recent target has been petroleum-based artificial food dyes based on concern that they promote behavioral problems in children. The research is mixed. But of all the items on Kennedy’s agenda, this is the one I am least concerned about. Artificial food dyes have no nutritional value or any known benefits. If there is even a chance that they could be harming Americans, we should work to get them out of the food supply. It won’t hurt us if our sugar-laden breakfast cereals are a slightly duller shade of red, green, or purple. I would argue that limiting artificial dyes in the food supply may encourage manufacturers to use natural dyes that could provide health benefits like beet juice, turmeric, or chlorophyll. This is a non-issue in my eyes. Will We Make America Healthy Again? America has a diet problem. As a dietitian, I appreciate that Secretary Kennedy is promoting health and wellness. But, swapping out beef tallow for seed oils isn’t the answer to the obesity epidemic. Autism spectrum disorder (ASD) affects about 1 in 31 children in the United States, and I’m pleased that the Secretary is so driven to find the cause. But I don’t think that handicapping our research institutions and limiting fluoridation or artificial dyes will get us any closer to discovering what causes ASD. I fear that the Secretary’s agenda is overly focused on sowing mistrust in traditional healthcare, while inadequately focused on the health and wellness of the Americans that the DHHS is charged with caring for. It remains to be seen less than 100 days into his tenure whether his agenda will “enhance the health and well-being of all Americans,” but I can already see that he is not interested in “fostering sound, sustained advances in the sciences,” and that alone frightens me. Note: This article originally appeared on Medscape .

TOPLINE: In patients with depression resistant to National Health Service (NHS) Talking Therapies, mindfulness-based cognitive therapy (MBCT) plus treatment as usual was more effective in alleviating symptoms than treatment as usual alone, a new trial found. Additionally, MBCT plus treatment as usual had a 99% probability of being cost-effective. METHODOLOGY: Researchers conducted a parallel, randomized, controlled, superiority trial across three sites in the United Kingdom (2021-2023). The study included 234 patients with major depressive disorder (mean age, 42.5 years; 71% women; 86% White) who couldn't achieve remission after ≥ 12 sessions of NHS Talking Therapies. Participants were randomly assigned to receive either treatment as usual alone (n = 116) or MBCT plus treatment as usual (n = 118), with minimization on the basis of depression severity, antidepressant use, and recruitment site. The primary outcome was depression symptoms, measured using the Patient Health Questionnaire-9 at 34 weeks. Cost-effectiveness was assessed using the Adult Service Use Schedule. TAKEAWAY: Participants who received MBCT plus treatment as usual had significantly reduced depression symptoms than those who received treatment as usual alone (P = .0006). MBCT plus treatment as usual resulted in lower costs and higher utility scores than treatment as usual alone during the study period. Analysis revealed a 99% probability that MBCT plus treatment as usual was cost-effective at the £20,000 per quality-adjusted life-year threshold. No serious adverse events related to the trial or treatment were observed. IN PRACTICE: "Our findings show that psychological further-line treatment for depression can bring clinical benefit at an affordable price, potentially helping to reduce the long-term disability burden and economic costs associated with difficult-to-treat depression," the authors wrote. SOURCE: The study was led by Thorsten Barnhofer, PhD, School of Psychology, University of Surrey, Guildford, England. It was published online in the June 2025 issue of The Lancet Psychiatry . Note: This article originally appeared on Medscape .

Key Takeaways Structured safety plans, such as the Stanley-Brown model, significantly reduce suicide attempts by 43% compared to treatment as usual. The Collaborative Assessment and Management of Suicide (CAMS) and CBT-SP are effective interventions focusing on suicidal drivers and ideations. Early implementation of safety plans in outpatient settings can prevent progression to severe suicidality and should be part of clinical policy. Telehealth adaptations and environmental safety measures, including firearm and medication management, are essential for effective suicide prevention. Despite advances in medicine, suicide rates continue to rise. As of 2022, the suicide rate in the United States was 14.2 deaths per 100,000 people, which translates to approximately 49,476 suicides. Most mental health clinicians, tragically, will experience at least 1 patient who will die from suicide during their career. One of the most daunting clinical difficulties is that suicide is almost impossible to predict. After a comprehensive assessment, if we determine that the patient is not in imminent danger, we then attempt to collaboratively engage them in a safety plan. A more formal written safety plan was developed by Stanley and Brown in 2008, which clarifies the warning signs, internal coping strategies, external distraction strategies, engagement of selective specific supportive individuals and professional contacts, and removal of access to weapons. The Suicide Plan Intervention (SPI) has been identified as a best practice by several suicide prevention organizations. Those of us who trained prior to Stanley and Brown’s safety plan and many others do not use a formal safety plan template. Traditionally, we perform a comprehensive risk assessment and make a formulation and plan. If the patient is deemed not to be in imminent danger, a plan of safe follow-up addressing state-based factors and monitoring would be discussed. This more informal plan may be sufficient, but it may miss certain key pieces that a more formalized structured plan would fulfill as a part of practice habit or policy. Also, for medical directors in large group practices, such as myself, overseeing clinical quality and care for many clinicians that include psychiatrists and advanced practice providers, a structured system of clinical assessment and plan for suicidal patients as a part of clinical policy and/or practice culture makes sense. When faced with anxiety of treating a patient with acute suicidality, a structured safety plan system such as the SPI that has been put in place at a time prior to crisis can be stabilizing and grounding. Other interventions and resources for clinicians that have been studied to address suicide in the outpatient setting include the Collaborative Assessment and Management of Suicide (CAMS). CAMS also uses a templated form entitled the Suicide Status Form (SSF). This form also addresses many of the elements of the SPI. Additionally, it focuses on the patient’s suicidal drivers, such as psychological pain, hopelessness, and self-regard/self-hatred and makes these drivers a central focus of therapy. There have also been manualized therapies such as cognitive behavior therapy (CBT)-SP, a 12 session CBT focused on suicidal ideations and behaviors. This treatment integrates the SPI within a CBT model. These models are primarily therapy models for patients with suicidal ideations and behaviors. This article is primarily aimed at outpatient psychiatric clinicians who provide medication management and supportive therapy. Clinicians who have supportive add-on therapies have a significant role in identifying suicide warning signs and implementing CBT/dialectical behavior therapy skills into a medication follow-up. I propose that implementation of the SPI early in treatments, before a crisis, may prevent progression of more severe suicidality. I will also make some suggestions for how to implement a safety plan system in a larger group practice, especially one that contains a variety of different levels of clinical clinicians. I will describe how clinicians must develop the ability to identify warning signs, build coping strengths, create strategies for external distraction, identify primary support individuals and professional contacts, and address environment safety within a collaborative relationship. My goal is to provide a description of how this written template can be incorporated into an ongoing medication management treatment. Safety Plan Background Studies utilizing formalized written safety plans demonstrate significant benefits. Meta-analysis of the SPI in emergency patients has shown 43% decrease in suicide attempts and/or completion (NNT 16) when compared with treatment as usual (TAU). TAU was basically that after a comprehensive suicidal assessment, the patient was given a follow-up appointment in mental health. It is well-known that patients do not have reliable follow-up from emergency departments, making an SPI type intervention that much more important. The interventions were performed primarily face-to-face and took an average of 20-25 minutes. Although the intervention decreased suicidal behavior, it did not significantly change suicidal ideations. This indicates that patients have a greater behavioral capacity to refrain from acting on suicidal thoughts, although the ongoing distress that generates thoughts of ending their life persists and underscores the continued need for ongoing treatment. With the rise of telehealth in psychiatric outpatient practice, it is important to examine whether telehealth safety plans might differ significantly from in-person ones. Typically, the protocol involves collaboratively filling out the form in writing and then printing it for the patient to take home. This process can be adapted for telehealth by uploading the completed form to the patient’s portal or emailing it to them. Additionally, it may be beneficial for the patient to upload the safety plan to their mobile phone, take a picture of it, or write down the key elements in their phone’s note section for easy reference during stressful times. Surveys of clinicians find that most clinicians (87.6%) believe that a written safety plan is appropriate when patients have “thoughts about ending their life by suicide.” I would propose that in the context of ongoing outpatient treatment, it should be implemented even earlier, perhaps even with passive suicidal thoughts. If it is discussed as a part of the ongoing treatment, then the creation of a written document is very brief, much less than 20 minutes. It makes suicide prevention an explicit goal of the treatment and develops a potential plan before the clinician is suddenly thrust into a crisis in which intent and plan has become imminent. Some clinicians may include a separate tab in the EHR for safety plan documentation, or it can be documented within the history of present illness and referred to in future sessions. Discussing the safety plan as part of ongoing treatment allows the clinician to revisit aspects of it as needed, depending on the level of warning signs. This can be as frequent as every session and can be actualized by verbally identifying the warning signs as they present and revisiting the already rehearsed and practiced coping strategies. Identifying Warning Signs Identifying warning signs is enhanced by a strong ongoing therapeutic relationship. This is much more difficult in a fast-paced brief medication model. If working within a brief medication model, it is very important to recognize when the tempo needs to slow down, and the sessions shift toward a combined medication-therapy model at greater frequency. One of the frequent problems that I see as a medical director managing morbidity and mortality case reviews is the tendency to not recognize when a patient should be seen in longer and more frequent sessions. It is important to have a working alliance that focuses not only on symptom stabilization with medications, but on increasing awareness of emotional triggers for regression that could lead to self-destructive action-oriented behaviors. This allows for a discussion very early on about how to address thoughts, feelings, images, and behaviors that are counter to the working goals of the treatment before it manifests as acute suicidal behavior. For example, think about a patient with borderline psychic structure and emotional dysregulation who has had a series of self-harm incidents, such as cutting and burning, triggered by comparative cognitions. Whenever she is with someone who appears more successful than her, negative automatic thoughts about her own worthlessness and self-disgust are triggered. Understanding this dynamic is part of the therapeutic alliance, and having processed these feelings during outpatient treatment enables us to label them when they occur. Building Internal Coping Strategies The next level of a written safety plan after identifying warning signs is to clarify the patient’s internal coping strategies to be used when suicidal ideations intensify. Having them written out early on enables the patient and clinician to revisit these strategies as distress levels wax and wane. In primary medication management with add-on supportive therapy, there can be the development of a dialogue around a discussion that goes like this: “When this happens (self-harm urge secondary to comparing thoughts, which has a dynamic origin) use a behavioral skill such as relaxation response, grounding techniques, or mindfully observing the thoughts nonjudgmentally and nonreactively, etc.” The skills should have utility, and be worked on and revisited in the treatment. Developing a List of People and Places That Provide Distraction Distraction is the next line of defense in a safety plan. The patient is encouraged to independently utilize their internal coping and distraction strategies to take their mind off problems without necessarily having to contact specific supportive individuals. The distraction list is a group of people that they can connect with, but not necessarily disclose that they are having suicidal ideations. List of Supportive People to Be Contacted by the Patient in Crisis This level of need requires some forethought. Who are the patient’s safety net? In the case of a crisis, who would be the individuals that would understand the level of distress the patient is experiencing and respond in a way that is deescalating? This goes beyond having people and places for distraction. This level of engagement requires a patient’s trust in the support person at the level of disclosing significant distress and safety needs. This is an opportunity to talk about the patient’s family and core support systems. It is crucial to involve them ahead of time if it appears that the risk of regression is significant. Patients often resist contacting and letting people know. The clinician can often facilitate these discussions by contacting the family member either separately, if given permission, or together with the patient. It is important to frame the connection in a way that is not intrusive and has the possibility of enhancing supportive understanding. It is helpful to let the patient know that the goal is not to share private information, but rather to thank the support person for being there for the patient and help them understand the situation in a destigmatizing manner. It is also important to discuss with the patient what will be shared with the family member or support person prior to calling and to collaboratively come up with an explanation that is comfortable for the patient. This is especially critical when there is cultural or familial stigmatization of mental illness. Knowing that you have a connection to a supportive person of a suicidal patient can be extremely comforting to both the patient and their clinician. The adage ‘it takes a village to raise a child’ applies to the care of a patient with suicidal ideation as well, who needs a wraparound supportive system that can monitor the patient much more than a single clinician can in outpatient clinical practice. The benefits of developing nonprofessional support networks for patients with suicidal ideation have been studied. For example, in the Youth Support Team study, adolescents with suicidal ideation being discharged from the hospital nominated “caring adults” to serve as support persons for them after hospitalization. These adults attended a psychoeducational session to learn about the youth’s problem list and treatment plan, suicide warning signs, communicating with adolescents, and how to be helpful in supporting treatment adherence and positive behavioral choices. The adults received weekly supportive telephone calls from YST staff for 3 months. Remarkably, the hazard ratio indicated a 6.6-fold increased risk of death for the TAU group vs the YST group. This increased mortality may not necessarily be from suicide alone, as it included accidental deaths from motor vehicles or drug overdose. Continued studies looking at the mechanisms of benefit are needed, but it does speak to the power of the clinician attempting to facilitate patients reaching out and designating a caring support team, as well as actively supporting and educating the patient’s chosen support team. A List of Professionals That Can Be Contacted in Crisis In addition to the list of close friends and family that can be contacted in a crisis, it is important to have a clear, explicit list of contact numbers for professionals and professional services. This should include the psychiatrist and therapist and could also include a primary care physician. Additionally, it should list professional service lines such as the crisis line 988, which is staffed 24/7 by crisis counselors who can help stabilize and direct patients in times of need. It is crucial to clarify when these professionals are available and ensure the patient understands that they should access emergency services if they are in a crisis with intent to end their life. Making the Environment Safer Discussing a plan to make the environment safe is imperative but can be challenging, especially with patients who are reluctant to give up their guns. This reluctance is more common among men. Although men attempt suicide half as frequently as women, they are twice as likely to complete it, largely due to the use of more lethal means, particularly firearms. Approaching the issue as a temporary measure to ensure safety while working on finding the right medication regimen and stabilizing the patient's mental health can sometimes be understood and agreed upon by the patient. Some negotiation may still be necessary. Ideally, it would be best if the guns were removed and placed in another family member’s house. However, during negotiations, it is important to remember that the level of risk associated with the gun lies on a spectrum depending on where and how it is stored. The clinicians’ goal is to put as much of a barrier between the patient and their loaded gun as possible. For example, a loaded gun on the bedside table poses a much higher risk than an unloaded gun locked in a gun cabinet in the basement. Limiting the number of pills that the patient has access to is another way to help keep them safe. If the patient is at significant risk, it might be appropriate for the clinician to prescribe no more than a week’s supply at a time. Alternatively, if the patient has a trusted support person and can work within a collaborative safety plan, it could be beneficial for the family member to manage the medications and distribute a week's supply in an administrative tray. There can be challenges with the patient feeling infantilized by these systems, but it is important to frame it as a testament to their executive decision-making and planning abilities. While many patients may struggle to acknowledge their vulnerability to impulsivity, they are often more willing to accept the clinician’s authority that the medication, rather than themselves, could make their brain more prone to impulsive actions. Therefore, a different structure is needed while medications are being titrated. This is especially important when starting a new antidepressant, particularly in younger individuals where the prefrontal cortex is less developed. Prescribing the appropriate number of refills for patients requires significant care and caution. The best practice is to time refills for when the patient has a return appointment, allowing medications to be reconciled and the appropriate amount prescribed based on a current evaluation and risk assessment. However, if a patient misses an appointment and calls for a refill, this can be problematic, especially if there have been changes in the patient's life that affect their level of risk since the last visit. Clinicians generally set the next appointment based on medical necessity, but this can be disrupted if the patient is inconsistent with keeping appointments. With EHR, clinicians might reflexively click the quick refill option, which can be particularly problematic if the original prescription was for 90 days. As medical directors/managers, it seems prudent to educate clinicians in the group not to prescribe a refill without scheduling another appointment and to provide only a bridge prescription until that appointment. A good practice policy is to only give 90-day prescriptions without refills to patients who are well-known and stable. It also would seem to be good management to encourage clinicians to only see patients every 90 days if they are in remission with stable medications and otherwise approximately monthly or even less according to medical necessity. Concluding Thoughts Formal safety plans save lives. Evidence suggests there is significant benefit in incorporating the plan early for patients with ideations or past intent. This allows the patient and clinician to collaborate on a plan that minimizes suicide risk well before a crisis occurs. The need to tailor the frequency and length of sessions to the patient’s level of risk is emphasized. For the clinician and patient to be aware of warning signs, a certain level of depth and insight into the patient’s individual vulnerabilities must be achieved. This is best accomplished within treatments that include, at least when medically necessary, add-on supportive therapy with sessions of sufficient length and frequency. Making safety plans a part of a medical director’s policies for group practices has significant benefits, especially where there are clinicians of various levels of training and experience. We strongly encourage safety plans to be implemented early for patients with ongoing suicidal ideations or past intent or attempts. Hopefully, this intervention, which requires relatively brief time-commitment, will help mitigate the increasing suicide rates and contribute to our continued efforts to achieve the ideal goal of zero suicides. Note: This article originally appeared on Psychiatric Times .

Maintaining optimal vascular health throughout late life can significantly lower the risk of developing dementia before age 80 years, new research showed. Investigators estimated the proportion of new dementia cases linked to modifiable vascular risk factors. The results suggested that 22%-44% of dementia cases by age 80 years could be attributed to poor vascular health through age 74 years. The findings highlighted the “potentially immense value of early detection of vascular risk factors and primordial prevention (eg, vis-à-vis promotion of physical activity and healthy body weight management) beginning in midlife,” wrote the study team, led by Jason Smith, PhD, with Johns Hopkins Bloomberg School of Public Health in Baltimore. The study was published online on June 2 in JAMA Neurology . Vascular Health Equals Brain Health Hypertension, diabetes, and smoking are widely recognized modifiable vascular risk factors for dementia. While their roles have been studied individually, the cumulative impact of these risk factors across the lifespan — and how this varies by genetic background, race, and sex — has been less clear. Smith and colleagues used data from the Atherosclerosis Risk in Communities Neurocognitive Study, with 33 years of follow-up, to assess the fraction of dementia attributable to hypertension, diabetes, and smoking measured at different life stages. A total of 7731 participants were included in the analysis of risk factors measured at age 45-54 years (58% women, 71% White, 29% Black); 12,274 contributed data at age 55-64 years (55% women, 76% White, 24% Black); and 6787 contributed data at age 65-74 years (56% women, 80% White, 20% Black). Overall, a total of 2218 people developed dementia by their 80th birthday. By age 80 years, the population attributable fraction of dementia attributable to at least one vascular risk factor measured at age 45-54 years was 22%; at 55-64 years, it was 26%, and at 65-74 years, it was 44%. Only 2%-8% of dementia cases occurring after age 80 years were attributable to these vascular risk factors. Subgroup differences emerged. For example, the attributable fractions for the vascular risk factors were higher in APOE-ε4 noncarriers aged 55 years or older (range, 33%-61%). “This reflects the fact that in populations with lower genetic Alzheimer risk, the extent of the relative contribution of vascular disease to dementia risk is greater,” the study team explained. Attributable fractions for the vascular risk factors were also higher in Black individuals aged 45 years or older (range, 26%-53%) and women aged 55 years or older (range, 29%-51%). Risk factor clusters such as hypertension plus diabetes and smoking plus diabetes significantly increased dementia risk, with hazard ratios ranging from 2.00 to 3.54, depending on age and risk factor combination. The importance of hypertension and diabetes increased with age, whereas the importance of smoking decreased with age. “Given the contribution of vascular disease to dementia and the overlap in risk factors between CVD and dementia, interventions that address these underlying risk factors have the potential to reduce the risk of both outcomes,” the co-authors of a linked editorial said. These results also suggest that “to be optimally effective, interventions to reduce dementia risk by addressing vascular risk factors may need to be individualized and targeted based on factors such as age, genetics, race, and sex,” Roch A. Nianogo, MD, PhD, with University of California, Los Angeles, and Deborah E. Barnes, PhD, MPH, with University of California, San Francisco, wrote. Note: This article originally appeared on Medscape .

Key Takeaways: The antipsychiatry movement is experiencing a resurgence, challenging the legitimacy of psychiatric practices and treatments. Recent government actions and influential figures are questioning the role of psychiatric medications, potentially impacting public perception. Psychiatry is supported by scientific evidence, proving the reality and treatability of mental illnesses. Education and advocacy are crucial for psychiatrists to counter misinformation and maintain public trust in mental health care. AFFIRMING PSYCHIATRY The Wall Street Journal recently published an article provocatively entitled “Generation Xanax: The Dark Side of America’s Wonder Drug.”1 Writing as if it were the 1970s, the authors for this exposé reveal that “as concerns increase about the potential adverse effects of these drugs, some patients who try to quit are suffering what amounts to a hangover they can’t escape.” They then outline the usual risks and document common downsides of benzodiazepine use, such as overuse, dependence, and withdrawal. For instance, “many doctors” say the drugs are overprescribed, whereas “some doctors” have given up prescribing them altogether. And, of course, there are quite a few horror stories of patients who took benzodiazepines and got drastically worse or found it agonizing to get off of the medications. As the article concludes, one patient explains, “I went from being independent and totally functional to just slowly declining into this absolute pit of hell.” These stories are indeed horrible, and they are the kind of thing that keeps us psychiatrists up late into the night. But missing from the article are any mentions that anxiety disorders are medically disabling, increase mortality, and raise the risk of other chronic illnesses such as stroke and heart disease. The article contains no indication of the countless individuals with life-threatening and treatment-resistant anxiety who have been helped by benzodiazepines. Nor does it compare negative reactions to benzodiazepines with horror stories that some individuals taking nonpsychiatric drugs such as statins or various antibiotics could tell us. Finally, it fails to explain how almost all doctors work very carefully with patients to avoid overuse. Large-scale studies have shown, for instance, that long-term benzodiazepine use rarely results in escalating doses, does not increase the risk of dementia, and does not increase the risk of hip fractures due to falls. Healthy Again—Without Psychiatry? However, it is not the rather banal and distorted content of the article that is worrisome. Rather it is the timing of this article that is particularly ominous. It comes a month (to the day) after the White House published President Donald J. Trump’s executive order establishing the Make America Healthy Again Commission. Overall, the stated intention of the document is to address escalating rates of chronic illness within our society. But psychiatry is not to be neglected here. Citing concerns about increasing diagnoses of autism and attention-deficit/hyperactivity disorder (ADHD) , this sweeping document directs executive agencies to “assess the prevalence of and threat posed by the prescription of selective serotonin reuptake inhibitors [SSRIs], antipsychotics, mood stabilizers, stimulants, and weight-loss drugs,” as well as to assess the “threat” of medication overuse toward worsening chronic illness. Perhaps not coincidentally, the order accompanies the arrival of Robert F. Kennedy Jr. as the new Secretary of Health and Human Services. In confirmation hearings, Kennedy confirmed that he wanted to study whether SSRIs contribute to mass shootings and claimed that some people he knows “have had a much worse time getting off SSRIs than people have getting off heroin.” Does God Believe in Mental Illness? One person who would likely agree with Kennedy’s skeptical view of psychiatric treatment is the famous evangelical Christian pastor John MacArthur. In addition to his ministerial work, MacArthur has published more than 100 books with multiple bestsellers, including his million-selling MacArthur Study Bible. His influence is immense, and for the past year, he has been using it to let the public know that mental illness does not exist. Rather, it is a “noble lie” of psychiatry that is finally being disproved. He has written: “There’s no such thing as PTSD [posttraumatic stress disorder]. There’s no such thing as OCD [obsessive-compulsive disorder]. There’s no such thing as ADHD.” It turns out that PTSD is simply grief, according to MacArthur, and depression is just a feeling of sadness or melancholy—a truth that ought to lead to the “death of antidepressants.” Certainly, many evangelical Christians were scandalized by his comments, and there has been a strong response from that community. But MacArthur was hardly put off by this, publishing a written document called “Dispelling Myths About ‘Mental Illness’: A Biblical Perspective,” in which he doubles down on his claims about psychiatry, citing the usual antipsychiatry list of grandees, including Thomas Szasz and Robert Whitaker. Antipsychiatry Zombie Apocalypse All this makes me wonder whether the antipsychiatry movement is as moribund as it seemed to be only a few short years ago. Antipsychiatry—the belief that psychiatric practice is unscientific, toxic, and oppressive—peaked in the 1970s, after all. Although not all of its criticisms of psychiatry turned out to be valid, the antipsychiatry movement did have the positive effect of spurring psychiatry toward more careful diagnosis, more scientifically justified treatments, and greater patient empowerment in the treatment process. Since the 1970s, the antipsychiatry movement has slowly faded. Although critics still raise their voices on a regular basis, those voices have become decreasingly relevant and increasingly distant from mainstream public views about the nature and treatment of mental illness. Fortunately, the vast majority of the American public now fully supports mental health diagnosis and treatment, and the struggle to enforce parity laws continues to advance. When I published a book on this subject in 2021, my biggest concern was whether it would be rendered unnecessary within a few years—the current rate of social acceptance seemed to indicate that the view of mental illness as medically treatable and real was going to achieve the status of common sense, not only among medical professionals but also the public at large. And yet, the antipsychiatry movement seems to have lurched off its deathbed and staggered into the streets. Unlike the zombies featured in most apocalypse movies, this one is armed to the teeth. Suddenly, the antipsychiatry movement has the ears of those in high places. Suddenly, the government apparatus is going into action against our field. Suddenly, government-funded research is going to switch from investigating which psychiatric treatments help us to help our patients and instead focusing on which ones might hurt us. Education Is Advocacy What are we, as psychiatrists, to do in a time like this? What we should do is what psychiatrists should always do when dealing with a crisis: Keep our heads up and stick to the science that guides us. In this case, the most important thing we can do is remember that reality is on our side. Major mental illnesses are scientifically proven to be medically real. Major mental health treatments are scientifically proven to be effective. The majority of the public wants our help, and the majority of the public has experienced mental illness themselves or in a loved one. Time and reality are on our side. As always, our job as psychiatric clinicians is to educate others, starting with our patients, their families, our own families, and our own communities. Next, our job is to explain the nature and treatment of mental illness to community groups, members of the media, and members of government. We have every reason to be optimistic that our efforts will ultimately succeed and put us back on the right path. Once people see that mental illness is a real medical illness, they cannot unsee it. And once people experience (directly or indirectly) quality mental health treatment, then nothing is going to convince them that the whole thing is a sham. There is no way of getting the genie of mental illness back into the bottle. Psychiatry is not going to go away. It is not going away because the life-or-death need for psychiatry is not going away in our lifetimes, so we will persist. We will get on with the work of treating our patients and educating our communities, and they will stand with us. Note: This article originally appeared on Psychiatric Times .

Keypoint: The government has always played an important role in health care. Recent changes, however, are actively altering the practice of medicine and are posed to have a deep and lasting psychiatric impact on patients. Learn more here. The government has always played an important role in health care: it has established agencies to ensure drug safety, created Medicare and Medicaid to improve access, etc. Recent changes, however, are actively altering the practice of medicine and are posed to have a deep and lasting psychiatric impact on patients. Although this is a rapidly evolving situation, here is a closer look at the facts as this issue went to press. Cuts to Top Health Agencies In early 2025, the US Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), Substance Abuse and Mental Health Services Administration (SAMHSA), Veterans Administration (VA), and other organizations experienced huge slashes to their budgets and staff.1 Additionally, on January 20, President Donald J. Trump issued an executive order freezing government hiring.2 Elon Musk, formerly a leader of the Department of Government Efficiency (DOGE), was directed to “dismantle government bureaucracy, slash excess regulations, cut wasteful expenditures, and restructure federal agencies.”3,4 The sudden cuts, as well as terms like wasteful, have startled experts like Robin Weiss, MD, a past president of The Maryland Psychiatric Society and psychiatrist who has worked for the National Academy of Sciences, a federal advisory panel, and in private practice. “It’s exhausting and demoralizing to find that every day, the institutions one holds dear are not just being defunded but also slandered,” Weiss told Psychiatric Times. “I am 75 years old, and I worked for the National Academy of Sciences in the 1980s during the early years of the HIV/AIDS epidemic. There was plenty of warranted controversy about our country’s response, but I also got to know many public servants during those years. So many people who choose to devote themselves to public service have amazing expertise, and they often forfeit the opportunity to earn more in the private sector in exchange for meaning. They care about us—the public—and they have devoted their careers to serving us, so to watch them be treated shabbily, and their expertise dismissed, is heart-wrenching.” With much discussion on both sides, what are the actual numbers? FDA Budget: The “FDA’s budget request reflects the Agency’s support of the Make America Healthy Again (MAHA) agenda in key areas of importance for human and animal health… [which includes] $234. million... to address the nation’s chronic disease epidemic, restore trust in our food system, and strengthen America’s nutritional and food safety.” Official documentation lists a $6.8 billion budget for 2026, which represents a decrease of about $270 million compared with the FY 2025. This includes a 4% increase in user fees, now sitting at $137.3 million. Layoffs: The FDA lost 3500 full-time staffers to layoffs, including Brian King, PhD, MPH, the chief tobacco regulator, and his fellow deputies, along with Peter Marks, MD, PhD, who led the development of the COVID-19 vaccine. Even more resigned after being offered reassignment in distant US locations. Impact: The expansive staffing cuts are expected to slow public notices about recalls and product safety issues, as 130 members of the communications team were part of the layoffs. Additionally, thus far, notices that have been released contain more mistakes and less plain language, which experts fear could lead to delays in the delivery of critical information. CDC Budget: The CDC experienced significant cuts to its budget, including the rescinding of $11.4 billion in grant funding to state and local health departments, largely related to COVID-19. Layoffs: Approximately 2400 staffers from various departments and programs were laid off. Layoffs fell predominantly in areas involving deaths and injuries, apart from infectious diseases, such as programs focused on the prevention of asthma, smoking, gun violence, climate change, and more, many of which impact patients with mental illness. Also cut were the Freedom of Information Act team, the Division of Violence Prevention, and laboratory teams testing antibiotic resistance. Additionally, the research center focused on protecting worker health was almost entirely eliminated. Lastly, at least 9 high-level directors were placed on administrative leave and offered reassignment to another US Department of Health and Human Services (HHS) agency. Impact: The administration has shared that the CDC will now “focus on returning to its core mission of preparing for and responding to epidemics and outbreaks.”1 However, workforce reduction has key opinion leaders concerned that the remaining “skeleton staff” may be “capable only of performative gestures toward the work mandated by law and congressional budgets.” David Fleming, MD, who chairs the advisory committee to the CDC director and previously served as acting CDC director in 2002, expressed his concern in a recent JAMA report: “It is resulting in a federal agency that is not going to be able to function effectively." Weiss echoed this concern, sharing with Psychiatric Times that those who remain employed may be feeling traumatized by the loss of their peers. “I see a patient whose funding comes from the CDC. Some of it is now tied up in the lawsuit that the states brought against the federal government, so for right now, it isn’t cut. But there is worry that their core funding from the CDC will be cut completely in the 2026 budget. This patient coined a tragically apt term in our session: Pre-TSD, or pretraumatic stress disorder. They go to work every day and wait for the other shoe to drop. So many state and federal workers are in similar positions. It’s like a mass trauma.” Furthermore, this may impact disease prevention worldwide. The CDC maintains a repository of data for research references, and laboratories globally submit biological samples and data for historical filing; now, there are very few staff left—if any at all—to receive such information, damaging critical research infrastructure. NIH Budget: The administration has canceled hundreds of NIH grants. Furthermore, a draft of the budget for the HHS proposes a $20-billion cut for the NIH in 2026, which equates to an approximate 40% reduction. According to a recently released Senate Committee on Health, Education, Labor, and Pensions minority staff report, $2.7 billion in NIH funding for research has also been cut. Additionally, the number of new research grants hit its lowest point in more than a decade. Layoffs: The NIH lost more than 1000 employees in an initial round of firing, followed by at least 1200 jobs in April. Other dismissals included scientists involved in research on the brain, computer specialists, and nearly the entire communications staff. At least 5 directors of the NIH’s 27 institutes and centers were put on administrative leave or removed, including Eliseo J. Pérez-Stable, MD, from the National Institute on Minority Health and Health Disparities; Diana Bianchi, MD, from the Eunice Kennedy Shriver National Institute of Child Health and Human Development; Shannon Zenk, PhD, MPH, RN, FAAN, from the National Institute of Nursing Research; Vence Bonham, Jr, JD, the acting deputy director of the National Human Genome Research Institute; and Jeanne Marrazzo, MD, MPH, from the National Institute of Allergy and Infectious Diseases. Impact: Approximately $68.8 million in NIH grants related to mental and behavioral health were terminated. Because of canceled grants and loss of funding, many research labs have come to a halt, including in key research areas like Alzheimer disease. One researcher, who previously received a grant of approximately $6 million from the NIH to research the underlying mechanisms of neurodegenerative diseases, claimed, “It is not an exaggeration to say that the true cost of the NIH’s decision may be that thousands of American lives are needlessly degraded or sacrificed.” SAMHSA Budget: Approximately $1 billion in appropriated SAMHSA funds slated to help reduce the overdose crisis have been rescinded. Additionally, state and county public health departments are facing abrupt cancellations and revocations of approximately $11.4 billion in COVID-19–era funding for grants connected to addiction and mental health. Layoffs: Under the restructuring of the HHS, SAMHSA will become a part of the new Administration for a Healthy America (AHA). This restructuring announcement followed the reduction of the HHS by 20,000 employees. SAMHSA began the year with approximately 900 employees, but up to 50% of them may be part of the cuts. In a recent statement, an HHS official said, “The reorganization of SAMHSA into AHA is part of ongoing efforts to improve the efficiency and effectiveness of public health programs. By consolidating SAMHSA’s operations under AHA, we aim to streamline resources and eliminate redundancies, ensuring that essential mental health and substance use disorder services are delivered more effectively. This restructuring will enhance the ability to address public health needs by fostering a more coordinated approach to prevention, treatment, and recovery services.” Impact: SAMHSA has made profound recent improvements in addressing the mental health, substance use, and suicide crises in America. The 988 Suicide & Crisis Lifeline has helped more than 16.5 million individuals since its launch in 2022. In the past year, overdose deaths have decreased by 24%. Leaders of psychiatric organizations are deeply concerned by these new cuts and how they may undo this progress. “I am most concerned about federal cuts to agencies like SAMHSA that provide vital funding for community mental health programs, crisis services, and workforce development. These aren’t abstract line items—they’re the foundation of care for patients with serious mental illness, particularly in underresourced areas. Disrupting these supports at a time when our mental health system is already strained will deepen disparities and increase suffering. I also believe that health care funding cuts, in groups under so much strain, will also impact health care professionals who care for them and increase the moral injury they experience in the field,” Jhilam Biswas, MD, FAPA, told Psychiatric Times. Biswas is director of the Psychiatry, Law, and Society Program at Brigham and Women’s Hospital and president of the Massachusetts Psychiatric Society (MPS). VA Budget: The VA maintains a vast network of contracts that equate to $67 billion annually. In February, DOGE instructed the VA to cancel approximately 875 contracts; this number was later reduced to 585 “non–mission critical or duplicative” contracts worth $1.8 billion. Layoffs: At least 2400 VA probationary employees have already been laid off. Many of those eliminated were veterans; some could be reinstated following pending court actions. However, the administration has shared plans to eliminate 80,000 more jobs and review thousands more contracts. Impact: A decrease in staff could equal a decrease in services, with longer wait periods, fewer appointment options, and fewer services for veterans. Studies involving veteran participants and experimental treatments have been disrupted; approximately 200 research staff members involved in 300 or more trials were affected by the changes, affecting treatment for nearly 10,000 veterans. “What I think is most important for mental health clinicians outside of the VA to know is that their fellow mental health practitioners and their leaders in VA mental health are demonstrating enormous courage and integrity in fulfilling their commitment to high standards of care for veterans despite facing unprecedented challenges,” an anonymous source shared with Psychiatric Times. Terminology Under Scrutiny Although there is no official documentation, agencies and news sources have reported and compiled a list of more than 350 words that have been flagged per directives and guidance issued by the federal government (Table). These words have been eliminated from government websites and documents, and their mention can result in the cancellation of research grants or other agreements. However, the list continues to grow, and it is unclear which words are outright banned vs which should be avoided, as the directives are vague and inconsistent across agencies. “The assault on our science and on our terminology is a fundamental assault on our knowledge and our profession. We are nothing if we cannot explore all that our science and our values point us to. I would point to an example from the Reagan administration. It ruled that the word social be stricken from all federal grants and set American psychiatry back for almost 40 years. The current list of banned words and related concepts is much more extensive, and the costs in terms of progress will be substantial,” Kenneth Thompson, MD, a public service psychiatrist, told Psychiatric Times. Researchers are scouring existing grants using lists of flagged words and self-censoring future work in the hopes of improving grant likelihood. Others are moving toward safer topics to ensure they can finish their advanced degrees and move into academia. Some may leave academia altogether. “The cuts to research funding will have devastating impacts and will undoubtedly stall career pathways for many promising early-career scientists,” said Steve Koh, MD, MPH, MBA, DFAPA, chief of the General Psychiatry Division and director of the Community Psychiatry Program at the University of California, San Diego. “Restricting the language clinicians and researchers can use—whether implicitly or explicitly—has far-reaching consequences. If we cannot name the realities of public health, trauma, inequity, or systemic risk, we risk creating blind spots in care and innovation. We must not allow fear or politics to erode scientific inquiry or silence clinical truth,” Biswas said. H. Steven Moffic, MD, an award-winning psychiatrist, longtime activist, and Psychiatric Times columnist, believes these banned words are an attack on the very core of the field. “Psychiatry, at its essence, is based on word interchanges. Starting way back with Sigmund Freud, patients need to feel comfortable in expressing anything, while we have to say the right things at the right time to help patients through very uncomfortable problems that they would rather repress. All of us in mental health care and our connected organizations have to do some soul-searching about how we will react to banned words and books. This list reminds me of the book 1984. One strategy I would not recommend is just ignoring the whole matter,” Moffic said. By limiting the ways in which research can be communicated, scientific integrity is threatened, and the evidence base that informs public health policy becomes skewed. This ultimately harms minoritized populations. “Banning specific words in clinical research and health care will not erase the realities and needs of the individuals those words represent. These bans only create obstacles to studying the very populations they aim to obscure, which further emphasizes the underlying political motives behind them. Given how long the list of words is, there comes a point in time when one must ask: Which words aren’t banned? Ironically, banning words that represent minority experiences actually hurts everyone. Neglecting the distinct influences of race, gender, ethnicity, sexual orientation, and/or gender identity in research obscures vital insights that could improve health care outcomes for all,” said Scott Leibowitz, MD, a child and adolescent psychiatrist who worked in 3 academic pediatric gender clinics and is a board member at-large for the World Professional Association for Transgender Health. Many clinicians are expressing particular fear for LGBTQ+ individuals, specifically transgender individuals, who seem to bear the brunt of research censorship initiatives. “Recent actions by the federal government have completely decimated research that aims to improve the health of LGBT people. We are likely to lose an entire generation of researchers who had dedicated their careers to supporting this population, which experiences dramatic mental health disparities,” said Jack Turban, MD, a pediatric psychiatrist, author of the book Free to Be: Understanding Kids & Gender Identity, and Psychiatric Times advisory board member. “Perhaps even more insidious is that recent anti-LGBT laws and other government actions are likely worsening the health of these populations, but we will not be able to study or document these impacts to protect future generations. LGBT people already suffer from dramatic disparities in terms of both mental and physical health. These will undoubtedly worsen as we lose our ability to study and support the health of this population.” This panic has trickled down to patients and their caregivers as well, as shared by Weiss. “I have patients who are fearful: one with a transgender kid who worries that the country’s mood is turning against her child; a lesbian in a gay marriage who fears that, in an economic downturn, things could get ugly for them; others who feel defeated because there’s hate in the air.” A White House spokesman claims that this compiled list is an error and that the only words that do need to be prohibited revolve around “gender ideology”: gender, inclusion, identity, diversity, inter, intersex, equity, equitable, transgender, and trans. However, the list of banned words circulating at the National Science Foundation includes several other words that raise red flags, such as women, disability, bias, status, trauma, Black, Hispanic, socioeconomic, and ethnicity. “Many researchers in this area will try to find research funding from nongovernment sources, but there simply are not enough private foundations to compensate for this massive loss of research funding,” Turban told Psychiatric Times. Concluding Thoughts In the wake of change and uncertainty, mental health clinicians are banding together and relying on community to help navigate the new reality. “At MPS, we are actively listening to our members across the state to understand how these policy shifts are affecting their work on the ground. Our strategy is to advocate clearly and collaboratively—with legislators, community stakeholders, and other medical organizations—to protect research integrity and patient-centered care. Clinicians and researchers should know they are not alone. We must stay informed, speak up, and support our professional voice and solidarity through these uncertain times,” Biswas said. Psychiatric clinicians believe a united front is the best way to communicate the importance of mental health care for all. “It is of paramount importance to ensure that we maintain scientific integrity and keep patients at the heart of all the research work that we do. Regardless of changes from the federal government, our commitment to our patients will remain our top priority. We will continue to value and treat all patients with equal regard and respect. Some words may change but our research initiatives to seek the truth and to improve patients’ lives will not change. We encourage our colleagues to focus on our truth north of continuing to advance our knowledge and improvements to care for our patients,” Koh said. “The attacks on the funding and the direction of federal health and mental health policy will injure all populations who depend on federal policy and federal resources. All marginalized communities will feel the brunt, including communities of color and sexual minorities. Psychiatry must respond by unfalteringly continuing to build a diverse workforce that reflects the people of the nation. It must advocate for communities in need, and it must oppose the inhumane, antihuman rights initiatives of this regime,” Thompson said. “We have a hard fight before us. The questions will be: What side did psychiatry take in the struggle—for democracy or against it? For human rights or against them? For a humane, caring society or against it?” Note: This article originally appeared on Psychiatric Times .

Martha Sajatovic, MD: Hello. I'm Dr Martha Sajatovic. I direct the Neurological and Behavioral Outcomes Center at University Hospitals Cleveland. Joining me here today is Dr Camilla Kilbane, who directs the Parkinson's Disease and Movement Disorder Center, also at University Hospitals Cleveland. Thanks for joining me, Camilla. Camilla Kilbane, MD: Thank you for inviting me. I'm looking forward to this conversation. Sajatovic: Camilla, let's start off with the way we communicate with our patients. What do you think are the most important areas or topics that we have to address with our patients and their families about the issue of tardive dyskinesia (TD)? Kilbane: I think there are many things that are important to discuss when we're talking about TD. One of them is the movement: “How is it affecting you physically? Are you having difficulty with chewing, eating? Are you having difficulty performing any tasks?” Or, “How does TD affect you psychologically? Does it make you embarrassed? Does it make you not want to go out in public?” These are all open-ended questions that can then start a dialogue between the physician or the provider and the patient and their families. Sajatovic: As a psychiatrist, I am more likely to see people who are exhibiting movements consistent with TD that the patient isn't aware of. Or maybe they're aware of them, but they're not sure what it is. They'll have been prescribed an antipsychotic medication for a variety of different reasons. So, I will talk about the specific role of antipsychotic drugs in being a risk factor for TD. Sometimes it's a dialogue with the patient, sometimes with a family member to consider, “What is this?” But what we really look at is “How is this affecting your life? Is it something that is a burden for you?” And, “Could we look at whether there are treatment options that might help you?” Kilbane: When patients come to the neurologist, there is a self-selection bias, I think, and most of my patients are probably much more motivated and have done more research about the diagnosis as opposed to those who come to the psychiatrist, who either refers the patient to me or initially approaches the diagnosis. I think it's a very different conversation that you are having with your patients, compared with me. Martha, can you tell me how your care plan might differ depending on the patient and the clinical diagnosis that caused them to need psychotropic medication? Sajatovic: Their psychiatric diagnosis definitely is going to be a driver. We know that people with some types of serious mental illness — for example, schizophrenia or bipolar disorder — may process information differently. It may have to be delivered in a slower way or involving others or may need a series of visits. I do think it is really critical to make sure that the patient has a choice and a voice. Regardless of their diagnosis, this could be an opportunity to bring family members in. They may notice impairments or symptoms that are relatively subtle — both psychiatric and TD symptoms — that the patient doesn't volunteer and that I may not see in a 30-minute or 45-minute office visit. Sometimes patients or family members will suggest that they maybe should just stop the drug, and I think that's an important point of communication between the psychiatrist and the patient. I will talk about the likelihood that you will have a psychiatric relapse if we stop the drug or if you stop the drug on your own. Many patients and families will have already experienced having at least one psychiatric relapse episode, and that is usually not something that anybody wants to go through. It's painful; it's difficult to recover. That is a foundational discussion to have before we go into “What are my treatment options for TD?” Kilbane: I think sometimes people just want information, right? They want to be informed about their condition and feel empowered that they're making the choice themselves, and that can sometimes be a step in the right direction. Then it really becomes a discussion about, “How is it impacting you?” And then we start talking about the medication treatments if they're interested in pursuing those. How do you build that therapeutic trust and alliance with your patients with regards to treating their psychiatric disorder and possibly TD? Sajatovic: That's an excellent question. I would say that's important for any kind of clinician. For mental health clinicians, that it's particularly important because mental health conditions very often are highly stigmatized. I won't dictate most of the time what you need unless it's an acute, immediate safety issue. People need to feel comfortable with expressing their emotions and what they want to do or not want to do. Just because I think something is a problem or not a problem may not be where they are. I can think of a patient that I had who worked as a hairdresser and clearly had movements of her hands. You know, a little bit of bilateral writhing. When I talked with her about treatment, she told me that she was absolutely not interested in treatment because she was already on eight other drugs. She came to a session a couple years later and said that she noticed that she was putting her hands in her pockets so that her clients wouldn't see her hands moving. So, she had a behavior or a metric that was bothersome to her, and that's what she wanted to see go away. Kilbane: That’s a really great example. Sometimes people just have to think about it for a while and let it marinate in their head, and then they might be ready at some point. And, of course, when you’ve already had a side effect to a medication, you may be more cautious to try another medication. I think this idea of “bringing it back gently” and discussing it is a really great idea. And I think that's a lot of what I do too. My job is to inform patients, give them the information about what I think is going on with them, and then we have the discussion about should there be treatment or not. Sajatovic: I wonder how you communicate with the individual who comes to you saying, “I think I have TD, should I get treatment?” Kilbane: For me, it's really important to first of all make sure I know what the clinical diagnosis is. Then, I think it's important to get into what impact the tardive movements have on the individual. What I may perceive as mild TD can have a major impact in somebody's life, whether it’s vocational, psychological, or physical. If you're a dentist and you have a tiny little tremor, you may lose your practice because nobody's going to come to your practice anymore. I think the same thing goes for TD. Learning more about the person you're seeing is going to help you decide if you think the treatment is going to be good. But I think the important part is, if it bothers the patient — even though you think it's mild — you ought to treat it because it's impacting their quality of life. And I think that's a really important part of this more patient-centered and shared decision-making. And we can agree to disagree too — they're consenting adults who come in for discussions, and we go through all of the possible pros and cons. One of the other things I tell patients is that if you decide to try this medication — a VMAT2 inhibitor for this movement — it doesn't mean you have to stay on it for life. So just giving patients the feeling that it's their choice and they can also change their mind, sometimes that also helps in that discussion about should we do it or should we not. Sajatovic: Right, and I would say that the flip argument is very often once they try it, the TD goes away and they feel a lot better. Kilbane: Exactly. Sajatovic: And then, looking back, they’re thinking, “I was a lot more worried about it than I needed to be.” Kilbane: Exactly. Sajatovic: But we have to go through that discussion and that shared decision-making. We want to give them the tools and the confidence to make a decision that's right for them every day. Thank you, Camilla. That was really a wonderful conversation. Kilbane: It was my pleasure. Note: This article originally appeared on Medscape .