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- Public Health and Psychiatry: Two Ways to Treat Mental Illness
Two different approaches can work in tandem to help those with mental disorders. Key points Major neuroscientific advances are leading to new treatments for psychiatric disorders. Public mental health targets social factors that increase risk of developing psychiatric disorders. Both approaches are important in decreasing disabilities associated with mental illness. Psychiatric disorders are common and among the most disabling of all medical illnesses. Even disorders with less severe symptoms can lead to substantial disability. Over the last decade, major progress has been made in elucidating the genetic and neuroscientific underpinnings of psychiatric illnesses. Advances in molecular sciences, cognitive sciences, and neuroimaging are increasingly attracting research-oriented medical students, including those in combined MD-Ph.D. programs, into psychiatry residency training. New classes of medications are being developed. Evidence-based treatments, including, for example, specific psychotherapies, transcranial magnetic stimulation, and ketamine infusions, are increasing the number of therapeutic tools available to mental health professionals. Although treatments are available, substantial barriers can interfere with a person’s ability to access treatment. These barriers may include lack of or inadequate health insurance, provider shortages, and/or illness-related symptoms that hinder willingness to seek and follow through with treatments. Implementation research to develop better ways of reaching individuals who would benefit from treatment could lessen the impact of disabilities resulting from mental illnesses. Public Mental Health Although reaching individuals already suffering from mental disorders is imperative, there is an additional approach that can decrease harm from mental disorders. This approach involves public mental health. In addition to biological underpinnings of mental disorders, societal factors can increase the risk of psychiatric illness. These factors may augment biological risks. As pointed out by Ulrich Reininghaus and colleagues in a recent review in JAMA Psychiatry , “Ethnicity, education level, and socioeconomic status can lead to different risk distributions for subpopulations depending on their position in the social strata.” Public mental health strategies attempt to identify interventions that may decrease these risks and thus reduce the number of individuals who develop mental illness. Biologic factors may have a stronger influence than predisposing societal factors in the development of some disorders. However, adverse early life experiences can substantially increase the risk of developing certain psychiatric illnesses . Public mental health approaches can help determine which groups of individuals are most susceptible to specific social adversities that predispose them to various behavioral and cognitive symptoms. As reviewed by James Kirkbride and colleagues in an article in World Psychiatry, specific types of early interventions may be effective at diminishing the later development of certain disorders. Such interventions may involve early recognition and intervention programs, early education programs , and public policies addressing poverty and childhood adversity. The purpose of this post is not to review the field of public mental health. Rather, it is to encourage a multi-pronged research agenda that works to develop treatments to ameliorate symptoms of mental illnesses and interventions to decrease the development of such disorders. These approaches must be complementary, not competitive. Note: This article originally appeared on Psychology Today .
- A New and Early Predictor of Dementia?
Signs of frailty may signal future dementia more than a decade before cognitive symptoms occur, in new findings that may provide a potential opportunity to identify high-risk populations for targeted enrollment in clinical trials of dementia prevention and treatment. Results of an international study assessing frailty trajectories showed frailty levels notably increased in the 4-9 years before dementia diagnosis. Even among study participants whose baseline frailty measurement was taken prior to that acceleration period, frailty was still positively associated with dementia risk, the investigators noted. "We found that with every four to five additional health problems, there is on average a 40% higher risk of developing dementia, while the risk is lower for people who are more physically fit," study investigator David Ward, PhD, of the Centre for Health Services Research, The University of Queensland, Brisbane, Australia, told Medscape Medical News. The findings were published online on November 11 in JAMA Neurology . A Promising Biomarker An accessible biomarker for both biologic age and dementia risk is essential for advancing dementia prevention and treatment strategies, the investigators noted, adding that growing evidence suggests frailty may be a promising candidate for this role. To learn more about the association between frailty and dementia, Ward and his team analyzed data on 29,849 participants aged 60 years or above (mean age, 71.6 years; 62% women) who participated in four cohort studies: the English Longitudinal Study of Ageing (ELSA; n = 6771), the Health and Retirement Study (HRS; n = 9045), the Rush Memory and Aging Project (MAP; n = 1451), and the National Alzheimer’s Coordinating Center (NACC; n = 12,582). The primary outcome was all-cause dementia. Depending on the cohort, dementia diagnoses were determined through cognitive testing, self- or family report of physician diagnosis, or a diagnosis by the study physician. Participants were excluded if they had cognitive impairment at baseline. Investigators retrospectively determined frailty index scores by gathering information on health and functional outcomes for participants from each cohort. Only participants with frailty data on at least 30 deficits were included. Commonly included deficits included high blood pressure, cancer, and chronic pain, as well as functional problems such as hearing impairment, difficulty with mobility, and challenges managing finances. Investigators conducted follow-up visits with participants until they developed dementia or until the study ended, with follow-up periods varying across cohorts. After adjusting for potential confounders, frailty scores were modeled using backward time scales. Among participants who developed incident dementia (n = 3154), covariate-adjusted expected frailty index scores were, on average, higher in women than in men by 18.5% in ELSA, 20.9% in HRS, and 16.2% in MAP. There were no differences in frailty scores between sexes in the NACC cohort. When measured on a timeline, as compared with those who didn't develop dementia, frailty scores were significantly and consistently higher in the dementia groups 8-20 before dementia onset (20 years in HRS; 13 in MAP; 12 in ELSA; 8 in NACC). Increases in the rates of frailty index scores began accelerating 4-9 years before dementia onset for the various cohorts, investigators noted. In all four cohorts, each 0.1 increase in frailty scores was positively associated with increased dementia risk. Adjusted hazard ratios [aHRs] ranged from 1.18 in the HRS cohort to 1.73 in the NACC cohort, which showed the strongest association. In participants whose baseline frailty measurement was conducted before the predementia acceleration period began, the association of frailty scores and dementia risk was positive. These aHRs ranged from 1.18 in the HRS cohort to 1.43 in the NACC cohort. The 'Four Pillars' of Prevention The good news, investigators said, is that the long trajectory of frailty symptoms preceding dementia onset provides plenty of opportunity for intervention. To slow the development of frailty, Ward suggested adhering to the "four pillars of frailty prevention and management," which include good nutrition with plenty of protein, exercise, optimizing medications for chronic conditions, and maintaining a strong social network. Ward suggested neurologists track frailty in their patients and pointed to a recent article focused on helping neurologists use frailty measures to influence care planning. Study limitations include the possibility of reverse causality and the fact that investigators could not adjust for genetic risk for dementia . Unclear Pathway Commenting on the findings for Medscape Medical News , Lycia Neumann, PhD, senior director of Health Services Research at the Alzheimer's Association, noted that many studies over the years have shown a link between frailty and dementia. However, she cautioned that a link does not imply causation. The pathway from frailty to dementia is not 100% clear, and both are complex conditions, said Neumann, who was not part of the study. "Adopting healthy lifestyle behaviors early and consistently can help decrease the risk of — or postpone the onset of — both frailty and cognitive decline," she said. Neumann added that physical activity, a healthy diet, social engagement, and controlling diabetes and blood pressure can also reduce the risk for dementia as well as cardiovascular disease. Note: This article originally appeared on Medscape .
- Newly FDA-Cleared TMS for Major Depressive Disorder
Key Takeaways Magstim's Horizon Inspire TMS system is FDA-cleared for MDD, OCD, and anxious depression, offering a nonpharmacological treatment alternative. TMS is increasingly used for patients unresponsive to traditional treatments, with insurance coverage expanding to include Medicare. The Inspire system provides customizable, portable, and cost-effective TMS treatments, supported by extensive research and advanced data analytics. Magstim's Horizon 3.0 system features advanced navigation technology, enhancing treatment precision and simplifying clinical workflows. Magstim just announced that the US Food and Drug Administration (FDA) has granted clearance to its Horizon Inspire transcranial magnetic stimulation (TMS) system to treat major depressive disorder (MDD), obsessive-compulsive disorder (OCD), and anxious depression. “Physicians, nurse practitioners, and mental health care professionals tell us that patients are searching for alternatives to pharmaceutical treatments,” said Ronnie Stolec-Campo, the CEO of Magstim. “FDA-cleared TMS is a proven and effective treatment with minimal side effects. We designed the Inspire to enable both experienced TMS providers as well as those who are new to TMS.” The use of TMS for treating MDD and OCD is increasing, driven by new studies demonstrating its effectiveness over other treatments. One-third of patients with MDD experience inadequate response to pharmacotherapy and psychotherapy. After 2 failed antidepressant trials, a different therapeutic modality might be beneficial, including TMS. The Inspire system allows clinicians to provide easy to use, cost effective, portable, high-power, air-cooling, back-to-back customizable TMS treatments. The Inspire system is built using Magstim TMS technology, which is cited in more than 20,000 peer reviewed research papers. It is used in hospitals, clinics, and research centers worldwide. The system also leverages intuitive preset clinical workflows to simplify the treatment process, and delivers precise results with no pulse decay, ensuring the correct dosage. Magstim’s air-cooled coil reduces downtime and eliminates additional cooling expenses. Furthermore, its advanced data analytics tools improve the efficacy of the treatment. TMS is now mostly covered by insurance, including Medicare. Additionally, the range of clinicians available to utilize TMS has expanded: many states now permit both psychiatrists and psychiatric nurse practitioners to prescribe and treat patients with TMS. Earlier this year, the FDA granted clearance to Magstim’s TMS technology, Horizon 3.0 with StimGuide Pro, which is indicated for adults with MDD who failed to achieve improvement from prior antidepressant trials, and for adults with OCD. Horizon 3.0 with StimGuide Pro is the first integrated TMS system with navigation, adding new advanced camera technology designed to allow for precise treatment targeting and a central screen intended to reduce complexity. The Horizon 3.0 TMS Therapy System has also received prior clearance for decreasing comorbid anxiety symptoms in adults with MDD. “We are passionate about helping patients worldwide to improve their mental health,” said Stolec-Campo. “We worked with leading psychiatrists, clinicians, and researchers to develop this system, enabling advanced treatments and simplified practice workflows. TMS is life-saving technology that provides nonpharmacological, noninvasive treatments.” A psychiatric provider, Khaled Bowarshi, MD, also shared this about Magstim’s products: “Our TMS patients have experienced a high-degree of success, allowing them to change their lives. We strive to provide the best technology for our patients.” “Magstim engineered the very first commercially available TMS research technology, and we remain committed to our foundation of research,” said Stolec-Campo. “We are unique in the industry because we do not charge pay per use fees, we maintain a dedicated service and support team, and we manufacture our own technology.” Note: This article originally appeared on Psychiatric Times .
- Can Weight Loss Drugs Also Treat Addiction?
A new study provides more evidence that glucagon-like peptide 1 receptor agonists (GLP-1 RAs) used to treat diabetes and obesity could be repurposed for opioid use disorder (OUD) and alcohol use disorder (AUD). Researchers found that patients with OUD or AUD who were taking semaglutide (Ozempic, Novo Nordisk) or similar medications for diabetes or weight-related conditions had a 40% lower rate of opioid overdose and a 50% lower rate of alcohol intoxication than their peers with OUD or AUD who were not taking these medications. Their real-world study of more than 1 million adults with a history of OUD or AUD provide “foundational” estimates of the association between glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 RA prescriptions and opioid overdose/alcohol intoxication “and introduce the idea that GLP-1 RA and other related drugs should be investigated as a novel pharmacotherapy treatment option for individuals with OUD or AUD,” the investigators led by Fares Qeadan, PhD, Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, Illinois, wrote. The study was published online on October 17 in the journal Addiction . Protective Effect? As previously reported by Medscape Medical News, earlier studies have pointed to a link between weight loss drugs and reduced overdose risk in people with OUD and decreased alcohol intake in people with AUD. Until now, most studies on GLP-1 RAs and GIP agonists like tirzepatide (Mounjaro) to treat substance use disorders consisted of animal studies and small-scale clinical trials, investigators noted. This new retrospective cohort study analyzed de-identified electronic health record data from the Oracle Health Real-World Data. Participants, all aged 18 years or older, included 503,747 patients with a history of OUD, of whom 8103 had a GLP-1 RA or GIP prescription, and 817,309 patients with a history of AUD, of whom 5621 had a GLP-1 RA or GIP prescription. Patients with OUD who were prescribed GLP-1 RAs had a 40% lower rate of opioid overdose than those without such prescriptions (adjusted incidence rate ratio [aIRR], 0.60; 95% CI, 0.43-0.83), the study team found. In addition, patients with AUD and a GLP-1 RA prescription exhibited a 50% lower rate of alcohol intoxication (aIRR, 0.50; 95% CI, 0.40-0.63). The protective effect of GLP-1 RA on opioid overdose and alcohol intoxication was maintained across patients with comorbid conditions, such as type 2 diabetes and obesity. “Future research should focus on prospective clinical trials to validate these findings, explore the underlying mechanisms, and determine the long-term efficacy and safety of GIP/GLP-1 RA medications in diverse populations,” Qeadan and colleagues concluded. “Additionally, the study highlights the importance of interdisciplinary research in understanding the neurobiological links between metabolic disorders and problematic substance use, potentially leading to more effective treatment strategies within healthcare systems,” they added. Questions Remain In a statement from the UK nonprofit Science Media Centre, Matt Field, DPhil, professor of psychology, The University of Sheffield, Sheffield, England, noted that the findings “add to those from other studies, particularly animal research, which suggest that this and similar drugs might one day be prescribed to help people with addiction.” However, “a note of caution is that the outcomes are very extreme instances of substance intoxication,” added Field, who wasn’t involved in the study. “Those outcomes are very different from the outcomes used when researchers test new treatments for addiction, in which case we might look at whether the treatment helps people to stop taking the substance altogether (complete abstinence), or if it helps people to reduce the amount of substance they consume, or how often they consume it. Those things could not be measured in this study,” he continued. “This leaves open the possibility that while Ozempic may — for reasons currently unknown — prevent people from taking so much alcohol or heroin that they overdose and end up in hospital, it may not actually help them to reduce their substance use, or to abstain altogether,” Field said. The study had no specific funding. The study authors and Field declared no relevant conflicts of interest. Note: This article originally appeared on Medscape .
- Guns and Children: What Is Responsible Ownership?
Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I'm Dr F. Perry Wilson of the Yale School of Medicine. We've got to talk about kids' access to guns. I know this is a charged issue. In this space, I often editorialize; I give my thoughts and impressions of a medical study with an understanding that reasonable discourse is still possible, at least when it comes to healthcare. But guns are different. Some of you may think an associate professor of medicine and public health is a great person to discuss the gun issue, as it is firmly a medicine and public health problem. Some of you may think guns have absolutely nothing to do with either of my specialties and that I should stay in my lane. But I don't want to avoid this. We don't know all the details surrounding the most recent school shooting, in Georgia, but we do know that the weapon used by the 14-year-old shooter had been in his home. Some reports suggest that it was actually his gun, given to him as a gift from his father. And this week, we have some hard data on how gun owners with kids think about the relationship between kids and guns. Let's try to figure this out. Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I'm Dr F. Perry Wilson of the Yale School of Medicine. We've got to talk about kids' access to guns. I know this is a charged issue. In this space, I often editorialize; I give my thoughts and impressions of a medical study with an understanding that reasonable discourse is still possible, at least when it comes to healthcare. But guns are different. Some of you may think an associate professor of medicine and public health is a great person to discuss the gun issue, as it is firmly a medicine and public health problem. Some of you may think guns have absolutely nothing to do with either of my specialties and that I should stay in my lane. But I don't want to avoid this. We don't know all the details surrounding the most recent school shooting, in Georgia, but we do know that the weapon used by the 14-year-old shooter had been in his home. Some reports suggest that it was actually his gun, given to him as a gift from his father. And this week, we have some hard data on how gun owners with kids think about the relationship between kids and guns. Let's try to figure this out. I think the best thing I can do with this subject is stick to the facts as much as possible and flag carefully where I am drawing inference. So let's get started. Fact No. 1 : Firearm-associated injuries are the leading cause of death in children and adolescents in the United States, outpacing motor vehicle accidents since 2020. A bit more than half of these are deaths from suicide. Fact No. 2 : Children with guns in the home are more likely to die from suicide. This meta-analysis from the Annals of Internal Medicine estimated that the risk for completed suicide is 3.2 times higher when a gun is in the home, and the risk for homicide is two times higher. Fact No. 3 : Studies show that four storage practices are associated with a lower risk of a child being harmed by a gun in a home: Guns should be locked safely, stored unloaded, and stored in a different location than ammunition, which should also be locked. Each of these factors was associated with a 50%-70% reduction in the risk of a child being harmed by a firearm. Looking at these data, it makes me think of the concept of "responsible gun ownership." Just to be clear, I'm moving out of facts and into inference now. None of these reductions are 100%. Given the risk associated with owning a gun in a house with children, is there a way to do it safely? Truly safely? Or is that a pipe dream? Is it akin to talking about "responsible tiger ownership" or something? One thing I have heard from gun owners — and yes, while I do not personally own a gun, I am friends with quite a few people who do — is that when there are kids in the home, responsible gun ownership is not just about locking guns away safely. It's about teaching kids what responsible gun use looks like and providing clear guidance on when and how gun use is acceptable. And that sounds pretty good to me; a little education is never a bad thing. Unless that education gives parents a false sense of security. And that's what has me worried after reading this paper, "Parental Engagement With Children Around Firearms and Unsecure Storage," from JAMA Pediatrics , which came across my desk this week. This is a rather simple survey study, a representative sample of gun-owning adults with children in their home, from nine states, which I've shown here. The survey was fairly detailed, going into the type of firearm, the characteristics of the parents and the family, as well as the storage of the guns. Overall, you can see that a majority of parents reported discussing firearm safety with their kids. Half had demonstrated proper firearm handling. A third had taught their kids how to shoot a firearm. This is all fine — until you look at the association between teaching your kids about guns and safe gun storage. What the authors found was striking: Parents who said they taught their kids about proper firearm handling, or taught their children to shoot a firearm, were up to twice as likely to have at least one gun unlocked and loaded in the house. That's the data. The inference is that these parents feel safer having educated their children about guns, and thus feel more comfortable leaving a loaded gun unlocked. This scares me a bit because the data linking safe storage of firearms with safe kids are so strong. But the data we don't have is the relative impact of unsafe storage among gun-educated vs -uneducated children. There's an argument to be made that maybe these kids are fine, that they know enough about the gun to respect the gun. But we'd do well to remember that kids make mistakes. Kids are impulsive and irrational. Kids can develop depression, schizophrenia, and psychosis without their parents being fully aware. And a kid who knows how to use a gun, and who has free access to a gun, may in fact be particularly dangerous in the right circumstance. That's an inference, of course. But the facts remain clear. There are millions of kids living in houses with guns. These kids are at higher risk of dying from a gun. Safe storage mitigates that risk. Whether education mitigates the risk of unsafe storage remains an open question. We can always say wait for more data, but the precautionary principal is pretty clear on this one. If you own a firearm and you have a child in the house, no matter how well you've taught that child to respect the weapon, how knowledgeable they are about it, how safe they have demonstrated they can be with it, please lock it up — unloaded — and lock ammo up elsewhere. Keep the tiger in the cage. Note: This article originally appeared on Medscape .
- Mental Health and Personal Finances Amongst Top Stressors for Students
A recent survey found mental health and finances were some of the top stressors for college students. Q&A It is back to school season, and while this can be an incredibly exciting time for some students, it can also be very stressful. College students in particular face a complex challenge: student loan debt. According to a recent nationwide survey of over 1200 college students, mental health (55%) and personal finances (32%) are among the top 5 stressors for this group, joined by physical health (40%), academics (31%), and inflation/rising prices (25%).1 Psychiatric Times sat down with Seli Fakorzi, MA, LPC-S, director of Mental Health Operations at TimelyCare, to discuss the impact of debt on youth mental health and how clinicians can help. PT: How do you think student loan debt affects college student mental health? Fakorzi: Students face a mountain of pressures competing for their time and energy daily. A nationwide survey found finances are a top stressor for college students.1 Whether it is one major challenge or a number of competing pressures, when a student becomes overwhelmed, it affects their lives in multiple ways—including their academic performance. PT: Does the cancellation of student loan debt forgiveness after having it promised worsen the situation? Fakorzi: Students have been stressed about their financial situations long before a student loan debt forgiveness plan was introduced, and we expect they will remain stressed even after its cancellation. That is why it is critical to remove financial barriers to care and provide resources for students so they can find the mental health and wellness support they need, when they need it. PT: How should mental health clinicians address student loan debt with their student patients? Fakorzi: These tips stand for clinicians supporting college students with any personal financial stress, not just stress from student loan debt: -Provide resource guidance . Encourage students to make a financial plan and offer them support to find a trusted financial planner or advisor who can help guide them through that process . -Foster community . Chances are that students are experiencing similar situations—especially when it comes to student loan debt. We know the -way students cope and find support for their mental health is through their peers. Encouraging students to connect with peers can make them feel less alone. -Encourage students to manage stress . This looks different for everyone—for some, that includes practicing self-care. For others, it means hitting the gym a few days a week to exercise. Asking students where they find stress relief and encouraging them to practice that multiple times per week is important. PT: There have been several landmark Supreme Court decisions surrounding colleges/universities, most recently with affirmative action. Do you think this time of change increases back-to-school stress? Fakorzi: There will always be stressors out of students’ control and outside influences that will impact student mental health and well-being. The good news is that colleges and universities realize that the student mental health crisis is far from over, and they continue to invest in resources that help bolster on-campus resources to support student health and well-being, ultimately leading to better engagement and academic performance. Ms Fakorzi is director of Mental Health Operations at TimelyCare. Related Article: Seasonal Patterns Identified for Suicidality in Children, Teenagers Among Children, Mental Disorders Associate With Gender, Family Income, Obesity
- Human Trafficking — in Nutshell
Today, I learned a lot about the reality of human trafficking and the underlying exploitation that exists….I attended the Refugee Mental Health and Wellness Conference… Human trafficking is a multifactorial issue, as it can be local or global in nature, depending on who and how someone is caught. One of the most common tactics to draw youth into the country is coercion…Opportunistic individuals lurking in society…portray their goodwill and desire to help unfortunate people achieve their dreams…which is a total lie… They are essentially anti-social, “salesmen” that prey on vulnerable humans that are seeking out a glimpse of hope…From my knowledge and understanding today, they “sell” people in third world countries the idea that they will bring these individuals to America to fulfill their dream…typical example would be going to Brazil and scouting out 15–16-year-old girls from low socio-economic backgrounds…selling them on the concept of becoming a model in the US. After charging them an arbitary amount $5–6K, then coach them to hopefully be successful during the VISA. Its a number game, as the value of each human life does not matter to these ruthless individuals, who exploit young teens. Upon entry into this country, they literally trap the person into a world of “slavery”, by charging them an additional $15–20K, upon entry into this country. As a result, it encroaches on the idea of modern day “slavery” as these people are unable to pay the debt. Left with no other choice, they are forced into sex trafficking, to pay off this debt. However, they are charge ridiculous amounts of interests, which results in entrapment. The person is trapped in a vicious cycle of servitude, where they are charged an exorbitant amount of money for the “help” they received. They are used and “serve” their “master” who entrapped them into this country, with no hope of escape. Unfortunately, based on the nature of the departure from their home country, they have loose or limited ties to their family on origin. At times, there are 30–40 people in 1200–1400 sq. foot homes, in one bathroom, with their rights, liberties, and freedoms are revoked. Their basic necessities are neglected are their body and brain are put their so much trauma at the expense of living this “false American dream”. These young teens live such impoverished lives which revolves around prostitution, drugs, mental illness (strongly influenced by recurrent trauma), isolation, major financial debt, and no hope of escaping their vicious cycle. Many individuals continue to have sequela of trauma as a result of human trafficking, which completely alter the course and direction of their life. They are unable to maintain any sense of regularity, as they are constantly trying to escape their violent, vicious thoughts, which blossom into underlying personality traits, if not disorders. I use to think that only certain areas were affected by human trafficking, which is far from the truth. I learned through a detective that I met, that some of worst pimps run their operations from surbuban settings.I guess, today I gained an awareness that the crime next to drug/guns is human trafficking. I think thats why I enjoyed seeing children for mental health issues…to target or prevent any underlying cycle of worsening mental health…hoping to influence or strongly alter the course of a young child’s life from a family dynamic and holistic perspective. I think children are so amazing but they need responsible authoritative parents, good mentors, coaches, teachers Source: Medium: Dr. Vilash Reddy
- The 1-2-3 Magic of Effective Child Discipline
1-2-3 Magic is the no. 1 selling child discipline program in the country! The 1-2-3 Magic program keeps parents in charge and is proven to be effective, produces results quickly , and is the only parenting program based on the fact that parents talk too much ! This an amazing tool for children with behavioral problems, irritability, poor boundaries. Really helps and coach you on how to be an authoritative parent with positive and negative reinforcement. Kids need disciplining but kind words and external validation. Conditions Helpful: ADHD; ODD; Impulse Control Disorder; etc. Parenting is one of the most important jobs in the world, and it can also be one of life's most enjoyable experiences. Small children are engaging, affectionate, entertaining, curious, full of life, and fun to be around. For many adults, parenting provides profound and unique benefits unequaled by any other area of life. Yet being a mom or a dad can also be unbelievably frustrating. Repeat the Twinkie scene more than a thousand times and you have guaranteed misery. In extreme but all-too-common situations, that misery can become the source of emotional and physical abuse. That's no way for anyone―child or adult―to live. Children don't come with a How-To-Raise-Me training manual. That's why there is a program like 1-2-3 Magic. The 1-2-3 program is currently being used all over the world by millions of parents (including single and divorced), teachers, grandparents, day care centers, babysitters, summer camp counselors, hospital staff, and other child caretakers, all of whom are working toward the goal of raising happy, healthy children. The 1-2-3 program is also being taught and recommended by thousands of mental health professionals and pediatricians . At parent-teacher conferences, teachers recommend 1-2-3 Magic to the parents of their students (and sometimes parents recommend 1-2-3 Magic for Teachers to the teachers!). Why all the enthusiasm? As one parent put it, "1-2-3 Magic was easy to learn and it gave me results. I went back to enjoying my kids and being the kind of mother I knew I could be." More than twenty-five years after the launch of the program, we're hearing from parents today who say, "My kids were great kids and now they're nice adults. We enjoy being with them." 1-2-3 Magic helps children grow up to be self-disciplined adults who are competent, happy, and able to get along with others. In other words, it helps produce emotionally intelligent people―people who can manage their own feelings as well as understand and respond to the emotions of others. 3 Tips for Tantrums Stop talking – Children see parents' reasons and explanations as sure signs that the parent doesn’t know what he or she is doing. Parents need a plan that focuses on gentle but decisive actions—not words. Check out – When a child whines or melts down after a denied request, the parent has 10 seconds to decide what to do. No talking, for example, no eye contact, increase physical distance as much as possible. Soon the kids will begin to realize that tantrums get them only one thing: Nothing. Be Consistent – Can you apply the same strategies in public? Not only can you, you have to! Attempts at reasoning or distraction in a restaurant or grocery store will bring on a tantrum in no time at all. Source: Tiktok @onelifepsych - I have 20k followers where I discussed diagnosis, helpful tools to understood what you are going through. Check it out. Super helpful I hope.
- The Use of Biomarkers for Alzheimer’s Disease in Primary Care
In our previous case-based review, I teased the opportunity to use biomarkers to increase the accuracy and expediency of the diagnosis of Alzheimer's disease (AD). These tests are no longer confined to the research setting but are now available to specialists and primary care clinicians alike. Given that most cognitive disorders are first identified in primary care, however, I believe that their greatest impact will be in our clinical space. The pathologic processes associated with AD can be detected approximately two decades before the advent of clinical symptoms, and the symptomatic period of cognitive impairment is estimated to occupy just the final third of the disease course of AD. Using imaging studies, primarily PET, as well as cerebrospinal fluid (CSF) and even blood biomarkers for beta amyloid and tau, the pathologic drivers of AD, clinicians can identify patients with AD pathology before any symptoms are present. Importantly for our present-day interventions, the application of biomarkers can also help to diagnose AD earlier. Amyloid PET identifies one of the earliest markers of potential AD, but a barrier common to advanced diagnostic imaging has been cost. Medicare has now approved coverage for amyloid PET in cases of suspected cognitive impairment. In a large study of more than 16,000 older adults in the United States, PET scans were positive in 55.3% of cases with mild cognitive impairment (MCI). The PET positivity rate among adults with other dementia was 70.1%. The application of PET resulted in a change in care in more than 60% of patients with MCI and dementia. One quarter of participants had their diagnosis changed from AD to another form of dementia, and 10% were changed from a diagnosis of other dementia to AD. Liquid biomarkers can involve either cerebrospinal fluid or blood samples. To date, CSF testing has yielded more consistent results and has defined protocols for assessment. Still, collection of CSF is more challenging than collection of blood, and patients and their families may object to lumbar puncture. CSF assessment therefore remains generally in the province of specialists and research centers. Primary care clinicians have been waiting for a reliable blood-based biomarker for AD, and that wait may be about to end. A study published in July 2024 included 1213 adults being evaluated for cognitive symptoms in Sweden. They completed a test measuring the ratio of phosphorylated tau 217 vs non-phosphorylated tau 217, with or without a test for serum amyloid ratios as well. These tests were compared with clinicians’ clinical diagnoses as well as CSF results, which were considered the gold standard. Using only clinical tools, primary care clinicians’ and specialists’ diagnostic accuracy for MCI and dementia were just 61% and 73%, respectively. These values were substantially weaker vs the performance of either the serum tau or amyloid ratios (both 90% accurate). The authors concluded that serum testing has the potential to improve clinical care of patients with cognitive impairment . Where does that leave us today? Commercially available blood biomarkers are available now which use different tests and cutoff values. These may be helpful but will probably be difficult to compare and interpret for primary care clinicians. In addition, insurance is less likely to cover these tests. Amyloid PET scans are a very reasonable option to augment clinician judgment of suspected cognitive impairment, but not all geographic areas will have ready access to this imaging study. Still, it is an exciting time to have more objective tools at our disposal to identify MCI and AD. These tools can only be optimized by clinicians who recognize symptoms and perform the baseline testing necessary to determine pretest probability of MCI or dementia. Note: This article originally appeared on Medscape .
- Addressing Alcohol or Cannabis Use in Patients With Anxiety Disorders
Keypoint: In this CME article, learn more about how to assess the impact of alcohol and cannabis use on anxiety treatment outcomes, recognizing potential adverse effects and interactions. CATEGORY 1 CME Premiere Date: August 20, 2024 Expiration Date: February 20, 2025 This activity offers CE credits for: 1. Physicians (CME) 2. Other All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered. ACTIVITY GOAL To engage readers in an introductory review of the common issues pertaining to comorbid anxiety disorders and alcohol and cannabis use so that they gain insights into effective screening strategies and intervention approaches. LEARNING OBJECTIVES Learn to assess the impact of alcohol and cannabis use on anxiety treatment outcomes, recognizing potential adverse effects and interactions. Learn about evidence-based behavioral interventions, including cognitive behavioral therapy and motivational interviewing, tailored to address co-occurring anxiety and alcohol/cannabis use. TARGET AUDIENCE This accredited continuing education (CE) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders. ACCREDITATION/CREDIT DESIGNATION/FINANCIAL SUPPORT This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Physicians’ Education Resource,® LLC, and Psychiatric Times.® Physicians’ Education Resource, LLC, is accredited by the ACCME to provide continuing medical education for physicians. Physicians’ Education Resource, LLC, designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This activity is funded entirely by Physicians’ Education Resource, LLC . No commercial support was received. OFF-LABEL DISCLOSURE/DISCLAIMER This accredited CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this accredited CE activity is for continuing medical education purposes only and is not meant to substitute for the independent clinical judgment of a physician relative to diagnostic or treatment options for a specific patient’s medical condition. The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of Physicians’ Education Resource, LLC. FACULTY, STAFF, AND PLANNERS’ DISCLOSURES AND CONFLICT OF INTEREST (COI) MITIGATION The authors report that they were supported by grants from the National Institute on Alcohol Abuse and Alcoholism (K24AA025703), the National Institute of Mental Health (K23MH126078), and the National Institute on Drug Abuse (T32DA007250). Otherwise, none of the staff of Physicians’ Education Resource, LLC, or Psychiatric Times or the planners or the authors of this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, reselling, or distributing health care products used by or on patients. HOW TO CLAIM CREDIT Once you have read the article, please use the following URL to evaluate and request credit: https://education.gotoper.com/activity/ptcme24aug . If you do not already have an account with PER®, you will be prompted to create one. You must have an account to evaluate and request credit for this activity. Many individuals with anxiety disorders use alcohol or cannabis for temporary relief of worry, sleeplessness, tension, and other typical anxiety symptoms. For some, this coping response can lead to worsening anxiety and impairment over time. Common anxiety disorders and related conditions such as generalized anxiety, panic, social anxiety, and posttraumatic stress disorder (PTSD) also are correlated with the development of substance use problems. Prevalence estimates suggest that 15% to 20% of individuals with anxiety have a substance use disorder (SUD),5,6 with alcohol and marijuana being the most commonly used substances. Nearly 1 in 5 individuals with anxiety report using alcohol to cope with symptoms. Adults with anxiety are 2 to 3 times more likely to use cannabis compared with the general population, with rates increasing post legalization. The following is a review of how the use of alcohol and cannabis may complicate anxiety treatment. Given the widespread consumption of alcohol and cannabis, the review will include some ways clinicians can recognize and treat problematic levels of use. Many patients with both anxiety and substance use problems seek treatment in mental health rather than addiction treatment settings, highlighting the importance of psychiatric clinicians in addressing these co-occurring conditions. SUDs and Anxiety Disorders SUDs are characterized by difficulty controlling use despite serious consequences for one’s life or health. In DSM-5-TR, SUDs are categorized as mild, moderate, or severe. Risky alcohol or cannabis use that falls short of a SUD can still complicate a patient’s anxiety treatment, although consumption parameters describing risky use are better defined for alcohol. The current recommended alcohol use limits from the National Institutes of Health are 1 drink per day (or 7 per week) for women and 2 drinks per day (or 14 per week) for men. Patients with anxiety disorders may be better off drinking even less. Older adults and those with comorbidities such as diabetes and high blood pressure have increased vulnerability. In addition to worsening anxiety symptoms, alcohol use—even at low levels—has the potential to reduce the effectiveness of anxiety disorder treatment through adverse medication interactions or interference with exposure-based behavioral interventions. Cannabis continues to become more accessible and socially accepted due to increasing state-level legalization, which currently includes 24 states and the District of Columbia. Results of a recent survey indicate that individuals consider daily cannabis use and secondhand smoke safer than tobacco smoke. In contrast with alcohol, thresholds that mark unhealthy cannabis use can be difficult to define, especially given the variety of cannabis modes of use, strains, and potency levels. Initial research suggests that although cannabis use (ie, less than once a month) is not associated with anxiety treatment outcomes, heavier cannabis use (ie, 2 or more times per week) is associated with poorer outcomes. Some patients may see their cannabis use as helpful in reducing anxiety—a view that is supported by results from limited retrospective studies. Nevertheless, although cannabis and other substance use may indeed provide short-term relief from anxious symptoms, it is important to note that reliance on substances to calm anxiety may limit opportunities for patients to learn more adaptive strategies to manage anxiety, such as emotion regulation skills. Psychiatric clinicians should discuss these complex issues around cannabis use with patients in an open manner. This includes acknowledging potential benefits experienced by patients while assessing and educating patients about aspects of use that may conflict with patients’ anxiety management goals. For example, while dosing considerations for cannabis depend on several factors (eg, mode of use or product strength), key information to share with patients includes findings that higher doses (12.5 mg) of tetrahydrocannabinol (THC), a psychoactive ingredient in cannabis, can be associated with increased anxiety and that the average THC content in cannabis products has increased over the past 2 decades. Anxiety disorders are associated with both cannabis use ( OR, 1.24) and cannabis use disorder (1.68), with greater frequency of cannabis use associated with greater odds of psychosis (risk ratio: 1.10 for monthly use, 1.35 for weekly use, 1.76 for daily use), and past-year use demonstrating greater odds of panic disorder compared with individuals who did not use cannabis in the past year (unadjusted OR, 1.2-2.3). In addition, ingesting large amounts of cannabis can induce anxiety. Screening and Assessment Many relatively brief screening instruments are available and well-validated to identify problems with alcohol, cannabis, and other commonly used substances, such as the patient-reported (and easily administered) Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). ASSIST consists of 8 questions covering tobacco, alcohol, cannabis, and other drugs. A risk score (low, moderate, or high) is provided and can be used to consider intervention level (eg, brief advice to reduce use or a more extensive approach). The Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) tool is a similar instrument designed to be self-administered on a computer in health care settings. It also yields risk scores. For both alcohol and cannabis, clinicians should ask patients about quantity and frequency of use, symptoms of cannabis or alcohol use disorder, and any other problems they may have encountered. It is also useful to explore beliefs about anxiety-related effects or benefits and other motivations for alcohol or cannabis use. Other helpful details from the patient would include drinking frequency above recommended limits and the extent to which the patient uses alcohol to manage anxiety symptoms. When assessing cannabis use, some additional relevant considerations include the extent of daily use and age of first use, given that more frequent use and use at younger ages (eg, during adolescence) are consistently associated with worse mental health outcomes compared with occasional use and older age of starting to use. The clinical interview can also assess quantity of use and THC potency based on patients’ perceptions or the information they obtain from product labels. Intervention Strategies Clinicians can use several evidence-based approaches to help patients with anxiety reduce problematic alcohol and cannabis use. Behavioral intervention strategies such as cognitive behavioral therapy (CBT) and mindfulness training can be applied to both anxiety symptoms and substance use, and they can be effective in teaching patients new coping skills. Meta-analyses of intervention studies have indicated that CBT for SUD has a moderate to large effect size, indicating strong evidence for efficacy (eg, d = .45; g = .80), whereas mindfulness-based interventions, such as mindfulness-based relapse preventions, have small to medium effects (eg, d = .37-.58). Pharmacological treatments are more established for alcohol use than they are for cannabis, but new compounds are actively being tested. Recommended dosages are titrated based on a variety of patient factors and should be determined on a case-by-case basis. Lastly, promising digital therapies such as mobile apps can help patients manage anxiety and track and reduce substance use over time. A systematic review indicates a range of effect sizes and evidence quality regarding the efficacy of apps for substance use (d = .17-.70). Thus, we recommend using apps that have strong quality of evidence and have undergone more rigorous testing. For patients willing to engage in structured behavioral interventions, CBT is a helpful treatment approach for either cannabis or alcohol use problems. Principles of CBT such as learning new behavioral and thought patterns, tracking behaviors, and managing avoidance are relevant to both anxiety and substance use treatment. Typical CBT protocols for SUD range from 8 to 14 sessions. Sessions focus on increasing awareness of antecedents and consequences of substance use and leveraging behavior-change principles to reduce or eliminate substance use through environmental and social reinforcement. Throughout treatment, individuals learn about processes that underlie substance use, with an emphasis on understanding the thoughts and behaviors associated with their substance use, and gain skills to modify unwanted behaviors. In doing so, individuals become better equipped to identify and cope with triggers, challenge thoughts that precipitate use, manage high-risk situations, and reinforce behaviors that align with their recovery goals. Patients can be guided to understand how substance use may worsen anxiety and how to find room for alternative coping behaviors (eg, pleasant activities, mindfulness meditation). Many manualized CBT interventions address both substance use and anxiety disorders. Motivational interviewing (MI) is another key strategy for addressing cannabis use and unhealthy drinking that can be integrated into mental health care settings. MI is a patient-centered collaborative style of communication useful for strengthening motivation and commitment to change. Using MI, clinicians can help evoke reasons for change, resolve ambivalence, and move to action around reducing alcohol and cannabis use. Open-ended questions can help clinicians explore patients’ ambivalence related to reducing substance use and reinforce self-efficacy and “change talk” associated with anxiety coping that does not involve substances. Mindfulness-based relapse prevention also may be valuable in reducing substance use and building skills to manage anxiety. Common across mindfulness-based and exposure-based therapies is a focus on building interoceptive awareness—eg, awareness of one’s body signals—and observing them without judgment instead of avoiding them or fearing them. For example, patients may be advised to practice mindfulness when experiencing substance cravings and to increase present-moment awareness. Medications to help reduce alcohol use can be useful, especially in conjunction with CBT,5,although medication development for cannabis has been less successful. Selective serotonin reuptake inhibitors (SSRIs) can help with comorbid anxiety and alcohol use problems. Gabapentin has demonstrated positive effects on alcohol treatment outcomes, mood symptoms, and sleep. Topiramate can reduce the frequency of alcohol use and cravings as well as PTSD symptom severity. Naltrexone and disulfiram have been effective in treating patients with PTSD and alcohol use disorder, showing a reduction in alcohol use and symptoms of PTSD . Naltrexone is often the first choice to specifically address alcohol use cravings, and at least 3 to 4 months is a reasonable trial period. Clinicians should be mindful of specific potential interactions between medications (eg, psychiatric medications and disulfiram). However, alcohol use medications generally are well tolerated and can potentially be used in combination with medication for anxiety (eg, as in prior research on naltrexone and sertraline). Despite the testing of new compounds, there are no currently approved medications for the management of cannabis use disorder. This gap makes the use of behavioral interventions particularly important for the comorbidity of cannabis and anxiety. Some work suggests that active cannabis use can counteract the efficacy of SSRIs and increase the risk of adverse effects. Cannabis affects how the liver breaks down these medications, leading to higher doses in the bloodstream. Several mobile apps to reduce anxiety are available, and others focused on alcohol and cannabis use are in different stages of testing.The small number of established apps to help treat SUD includes reSET and reSET-O, which use cognitive behavioral and contingency management principles to target substance use generally (reSET) as well as opioid use disorder specifically (reSET-O). These apps are cleared by the US Food and Drug Administration as SUD digital therapeutics and are available to prescribe for insurance reimbursement. The Step Away app is focused on reducing unhealthy alcohol use (whether through moderation or abstinence) and is based on principles of motivational enhancement, relapse prevention, and community reinforcement. These emerging tools may be especially helpful for patients without access to other forms of treatment. Concluding Thoughts Cannabis and alcohol use are often associated with anxiety, and these combined problems may be challenging to manage. Screening in psychiatry is essential because patients are more likely to seek mental health care than they are to seek addiction treatment. Although there is a need for additional intervention development, behavioral strategies such as MI and CBT can reduce alcohol and cannabis use in those with anxiety. Medications to help reduce unhealthy alcohol use are well established and should be more widely offered in mental health settings, whereas medications to reduce cannabis use have yet to show efficacy. Despite wide availability, the generally unregulated status of apps has prompted new approaches to understanding available products. Guidelines from professional organizations such as the American Psychiatric Association can be useful in staying up-to-date on new mobile app developments and informing patients and clinicians about emerging treatment options. Note: This article originally appeared on Psychiatric Times .
- It’s Time for Social Psychiatry’s Comeback
Neglecting the impact of social determinants of health has come at a big cost. Key points Social psychiatry strives to combat the social and environmental contributors to mental distress. Social determinants of health or SDoH are non-medical social factors that affect health outcomes. SDoH speak to the social fabric of our lives—the conditions to which we are born, raised, work, live, and age. The Social Determinants of Health Network promotes the education of professionals and the public about SDoH. In the mid-twentieth century, psychiatrists were, with much zeal, striving to combat the social and environmental contributors to mental distress by focusing on strengthening families, encouraging healthy lifestyles, and advocating relevant legal and health policy issues. Unfortunately, in subsequent decades, a lack of political will (admitting to the social antecedents of mental health issues would require elected officials to work to change laws) and withering public funding meant the social psychiatry approach became not only forgotten but also unpopular. The era of psychiatry I trained in, in the early 2000s, for the most part, had embraced (and continues to embrace) a biological approach. This means that today, a conversation with a psychiatrist about mental health symptoms will mostly be focused on neurobiology, genetics, misfiring brain structures, and neurotransmitters gone awry. And yes, well-trained psychiatric practitioners who approach their practice from a bio-psych-social approach will take into consideration social factors but too often this is cursory. Why? Twenty-first-century psychiatric practice is simply not enabled or encouraged to support an in-depth assessment of or response to the social determinants that are causing mental distress to our patients. Too often frontline clinicians feel their hands are tied. The consequences of abandoning social psychiatry I’ve witnessed how the abandonment of social psychiatry leads to highly unsatisfactory outcomes such as the over-pathologizing of mental distress in individuals with diagnoses such as depressive and anxiety disorders when, in fact, the real culprits are social factors. Also overmedicating with anti-depressant, anti-anxiety, and insomnia medications— all inadequate band aids that don’t address the root cause of the symptoms and come with side effects. The distinct trend in recent decades has been to ignore social psychiatry approaches that call out the mental health effects of broken systems and an unjust world. And this has come at a big cost with an over-reliance on individual responsibility and “fixing” brains or “altering” mindsets when changes to societal policies may have elevated the mental wellness of large swathes of the general population. Will the management of social determinants finally become a reality in health care? Imagine then, how delighted I was to come across this recent article about Past APA President Dilip Jeste, M.D., who wants to make the assessment and management of social determinants of health (SDoH) a reality in psychiatry and general medicine, not just an aspiration. He founded the Social Determinants of Health Network, a dedicated 501(c)(3) nonprofit foundation, to promote research and foster the education of healthcare professionals and the public about SDoH. What is the meaning of SDoH? SDoH are “non-medical social factors that affect health outcomes.” They are societal problems that affect both individuals and the larger population and have a well-established influence on mental health, risk for mental illnesses, and overall quality of life. SDoHs speak to the social fabric of our lives, the conditions in which we are born, raised, work, live, and age, and also the systemic and institutional forces that shape our everyday life circumstances. SDoH include: Exposure to childhood trauma including ACEs The presence or absence of supportive social connections Exposure to stigma and discrimination Your financial status (including issues related to access to education) Your employment Access to transportation Access to food and shelter To date, the problem has been less about the psychiatric profession resisting social determinants and more about practicality. What tools can practitioners use to formally assess and address the social determinants that affect our patients’ health in our clinics? What are the associated diagnostic terms? Are there expert consensus guidelines or algorithms that show us what actions we need to take when we identify SDoH that are affecting our patient’s health? How will health systems reimburse the time practitioners spend focusing on social determinants? I’m looking forward to embracing a new era that will provide solutions to these practicalities and normalize the management of social determinants as a routine part of health care because social psychiatry is long overdue for a comeback. Note: This article originally appeared on Psychology Today .
- Family Medicine and Geriatric Psychiatry Topics Highlighted at Annual Conference
Key Takeaways GLP-1 receptor agonists effectively manage obesity, reducing appetite and achieving weight loss in patients with BMI ≥30 or ≥27 with comorbidities. The Confusion Assessment Method is optimal for diagnosing delirium, while the Geriatric Depression Scale is sensitive for detecting depression in older adults. Collaborative care models between family medicine and psychiatry enhance patient outcomes by addressing both physical and mental health needs. Reducing stigma and integrating behavioral health services in family medicine can improve access to psychiatric care. CONFERENCE SPOTLIGHT The Spotlight series highlights speakers at the Family Medicine Experience 2024 (FMX 2024), hosted by the American Academy of Family Physicians. Name Ecler Jaqua, MD, MBA, FAAFP, AGSF, FACLM, DipABOM, AAHIVS Title Associate Professor Institution Loma Linda University Hometown Pomona, CA Tell us about yourself. I am an associate professor of family medicine at Loma Linda University Health, specializing in family medicine and geriatrics. My work is driven by a passion for holistic and comprehensive care, ensuring the well-being of my patients across different stages of life. In addition to my clinical practice, I enjoy teaching and mentoring the next generation of physicians, and I have completed certifications in lifestyle medicine, obesity medicine, and HIV specialization. I am also actively involved in program leadership and quality improvement initiatives. Can you please discuss some key take home points from your presentation at the FMX 2024 conference? At the FMX conference, I presented on 2 key topics. First, I discussed the role of GLP-1 receptor agonists in managing obesity, emphasizing their ability to reduce appetite and achieve significant weight loss in patients with a body mass index greater than or equal to 30 or greater than or equal to 27 with comorbidities like type 2 diabetes. I also covered protocols for initiating treatment and managing adverse effects. In my second topic, I compared cognitive screening tools, highlighting the Confusion Assessment Method as the best tool for diagnosing delirium, while the Geriatric Depression Scale is highly sensitive for detecting depression in older adults . Do you have any suggestions for improving the integration between family medicine and psychiatry to enhance patient care? Improving integration between family medicine and psychiatry can be achieved by fostering collaborative care models where mental health professionals work closely with family physicians to address both physical and mental health needs. Regular interdisciplinary case reviews, shared care plans, and streamlined referral processes can enhance patient outcomes, ensuring timely and holistic treatment for conditions like depression, anxiety, and chronic illnesses with mental health components. Additionally, training family physicians in primary care psychiatry can help bridge the gap in access to mental health services . What do you believe to be some factors that prevent patients from seeking help at times from a psychiatrist? Any suggestions for improvement? Patients may avoid seeking help from a psychiatrist due to stigma surrounding mental health, fear of being judged, or a lack of understanding about psychiatric care. Limited access to services and financial concerns can also be barriers. To improve this, increasing mental health education, normalizing conversations about mental health in primary care settings, and integrating behavioral health services within family medicine can help reduce stigma and improve access to psychiatric care. How do you deal with patient compliance and managing adverse effects from various psychiatric medications? Managing patient compliance and adverse effects from psychiatric medications involves open communication, educating patients about potential adverse effects, and setting realistic expectations about treatment outcomes. I regularly assess patients for tolerance and adherence, adjusting medications as needed to minimize side effects while maintaining effectiveness. Collaborative decision-making, involving patients in their treatment plans, also helps improve compliance and addresses any concerns early on. What advice about patient care would you like to share with your medical colleagues in psychiatry? For my colleagues in psychiatry, I would emphasize the importance of maintaining a patient-centered approach by fostering trust and open dialogue. Collaborating with other health care providers, particularly in primary care, can provide a more comprehensive understanding of the patient’s overall well-being, improving outcomes. Any words of wisdom or favorite quotes? One of my favorite quotes is: "The good physician treats the disease; the great physician treats the patient who has the disease." – William Osler. Another quote I value is, "People don’t care how much you know until they know how much you care." – Theodore Roosevelt. This serves as a reminder that compassion and empathy are foundational in building strong patient relationships and delivering effective care. Note: This article originally appeared on Psychiatric Times .