Outpatient psychotherapy use in the United States rose sharply between 2018 and 2021, an increase that was driven primarily by young, urban professionals with higher family incomes, new data exposed significant disparities in access to this treatment type. Results of a large population-based repeated cross-sectional study revealed that psychotherapy use increased significantly faster for women vs men, younger individuals vs their older counterparts, college graduates than those without a high school diploma, and privately insured vs publicly insured individuals. Overall, psychotherapy use increased significantly faster among several socioeconomically advantaged groups, and inequalities were evident in teletherapy access. These trends and patterns highlight a need for clinical interventions and healthcare policies to broaden access to psychotherapy, including teletherapy, the authors noted. “While psychotherapy access has expanded in the US, there’s concern that recent gains may not be equally distributed, despite or maybe because of the growth of teletherapy,” study author Mark Olfson, MD, MPH, Department of Psychiatry, Mailman School of Public Health, Columbia University, New York City, said in a press release. “This increase in psychotherapy use, driven by the rise of teletherapy, has largely benefited socioeconomically advantaged adults with mild to moderate distress,” he added. The findings were published online on December 4 in JAMA Psychiatry . Psychotherapy Uptick Psychotherapy is among the most widely used methods for delivering mental health care in the United States. A recent study conducted by Olfson and colleagues showed that the percentage of US adults receiving psychotherapy increased from 6.5% in 2018 to 8.5% in 2021. However, it was unclear how this overall increase varied across different sociodemographic groups or levels of psychological distress. Analyzing population-level trends in psychotherapy use can identify sociodemographic groups with declining access to services, providing valuable insights for developing initiatives to improve accessibility, the investigators noted. To evaluate national trends in psychotherapy use, the researchers analyzed data from the 2018-2021 Medical Expenditure Panel Survey (MEPS). These are yearly surveys representing noninstitutionalized adults across the United States. The study included 89,619 adults. Of these, 51.5% were women, nearly half were aged 35-64 years, and 62.2% were White individuals. The study used a repeated cross-sectional design with new, nationally representative samples of about 22,000 participants each year. The investigators tracked the overall increase in psychotherapy use, especially among groups at higher risk for untreated mental health conditions. They also examined how video-based therapy (teletherapy) was being used, paying particular attention to differences in access among various demographic groups and levels of psychological distress, given ongoing concerns about equity in telehealth access . Psychological distress was measured using the Kessler-6 scale, with scores ≥ 13 defining serious psychological distress, 1-12 defining mild to moderate distress, and 0 defining no distress. Psychotherapy use increased across all racial and ethnic groups, with rates rising among Black (5.4% to 7.1%), Hispanic (4.1% to 5.8%), White (7.5% to 9.8%), and other, non-Hispanic (4.8% to 6.6%) individuals. Participants with mild to moderate distress experienced the greatest increases in psychotherapy use (8.6% to 11.2%, respectively). After adjusting for age, sex, and level of psychological distress, investigators found that psychotherapy use increased to a greater degree among women (7.7% to 10.5%) vs men (5.2% to 6.3%), younger adults aged 18-34 years (8% to 11.9%) vs adults aged 65 years or older (3.6% to 4.6%), and college graduates (7.6% to 11.4%) than those without a high school diploma (5.5% to 7%). A National Priority Adults with higher incomes — defined as two to four times the federal poverty level — had greater increases in psychotherapy use (5.7% to 8.2%) than those below the poverty level (9.7% to 10%). Unsurprisingly, privately insured individuals saw more significant increases (6.1% to 8.9%) than publicly insured individuals (8.8% to 8.8%). Also, there was a larger increase in psychotherapy use among employed individuals (5.7% to 8.9%) than among unemployed individuals (10.8% to 10.5%). In addition, there was a significantly greater increase in psychotherapy use among urban residents (6.5% to 8.7%), whereas it declined among rural residents (6.4% to 5.9%). Data on teletherapy use from 2021 revealed that 39.9% of adults receiving psychotherapy had one or more teletherapy visits . Teletherapy use was higher among younger adults, women, college-educated individuals, those with higher incomes, those with private insurance, and those who lived in urban areas. The authors noted that while teletherapy is intended to remove transportation and time barriers and was widely adopted during the pandemic, the findings show that those who were older, less educated, and with lower incomes were less likely to use it. Notably, urban residents were more than twice as likely to use teletherapy than rural residents. Prior to the COVID-19 pandemic , teletherapy was viewed as a potential solution for individuals living in rural areas facing a shortage of mental health professionals, but study results showed that “teletherapy does not appear to have addressed this public health challenge,” the investigators wrote. “The trends we are seeing underscore the need for targeted interventions and health policies that expand psychotherapy access to underserved groups,” said Olfson. “Ensuring that individuals in psychological distress can access care is a national priority. Addressing technical and financial barriers to teletherapy could help bridge the gap in access and promote equity in mental health care,” he added. Study limitations included a possible underreporting of psychotherapy use by participants. In addition, MEPS does not include nursing home residents, incarcerated, and unhoused individuals. Study funding was not disclosed. Olfson reported no relevant disclosures. Note: This article originally appeared on Medscape .

TOPLINE: Internet use is associated with fewer depressive symptoms, higher life satisfaction, and better self-reported health among adults aged 50 years or older across 23 countries than nonuse, a new cohort study suggests. METHODOLOGY: Data were examined for more than 87,000 adults aged 50 years or older across 23 countries and from six aging cohorts. Researchers examined the potential association between internet use and mental health outcomes, including depressive symptoms, life satisfaction, and self-reported health. Polygenic scores were used for subset analysis to stratify participants from England and the United States according to their genetic risk for depression. Participants were followed up for a median of 6 years. TAKEAWAY: Internet use was linked to consistent benefits across countries, including lower depressive symptoms (pooled average marginal effect [AME], −0.09; 95% CI, −0.12 to −0.07), higher life satisfaction (pooled AME, 0.07; 95% CI, 0.05-0.10), and better self-reported health (pooled AME, 0.15; 95% CI, 0.12-0.17). Frequent internet users showed better mental health outcomes than nonusers, and daily internet users showed significant improvements in depressive symptoms and self-reported health in England and the United States. Each additional wave of internet use was associated with reduced depressive symptoms (pooled AME, −0.06; 95% CI, −0.09 to −0.04) and improved life satisfaction (pooled AME, 0.05; 95% CI, 0.03-0.07). Benefits of internet use were observed across all genetic risk categories for depression in England and the United States, suggesting potential utility regardless of genetic predisposition. IN PRACTICE: "Our findings are relevant to public health policies and practices in promoting mental health in later life through the internet, especially in countries with limited internet access and mental health services," the investigators wrote. SOURCE: The study was led by Yan Luo, Department of Data Science, City University of Hong Kong, Hong Kong, China. It was published online November 18 in Nature Human Behaviour. LIMITATIONS: The possibility of residual confounding and reverse causation prevented the establishment of direct causality between internet use and mental health. Selection bias may have also existed due to differences in baseline characteristics between the analytic samples and entire populations. Internet use was assessed through self-reported items, which could have led to recall and information bias. Additionally, genetic data were available for participants only from England and the United States. DISCLOSURES: The study was funded in part by the National Natural Science Foundation of China. The investigators reported no conflicts of interest. Note: This article originally appeared on Medscape .

TOPLINE: Study findings underscored that with regard to the risk for dementia in White individuals of British descent, there is no safe level of alcohol consumption. METHODOLOGY: A linear and non-linear mendelian randomisation (MR) analysis within a population of White British drinkers within the UK Biobank (recruited between 2006 and 2010) to explore the causal association between light-to-moderate alcohol consumption and the risk for dementia. Alcohol consumption was self-reported weekly/monthly intake of various types; alcohol consumption was categorised as safe (≤ 14 units/week) and unsafe (> 14 units/week) per Alcohol Change UK and UK Department of Health Guidelines. The primary outcome was all-cause dementia identified in hospital and mortality records. Cox models were utilised for convention analysis, linear/non-linear MR based on a genetic score calculated from 95 single-nucleotide polymorphisms from a meta-genome study of 941,280 Europeans. TAKEAWAY: Of 313,958 current drinkers consuming a median of 13.60 units of alcohol/week (interquartile range, 7.10-25.20), 1.7% (n = 5394) were diagnosed with dementia (an average follow-up was 13.2 years [SD, 20]). In all, 48.6% (n = 152,644) consumed > 14 units/week. Multivariate analysis demonstrated a J-shaped relationship between alcohol consumption and dementia risk in current drinkers; lowest dementia risk was associated with alcohol consumption of 11.9 units/week (men: 16.8 units/week, P = .04; women: 8.4 units/week, non-significant). Summary-level MR analyses confirmed a positive link between genetically predicted alcohol intake and dementia risk across genders (weight median, overall predictive hazard ratio [PHR], 2.41 [95% CI, 1.76-3.30; P < .001]; for men, PHR, 1.64 [95% CI, 1.19-2.24; P = .002]; for women, PHR, 2.13 [95% CI, 1.41-3.21; P < .001]). IN PRACTICE: "Our analysis found distinctly more significant association between alcohol consumption and dementia risk among women drinkers…[but] suggested that alcohol's impact on dementia results may be more evident in women, who typically had lower rates of other risk factors," the authors wrote. Nevertheless, "our findings suggested that there was no safe level of alcohol consumption for dementia." SOURCE: The study was conducted by Lingling Zheng, Shenzhen University of Advanced Technology, Guangdong, China, and appeared online in eClinical Medicine. LIMITATIONS: Limitations included potential biases due to confounders and reverse causality, self-reported alcohol consumption, missing confounders (eg, change in alcohol consumption over time), misclassification errors, and limited generalisability. DISCLOSURES: The study was partially supported by a Shenzhen Science and Technology Program grant and Strategic Priority Research Program of Chinese Academy of Sciences. The authors had no financial disclosures of interest. Note: This article originally appeared on Medscape .

Healthy Coping Skills for Uncomfortable Emotions Coping Strategies Coping Strategies are actions we take -- conciously or unconsciously - to deal with stress, problems, or uncomfortable emotions. Unhealthy coping strategies ten to feel good in the moment, but have long-term negative concequences. Healthy coping strategies may not provide instant gratification, but they lead to long-lasting positive outcomes. ​ Examples of unhealthy coping strategies: Examples of healthy coping strategies: • Drug or alcohol use • Exercise • Overeating • Talking about your problem • Procrastination • Healthy eating • Sleeping too much or too little • Seeking professional help • Social withdrawal • Relaxation techniques (e.g. deep breathing) • Self-harm • Using social support • Aggression • Problem-solving techniques Example Scenarios Scenario Discussion Questions • What consequences might result from this individual’s unhealthy coping strategy? • What healthy coping strategies could be helpful for the individual? • What barriers might be preventing the individual from using healthy coping strategies? Healthy vs. Unhealthy Coping Strategies Describe a problem you are currently dealing with: ​ My unhealthy coping strategies: ​ Consequences of unhealthy coping strategies: ​ 2. ​ Healthy coping strategies I use, or could use: Expected outcomes of healthy coping strategies: ​ Barriers to using healthy coping strategies: 1. ​ ​ 2. ​ ​ 3. ​ ​

Key Takeaways "Crazy" is a complex term with dual connotations, reflecting both derision and praise, akin to historical literary reversals of values. American culture's "trickle-up effect" influences global perceptions, exporting psychiatric concepts and cultural elements worldwide. The series will explore "crazy" through popular culture and philosophy, challenging the dominance of rationalism and technology in understanding mental health. A deeper understanding of madness is advocated, beyond traditional psychiatric frameworks, incorporating cultural, historical, and philosophical perspectives. SECOND THOUGHTS Mad, bad, and dangerous to know. – Lady Caroline Lamb on Lord Byron In the 19th century, the most common expression for irrationality and insanity was “madness,” as the English poet Lord Byron’s lover attested. In this century, it is probably “crazy”—which we will get to shortly. But what exactly did Lady Caroline Lamb mean? She seems to have made sure she covered several possibilities—not just mad but bad—and dangerous to boot. And today, “crazy” seems to cover all of them, which is why we need to deconstruct its meaning. Another late 19th century figure of English literature, Samuel Butler wrote a novel called Erewhon (“nowhere” backwards) that is classified as utopian fiction. We can also read it as a satire on Victorian British society and a visionary attempt to extrapolate Darwin’s evolution to the industrial revolution to imagine machine consciousness and self-replicating machines. His themes could be ripped out of today’s headlines. As a psychiatrist, however, the most provocative idea in Erewhon is the satirical reversal of attitudes to crime and illness. In Erewhonian law, offenders are treated as ill and sick individuals are treated like criminals. Either way, Lady Caroline Lamb had Byron covered! In Erewhon, Butler portrays this reversal with scenes of neighbors visiting the family of an offender with flowers and condolences while someone who falls ill is treated with avoidance and scorn. Nothing in the entire utopian/dystopian genre since Thomas More’s Utopia (“nowhere” in Greek, published in Latin in 1516) is more striking than this reversal of values, reminiscent of German philosopher Friedrich Nietzsche’s “transvaluation of all values” and recalls George Orwell’s Newspeak in Nineteen Eighty-Four where everything is the opposite of its ascribed name.4 The Ministry of Truth, for example, is concerned with lies. “The Trickle-Up Effect” In English today, we use the word crazy much more often than mad in an expansive popular take on “madness.” And like the reversals in Butler’s and Orwell’s dystopias, crazy can now be a term of derision and dismissal, condescension and disqualification on one hand, or on the other hand, approval, even praise, and an invitation to a different, transgressive way of being (eg, the songs “Crazy” by Seal and “Let’s Get Crazy” by Prince). Two things are top of mind in this series and they are both very American. The first, which I enjoy, is America’s secret cultural strength: how things bubble up from lower classes, from the street to mainstream culture. “Bottom up” instead of “top down” like the European culture of symphonies and operas. Think about the music that spawned from the American underclass and its marginalized groups: New Orleans’ ragtime, jazz, blues, rhythm and blues, rock’n’roll, and Detroit’s Motown and New York’s hip-hop. Think about Hollywood’s noir films that went from B movies to cult classics. Think about lowrider culture in East LA. In the opposite of trickle-down economics, we can call it the “trickle-up effect.” The incarnation of the American dream. One of the striking things about my professors of philosophy is their marriage of high and low culture. Not just analyses of Greek myths like “Antigone” (one of my favorites) or Verdi’s opera “Aida” (another favorite) but English rocker David Bowie (Simon Critchley), Russian feminist protest group Pussy Riot (Slavoj Žižek), and Valerie Solanas’ radical feminist “SCUM Manifesto” (Avital Ronell). Slavoj Žižek edited a book called Everything You Wanted to Know About Lacan (But Were Afraid to Ask Hitchcock) where Hitchcock’s thrillers are used to explore concepts in Lacanian psychoanalysis. Simon Critchley has a column on philosophy called “The Stone” in The New York Times and has participated in and written about the punk movement in England. The queen of this approach is Avital Ronell at New York University, who was a student of Algerian French philosopher Jacques Derrida, and applies his deconstructive method to popular culture. She investigates things that appear in the margins like the “SCUM Manifesto” and the everyday notion of “stupidity” which is like a “black hole devouring the light of rationality” (as a reviewer wrote). In this way, Ronell takes on the “repressed conditions of knowledge” and makes them accessible and relevant for the mainstream and for philosophy. “Crazy Like Us” The second thing is more equivocal and that is how America exports its culture worldwide in what political scientists call “soft power.” Hollywood movies, American music from rock’n’roll to hip hop, fast food (see my column on fast food and slow thought), and how we imagine health and mental health. American journalist Ethan Watters describes this in his book, Crazy Like Us: The Globalization of the American Psyche. In it, Watters points to the rise of anorexia in Hong Kong, the American invention and spread of posttraumatic stress disorder, and other cases. I would argue that not only does the West’s most powerful centripetal culture dominate psychiatry and mental health worldwide, but that its fads, obsessions, and blind spots get exported along with our best intentions. Going Deep by Staying Shallow In this new series in “Second Thoughts,” I will explore what we mean by crazy through popular culture (going deep by staying shallow) and the humanities (cinema, history, literature, philosophy)—all with a psychiatrist’s eye. And how the reciprocal relationships between American psychiatry and popular culture create a product that gets exported around the world. The Global Mental Health Movement may have started elsewhere but it is now fully embraced by academic psychiatry and funding sources in Canada and the US, and my North American colleagues are spreading this with messianic zeal. We are going to have some fun with this. Yet, just in case you think it is not serious, we will also revisit the anti-stigma campaigns that I see as part of social psychiatry’s “public works projects.” And we will try to understand the push by those who call themselves “progressives” towards the enlightenment project of progress through rationality and science. My question about that is: When did science (and a narrow and restrictive notion of science at that) become the measure of all things? For there is a dark side to this progressive rationalism in which we see a general intolerance for what is subjective and irrational. As Neil Postman, America’s foremost critic of education and media put it in his masterful polemic Technopoly, defined as the surrender of culture to technology, “Technopoly is at war with subjectivity.” The real intolerance towards those with mental illness, in my view, is not that we are ill-informed or prejudiced (we are, including psychiatrists, sometimes). Rather, that there is no room in a society dominated by technology and a narrow view of science for real diversity and subjectivity, not to mention eccentricity, playfulness, and satire. No amount of political correctness about the neurodivergent has really moved the needle on public acceptance of diversity. Individuals on the autistic spectrum have become the object of comedy (think of Sheldon Cooper, the eccentric genius of “The Big Bang Theory” TV series). As a social philosopher, “crazy” offers an apparatus or tool to study how ideology takes root to colonize the popular imagination, creating hegemony with this fluid yet pernicious cultural category. I will define these key words. As a psychiatrist, “crazy” (and “insane” which may be more offensive) overlaps imperfectly with the subject of psychiatry. Schizophrenia, coined by Eugen Bleuler, MD, in 1908, is the medical psychiatric version of “crazy.” As the central psychiatric term of the 20th century, schizophrenia has been called “the sublime object of psychiatry.” Along the way, we will examine French philosopher Michel Foucault’s Madness and Civilization (which may well be the trigger that made me want to become a psychiatrist after Marcel Lemieux, MD, introduced me to him 50 years ago [see my column: “The Revolving Door”]) and other histories of psychiatry and madness. We will separate histories: the history of psychiatry, the history of the social and cultural construction of madness (which is what Foucault attempted), and finally, the history of the lived experience of madness which has been undertaken by the social sciences, historians, and humanists, with very limited results. What is new and refreshing in this is the voice of individuals experiencing mental, relational, and social suffering themselves. We will also revisit Derrida’s deconstruction and other tools for doing philosophical archaeology, digging down deep into our cultural origins to root out how we came to think and feel the way we do about something like “crazy.” Finally, beyond deconstruction, we desperately need a philosophy of madness, and we will review the dense work of Wouter Kusters, a brave Dutch philosopher and linguist who offers just that. My next column will take on a popular view of “crazy.” “Crazy, manic, twisted, suicidal, psychotic”—this is a view of psychiatry through one of the most important vehicles of culture in our time: popular music. Or, Everything you wanted to know about crazy, but forgot to ask your DJ. Get ready for “Help!” (The Beatles), “Suicide Is Painless” (the M.A.S.H. theme), “Manic Depression” (Jimi Hendrix), “19th Nervous Breakdown” (The Rolling Stones), and “Psychotic Reaction” (The Count Five). Note: This article originally appeared on Psychiatric Times .

Older adults who are sensitive to the distress of others are more likely to feel anxious or depressed themselves because of a psychological mechanism called “emotional contagion,” researchers suggested. Emotional contagion is an adaptive response that occurs unconsciously when people mimic the facial expressions, gestures, and postures of others, leading to a convergence of emotions. “Just as some people are more likely to catch a respiratory virus through close contact, others are more susceptible to ‘catching’ the emotions of the people around them,” said Marie-Josée Richer, PhD, a psychoeducator at the University of Montreal, Montreal, Quebec, Canada. Vulnerability to emotional contagion emerged as the strongest factor contributing to psychological distress in Richer’s cross-sectional study of 170 older adults who were dealing with adversity. Those who were most vulnerable to emotional contagion were 8.5-10 times more likely to present symptoms of anxiety or anxious depression than those who were less vulnerable. This research is part of a series of studies on stress contagion led by Pierrich Plusquellec, also of the University of Montreal and principal investigator of the current study. “We aimed to explore elements of contagion among older adults in light of the known physiological changes in their ability to regulate stress and emotions and the daily contexts of proximity, such as caregiving and community living in a retirement home, which may increase opportunities for emotional contagion,” Richer told Medscape Medical News. The study was published online on October 29 in PLOS Mental Health . Dealing With Adversity Researchers explored a wide range of factors — sociodemographic aspects, indicators of autonomy, social support, coping styles, vulnerability to emotional contagion, and empathy — to assess which ones most influenced two profiles of psychological distress and one profile with no distress. This cross-sectional study included 170 older adults (mean age, 76 years; 85% women) living in a community setting in Quebec. Sixty percent lived alone, 90% completed at least secondary school, and most had annual incomes between $21,000 and $60,000. All participants were dealing with some type of adversity, which was defined as challenges, obstacles, or difficult conditions such as bereavement or conflict with a spouse (explicit adversity) or vulnerability to emotional contagion (implicit adversity). As assessed by the Hospital Anxiety and Depression Scale, 65.9% of participants had a clinical or subthreshold level of anxiety and depression. Based on the scale’s clinical cutoff scores for the anxiety and depression subscales, the researchers grouped participants according to one of three profiles: No distress, anxiety (44% of participants), and anxious depression (21%). All between-group demographic indicators were similar except for sex: There was a slightly higher-than-expected proportion of men in the anxious depression group. Vulnerability to emotional contagion, satisfaction with their social network, and coping styles emerged as factors that increased the likelihood of being in either of the psychological distress groups, relative to individuals with no distress. All groups differed in perceived stress due to adversity. Individuals with no distress symptoms reported significantly less stress than those in the other two groups. Those with anxiety symptoms alone reported less stress than those with anxious depression. In addition, the use of medication to treat anxiety or depression was higher than expected for those in the anxious depression group. After controlling for adversity and psychotropic treatment, vulnerability to emotional contagion had the strongest relationship with both psychological distress profiles. This was a “surprising” result, according to Richer. Coping styles also differed between the groups. Overall, participants in the anxious depression group used less proactive, reflective, strategic planning, preventive, and emotional support strategies than those in the other two groups. The authors acknowledged that recruitment bias could have affected the results, given that more than 75% of the sample lived in high-end private residences. In addition, the cross-sectional design of the study precluded speculation on causation. Nevertheless, they concluded, “Our results support the value of interventions like programs aimed at improving satisfaction with one’s social network and enhancing the cognitive mastery of emotional contagion to reduce or prevent psychological distress in the growing aging populations.” “When supporting individuals experiencing psychological distress, assessing the emotional state of their social environment — rather than just its level of support — seems essential,” said Richer. “A deterioration in the emotional state of the social environment, combined with an increased vulnerability to being affected by others’ emotions, could also serve as an indicator of mental health risk. “We believe it may be possible to teach individuals how to better navigate the positive and negative impacts of emotional contagion,” she continued. “The first step would involve psychoeducation about this type of adversity and its role. The second step would focus on emotional regulation and coping strategies to help individuals manage the emotions they absorb from others.” Good Emotions, Too? Commenting on the study for Medscape Medical News , Alan Cohen, PhD, associate professor of environmental health sciences at Columbia University Mailman School of Public Health in New York City, said, “This makes some sense, but probably susceptibility to emotional contagion works for good emotions, too, and has benefits earlier in life.” He cited better social skills, better ability to gauge the mood of a crowd, and more empathy as examples. “Natural selection probably maintains a balance and diversity of emotional contagion capacities in human populations, and there are likely pros and cons to being anywhere on the spectrum,” he said. “Maybe the right ‘treatment’ would be to expose these people to positive emotional environments. They should benefit the most,” he added. “But further research is needed to see if [emotional contagion] really is symmetrical for good and bad emotions, and if not, what it means.” Note: This article originally appeared on Medscape .

Key points Getting a depression diagnosis with little explanation, reassurance, or monitoring can lead to poor results. Integrative treatment addressing emotional, cognitive, physical, and spiritual symptoms is too rare. Psychoeducation isn't optional. Being provided with a roadmap for recovery is essential. Developing a constructive collaborative relationship with your doctor is key to a good outcome. There are many signs of depression and they often manifest in different ways physically, emotionally, and cognitively. Medication for biological depression is ideally targeted to specific symptoms. Some medications focus more on mood, others on thinking processes, others on sleep issues, etc. But, even when medication is called for, it is never the sole solution to achieving the optimal outcome. Many people make the mistake of assuming an "either/or" attitude: "I will either take an antidepressant or practice Tai Chi or go into therapy to cure my depression." Ultimately, though, an integrative approach may be most effective. You may want to start psychotherapy and see how it goes before considering medication. Incorporating breathing techniques that increase mindfulness into your daily life can be helpful in regulating mood. Eating well and exercising regularly support a positive mindset. The key is to address the whole you. Lack of Access to Specialized Care One of the challenges to getting good treatment for depression is that many people who suffer from it are not being treated by practitioners who specialize in the condition. Unlike other medical conditions, like cancer, heart, and kidney disease, depression is often not treated by specialists in the field. According to one study from 2016-2019, more than 60 percvnt of psychiatric medications were prescribed by general practitioners, nurse practitioners, and physician assistants, not psychiatric specialists. Research published in Health Affairs found that a significant percentage of primary-care doctors reported feeling less equipped to handle mental health problems than conditions such as asthma and high blood pressure. While for some patients, a quick prescription for Prozac, Zoloft, or another antidepressant may be effective, for others it will take trial and error and close monitoring to land on the right combination of drugs. This type of strategic, symptom-specific prescribing of psychiatric medication , with frequent follow-up, is not something typically provided by a primary-care doctor. Time for Patients is in Short Supply The time patients spend with doctors in America is in short supply, which is another factor that can prevent a successful treatment outcome. Today most primary care physicians work in large clinics run by corporate entities. Many are pressured to see a high volume of patients in an insufficient amount of time to conduct a comprehensive consultation. In many cases, diagnoses are made based on forms a patient fills out rather than an in-depth interview. Disorders of thoughts, emotions, impulsivity, obsessions and compulsions, memory, attention, and judgment may only be apparent when a doctor has the chance to observe how a patient talks, looks, and acts. The importance of having a good consultation cannot be overstated. People who are depressed are almost always anxious about their condition. Receiving a quick diagnosis with little explanation, preparation for treatment, or reassurance can lead to disappointing results. A patient may stop taking their medication if it doesn’t work as quickly as they anticipated or if they experience an unexpected side effect and have received no guidance about how to handle it. An inadequate consultation can lead to a failed outcome, which leads to even more hopelessness. More than 2500 years ago, Hippocrates, the father of medicine, is believed to have said, “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” Ideally, by the time your consultation is over, you, as a patient, feel known. You feel confident that your doctor understands your physical, emotional, and biological/genetic situation. You sense that you can have a constructive collaborative relationship with your doctor. You’ve been presented with a meaningful diagnosis and better understand the condition from which you’ve been suffering. You have been prepared for what the treatment process will look like You’ve been given reassurance that your future will be brighter. In our view, psychoeducation is not an optional deliverable. You wouldn’t embark on a road trip to a new destination without using your GPS or looking at a map, so why should you be expected to go on the journey to recovery without some educational navigation assistance? Without understanding the how, what, when, where, and why of depression and recovery from it, people are often overwhelmed with anxiety and confusion, stop taking medication before it becomes effective, and sabotage a successful outcome without realizing it. If you or a loved one are experiencing signs of depression , seeking treatment from a professional is a must. If you find that your mental health consultation leaves you feeling confused about your condition, the recommended treatment, and what the recovery process will look like—or if you feel a lack of connection with your practitioner—seek a second opinion. Ultimately, being provided with preparation, reassurance, and hope as you begin your journey to recovery can make all the difference in whether or not treatment is successful. Note: This article originally appeared on Psychology Today . To find a therapist, visit the One Life Psychiatry .

TOPLINE: Postpartum exercise reduces the severity of depressive and anxiety symptoms. Initiating exercise within 12 weeks postpartum is linked to greater reductions in depressive symptoms . METHODOLOGY: Researchers conducted a systematic review and meta-analysis including 35 studies with a total of 4072 participants. The review included randomized controlled trials and nonrandomized interventions examining the impact of postpartum exercise on depression and anxiety. Participants were postpartum individuals within the first year after childbirth, with interventions including various types of exercise. Data sources included online databases with data up to January 2024, reference lists, and hand searches. The Grading of Recommendations, Assessment, Development, and Evaluation framework was used to assess the certainty of evidence. TAKEAWAY: Postpartum exercise-only interventions resulted in a moderate reduction in the severity of depressive symptoms (standardized mean difference [SMD], −0.52; 95% CI, −0.80 to −0.24). Exercise-only interventions were associated with a small reduction in the severity of anxiety symptoms (SMD, −0.25; 95% CI, −0.43 to −0.08). Initiating exercise within 12 weeks postpartum was associated with a greater reduction in depressive symptoms compared with starting later. Postpartum exercise was associated with a 45% reduction in the odds of developing depression (odds ratio, 0.55; 95% CI, 0.32-0.95). IN PRACTICE: “Further investigation should aim to investigate the effects of postpartum exercise in individuals who experienced perinatal complications and in those who had limitations to exercise during pregnancy. Additionally, more investigation is required to address the possible lasting effects of postpartum exercise on maternal mental health as there were very limited studies reporting on this outcome,” the authors of the study wrote. SOURCE: This study was led by Margie H. Davenport, University of Alberta in Edmonton, Alberta, Canada. It was published online in British Journal of Sports Medicine . LIMITATIONS: This study’s limitations included high heterogeneity among included studies, small sample sizes in some studies, and the combination of exercise with other interventions in some cases. These factors may have affected the generalizability and precision of the findings. DISCLOSURES: This study was funded by the Christenson Professorship in Active Healthy Living. Davenport is funded by a Christenson Professorship in Active Healthy Living. Stephanie-May Ruchat is funded by the Université du Québec à Trois-Rivières research chair in physical activity and maternal and neonatal health. No relevant conflicts of interest were disclosed by the authors. Note: This article originally appeared on Medscape .

COMMENTARY For those of us who grew up in Chicago, as I did, it was virtually impossible to ignore University of Chicago’s Orthogenic School. The school ostensibly treated youths with autism spectrum disorder (ASD) . At the time, autism was blamed on “refrigerator mothers,” a term coined by Bruno Bettelheim, PhD, a psychology professor and an administrator at the school. Related psychoanalytically inspired theories also loomed large in the 1950s and 1960s, which were the heydays of psychoanalysis. A European emigree who escaped the Reich, Bettelheim was a larger-than-life figure, even though his credentials later came under fire. In contrast, his book about the psychological underpinnings of fairy tales, The Uses of Enchantment (1973), retains its cache to this day. Much like the “disappeared” from Argentina’s “Dirty War,” or like fictional serial killers’ victims on Netflix, it sometimes seemed as if everyone had a friend of a friend or knew of a neighbor’s family member who had been carted off to this once prestigious but subsequently disgraced school. The school’s staff—and Bettelheim himself—would later stand accused of physically mistreating those youthful charges, not to mention psychologically damaging their maligned mothers. Even the diagnoses of ASD that supposedly “qualified” students for admission to the school would be called into question. Bettelheim eventually died by suicide. Bettelheim did indeed have a PhD in aesthetics, which probably contributed to the quality of his well-received book about fairy tales. But he represented himself as a psychologist, even though his European diploma could not be found. He claimed that it was misplaced during the war years. In contrast, it was confirmed that he trained as a psychoanalyst in Europe, where prior training in psychiatry, neurology, or psychology was not required, as it once was in the US. There is much to be said about Bettelheim that is beyond our scope here but suffice it to say that what he lacked in credentials, he compensated for with chutzpah. He was lauded for his 3 weeks’ worth of “research” (conducted without experimental design) on children reared by Israeli collectives or kibbutzim.2 That study became Children of the Dream (1967). Previously, Bettelheim chronicled his own concentration camp experiences in a widely cited 1943 paper on “Individual and Mass Behavior in Extreme Situations.” That study made him a de facto spokesperson about the stresses of concentration camps—yet it was later learned that he himself had never been incarcerated in a camp, as he had claimed. Most importantly, Bettelheim promoted since-debunked and much-maligned—yet highly persuasive—theories about “refrigerator mothers” who allegedly caused their children’s autism. His best-selling book, The Empty Fortress: Infantile Autism and the Birth of the Self (1967), established him as an expert in the field and attracted the not-always-favorable attention of well—respected reviewers, such as Stella Chess, MD, in JAMA, and elsewhere. Many medical journals subsequently denounced his studies on autism. Scientific research has since linked up to 80% of ASD cases to genetic factors (with some inherited from parents, but probably more from accidental chromosomal breakage or spontaneous mutations). Some 200 to 1000 genes contribute to ASD risks . Moving forward to the present day: knowing about this background—and remembering my “disappeared” neighbor—I would come to feel especially saddened whenever I encountered parents of children on the spectrum who could not shake the lingering shadows left by these unfounded accusations made decades earlier. As recompense, I could console them with current scientific data that contradicts Bettelheim’s theory, or I could direct them to high quality informational programs on ASD, like the ones hosted by Mount Sinai’s Seaver Center, which is affiliated the same medical school where I serve as voluntary faculty. . . or I could take an entirely different approach and alert them to the success of IDF’s Unit 9900. This unique unit is comprised of young adults who are on the spectrum and who are recruited because they can hyperfocus for hours on end and can attend to details that escape the attention of neurotypical soldiers. These volunteer recruits are noncombatants who work on computer screens and take part in an aptly named program, Spectrum of Talent. My goal was not to goad anyone to enlist their children in Israel’s IDF, not by a longshot, given that we in psychiatry are mandated to maintain strict boundaries about separating our own political or philosophical or religious persuasions from our patients’ belief systems. Rather, my intent was to reassure distressed families that their children with ASD could possess untapped abilities that are deemed valuable enough to merit a special program. More about Unit 9900, which is referred to as “Roim Rachok” (translated as “we see far”) and which was the progenitor of related and expanded programs in IDF, and which has been written about extensively in Times of Israel articles,5-8 as well as by American business publications. Articles on the topic appear in men’s magazines such as Esquire or in The Atlantic, a more generic literary monthly. Hadassah Magazine, published by a Jewish women’s organization, also weighs in on “An IDF Program for Teens on the Autism Spectrum.” The mere fact that this unique unit was the brainchild of unrelated parents of adolescents with ASD is especially compelling, for it confirms that families can advocate for their children, to help them achieve more than had previously been expected of them and to help these young adults integrate into society at large and shed their outsider status. Even though persons with ASD can be exempted from Israel’s military obligations, the participants in this pilot program volunteer on their own accord. Many elect to remain after completing their terms of service. Qualified volunteers are routed to professional training programs that tap into their innate skills, skills which confer a comparative advantage over neurotypical individuals. By their own admission, these young adults with autism focus on details for extended periods of time and relish repetitive tasks rather than resenting them. Many like lists of tasks. The first graduates learned to analyze aerial and satellite photographs. The expanded program trains participants for software quality assurance, information sorting, electro-optics, and electronics. A key 9900 task is to screen vast numbers of photos of the same subject matter in order to detect small variations between them. Sometimes they scour social media for emerging trends. Apart from their technological know-how, many participants possess specialized knowledge on topics ranging from archaeology, languages, or music. When enlisted, these special soldiers are accompanied by therapists and psychologists who help them navigate potentially stress-inducing social barriers that they face. About 90% finish their program, prepared for future careers in technological fields should they decide to leave the IDF. As testimony to the success of this pilot program, military divisions in the UK, US, and Singapore expressed interest in developing the model on their own shores. How uplifting this information can be, especially for families of children who might have been marginalized and undermined. Note: This article originally appeared on Psychiatric Times .

Key Takeaways Lithium showed a trend towards reducing suicide risk, but results were not statistically significant in the meta-analysis of seven RCTs. The study found moderate-quality evidence supporting lithium's potential to lower mortality rates, despite statistical insignificance. Clinicians should consider lithium for suicide prevention, taking into account patient-specific risk factors and characteristics. Further research is necessary to clarify lithium's long-term antisuicidal effects and its impact on impulsivity reduction. TRANSLATING RESEARCH INTO PRACTICE Rajesh R. Tampi, MD, MS, DFAPA, DFAAGP, Column Editor A monthly column dedicated to reviewing the literature and sharing clinical implications. There is some controversy regarding lithium’s ability to prevent suicide. Given the challenges related to suicide research, specifically that rates of death by suicide are so low that a very large sample size is needed to achieve statistical significance, it is difficult to measure suicide in a single study. Relatively small sample sizes limited previous systematic reviews. This column reviews a systematic review and meta-analysis of 7 randomized controlled trials (RCTs), including a recent RCT that enrolled over 500 participants. The aim was to provide clarity on lithium’s efficacy in suicide prevention . The Study Riblet NB, Shiner B, Young-Xu Y, Watts BV. Lithium in the prevention of suicide in adults: systematic review and meta-analysis of clinical trials. BJPsych Open. 2022;8(6):e199. Study Funding This study was funded by the Veterans Affairs National Center for Patient Safety Center of Inquiry Program in Ann Arbor, Michigan. Study Objectives To assess the efficacy of lithium in preventing suicide. Methodology This study was a systematic review and meta-analysis of RCTs exploring the effect of lithium on suicide. Systematic review followed Cochrane guidelines, and the investigators searched the literature from January 1, 2015, to November 30, 2021, using 5 databases: MEDLINE (via Ovid), Excerpta Medica Database (Embase), Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Central Register of Controlled Trials (CENTRAL), and PsycInfo. Additionally, references of the included studies were reviewed, and ClinicalTrials.gov was searched for additional studies. Eligibility criteria included RCTs with adults older than 18 years assigned to lithium or control (placebo, usual care, or waitlist) and reporting death by suicide as a primary or secondary outcome. There were no restrictions on language. Studies were included regardless of suicide events and were not limited by diagnostic condition. The efficacy of lithium vs control for preventing death by suicide was evaluated by calculating the OR with 95% CI and P values using the Peto method. Statistical significance was defined as P less than .05 and 95% CI not crossing 1. Heterogeneity was assessed using the Cochran Q test and the I2 statistic, with substantial heterogeneity defined as P less than .10 and I2 greater than 50%. Additional review of the data included confirmatory analysis using a Poisson regression model with random effects and calculating an incidence rate ratio (IRR) for suicides over person-years. Publication bias was assessed by generating a funnel plot for the primary outcome and visually inspecting for asymmetry. Quality of evidence was assessed using GRADEpro software. Ethics approval and informed consent were not required for this study. Study Results The systematic review yielded 7 RCTs that met eligibility criteria, comparing lithium with control using death by suicide. All studies were conducted in North America or Europe from 1973 to 2022 and involved adults with a diagnosis of major depressive disorder or bipolar disorder. The odds of suicide were lower for the 568 individuals on lithium compared with the 570 in the control group (OR, 0.30; 95% CI, 0.09-1.02; P = .05), although the difference was not statistically significant. The IRR also favored lithium (IRR, 0.22; 95% CI, 0.05-1.05; P = .06), but this result was similarly not statistically significant. No substantial or significant heterogeneity was observed among the studies (Cochran Q, 3.60; I2 = 0%; P = .61). One study (Girlanda 2014) had a wide CI and favored the control group, which was care as usual. All other studies favored the intervention group and used a placebo as the control group. Risk of bias assessment indicated concerns about study assignment and adherence due to reported nonadherence to the study drug and high attrition rates. Recruitment issues were also noted in several studies. A visual inspection of the funnel plot showed no evidence of publication bias. In the case of 1 participant death by drug overdose, the authors conservatively decided not to include this as a suicide. Had they included this death as a suicide, the study would have reached statistical significance and more strongly favored lithium. According to Grading of Recommendations Assessment, Development, and Evaluation (GRADE) analysis, the certainty of the evidence in favor of lithium was moderate, highlighting its importance in relation to mortality outcomes. Conclusions The 7 RCTs included in this systematic review and meta-analysis found that the odds of suicide were lower in individuals treated with lithium . However, these results were not statistically significant. Practical Applications This study provides moderate evidence that lithium lowers the risk of suicide . Clinicians should consider lithium as an intervention to reduce suicide risk. More data are needed to clarify the long-term antisuicidal effects of lithium and its role in decreasing impulsivity. Bottom Line This systematic review and meta- analysis aimed to provide clarity on an important topic in psychiatry: preventing suicide . Although the results were not statistically significant, this review had moderate-quality evidence supporting lithium’s ability to lower mortality rates. Clinicians should consider the unique risk factors, characteristics, and values of their patients when considering utilizing lithium in the treatment of suicidal patients. Note: This article originally appeared on Psychiatric Times .

The well-being of doctors is under significant strain, with acute and chronic stress, psychological trauma, ethical dilemmas, and negative experiences contributing to burnout and depression. This issue affects not only healthcare professionals themselves but also their patients and the whole healthcare system. A recent review in The New England Journal of Medicine summarizes research on the prevalence of burnout and depression among doctors while highlighting effective countermeasures. The authors offered suggestions for further research and actionable steps for clinics, medical organizations, and policymakers to address these challenges effectively. “This review highlights an important aspect of occupational health management that has gained traction in German hospitals in recent years,” said Peter Zwanzger, MD, chief physician in general psychiatry and psychosomatics at the kbo-Inn-Salzach clinic in Wasserburg am Inn, Germany, and a board member of the German Society for Psychiatry and Psychotherapy, Psychosomatics, and Neurology. Depression as the Core Diagnosis The authors of the review, Constance Guille, MD, and Srijan Sen, MD, PhD, psychiatrists at the University of South Carolina, Columbia, South Carolina, and the University of Michigan, Ann Arbor, Michigan, emphasized that depression is a better-defined diagnosis than burnout. Their analysis of 182 studies found 142 different definitions of burnout, leading to prevalence rates among doctors ranging from 0% to 80.5%. This variation prompted the authors to concentrate on studies related to depression. “These concepts — depression and burnout — are not equivalent, scientifically recognized diagnoses,” Zwanzger clarified. “Depression is a well-established, scientifically validated diagnosis found in all major diagnostic systems. In contrast, burnout is not a recognized diagnosis but rather a risk state, often related to occupational stress.” Symptoms that lead to a diagnosis of depression include low energy, lack of enjoyment, sleep and appetite disturbances, and negative thoughts, even including suicidal ideation. Symptoms are similar whether depression is triggered by external factors or internal pathological states. Workload as a Key Factor Excessive workload is a major cause of depression and burnout among doctors. In one study, young residents experienced up to a sixfold increase in depression rates after beginning clinical work, with shifts extending to as much as 90 hours per week. In comparison, a 40-45 hour working week caused a doubling in the incidence of depression. “One of the most important steps to counteract general overload is the regulation of working hours established under European labor laws,” Zwanzger explained. “This means that, particularly for residents, excessively long shifts and significant weekly hours should be a thing of the past.” Accessible Mental Health Measures Other systemic triggers of depression include lack of access to mental health services , frequent job-related frustrations, and inadequate sleep, according to the review authors. Women and minorities, including non-native speakers, are disproportionately affected, often due to additional family pressures on women and less social integration for minorities. “In Germany, it’s also observed that high-intensity workloads in some medical specialties lead to mental health complaints, including depression, burnout, and a higher risk of substance abuse and dependency,” Zwanzger said. “In response, workplace health management in German hospitals has advanced significantly in recent years. Many institutions have implemented screening programs for mental health concerns through occupational health services.” Recommendations for Medical Organizations and Hospitals The authors outline several recommendations: Substantial Investment in Reducing Administrative Tasks: Cutting the burden of paperwork for doctors allows them to focus more on patient care, potentially reducing feelings of guilt associated with administrative work. Easier Access to Mental Health Support: Increasing access to services targeting depressive symptoms and substance dependency for doctors can help reduce stigma for affected colleagues. Supporting Family Life: Consider options such as part-time working and on-site childcare facilities within hospitals to support doctors with families. Promoting Equality: Implement measures to ensure equal opportunities for women, ethnic, religious, and other minority groups, and to prevent sexual harassment and discrimination. Monitoring and Evaluating Initiatives: Consistently document and assess all measures to provide evidence-based recommendations for ongoing improvement and expansion of these interventions. Note: This article originally appeared on Medscape .

TOPLINE: Sleep-related daytime dysfunction is associated with an almost threefold higher risk for motoric cognitive risk (MCR) syndrome, a predementia condition characterized by slow gait and cognitive issues, a new study shows. METHODOLOGY: Researchers included 445 older adults without dementia (mean age, 76 years; 57% women). Sleep components were assessed, and participants were classified as poor or good sleepers using the Pittsburgh Sleep Quality Index questionnaire. The primary outcome was incidence of MCR syndrome. The mean follow-up duration was 2.9 years. TAKEAWAY: During the study period, 36 participants developed MCR syndrome. Poor sleepers had a higher risk for incident MCR syndrome compared with good sleepers after adjustment for age, sex, and educational level (adjusted hazard ratio [aHR], 2.6; 95% CI, 1.3-5.0; P < .05). However, this association was no longer significant after further adjustment for depressive symptoms. Sleep-related daytime dysfunction, defined as excessive sleepiness and lower enthusiasm for activities, was the only sleep component linked to a significant risk for MCR syndrome in fully adjusted models (aHR, 3.3; 95% CI, 1.5-7.4; P < .05). Prevalent MCR syndrome was not significantly associated with poor sleep quality (odds ratio, 1.1), suggesting that the relationship is unidirectional. IN PRACTICE: “Establishing the relationship between sleep dysfunction and MCR [syndrome] risk is important because early intervention may offer the best hope for preventing dementia,” the investigators wrote. “Our findings emphasize the need for screening for sleep issues. There’s potential that people could get help with their sleep issues and prevent cognitive decline later in life,” lead author Victoire Leroy, MD, PhD, Albert Einstein College of Medicine, New York City, added in a press release. SOURCE: The study was published online on November 6 in Neurology . LIMITATIONS: Study limitations included the lack of objective sleep measurements and potential recall bias in self-reported sleep complaints, particularly among participants with cognitive issues. In addition, the relatively short follow-up period may have resulted in a lower number of incident MCR syndrome cases. The sample population was also predominantly White (80%), which may have limited the generalizability of the findings to other populations. DISCLOSURES: The study was funded by the National Institute on Aging. No conflicts of interest were reported. Note: This article originally appeared on Medscape .