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

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

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

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

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

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

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

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

Cannabis has long been misunderstood and often mislabeled in psychiatric discourse. Mark Viner, MD, addressed the misconception in psychiatry about cannabis in a video interview with Psychiatric Times. Initially categorized as a psychomimetic in the 1970s, it was later separated from hallucinogens in the DSM-5 in 2013. This distinction is significant, as cannabis presents withdrawal symptoms, a characteristic not typically associated with classic hallucinogens. Despite this classification, cannabis continues to be confused with synthetic cannabinoids and other dangerous substances. As psychedelics gained recognition, terms such as atypical psychedelic or psychedelic-like agent emerged, reflecting cannabis’s complex effects. The younger generation has even introduced new terminology like psychoplasticine to describe its psychoactive properties. While high doses of potent THC can induce a psychedelic-like experience, cannabis is generally not classified as a traditional psychedelic. Addressing the Stigma and Misconceptions Cannabis is often misunderstood due to its association with psychosis. However, it is crucial to differentiate between cannabis intoxication and true psychotic disorders. Cannabis intoxication can lead to perceptual disturbances such as illusions and hallucinations, but these typically involve intact reality testing. This contrasts with the delusions and hallucinations seen in conditions like schizophrenia, where reality testing is impaired. The term "cannabis psychosis" is frequently misapplied. Many reports conflate cannabis-induced symptoms with catatonia, dissociation, severe anxiety, malingering hallucinations, perceptual distortions, and even enhanced creativity or imagination. Studies often fail to account for preexisting psychiatric conditions in patients who exhibit psychotic symptoms after cannabis use. For instance, a patient with schizophrenia who ceases medication while using cannabis may experience psychotic symptoms, but attributing this solely to cannabis is misleading. The Neurological Impact of Cannabis Cannabis affects the brain in unique ways, particularly through the cannabinoid receptors densely located in the basal ganglia. This region plays a crucial role in movement and psychomotor functions, yet the impact of cannabis on motor disorders remains underexplored. Catatonia, a poorly understood condition, can present in various forms—13 different types are recognized. Cannabis can induce mild forms of catatonia, such as catalepsy, mannerisms, grimacing, echolalia, and stupor. Evolutionary studies suggest that cannabis-induced catalepsy has parallels with hibernation behaviors in animals exposed to THC. Note: This article originally appeared on Psychiatric Times .

When you’re feeling stressed, sometimes there’s nothing like picking up your favorite comfort food — chocolate, chips, fries, ice cream, soda, or an alcoholic drink — to self-soothe. You know the feeling, and you can be sure your patients do, too. The message, then, to help patients is: Although it may feel good in the moment, a repetitive cycle of boosting your cortisol levels and seeking solace in food can make stress worse. Eating too many “treats” regularly can also shift your microbiome, metabolic health, and gut-brain relationship as a result. “Although many people may not realize it, there is a connection between how we feel and our food choices. We make hundreds of choices a day, including the type of foods we choose to eat, whether we order takeout or make a home-cooked meal, or whether we choose to fry a filet of fish or bake it,” said Roxana Ehsani, a registered dietitian nutritionist based in Miami. “How we feel mood-wise can dictate these food choices,” she added. “If we are feeling stressed, we may gravitate toward choosing a meal that provides stress relief or comfort, which may not be the most nutritious food choice.” Feeling and Feeding Our Emotions While it’s natural for people to reach for comfort foods during times of stress, strong emotions, or even boredom, it can become a problem when a pattern of subconscious behavior emerges. “I see people get into these patterns of feeling a negative emotion, reaching for comfort food, and feeling guilty, which creates a negative cycle of guilt and shame,” said Whitney Linsenmeyer, PhD, RD, assistant professor of nutrition and dietetics at Saint Louis University in St. Louis and a spokesperson for the Academy of Nutrition and Dietetics. This isn’t to say physicians should tell their patients to ban this type of comfort-seeking. They just need to know the consequences of too much of a good-tasting thing. “It’s fine to recognize you’re feeling sad and enjoy a food that brings you comfort,” she said. “The key is bringing awareness to it, understanding the reasons why you’re doing it, and maybe thinking about other ways you might comfort yourself, such as calling a friend or going for a walk.” These patterns emerge due to strong relationships across the body. When stressed, for instance, the body releases a hormone called cortisol through the hypothalamic-pituitary-adrenal axis, which increases blood flow, heart rate, breathing, and other factors such as blood clotting. Over time, persistently high levels of cortisol can lead to long-term health issues, such as obesity, insulin resistance, and metabolic syndrome. Comfort foods, in turn, can add to those long-term health issues due to added sugars, sodium, and unhealthy fats. As a result, spikes in blood sugar and blood pressure can then lead to even greater irritability and stress — as well as brain fog, poor memory, and low energy. “The gut-brain connection between your gastrointestinal [GI] tract and central nervous system goes both ways, where you might feel stress in your brain, but it manifests in your GI system as a stomachache or IBS [irritable bowel syndrome] flare,” Linsenmeyer said. “It can go the other way, too, where a disruption in healthy gut microbes through illness or poor diet can affect your cognitive health and well-being.” Chronic inflammation plays a role in the cycle of stress for both mental and physical health, which has become increasingly common in recent years as more people consume ultraprocessed foods that contain dyes, preservatives, and stabilizers but lack the fiber or nutrients of whole foods. “Studies have shown that when there are inflammatory markers in the gut, there are markers of neuroinflammation as well,” said Uma Naidoo, MD, director of nutritional and lifestyle psychiatry at Massachusetts General Hospital in Boston and author of the book, This Is Your Brain on Food. “Neuroinflammation has been linked to a host of mental health and neurological conditions, including anxiety, depression, mood disorders, and cognitive problems,” she said. “In my practice, I’ve seen that adjusting the diet of those with various psychiatric problems can help to calm this inflammation and improve mood, stress, and emotional well-being over time.” Trying Other Coping Strategies Another good message for patients: When you feel stressed and in need of a comforting snack, stop and bring awareness to the moment, Linsenmeyer said. Consider what’s prompting them to eat and identify where in the body the “hunger” is coming from, which could be physically in the stomach or more emotionally in the brain or heart. If a patient realizes they’re simply bored, encourage them to choose another activity to satisfy the craving for action, she said. If you realize your mouth wants to taste flavor or a crunchy texture, try to choose a healthy alternative. If they feel emotional, maybe they can find release through physical activity, journaling, meditation, or connection with a friend. To get started, Linsenmeyer recommends people become familiar with their behavioral patterns by tracking what they eat and drink across 3 days — and record their emotion each time. Consciously stopping and reflecting on both the foods and feelings can reveal when someone may feel stress throughout the day, how they react, and what else they could do instead. After learning the patterns, planning can start by setting up meals or snacks to make healthier choices throughout the week, Ehsani said, adding that it doesn’t have to be an extensive or stressful process. Once per week, she suggests people write down a few meals and snacks that they plan to make, check their inventory, and set themselves up for success. This could include buying healthy snacks, chopping fruits and vegetables for easy access in the fridge, and putting comfort foods in less convenient locations. “Then throughout your busy week, you don’t need to be as mindful about considering what to eat or cook, since you’ve already thought about your food choices ahead of time,” she said. “This can help eliminate making poor food choices when you’re feeling stressed or tired, especially at the end of a workday.” Naidoo also advised using the “SAW Method” to swap out unhealthy options, add in more vegetables and fiber, and walk to reduce stress and boost mood. For instance, swapping ice cream for fruits can help satisfy a sweet tooth, and adding cruciferous vegetables can provide a crunchy texture while cutting down on the sugars and salt in ultraprocessed foods that compound stress. “It’s about adapting these principles to what you need to do to help yourself,” she said. “When you’re making food choices, it’s important to consider how they will affect not only your physical body but your emotional self as well.” Note: This article originally appeared on Medscape .

Canada’s legalization of cannabis has been linked to an increase in schizophrenia cases, new research shows. Over a 16-year time period — spanning before and after legalization of cannabis for medical and recreational use — the number of new cases of schizophrenia associated with cannabis use disorder (CUD) in Ontario nearly tripled after legalization, investigators found. “There has been a lot of research on the association between cannabis use and schizophrenia and one of the main concerns about cannabis legalization is whether it might result in increases in cases of schizophrenia,” study investigator Daniel Myran, MD, MPH, with Ottawa Hospital Research Institute, Ottawa, Ontario, Canada, told Medscape Medical News. “We found that there have been concerning increases over time in the percentage of people with a new schizophrenia diagnosis who had received care for a cannabis use disorder before their diagnosis,” Myran added in a news release. The study was published online on February 4 in JAMA Network Open . A Growing Public Health Challenge The researchers evaluated the electronic medical records of more than 13.5 million residents of Ontario (mean age, 39 years) without a history of schizophrenia and considered three policy time periods between 2006 and 2022 — before legalization (January 2006 to November 2015), after legalization of medical cannabis (December 2015 to September 2018), and after legalization of nonmedical cannabis (October 2018 to December 2022). In total, 118,650 individuals (0.9%) had an emergency department visit or hospital stay for CUD. During the study period, 10,583 (9.0%) of individuals with CUD developed schizophrenia compared with 80,523 (0.6%) of individuals without CUD. After legalization of cannabis, the number of people in Ontario who required hospital care for CUD jumped by 270%, from about 1.3 in every 1000 people before legalization to 4.6 after legalization, results showed. In addition, the proportion of new cases of schizophrenia associated with CUD increased from 3.7% (95% CI, 2.7%-4.7%) before legalization to 10.3% (95% CI, 8.9%-11.7%) after legalization, with young men aged 19-24 years most likely to be affected. “Our study highlights the growing public health challenge posed by the combination of increasingly high-potency cannabis and rising regular cannabis use,” Myran said in the news release. Myran added that “part of the challenge with cannabis is that with all the discussion around medical cannabis, people may think if this is a medicine it can’t possibly be hurting me. I think the conversation has to be — just because cannabis is now legal and the social norms are changing, doesn’t mean that there is not at risk, particularly in younger people.” “Alcohol and tobacco are legal and that doesn’t not mean that those products are safe or without consequences,” he noted. The investigators pointed out that the study does not settle ongoing debate about whether or not heavy cannabis use can cause schizophrenia . However, Myran said, “what is clear from the scientific literature is that people who are going to develop schizophrenia if they use cannabis and they use it regularly, they will develop it earlier in life and their symptoms will be worse.” A Natural Experiment The author of an invited commentary said this study “adds further support for mounting evidence on the association between cannabis use and increased risk for psychosis, and it shows that this association is most robust among young adults who are developmentally vulnerable to both the neurologic effects of cannabis and developing psychosis.” “As legalization of cannabis becomes more widespread, along with a rapidly expanding commercial cannabis market, a natural experiment of population exposure to commercial cannabis markets is occurring,” wrote Jodi Gilman, PhD, with the Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston. “Epidemiologic studies should include long time intervals to account for processes of legalization and the emergence of mental illness, sufficient numbers to identify subpopulations at risk, such as young adults, and information concerning not only the quantity and frequency but also the potency of cannabis used. “Without these critical factors, this research will be skewed toward nonsignificant findings, potentially obscuring important associations between cannabis policy and mental health outcomes,” Gilman said. The study was supported by the Canadian Institutes of Health Research and by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care. Myran and Gilman had no relevant disclosures. Note: This article originally appeared on Medscape .

A few years ago, UCLA Health began asking patients if they used cannabis as part of an electronic previsit questionnaire completed before well visits. The question is still an unusual ask for most primary care clinicians, said Lillian Gelberg, MD, a professor of family medicine at the UCLA David Geffen School of Medicine. “Doctors don’t ask, and patients don’t tell,” she said. If a patient’s answers indicate a risk for cannabis use disorder— a complex diagnosis that involves clinically significant impairment or distress linked to the drug over a 12-month period — Gelberg receives a flag before the visit, enabling her to provide a brief intervention. “What I say to them is, ‘I thank you for completing your questionnaire, and I’m concerned about your scores on your cannabis screen,’” Gelberg said. The rate of people older than 12 years in the United States reporting daily or near-daily use of cannabis rose 15-fold between 1992 and 2022 , with an increase in absolute numbers of daily or near-daily users from about 1 million to 17.7 million over that period. And while some clinicians may not think their patients are part of that increase, screening may help identify those who are. A study of nearly 1700 patients found that 38.8% responding to a confidential survey in 2021 reported using cannabis in the previous year, but only 4.8% had that information in their electronic health record. Meanwhile, average levels of tetrahydrocannabinol (THC) in cannabis samples in the United States rose from 3.96% in 1995 to 16.14% in 2022. The drastic increases in potency, combined with inconsistent regulations between states, such as caps on potency or tracking systems verifying product quality, should be of concern, according to Fred Rottnek, MD, a professor and director of community medicine, as well as the program director of the addiction medicine fellowship , at the Saint Louis University School of Medicine in St. Louis. Experts say primary care clinicians need to ask about cannabis use to better counsel their patients about the health risks of the substance. A recent study published in JAMA Network Open reported a nearly threefold risk for death in patients within 5 years following an emergency department visit or a hospitalization due to cannabis use disorder. The causes of death linked to cannabis use included suicide, trauma, poisonings linked to opioids and other drugs, and lung cancer. And complications of cannabis can happen to anyone: Emergency department visits in adults older than 65 years were 19 times higher in 2019 than in 2005 in California. Why Ask? Researchers at UCLA Health identified actionable items — such as the identification of cannabis use disorder, need to discuss interactions with common prescription medications, and safety issues associated with the presence of edibles in the home— after they began screening sent out through their electronic health record in 2021. Overall, 17% of patients reported using cannabis, and 34.7% of those patients had results indicating a moderate to high risk for cannabis use disorder. Marjan Javanbakht, PhD, an adjunct professor in the Department of Epidemiology at the UCLA Fielding School of Public Health and co-lead author of the study, said her team uncovered much more cannabis use than they expected. She was also surprised at the 80% of patients who classified themselves as recreational users who were taking cannabis to manage a symptom. The most common uses were for sleep (56%), mental health symptoms (55.5%), stress (50.2%), worry or anxiety (36.3%), and nonspecific pain (31.7%). “Patients may be using marijuana instead of the medications that we’re prescribing for them,” Gelberg said. “And we need to have a dialogue about that.” Talking with adults older than 65 years is also crucial because this population prefers consuming cannabis through edibles, Rottnek said. “Edibles don’t kick in as quickly because like most drugs taken orally, it takes a while for them to absorb,” Rottnek said. Intoxication increases fall risks in older adults. In addition, clinicians may want to counsel patients on safe storage of their cannabis products if grandchildren or other children are in the home. Unintentional intoxication from edibles is well-documented in children: Between 2017 and 2021, 22% of such episodes in children reported to US poison control centers resulted in hospitalization. Clinicians may also want to talk to patients about interactions between cannabis and other medications, such as commonly prescribed analgesic, psychotropic, and cardiovascular agents. Both THC and cannabidiol (CBD) can alter levels of certain opioids, statins, antidepressants, and anticoagulants. THC also can increase the effects of central nervous system depressants, such as alcohol and benzodiazepines, increasing the risk for memory loss and confusion in older adults. For his younger patients, Rottnek said he worries about those with a family history of schizophrenia. “A lot of young people, teenagers and young adults, are showing up in ERs [emergency rooms] for psychotic breaks that can go for 5-7 days, depending on the potency of what they’re using,” he said. He also noted the risks associated with cannabis use during pregnancy, such as low birthweight in infants and psychopathology later in childhood. How to Ask When Rottnek teaches medical students, residents, and fellows about clinical interviewing, he advises starting with legal substances: Alcohol, tobacco, and cannabis. He advised against using the phrase, “You don’t smoke or drink, do you?” Instead, clinicians should adopt a more open-ended approach, such as, “Tell me about your cannabis use.” If a patient says they do use various substances, he asks about the route of ingestion, frequency of use, and why they use the substance to inform his discussion of how to reduce potential harms. The researchers from UCLA used a more systematic approach, using the World Health Organization’s screening test adapted for tobacco and cannabis. Javanbakht said patients are more truthful on self-administered, computerized questionnaires, which also save time for the clinician. Take Home Messages for Your Patients Many clinicians might associate harm reduction with syringe access or safe injection practices, but Rottnek said harm reduction is about making good day-to-day decisions. “If somebody’s engaging in an inherently risky behavior, how do you mitigate bad things from happening?” he said. He bases his harm reduction approach to counseling on a systematic review of measures to lower health risks for anyone using cannabis. Clinicians should advise patients to: Choose low-potency THC or balanced cannabis products with a balanced ratio of THC to CBD because products high in THC are associated with higher risks for acute and chronic mental health and behavioral problems. Limit use to 1 d/wk or weekends only. Daily use has been linked to mental health problems, cardiovascular disease, motor vehicle accidents, suicidal behavior, and neurocognitive effects. Abstain from using synthetic cannabinoids because more severe health effects have been linked to these products. Avoid combusted cannabis inhalation and instead use nonsmoking use methods. Regular inhalation of cannabis can induce chronic bronchitis. Avoid deep inhalation or breath holding to increase absorption, which can damage the lungs. Do not drive or operate heavy machinery for 6 hours after using cannabis. People with a history of schizophrenia, uncontrolled hypertension or coronary artery disease, or chronic obstructive lung disease or other lung pathology should not use cannabis because of a higher risk for related health problems. Note: This article originally appeared on Medscape .