Suicidal thoughts and behaviors (STBs) are among the most dreaded complications of treatment-resistant depression (TRD), which is associated with elevated risk of death from suicide as well as from other conditions, even when compared with nonresistant depression. According to 1 meta-analysis, the overall incidence of suicide and suicide attempts among adults with TRD is between 2 and 10 times that of individuals with nonresistant depression. Approximately 30% of individuals with TRD attempt suicide at least once in their lifetime, compared with about 15% of those with nonresistant depression. Even when compared with individuals with unipolar depression, patients with a history of TRD should be considered at high risk for STBs. Risk Factors Although many years of suicide research has generated a large body of knowledge about risk factors, we still know relatively little about the causal associations among risk factors and STBs, and the mechanisms through which risk factors translate into thoughts, behaviors, and fatal outcomes. As in other areas of clinical medicine, prediction models of suicide that work reasonably well in the general population may not generalize to diverse subpopulations, creating a risk of exacerbating rather than addressing health disparities. While we know a lot about suicide risk factors, we know far less about how to predict imminent risk of suicide, which—given the tragic intractability of suicide death across the past century5—remains the holy grail of suicide research. It remains unclear whether TRD is associated with any unique suicide risk profiles; still-growing knowledge indicates that risk factors for STBs among individuals with TRD closely resemble those for other individuals. For example, prior suicide attempts are the strongest risk factor for suicide death in TRD and in the general population. Moreover, factors often associated with TRD are also independent risk factors for STBs. These factors include early life adversity, personality disorders, anxiety, insomnia, chronic pain, substance use disorders, other co-occurring medical conditions, hopelessness, diminished problem-solving ability, low socioeconomic status, a paucity of social supports, and recent psychiatric hospitalization. While depression is associated with the presence of suicidal thoughts, other factors such as psychiatric comorbidity and impulsivity may be better predictors of STBs and suicide. In terms of psychological components of suicide risk, the influential Interpersonal Theory of Suicide proposed by Joiner et al focuses on 3 interconnected risk factors for suicidal thoughts: “thwarted belongingness,” “perceived burdensomeness,” and “hopelessness.”9 Although this theory is transdiagnostic, its relevance to the experience of many patients with TRD is clinically compelling. The growing literature on suicide risk factors suggests that TRD may be associated with increased risk of STBs largely because of its close association with other risk factors for STBs; these factors are often connected with TRD as contributing factors to treatment resistance or as consequences. The bad news is that managing depression itself may influence only part of the complex risk equation, potentially affecting suicidal thoughts more than acts. The good news is that there may be multiple levers that influence the transition from ideas to behavior. Many of these levers are directly relevant to the comprehensive, multimodal evaluation and care of patients with TRD. Treatments A range of pharmacological, psychological, and neurostimulation therapies have shown promise for reducing STBs including among individuals with TRD. In some studies, the antisuicide effects of treatment have appeared to be somewhat dissociable from the antidepressant effects, though this remains an area of continued inquiry. In addition, the impacts of treatments on suicidal ideation and attempts have been better studied than their impact on suicide deaths. Finally, in many treatment studies relevant to TRD and STBs, STBs have been assessed primarily as secondary outcome measures in studies not adequately powered to test these outcomes; there remains much need for well-designed studies in TRD cohorts in which STBs are the primary outcomes of interest. Clozapine: Based largely on the International Suicide Prevention Trial, clozapine was the first medication approved by the US Food and Drug Administration (FDA) to prevent suicidal behavior, specifically in individuals with schizophrenia or schizoaffective disorder. Because of its substantial adverse effect burden and monitoring requirements, clozapine has not been widely used or studied as an antidepressant adjunct among TRD cohorts. Its superiority in reducing suicide risk compared with newer second-generation antipsychotics approved for antidepressant augmentation in TRD has not been established. Ketamine and esketamine: Esketamine also carries a specific FDA indication for suicidality (since August 2020), particularly in the context of MDD, following its initial approval for TRD. Although data on the efficacy of intranasal esketamine or intravenous racemic ketamine for suicidality in TRD have been mixed, some studies have shown rapid reduction in suicidal ideation after single or repeated doses, sometimes independent of reduction in other core depressive symptoms. A topic of further research is whether effects on ideation persist beyond the period of active treatment and whether they translate into fewer suicide attempts and deaths. Lithium: The potential antisuicide effects of lithium have been reported for several decades. These effects have had some support from large pharmaco-epidemiological studies, particularly among individuals with bipolar disorder. A meta-analysis by Cipriani and colleagues demonstrated reduction in STBs among individuals with unipolar as well as bipolar illness; the authors hypothesized that lithium’s apparent antisuicide benefits may be related to prevention of relapse and/or reduced aggression and impulsivity. No adequate studies to date have compared lithium against other combinations or adjunctive antidepressant strategies in TRD with suicide as a primary outcome. Buprenorphine: Recent years have seen a resurgence of interest in opioid mechanisms in depression treatment, particularly κ receptor antagonists, which appear to be associated with little or no abuse liability compared with mu agonists. Although no opioid agents have been approved for major depressive disorder (MDD) or TRD, a small proof-of-concept, placebo-controlled trial of ultralow-dose buprenorphine (mean dose 0.44 mg), a partial μ agonist and κ antagonist, showed rapid onset reduction of suicidal ideation among individuals with depression when added to ongoing pharmacotherapy.14 This benefit persisted for the 4-week trial, suggesting potential promise in opioid mechanisms to reduce STBs in TRD. Neurostimulation: Studies on most forms of neurostimulation treatments used in TRD have shown reductions in STBs. These include studies on electroconvulsive therapy,15-17 repetitive transcranial magnetic stimulation,18-20 and vagus nerve stimulation. Among investigational neurostimulation treatments, similar preliminary promising results for STBs have been reported with magnetic seizure therapy and transcranial direct current stimulation. Anecdotal reports suggested increased suicide risk among depressed individuals receiving deep brain stimulation though this has not been observed in other studies. Psychotherapies: A large body of data suggests that psychological therapies have a role in treating TRD and are often critical in the approach to TRD. Similarly, numerous studies suggest that first-line, evidence-based psychotherapies have a role in reducing risk of STBs. These include cognitive behavior therapy; dialectical behavior therapy; interpersonal psychotherapy; acceptance and commitment therapy; and collaborative assessment and management of suicidality,32 a therapeutic framework specifically designed for patients with suicidality. Brief and ultrabrief therapy interventions have also been found to be effective.33 Though promising, most studies have focused on suicidal ideation rather than suicide attempts or deaths, and no controlled trials to our knowledge have focused on STBs specifically in TRD populations. Managing Risk Core components in the management of suicide risk among patients with TRD include regular assessment, safety planning, and supporting a hopeful and realistic therapeutic stance. Assessment of suicide risk: Comprehensive assessment of suicide risk includes appreciation of longer-term demographic and clinical risk factors, identification of current and past suicidal thoughts, and evaluation of potentially impulsive emotional and behavioral responses to stressful circumstances. Psychiatric practice over the next decade will likely increasingly integrate a range of novel risk assessment and mitigation approaches, including machine learning techniques that scour electronic health records, behavioral tasks to evaluate implicit cognitions, and the use of ecological momentary assessment from digital devices coupled with patient prompts to support coping and help-seeking behaviors and messaging to clinical teams in the context of imminent risk. Many health systems have adopted standardized suicide risk screens, such as the Columbia-Suicide Severity Rating Scale (Figure 1), which includes questions clinicians use in routine assessments for patients with TRD. Using a standardized scale, routine assessment, and documentation of suicide risk among patients at elevated risk is integral to good clinical practice. Safety planning: For the many patients with TRD who are at high risk for suicide, clinicians and patients should collaboratively agree upon a safety plan34 that typically includes (1) identifying warning signs for suicidal behavior; (2) using coping activities, including relaxation and distraction; (3) reminding of individuals and social situations that can provide distraction; (4) listing contact information for personal supports in a crisis; (5) recording phone numbers for professional and emergency resources and the 988 suicide prevention lifelines; and (6) describing steps to make the environment safer (eg, reducing access to firearms or stockpiled medications). The safety plan should be maintained by the patient and clinician and updated regularly, particularly at key transitions such as hospital discharge. Therapeutic stance: Recurrently dashed hopes, growing pessimism, self-blame, persistent suffering, and social isolation are often core experiences of individuals with TRD. Joiner’s triad of thwarted belongingness, perceived burdensomeness, and hopelessness are evocative of this experience and the enhanced risk of suicide they entail. Clinicians working with patients with TRD and suicidality are not immune to absorbing the nihilism of the individuals they work with. Aspects of a positive therapeutic approach can be found in the Table. Concluding Thoughts TRD is associated with elevated risk for STBs and suicide death even when compared with depression without documented resistance. Risk factors for suicide in TRD appear to be largely similar to those in the general population and are often themselves risk factors for and/or consequences of TRD. A range of therapeutic targets are likely to be relevant for reducing risk of suicide in TRD. Several pharmacotherapies have shown potential antisuicide benefits, including clozapine, ketamine/esketamine, lithium, and buprenorphine. However, research in this area is still evolving with few studies involving active comparators or long-term follow-up and not all focused on TRD. Most forms of neurostimulation have been associated with reduction in suicidal ideation though this remains a nascent area of research. Several psychotherapies show substantial promise for reducing STBs, though most have focused on suicidal thoughts rather than suicide and none have been adequately studied in TRD. An optimal therapeutic approach to suicide in TRD involves screening and ongoing assessment, suicide planning, a hopeful but realistic therapeutic stance that emphasizes attainable goals and consistency in the treatment relationship, and recruitment of consultation and peer supports to address therapeutic blind spots and burnout. While TRD is associated with elevated risk of suicide, most individuals with TRD do not attempt suicide and many achieve reduction in suffering and a meaningful quality of life. Note: This article originally appeared on Psychiatric Times

SAN DIEGO — In the clinical opinion of Jenny E. Murase, MD, caring for patients with delusional infestation — the conviction that one is infested by animate or inanimate pathogens without medical or microbiological evidence of a true infestation — puts a dermatologist's communication skills to the ultimate test. "The fact that delusional infestation is a fixed, false belief [means] we will never agree with patients on the etiology by definition," Dr Murase, a dermatologist with the Palo Alto Foundation Medical Group, Mountain View, California, said at the annual meeting of the American Academy of Dermatology. "But somehow, we must come to some kind of an agreement on how to approach this therapeutically." Patients with delusional infestation (DI) often describe a cutaneous sensation of itching or crawling, biting, stinging — a pins and needles sensation. "Formication is when there's a crawling sensation on the surface of the skin," she said. "That's something we can agree on — the fact that there is a shared understanding that they're experiencing some kind of sensation in their skin." First described in 1894, several different terms have been used to describe DI in the past, including acarophobia, delusions of parasitosis, Ekbom syndrome, and Morgellons disease. The current term used for DI includes other animate or inanimate pathogens besides parasites. The average dermatologist manages two to three patients with DI every 5 years, "so it's not uncommon," said Dr Murase, who also holds a faculty position in the department of dermatology at the University of California, San Francisco. Females are about 2.5 times more likely to be affected compared with males, she said, and 8%-12% of patients with DI have a friend or relative who shares the symptom, and they often accompany them to the office visit. "Initially, you're trying to determine if this a primary condition where it's only the cutaneous condition the patient is experiencing, or if there is a secondary condition like an underlying psychiatric disorder or medical condition or drug use that contributes to the sensation," she said. According to a descriptive study of 115 patients with DI, 50% had at least one drug detected in hair samples, and nearly 60% had evidence of some cognitive impairment that could not be explained by deficits in IQ. Another study of 147 patients with DI seen at the Mayo Clinic between 2001 and 2007 found that 81% had a prior psychiatric condition and 26% had a shared psychotic disorder. Phased Approach to Treatment Dr Murase discussed her phased approach to caring for patients with DI, based on a review article that she and colleagues published in the International Journal of Dermatology. Phase 1 involves preparing for the visit by asking staff to refer to patients with DI as VIPs and allowing them to talk freely about the sensation they're experiencing. "The goal is to improve the patient's condition, not to convince the patient that he or she is delusional," Dr Murase explained. "Many patients can't distinguish between when they're talking to the doctor and when they're talking to a nurse or a nurse practitioner; they like to feel that they're being heard and listened to." She also recommends scheduling patients with DI for the end of the day and arranging frequent follow-up visits. "Making them feel valued is the bottom line," she emphasized. "Remember: They're less likely to respect socially defined boundaries like time constraints, so you do have to set boundaries, and don't take what they may say to you personally. You're not going to be able to care for that individual unless you do that. They may appear defiant, frustrated, and angry, but the fact that they showed up in your office means that you can help that person." Phase 2 of care for these patients consists of building a therapeutic rapport by greeting them with a smile and positive attitude and using welcoming body language such as sitting side-by-side during the office visit as opposed to face-to-face, "so it's a less aggressive approach," she said. Next, ask about their goal with a question such as, "Is it more important for you to find the bug/virus or to improve your condition?" During the visit, "you're continually shifting from etiology — which they are desperate to understand — to a shared desire for treatment," Dr Murase said. "No one knows what causes DI and remember, in medicine we treat patients when the exact etiology is unknown. So, we're not doing anything that differently. Focus on the effect that the symptoms are having on their life. Say something like, 'it must be so miserable to be living this way. I really want to help you.' " Phase 3 of care for patients with DI involves performing a thorough history and physical exam. The initial office visit should include a full body exam to rule out any underlying dermatologic condition that may be causing the sensation they're complaining about. She cited a retrospective study of 108 patients who presented to the Mayo Clinic with DI as the main reason for their office visit. Of the 80 patients who had a biopsy, 61% had chronic dermatitis; 48% had excoriation, ulceration, or erosion; and 31% had nonspecific dermal inflammation. Whether to perform a biopsy or not is controversial, Dr Murase added, because it's probably not going to change the clinical impression or diagnosis. "If you agree to do the biopsy, get a verbal contract with the patient," she advised. "You might say, 'We're going to do this. You're going to choose the site, we're going to do a biopsy, but we are going to be in agreement here that, if we can't find the etiology, that you will still be open to going on therapy.' This is important because it establishes a therapeutic alliance." Since patients with DI often bring in their own specimens, she also recommends providing them with microscope glass slides without cover slips and asking them to use clear tape, not tape that is opaque or matted, to cover the specimen. To rule out other illnesses and conditions that could be triggering the perceived DI, she said lab tests to consider include a complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, calcium, hemoglobin A1c, vitamin B12, urinalysis, toxicology screen, HIV/hepatitis C, and rapid plasma reagin. Starting Treatment Phase 4 of care for patients with DI involves initiating therapy, which includes demonstrating empathy by reflecting on the detrimental effects of the patient's reported sensations on their quality of life. "Emphasize that you are not questioning their experience, and that you don't doubt that they feel things on their skin," Dr Murase said. "Recommend medications on an empirical or 'trial and error' pragmatic basis. I often tell patients, 'I will never give up on you if you will never give up on me.'" For treating patients with DI, her first-generation antipsychotic of choice is pimozide. She starts at a dose of 0.5 mg, building up to 2-3 mg once a day. Haloperidol is another option: 0.5 mg to start, building up to 1-5 mg every night at bedtime. "This requires monitoring for bone suppression via CBC and hypermetabolic complications via fasting lipids and HbA1c," she said. "There is also an increased risk of prolonged QT with pimozide and risk of extrapyramidal symptoms and tardive dyskinesia." Second-generation antipsychotics to consider include risperidone (0.5 mg to start, building up to 102 mg at bedtime); olanzapine (2.5 mg to start, building up to 5-10 mg at bedtime); aripiprazole (2-5 mg to start, build ing up to 10-15 mg a day), and quetiapine (12.5 mg to start, building up to 200 mg at bedtime). For all medical therapy she recommends starting patients with a low dose, increasing by 0.5 mg every 2-3 weeks, and let them be "stable and comfortable" for 3-4 months, and then taper down the dose by 0.5 mg every 2-4 weeks or more slowly. In the medical chart, Dr Murase recommends avoiding use of the terms "psychosis" and "delusions." Instead, "formication" (tactile hallucination of insects crawling on or within the skin) or "cutaneous dysesthesia" are better terms if patients access their records, she said. Note: This article originally appeared on MDedge.com, part of the Medscape Professional Network.

CASE VIGNETTE “Brandon” is a 42-year-old divorced African American man with acquired hearing loss who has become unemployed recently due to layoffs during the COVID-19 pandemic. He has been admitted to the hospital for sepsis, and psychiatry has been consulted for agitation. Although it is in the early stages of the pandemic with a high rate of mortality, he has been asking members of the emergency medicine team to remove their face masks while caring for him. The primary team is concerned that he is delusional because this seems unreasonable during a global pandemic. They place a behavioral flag on his medical record to notify other health care providers of a potentially dangerous patient. Although the patient has no psychiatric history, the team believes the patient’s behavior indicates a psychotic disorder, and they request recommendations for pharmacological treatment. Brandon grew up without regular access to health care. As a child, he suffered from recurrent fevers that his family only treated with painkillers. The family later found out that Brandon had been getting ear infections, and the lack of treatment eventually led to permanent hearing impairment. He was born to 2 hearing parents who wanted him to be able to speak and lip read to fit into hearing society. They did not learn or use American Sign Language and chose for Brandon to receive a mainstream education. As Brandon’s hearing has progressively decreased, he has found himself relying more on lip reading and facial expressions to follow conversations. With masking and social distancing during the COVID-19 pandemic, he has been afraid of losing even more of his autonomy and independence. Brandon’s admission to the hospital has been a long and painstaking process. Since coming to the hospital overnight, he has spoken to multiple nurses and several emergency medicine physicians who have all been non-Latinx White. His evaluations occur after visitor hours are over, and due to the hospital’s COVID-19 policy, most interactions have been 1-on-1. Although Brandon is comfortable speaking for himself, he has noticed that staff have an awkward demeanor around him. Because of past experiences of racism, he wonders if they are reluctant to interact with him because he self-identifies as Black. It has also been difficult to communicate with the team because the ambient noise in the emergency department interferes with his ability to hear what others are saying to him. Discussion: How does Brandon’s intersectionality affect his experience of the health care system? Brandon’s case highlights the complexity of patient experiences in health care. Health inequities are often discussed using single-identity categories such as race, gender, and sexuality. However, these categories interact with each other to affect how individuals experience their lives and interpersonal power dynamics.1 This is denoted by the concept of intersectionality—challenges that individuals experience may be better understood by considering their multiple identities at once as opposed to each category separately. In this case, aspects of Brandon’s social identity that may influence his care include his gender identity (male), his self-identified race (Black), and his disability status (hearing impaired). The care he receives may vary depending on clinician perceptions of the intersection of these identities. Intersections matter: Black American men tend to have a higher rate of chronic physical illness than non-Latinx White Americans of any gender, and research shows it is the combination of race and gender that accounts for this difference. Literature review has also highlighted that the medical literature commonly conflates Blackness with genetics—meaning that the etiology of a particular condition is attributed to a biological cause rather than social construction of race, further fueling potential racism. How should the team balance the ethical dilemma of providing adequate care when they may have concerns about their personal safety during the pandemic? Another consideration is the health care team’s personal safety during the pandemic. The clinicians seemed unwilling to make communication more accessible for Brandon due to the risk of their exposure to COVID-19. Although face masks can be a barrier to communication, removing them could indeed increase the likelihood that a health professional will contract COVID-19. However, clinicians have an ethical duty to provide equitable care. Unconscious biases may influence the extent to which clinicians are willing to accommodate patients’ needs. In this case, the clinicians, being White and in a position of power and privilege in the hospital, may not have considered options such as moving Brandon to a quieter area. Instead, they reacted to Brandon’s requests with fear, assuming that he was dangerous or mentally ill. At a systemic level, the Americans With Disabilities Act requires hospitals to provide effective communication with deaf and hard-of-hearing patients. However, hospitals often lack appropriate resources to support patients and may not provide assistive technology. Unfortunately, the early days of the pandemic highlighted that the US health care system did not have adequate resources to care for most patients. Hospitals struggled to provide hospital beds to inpatients, ventilators to patients in critical condition, and adequate personal protective equipment to medical teams. This scarcity amplified the disparities in access to care that were already present. In addition, even experiences of vicarious racism during the COVID-19 pandemic have been shown to have negative impacts on mental health. In response to the pandemic and pervasive audism, the National Association for the Deaf has released guidelines for communication with deaf and hard-of-hearing individuals for hospital medical care and video-based telehealth services.9 In the hospital, using pen and paper is an option, but it is not ideal for gathering patient history, which requires multiple questions in succession. In Brandon’s case, if the health care team had worn transparent face masks, this could have helped mitigate the conflict between effective communication and personal safety. Other examples of options for communication include video remote interpreting, speech-to-text, typing back, and captioned phone calls. By asking Brandon for his preferred mode of communication, the team would have learned that he does not know sign language and a video interpreter would not have been helpful. Ensuring that he was roomed in an area with wi-fi could have empowered Brandon to have more autonomy if he had an internet-based app on his smartphone to assist with communication. There are both institutional and interpersonal elements of this case that highlight the phonocentricity of medical care. Research has shown that psychiatric disorders tend to be more prevalent in individuals with hearing loss. Factors such as social isolation and loneliness may put patients at risk for mood disorders. Patients who are deaf or hard of hearing remain a population with unmet medical needs. What culturally appropriate recommendations can consulting psychiatrists provide for the primary team? Consulting psychiatrists can help clarify the patient's experience through a clinical interview and advocate for the patient within the clinical environment. Sociocultural factors contributing to power differentials within interpersonal interactions need to be identified. A helpful mnemonic for this purpose is ADDRESSING,12 which stands for: Age and generational influences Developmental disability Disability acquired later in life Religion and spiritual orientation Ethnicity/race identity Socioeconomic status Sexual orientation Indigenous heritage National origin Gender Consulting psychiatrists should help the primary team recognize and work effectively within these cultural differences. In addition to providing diagnostic clarification that the patient does not have a psychotic disorder, consulting psychiatrists can empathize with the primary team, offer a space for them to reflect on their pandemic fears, and help them recognize the pitfall of pathologizing behaviors that are appropriate responses to marginalization and discrimination. Brandon's frustration becomes understandable in the context of racist and ableist oppression, and interventions should instead be focused on ensuring the provision of equitable care. By adopting a cultural lens, consultants can ensure that patients like Brandon have access to adequate supports while receiving appropriate medical treatment. Further, psychiatrists may want to engage the team to conduct a comprehensive case formulation that takes cultural factors into account. The American Psychiatric Association Outline for Cultural Formulation (OCF) is a framework that encompasses the domains of the cultural identity of the individual; cultural concepts of distress; psychosocial stressors and cultural features of vulnerability and resilience; cultural features of the relationship between the individual and the clinician, treatment team, and institution; and an overall cultural assessment. To aid in the construction of a cultural formulation, the DSM-5 Cultural Formulation Interview was developed with standardized questions to help clinicians elicit and gather cultural information. Note: The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors; they do not represent the authors’ organizations of employment and are not affiliated with GAP. This article originally appeared on Psychiatric Times

Keypoint: Older adults with depression are at increased risk for highly complex multimorbidity. Older adults with depression have a more rapid progression of multimorbidity and a greater risk of developing highly complex multimorbidity (HCMM), according to study results published in The American Journal of Geriatric Psychiatry. Multimorbidity – or the presence of 2 or more long-term health conditions – is more prevalent among older individuals and is influenced by the number, severity, and complexity of chronic conditions. Although research indicates that depression may exacerbate the severity of multimorbidity, it is still unclear how the multimorbidity is affected by different subtypes and severity of late-life depression. To this aim, investigators conducted a population-based cohort study using data from the Korean Longitudinal Study on Cognitive Aging and Dementia, which collects information on community-dwelling older adults (aged 60 years and older). The investigators identified individuals in the dataset who completed the mood status and multimorbidity evaluations, did not exhibit complex multimorbidity (CMM), and underwent a minimum of 1 follow-up assessment within the 8-year follow-up period. The investigators characterized CMM as the presence of 3 or more chronic medical conditions across 3 or more distinct body systems at the initial assessment. Depression was measured through self-administration of the Geriatric Depression Scale (GDS). Participants with scores of 10 to 19 points were considered to have mild depression and scores of 20 and higher qualified as severe depression. The investigators also assessed sociodemographic characteristics, economic status, alcohol consumption, smoking status, and physical activity as potential covariates. The investigators included a total of 2,486 participants who were followed over an average period of 5.8 years. Among them, 988 (39.7%) participants self-reported experiencing depression at the initial assessment. Individuals who were depressed were older (P =.003) and were more likely to be women (P <.001), widowed or divorced (P <.001), live alone (P =.001), live in poverty (P <.001), and have less education (P <.001) than individuals without depression. The investigators found that individuals with depression demonstrated a faster progression in total multimorbidity scores (β, 0.132; 95% CI, 0.073-0.192; P <.001) compared with individuals who did not have depression. This change was even more pronounced for individuals with severe depression (β, 0.168; 95% CI, 0.054-0.281; P =.004) relative to those with mild depression (β, 0.125; 95% CI, 0.062-0.188; P <.001). The investigators also observed that individuals with depression demonstrated a faster progression in complexity scores for multimorbidity (β, 0.065; 95% CI, 0.029-0.102; P =.001) relative to individuals without depression. Again, the complexity score changes were more pronounced for severe depression (β, 0.100; 95% CI, 0.029-0.171; P =.006) compared with mild depression (β, 0.58; 95% CI, 0.018-0.097; P =.004). However, the severity scores for multimorbidity were similar between the groups (β, 0.001; 95% CI, -0.017 to 0.018; P =.870). Additionally, individuals with depression faced a 44% higher risk of developing highly complex multimorbidity – regardless of depression severity and subtype – relative to those without depression. “As depression is modifiable through timely screening and appropriate management in primary care and public services, multidisciplinary care, including comprehensive assessment, shared decision-making, and efficient communication of treatment plans, may be required to establish person-centered management of multimorbidity across mental and physical illnesses,” the investigators concluded. Study limitations include the lack of validation for depression categorization, reliance on self-reported chronic conditions, use of non-validated and self-reported depression assessment, and generalizability of the findings may not extend to other populations beyond community-dwelling Korean older adults. Note: This article originally appeared on Psychiatry Advisor

A persistent state of anger or annoyance coupled with frequent and intense temper outbursts in children and adolescents often signals clinically impairing irritability. Clinical irritability disrupts a child's daily life and can continue to cause problems into adulthood. Although irritability is one of the leading reasons children are seen for psychiatric care, it is understudied compared to other childhood disorders. Critically, evidence-based treatments for clinical irritability are also lacking. In a new study, researchers at the National Institute of Mental Health (NIMH) successfully used exposure-based cognitive behavioral therapy (CBT) to treat severe irritability in children. This promising breakthrough underscores the importance of tailored interventions in this area of child psychiatry. What is severe irritability in children? This study focused on severe and impairing irritability and temper outbursts in youth. All children feel angry or irritable at times. Severe irritability is more serious and can cause problems at home, during school, and with friends. Irritability and outbursts are part of many mental disorders, but they are core symptoms of disruptive mood dysregulation disorder (DMDD). DMDD is diagnosed in children and adolescents who show ongoing irritability, frequent anger, and intense temper outbursts. Symptoms of DMDD are severe and require treatment. Children with this high level of irritability get angry often and to a degree that is disproportionate to the situation and their age. When angry, they show temper outbursts, usually involving high motor activity and verbal or physical aggression. These children are also persistently irritable or cranky most of the time and across many situations. How did the researchers treat severe irritability in children? Researchers led by Melissa Brotman, Ph.D., in the NIMH Intramural Research Program tested a novel treatment for irritability. Developed in Dr. Brotman’s lab, the exposure-based CBT treatment draws on a highly effective treatment for anxiety—exposure therapy. In this pilot study, the researchers examined the effectiveness, acceptability, and feasibility of exposure therapy for severe irritability. Forty children (8–17 years) participated in the study, which took place at the NIH Clinical Center . Children had to have at least one of two core DMDD symptoms: chronically irritable mood or severe temper outbursts. Some children also had co-occurring anxiety or attention-deficit/hyperactivity disorder (ADHD), but they were not eligible for participation if diagnosed with other disorders, such as bipolar disorder, substance use disorder, schizophrenia, or autism spectrum disorder. All children received 12 sessions of exposure-based CBT following an established manual written by Dr. Brotman. Each treatment session had a child and a parent portion. The child portion focused on increasing tolerance to frustration. Clinicians carefully exposed children to anger-provoking situations, gradually moving up a hierarchy specific to that child. Examples could be taking away a preferred item (for example, stopping a video game or getting off the iPad) or starting a disagreeable activity (for example, brushing teeth or doing homework). Clinicians worked with the child to learn to tolerate and constructively respond to their feelings without a temper outburst. The parent portion focused on parent management skills. Parents were taught to actively ignore their child’s temper outbursts to stop reinforcing those behaviors. Instead, they learned how to focus on and consistently reward positive behaviors. Children were randomly assigned to be observed for either 2, 4, or 6 weeks before starting treatment. Clinical observers were blind to when active treatment began. This observation period allowed the researchers to confirm that symptoms changed only after treatment started and were not accounted for by the clinician’s expectations of the treatment. Clinicians, children, and their parents rated the child’s irritability symptoms and overall functioning during the observation period, during treatment, and 3 and 6 months after treatment. Depression, anxiety, and ADHD symptoms were also assessed for comparison. The acceptability, feasibility, and safety of the therapy were determined by rates of study dropout and adverse events. Did exposure-based CBT treatment help children with severe irritability? Irritability symptoms decreased significantly during treatment based on clinician, child, and parent reports. Overall functioning also improved—by the end of treatment, 65% of children were significantly improved or recovered based on the clinician measure. Symptoms did not return after treatment stopped and, in fact, treatment gains were maintained at the 3- and 6-month follow-ups. When examining the core symptoms of DMDD, 60% of children were considered recovered on the Temper Outburst scale and 25% were recovered on the Irritable Mood scale at the end of treatment. This result suggests a stronger effect of exposure therapy in decreasing temper outbursts compared to improving irritable mood. In contrast, the treatment was not associated with significant changes in anxiety, depression, or ADHD symptoms, suggesting its specificity in targeting irritability. No families dropped out once treatment began, suggesting exposure therapy was acceptable and feasible. Similarly, no adverse events were reported, supporting the safety of using exposure therapy with children. What can researchers do next to further treatment for children with severe irritability? Taken together, these results support the effectiveness, acceptability, and feasibility of exposure therapy for youth with severe irritability. Irritability symptoms and overall functioning improved during treatment per clinician, child, and parent reports and were maintained for several months after treatment stopped. This study has some limitations. First, it had a relatively small sample size with a limited racial, ethnic, and socioeconomic composition, which limits the generalizability of the results. Second, the study did not include a control group of children with irritability who did not receive treatment. Although the researchers addressed this concern by having multiple observation periods, comparing this novel treatment to current clinical care is a critical next step. Third, the study included a wide age range, making it important to test whether there are differences in outcomes based on age. Last, because clinicians delivered the child and parent components at the same time, future studies could examine the individual contribution of child exposure therapy versus parent management skills to determine whether one is driving treatment effects. The positive results from this pilot study set the foundation to further explore CBT treatment for childhood irritability. Although the therapy is not yet ready for clinical practice, it offers one of the few evidence-based treatments for this frequent and impairing childhood disorder. The researchers plan to test and refine the exposure therapy in larger, more controlled clinical trials to advance treatment for children with severe irritability and their families. Note: This article originally appeared on NIMH

Keypoint: War exposure was associated with a 62% greater prevalence of moderate or severe depression among Ukrainian adolescents. The mental health of Ukrainian adolescents has been substantially affected by the Russian invasion of Ukraine, according to results recently published in JAMA Pediatrics. Adolescents exposed to the war were more likely to screen positive for post-traumatic stress disorder (PTSD), depression, anxiety, substance use disorder, and eating disorders. Since the Russian invasion of Ukraine in February 2022, citizens in Ukraine have been increasingly exposed to traumatic events and have reduced access to mental health care. However, there has been a lack of quantitative research on the mental health consequences of this ongoing conflict, particularly among vulnerable populations such as adolescents. Therefore, investigators conducted the current study to evaluate the mental health burden among Ukrainian adolescents who were exposed to the war. The investigators recruited Ukrainian adolescents 15 years of age and older who were attending secondary schools (both within Ukraine and abroad) to establish the Adolescents of Ukraine During the Russian Invasion (AUDRI) cohort. Participants were asked about their demographic information, psychiatric conditions, displacement status, current place of residence, and whether they had been separated from their parents due to the war. Additionally, the investigators used validated tools to screen for PTSD, depression, anxiety, substance use disorders, and eating disorders. Overall, 12,522 adolescents responded to the survey and 8096 responses were eligible for analysis. A total of 7493 responses were from adolescents residing in Ukraine, while 603 responses were from adolescents living abroad. Most responses were from adolescents aged 15 (41.7%), 16 (31.3%), or 17 (16.6%) years, and 61.6% of respondents were girls. According to national-level estimates, nearly half (49.6%) of the respondents were directly exposed to war and 92.3% were exposed to any type of psychological trauma. Additionally, 33.2% of adolescents reported that they had been displaced and 20.7% indicated that they had been separated from their parents. The investigators observed that 35.0% of respondents met criteria for having been exposed to clinically relevant psychological trauma. For mood disorders, 25.0% of adolescents screened positive for moderate depression, 6.9% screened positive for severe depression, 11.9% were positive for moderate anxiety, and 5.9% were positive for severe anxiety. Additionally, substance use disorders were detected in 20.5% of respondents and 29.5% of adolescents qualified for an eating disorder. In regression models, the investigators found that that exposure to war was associated with a 62% greater prevalence (95% CI prevalence ratio, 1.45-1.81) and an 8.7 percentage point greater prevalence (95% CI prevalence difference, 6.6-10.9 percentage points) of moderate or severe anxiety. Furthermore, war exposure was associated with a 39% greater prevalence (95% CI prevalence ratio, 1.29-1.50) and 11.1 percentage point greater prevalence (95% CI prevalence difference, 8.6-13.7 percentage points) of moderate or severe depression. This increased prevalence was similar among adolescents living in Ukraine and those living abroad. These findings indicate that the prevalence of a positive screen for psychiatric conditions among adolescents in Ukraine is high. The investigators stated, “The Russian invasion of Ukraine in 2022 has put substantial mental health burden on Ukrainian adolescents within Ukraine and abroad.” Study authors concluded, “Mental health care efforts to alleviate the mental health burden of Ukrainian adolescents need to be scaled up to protect the country’s future.” Study limitations include regional variations in survey response rates, a gender imbalance of respondents, reliance on self-reported data, and an inability to distinguish between mental health burdens due to healthcare shortages vs war exposure. Note: This article originally appeared on Psychiatry Advisor

Keypoint: People experiencing psychological symptoms of menopause may benefit from CBT or mindfulness. Psychosocial interventions of cognitive behavioral therapy (CBT) and mindfulness-based interventions (MBI) improve depression and anxiety during menopause, according to systematic review and meta-analysis findings published in the Journal of Affective Disorders. These interventions also improved cognition and quality of life for individuals experiencing menopause. Although menopause is commonly associated with physiological symptoms like menstrual cycle changes, hot flashes, and night sweats, people experiencing menopause also frequently experience cognitive impairment, depression, and anxiety. Hormone replacement therapy is typically the first line treatment for physiological symptoms of menopause, but relatively little is known about the efficacy of psychosocial interventions for the improvement of non-physiological symptoms. To this aim, investigators conducted a systematic review and meta-analysis to determine if cognitive behavioral therapy (CBT) and mindfulness-based interventions (MBI) are effective in improving depression and anxiety among people experiencing menopause. The investigators searched publication databases from inception to August 2023 for randomized controlled trials assessing CBT and MBI for menopausal transition and reported at least 1 outcome related to cognition, mood, or quality of life. Overall, 30 studies were included for analysis, with a pooled sample size of 3501 participants. On average, participants were between 47 to 59 years of age, 2686 were undergoing gradual menopause, and 815 had treatment-induced menopause. OF the included studies, 20 reported mood outcomes, 4 assessed cognition, and 24 evaluated quality of life outcomes. Most psychosocial interventions were primarily group-based and conducted in person. For the meta-analysis, a total of 11 studies had available data on anxiety and 12 studies had data for depression outcomes. The investigators found that anxiety significantly improved with both MBI (d, -0.56; 95% CI, -0.74 to -0.39) and CBT (d, -0.22; 95% CI, -0.35 to -0.10). Similarly, depressive symptoms among people experiencing menopause were significantly reduced with MBI (d, -0.27; 95% CI, -0.45 to -0.09) and CBT (d, -0.33; 95% CI, -0.45 to -0.21). However, there was considerable heterogeneity of MBI data for anxiety (I2, 85.48%) and significant heterogeneity of CBT data for depression (I2, 85.48%). The investigators also found that cognition (d, -0.23; 95% CI, -0.40 to -0.06) and quality of life (d, -0.78; 95% CI, -0.93 to -0.63) were significantly improved with psychosocial interventions, though there was considerable heterogeneity of data and smaller sample sizes for these analyses. The overall quality of included studies was moderate, although 66.7% of the studies were judged to have some concerns for risk for bias, 23.3% of the studies had high risk for bias, and 10.0% had low risk for bias. “The findings of this review add to existing menopause literature by supporting the effectiveness of psychosocial interventions on non-physiological symptoms of mood, cognition, and quality of life,” the investigators noted. Study authors concluded, “Our review could inform the development of menopause services, in which enhanced professional training could pave the way for integrating mindfulness and CBT as conventional healthcare service options. At the center of treatment is the understanding of menopausal symptoms and embracing sufficient social support.” These findings may be limited by the failure to collect data regarding menopausal status, a lack of consideration or defining of participants who may identify as non-binary or trans men, and relatively short follow-up times for symptom changes. Note: This article originally appeared on Psychiatry Advisor

Keypoint: Patients with posttraumatic epilepsy vs those without a history of head injury or seizure/epilepsy had an approximately 3-fold increase in dementia risk. Compared with patients without a history of head injury or seizure/epilepsy, patients with posttraumatic epilepsy are at a greater risk of developing dementia, according to study findings published in JAMA Neurology. Posttraumatic epilepsy, accounting for 5%-20% of acquired epilepsies, has previously been linked to worse short-term outcomes. There is, however, a limited understanding of its long-term consequences. These uncertainties presented the need for additional investigation into the cognitive impacts and dementia susceptibility among individuals with posttraumatic epilepsy in contrast to individuals with either head injury or epilepsy alone. Using data through December 2019, with a median follow-up of 25.4 years, researchers conducted a prospective cohort study involving 12,558 older adults (mean age, 54.3; women, 57.7%; Black, 28.2%) already enrolled in the Atherosclerosis Risk in Communities (ARIC) study to determine the association between posttraumatic epilepsy and dementia risk. The primary outcome of interest was dementia, which was defined using cognitive assessments, informant interviews, and International Classification of Diseases (ICD) and death certificate codes. Head injury was defined by self-report and ICD diagnostic codes, seizure/epilepsy was defined using ICD codes, and posttraumatic epilepsy was defined as a diagnosis of seizure/epilepsy occurring more than 7 days after injury. Dementia risk was estimated using adjusted Cox and Fine and Gray proportional hazards models and head injury, seizure/epilepsy, and posttraumatic epilepsy were analyzed as time-varying exposures. At baseline, patients were grouped into 1 of 4 time-varying exposure categories: no head injury and no seizure/epilepsy (n=9962; 79.3%); head injury (n=1811; 14.4%); seizure/epilepsy (n=640; 5.1%); or posttraumatic epilepsy (n=145; 1.2%). Over a period of 250,372 person-years of follow-up, 2498 cases of dementia were observed. Compared with patients in the no head injury or seizure/epilepsy group, patients with posttraumatic epilepsy demonstrated the lowest cumulative dementia-free survival, which was associated with 4.85 (95% CI, 3.72-6.33) times greater risk for dementia. Compared with no head injury or seizure/epilepsy, head injury and seizure/epilepsy were associated with 1.64 (95% CI, 1.48-1.82) and 2.81 (95% CI, 2.39-3.31) times the risk for dementia, respectively. This risk for dementia remained significantly higher in patients with posttraumatic epilepsy than that associated with head injury alone or seizure/epilepsy alone, even after adjusting for vascular and genetic risk factors. Models considering the competing risk for death alone and death and stroke revealed a 3-fold increased risk for dementia with posttraumatic epilepsy. Stronger associations were observed in younger participants, with no evidence for interaction by sex or race. In secondary analyses, associations were similar for posttraumatic epilepsy occurring post-first (hazard ratio [HR], 4.63; 95% CI, 3.46-6.21) or post-second (HR, 4.24; 95% CI, 2.27-7.92) head injury, and with posttraumatic epilepsy occurring after mild (HR, 5.03; 95% CI, 3.57-7.09) or moderate/severe/penetrating (HR, 3.15; 95% CI, 1.82-5.46) head injuries. Compared with individuals in the seizure/epilepsy only group, as well as individuals in the head injury only group, individuals with head injuries following seizures/epilepsy were found to have a higher risk for dementia. However, compared with those in the posttraumatic epilepsy group, patients with head injuries following seizures/epilepsy had a lower risk for dementia. Compared with later onset (more than 3 years after head injury) posttraumatic epilepsy (HR, 3.06; 95% CI, 2.21-4.08), earlier onset (within 3 years of head injury) posttraumatic epilepsy demonstrated a stronger association with dementia (HR, 7.30; 95% CI, 5.14-10.37). This pattern was maintained even when the timing of posttraumatic epilepsy onset after head injury was stratified by injury severity. Study limitations included the limited generalizability of results to individuals who sustained a prior head injury at baseline, potentially confounding factors such as frailty, and reliance on self-reported data and ICD codes with inherent sensitivity and specificity limitations. “These findings provide evidence that PTE [posttraumatic epilepsy] is associated with long-term outcomes and supports both the prevention of head injuries via public health measures and further research into the underlying mechanisms and the risk factors for the development of PTE, so that efforts can also be focused on the prevention of PTE after a head injury,” researchers concluded. Disclosures: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures. Note: This article originally appeared on Neurology Advisor

Keypoint: A co-located bridging recovery initiative improved access to care for patients with OUD, but at a high care cost. Inpatients with opioid use disorder (OUD) referred to a co-located outpatient bridge clinic had more buprenorphine refills, reduced overdose rates, and greater linkage to health care professionals who provide medication for OUD (MOUD), according to study results published in JAMA Network Open. However, these patients experienced more readmissions, higher care costs, fewer hospital-free days, and similar hospital length of stay (LOS) compared with patients with OUD receiving usual care. Opioid use and overdose deaths are a major public health crisis in the United States. Because MOUD has proven to be the most effective component of substance use treatment in the outpatient setting, general hospitals have increasingly looked toward incorporating integrated addiction consultation services to improve outcomes for patients presenting with OUD. Therefore, researchers assessed the efficacy and utility of a co-located bridging recovery initiative on treatment and care outcomes among inpatients with OUD. The researchers conducted a parallel-group, randomized, single-center clinical trial (The Bridging Recovery Initiative Despite Gaps in Entry [BRIDGE]; ClinicalTrials.gov Identifier: NCT04084392) from the end of November 2019 through September 2021 at the Vanderbilt University Medical Center, Vanderbilt Psychiatric Hospital in Nashville, Tennessee. The primary outcome was hospital LOS among patients with OUD. Secondary outcomes included linkage to health care professionals who provided MOUD, number of buprenorphine-naloxone (or naltrexone) prescriptions filled, same-center emergency department visit and hospital readmission rates, hospital-free days, recurrent opioid use, mortality, quality of life (assessed via the Schwartz Outcome Scale-10), overdose, and care costs. Eligible participants were patients with active OUD who were 18 years and older, accepted a transitional prescription for naltrexone or buprenorphine-naloxone, and did not have a fixed outpatient MOUD plan before admission. The intervention was a co-located, multispecialty clinic that provided patients with a buprenorphine-naloxone bridge prescription and coordinated treatment with a clinician within 1 week of discharge. Patients then and presented at the clinic weekly for 8 weeks then twice monthly for treatment. The patient care team was composed of specialists in addiction psychiatry, infectious diseases, internal medicine, and pain anesthesia, as well as social workers, recovery coaches, and a nurse case manager. Usual care consisted of referral to a community healthcare professional for MOUD linkage by a non-specialty, hospital-based social worker team. The researchers included 355 participants who were randomly assigned 1:1 to the bridge clinic (n=167) or to usual care (n=168). Patients (median age=38.0 years) were mostly White (85.7%), non-Hispanic/Latino (95.5%), and men (57.9%). Demographic variables were balanced across study arms. The researchers found that hospital LOS was not significantly different between the intervention and usual care cohorts (adjusted odds ratio [aOR], 0.94; 95% CI, 0.65-1.37; P =.74). Furthermore, noted participants referred to the bridge clinic experienced more readmissions (aOR, 2.17; 95% CI, 1.25-3.76), higher care costs (aOR, 2.25; 95% CI, 1.51-3.35), and fewer hospital-free days (aOR, 0.54; 95% CI, 0.32-0.92) than participants in the usual care arm at the 16-week follow-up. However, the bridge clinic recovery initiative did increase the odds of receiving more MOUD refills (aOR, 6.17; 95% CI, 3.69-10.30), linkage to healthcare professionals who provided MOUD (aOR, 2.37; 95% CI, 1.32-4.26), and decreased the likelihood of an overdose (aOR, 0.11; 95% CI, 0.03-0.41). Study authors concluded, “These findings suggest that among a complex cohort of hospitalized patients with OUD, outpatient metrics may be positively affected through the connection to a bridge clinic, but higher resource use and higher expenditure may be required to achieve these goals.” These study findings may be limited, given the low response rate in follow-up, potential treatment bias due to the lack of blinding, and the researchers did not account for differences in OUD severity during randomization. Note: This article originally appeared on Psychiatry Advisor

Keypoint: Young people with ADHD experience higher levels of loneliness, which in turn contribute to worse mental health outcomes. Young people with attention-deficit/hyperactivity disorder (ADHD) experience higher levels of loneliness than their peers without ADHD, according to results from a systematic review and meta-analysis published in the Journal of Attention Disorders. These higher levels of loneliness are associated with additional mental health difficulties, emphasizing the need for early interventions in this population. Although individuals with ADHD often experience social difficulties, relatively little is known about the prevalence of loneliness — the subjective experience of perceived social isolation — among young people with ADHD. Because both ADHD and loneliness are separately associated with adverse mental health outcomes, understanding the prevalence and effect of this comorbidity may help researchers and providers develop mental health interventions for individuals with ADHD. To this aim, investigators conducted a systematic review and meta-analysis to determine the 1) prevalence of loneliness among young people (10 to 24 years of age) with and without ADHD and 2) how loneliness affects mental health in individuals with ADHD. The investigators searched publication databases for cross-sectional or longitudinal quantitative studies that evaluated at least 1 measure of loneliness among young people with ADHD. Participants’ ADHD was verified via Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses, International Classification of Disease (ICD) codes, or symptomatic presentation. A total of 20 studies were included, 17 of which included a comparison group in addition to individuals with ADHD. Additionally, 8 studies evaluated mental health difficulties associated with loneliness among young people with ADHD. The pooled sample size was 1253 for participants with ADHD and 5028 for the non-ADHD comparator cohort. The ADHD cohort primarily comprised boys/men while the non-ADHD cohort had more girls/women. The investigators observed that 9 out of the 17 studies found higher levels of loneliness in the ADHD group, while 4 showed no notable differences, 3 did not conduct significance tests, and 1 indicated lower loneliness levels in the ADHD group during adolescence compared to childhood. The meta-analysis results confirmed that younger people with ADHD reported significantly higher levels of loneliness (Hedges g, 0.41; 95% CI, 0.25, 0.58; P <.001) relative to individuals without ADHD. Despite concerns about potential publication bias, moderator analyses indicated no significant influence on the effect size. In the systematic review exploring the association between loneliness and mental health difficulties in young individuals with ADHD, the investigators found significant positive associations between loneliness and externalizing behavior, internalizing behaviors, depression, anxiety, and addiction among individuals with ADHD. Loneliness fully mediated the association between depression and ADHD symptoms, and a diagnosis of ADHD diagnosis was a significant predictor for major depressive disorder onset, even after controlling for confounders. Additionally, social anxiety and internet addiction were correlated with loneliness in young individuals with ADHD. Authors concluded, “This review highlights that loneliness may be an important problem in ADHD and clinicians should be aware of and assess the potential for elevated loneliness in this population.” The investigators noted, “A better understanding of the experience of loneliness in young people with ADHD, including what contributes to their loneliness, may aid in developing loneliness interventions targeted for this population.” Study limitations include a small number of studies, the narrow focus on loneliness, and the use of a dichotomous categorization of ADHD (which may have excluded less severe presentations of ADHD). Note: This article originally appeared on Psychiatry Advisor

Social Media Cause Depression How heavy Instagram and Facebook use may be affecting kids negatively Quick Read Studies show that depression among teenagers and young adults has gotten more common over the past decade. Social media use has also increased during the same time. It’s hard to say for sure that social media causes depression. Still, there are several ways that using social media could harm kids. Some experts think that connecting with peers online is less emotionally fulfilling than connecting in person. Research shows that teenagers who spend more time on social media also feel more isolated. It could be that kids who already feel isolated use social media more. But it could be that using social media actually makes kids feel isolated. Another theory is that social media is bad for teenagers’ self-esteem. Seeing lots of perfect pictures online might make kids (especially girls) view themselves negatively. Feeling bad about themselves can lead to depression. Social media can also cut into the time that kids spend on activities that make them feel good, like exercise and hobbies. Additionally, it can distract from important tasks like homework. Having to juggle those responsibilities can increase kids’ stress. Studies also suggest that using social media at night interferes with restful sleep for many teenagers. It’s important for parents to check in with kids about their social media use and help them develop healthy habits. You can encourage kids to turn off notifications, spend plenty of time on offline activities that make them feel good, and put phones away before bedtime. You can also set a good example by modeling balance in your own use of social media. Finally, be sure to keep an eye out for signs of depression and get professional help if you’re worried. It’s especially important to check on kids who are under a lot of stress. Full Artilce: Is using social media making our kids unhappy? Evidence is mounting that there is a link between social media and depression. In several studies, teenage and young adult users who spend the most time on Instagram, Facebook and other platforms were shown to have a substantially (from 13 to 66 percent) higher rate of reported depression than those who spent the least time. Does that mean that Instagram and TikTok are actually causing depression? These studies show a correlation, not causation. But it’s worth a serious look at how social media could be affecting teenagers and young adults negatively. One reason the correlation seems more than coincidental is that an increase in depression occurred in tandem with the rise in smartphone use. A 2017 study of over half a million eighth through 12th graders found that the number exhibiting high levels of depressive symptoms increased by 33 percent between 2010 and 2015. In the same period, the suicide rate for girls in that age group increased by 65 percent. Smartphones were introduced in 2007, and by 2015 fully 92 percent of teens and young adults owned a smartphone. The rise in depressive symptoms correlates with smartphone adoption during that period, even when matched year by year, observes the study’s lead author, San Diego State University psychologist Jean Twenge, PhD. Over that same time period there was a sharp spike in reports of students seeking help at college and university counseling centers, principally for depression and anxiety. Visits jumped 30 percent between 2010 and 2015, and they’ve continued to rise since the pandemic. Social media and depression One of the biggest differences in the lives of current teenagers and young adults, compared to earlier generations, is that they spend much less time connecting with their peers in person and more time connecting electronically, principally through social media. Some experts see the rise in depression as evidence that the connections social media users form electronically are less emotionally satisfying, leaving them feeling socially isolated. “The less you are connected with human beings in a deep, empathic way, the less you’re really getting the benefits of a social interaction,” points out Alexandra Hamlet, PsyD, a clinical psychologist. “The more superficial it is, the less likely it’s going to cause you to feel connected, which is something we all need.” Indeed, one exception to the depression correlation is girls who are high users of social media but also keep up a high level of face-to-face social interaction. The Twenge study showed that those girls who interact intensely offline as well as through social media don’t show the increase in depressive symptoms that those who interact less in person do. And there are some teenagers who aren’t successful in connecting with peers offline, because they are isolated geographically or don’t feel accepted in their schools and local communities. For those kids, electronic connection can be lifesaving. Social Media and Perceived Isolation Another study of a national sample of young adults (age 19-32) showed correlation between the time spent on social media and perceived social isolation (PSI). The authors noted that directionality can’t be determined. That is, “Do people feeling socially isolated spend more time on social media, or do more intense users develop PSI?” If it’s the latter, they noted, “Is it because the individual is spending less time on more authentic social experiences that would decrease PSI? Or is it the nature of observing highly curated social feeds that they make you feel more excluded?” Which brings us what we now call FOMO, or fear of missing out. Jerry Bubrick, PhD, a clinical psychologist at the Child Mind Institute, observes that “FOMO is really the fear of not being connected to our social world, and that need to feel connected sometimes trumps whatever’s going on in the actual situation we’re in. The more we use social media, the less we think about being present in the moment.” Instead we might be occupied with worrying why we weren’t invited to a party we’re seeing on Instagram, or making sure we don’t miss a single post from a friend. But if we’re always playing catch-up to endless online updates, we’re prioritizing social interactions that aren’t as emotionally rewarding and can actually make us feel more isolated. Social media and self-esteem Another theory about the increase in depression is the loss of self-esteem, especially in teenage girls, when they compare themselves negatively with artfully curated images of those who appear to be prettier, thinner, more popular and richer. “Many girls are bombarded with their friends posting the most perfect pictures of themselves, or they’re following celebrities and influencers who do a lot of Photoshopping and have makeup and hair teams,” explains Dr. Hamlet. “If that’s their model for what is normal, it can be very hard on their self-confidence.” Indeed, image-driven Instagram shows up in surveys as the platform that most leads young people to report feeling anxiety, depression and worries about body image. Curation of a perfect image may not only make others feel inadequate, it’s unhealthy even for those who appear to be successful at it, notes Dr. Bubrick. “Kids spend so much time on social media trying to post what they think the world will think is a perfect life. Look at how happy I am! Look how beautiful I am! Without that they’re worried that their friends won’t accept them. They’re afraid of being rejected.” And if they are getting positive feedback from their social media accounts, they might worry that what their friends like isn’t the “real” them. Less healthy activity Another possible source of depression may be what teenagers are not doing during while they’re spending time on social media, including physical activity and things that generate a sense of accomplishment, like learning new skills and developing talents. “If you’re spending a lot of time on your phone, you have less time for activities that can build confidence, a sense of achievement and connectedness,” explains Dr. Hamlet. Kids who are spending a lot of time on devices are not getting much in return to make them feel good about themselves, she adds. “Yes, you get a little dopamine burst whenever you get a notification, or a like on a picture, or a follow request. But those things are addicting without being satisfying.” Disrupted concentration Another thing disrupted by social media is the process of doing homework and other tasks that require concentration. It’s become common for teenagers to engage with friends on social media at the same time they are studying. They take pride in being able to multi-task, but evidence shows that it cuts down on learning and performance. “Basically, multitasking isn’t possible,” Dr. Hamlet notes. “What you end up doing is really just switching back and forth between two tasks rather quickly. There is a cost to the brain.” And with poorer concentration and constant interruption, homework takes substantially longer than it should, cutting into free time and adding to stress. Sleep deprivation and depression Some of the ways in which social media use impacts mood may be indirect. For instance, one of the most common contributors to depression in teenagers is sleep deprivation, which can be caused, or exacerbated, by social media. Research shows that 60 percent of adolescents are looking at their phones in the last hour before sleep, and that they get on average an hour less sleep than their peers who don’t use their phones before bed. Blue light from electronic screens interferes with falling asleep; on top of that, checking social media is not necessarily a relaxing or sleep-inducing activity. Scrolling on social media, notes Dr. Hamlet, can easily end up causing stress. “Social media can have a profound effect on sleep,” adds Dr. Bubrick. “You have the intention to check Instagram or watch TikTok videos for 5 minutes, and the next thing you know 50 minutes are gone. You’re an hour behind in sleep, and more tired the next day. You find it harder to focus. You’re off your game, and it spirals from there.” How to minimize negative effects of social media use While we don’t yet have conclusive evidence that social media use actually causes depression, we do have plenty of warning signs that it may be affecting our kids negatively. So it’s smart for parents to check in regularly with kids about their social media use, to make sure it’s positive and healthy, and guide them towards ways to change it, if you think it’s not. Also, be alert for symptoms of depression. If you notice signs that your child might be depressed, take them seriously. Ask your child how they are doing, and don’t hesitate to set up an appointment with a mental health provider. Steps you can take to ensure healthy social media use: Focus on balance: Make sure your kids are also engaging in social interaction offline, and have time for activities that help build identity and self-confidence. Turn off notifications: App developers are getting more and more aggressive with notifications to lure users to interrupt whatever they’re doing to engage constantly with their phones. Don’t let them. Look out for girls at higher risk of depression: Monitor girls who are going through a particularly tough time or are under unusual stress. Negative effects of social media can have more impact when confidence is down. Teach mindful use of social media: Encourage teenagers to be honest with themselves about how time spent on social media makes them feel, and disengage from interactions that increase stress or unhappiness. Model restraint and balance in your own media diet: Set an example by disengaging from media to spend quality family time together, including phone-free dinners and other activities. Kids may resist, but they’ll feel the benefits. Phone-free time before sleep: Enforce a policy of no smartphones in the bedroom after a specific time and overnight. Use an old-fashioned alarm clock to wake up. Frequently Asked Questions

Keypoint: On average, primary care providers diagnose ASD 1 year earlier than other health care providers. Although primary care providers (PCPs) diagnose children with autism spectrum disorder (ASD) 1 year earlier than psychiatrists and psychologists, the likelihood of a PCP diagnosing a child with ASD has decreased every year from 2004 to 2019, according to study findings published in Autism. Further research is needed to understand this discrepancy and improve efficient diagnoses among children with ASD. An early diagnosis of ASD can be essential for initiating treatment during critical periods of development. Early interventions often lead to better long-term outcomes by addressing core challenges in childhood and connecting patients to necessary supports that improve their quality of life. A significant factor in achieving an earlier diagnosis is primary care appointment attendance, as PCPs are in a unique position to consistently monitor a patient’s development from infancy to childhood. Yet, the diagnostic tools required for an ASD diagnosis require extensive training and are often only used in specialized treatment centers. To determine whether PCP diagnoses of ASD have changed over time, investigators conducted a secondary analysis of data from the National Survey of Children’s Health (NSCH), a caregiver-report survey of the health and well-being of United States children from birth to 17 years of age. The goal of the analysis was to determine the rate of PCPs diagnosing ASD over time and children’s ages at diagnosis. Caregivers reported if a health care professional had ever diagnosed their child with ASD and were then asked to retroactively report which type of provider was the first to diagnose their child with ASD. The investigators collapsed the responses of provider type into PCP and non-PCP. A total of 5296 caregiver-reported diagnoses of ASD were included in the current study. On average, children were 5.13 (SD, 3.32) years of age at diagnosis, 76.8% of participants were White, 87.3% were non-Hispanic/Latinx, 80.0% of the children were boys, and 14.3% of the study group were first diagnosed with ASD by their PCP. From 2004 to 2019, the investigators found the likelihood of a PCP diagnosing a child with autism decreased by about 2% every year (odds ratio [OR], 0.98; 95% CI, 0.96-1.00). In a binary logistic regression model that controlled for demographic characteristics, the year in which a child was diagnosed with ASD was a significant, negative predictor of being diagnosed by a PCP (β, –0.02; P =.02). On average, children diagnosed with ASD by their PCP were about 1 year younger (4.10 years; SD, 2.67) than children diagnosed by a non-PCP (5.30 years; SD, 3.38; P <.001). The investigators wrote, “The present findings support the role PCPs play in early access to diagnosis, as age at first diagnosis of [ASD] was approximately [1] year earlier among children whose [ASD] was first diagnosed by their PCP as compared with non-PCPs.” Study authors concluded, “Overall, the current results indicate that more widespread access to diagnosis in primary care settings may have the potential to greatly reduce diagnostic delays in the years to come.” These study findings may be limited, as the investigators did not account for changes in ASD diagnostic criteria over the study period. Additionally, there was a lack of specificity in the survey questions and an inability to account for potential covariates (ie, living in an urban vs rural area, insurance type, and diagnostic features). Note: This article originally appeared on Psychiatry Advisor