Psychiatry, Treatment Resistant Dr. Bruce Kehr My dear reader. In a recent blog post, I lamented that we psychiatrists have let many of our patients down by practicing a symptom-oriented, prescription medication-driven, one-size-fits-all treatment approach that leaves far too many of our patients continuing to struggle with chronic emotional problems. They become treatment-resistant and need a different approach to healing. Holistic psychiatry, also known as integrative psychiatry or holistic mental health, focuses on each patient as a unique individual who has an “embodied mind.” By that, I mean that a patient’s capacity to feel good, have a normal range of human emotional expression, and be cognitively intact is not just a function of what goes on in their brain—it is far more complex than that. Human Life Is Comprised of a Vast Information System Inside Us Holistic or integrative psychiatry recognizes that inside our bodies, brains, and the cells that comprise them is a vast and enormously complex and integrated “information system” and that the myriad different components of the system are constantly talking to each other. It considers the interplay between the mind, body, emotions, and spirit in understanding and addressing mental health concerns. Think this is just a lot of New Age hype? Read on to discover some mind-blowing examples of just how this works in us humans—and why we need to take this approach in any patient who is not recovering their mental health. You Become What Has Been Transplanted Inside You Consider this for a moment: For decades now, studies have demonstrated that patients who undergo heart transplants and receive a donor heart begin to adopt the personality characteristics and food preferences of the (now deceased) donor. You know that familiar expression, “It’s a gut feeling”? A major study in the journal Nature Communications found that species of bacteria you have in your gut microbiome can have a profound effect on your risk of developing depression. Of the 39 trillion “bugs” in your gut microbiome, the following bacterial species were identified as more abundant in depressed patients: Ruminococcaceae Sellimonas Eggerthella Lachnoclostridium Hungatella Additionally, these species of bacteria were depleted in depressed patients: Coprococcus Lachnospiraceae Ruminococcus gauvreauii group Eubacterium ventriosum Subdoligranulum Numerous studies have shown that fecal transplantation of healthy microbes into patients with depression and anxiety improved their symptoms. In contrast, transplanting unhealthy microbes into patients without these symptoms caused them to develop anxiety and depression. Holistic Psychiatry in the Treatment Resistant Patient: Evaluate and Treat the Whole Person Holistic psychiatry can be based on what is known as root cause analysis of all of the forces and factors that shape our mental health, as depicted in the infographic below. On the left-hand side are the “internal factors,” and below are the “external factors.” All of these factors can be addressed by a collaborative team approach involving a psychiatrist, a nutritionist, and a psychotherapist. A number of sophisticated, cutting-edge diagnostic tests can help delineate many of these root causes. Holistic Psychiatry Uncovers the Root Causes of Treatment-Resistant Depression, Anxiety, OCD, or PTSD Feel free to watch this webinar, entitled “Root Cause Psychiatry and the Treatment-Resistant Patient,” which illustrates how we treated two of our patients with treatment-resistant psychiatric conditions. What are some of the domains we test for in holistic psychiatry? Genetic Testing Whether we want to understand genes related to mood or anxiety disorders, genetic drivers of autism spectrum disorders, or the prevention and treatment of cognitive decline and dementia, companies such as IntellxxDNA and Genomind provide actionable solutions. Brain Health, Inflammation, and Autoimmunity Anti-brain antibodies that are associated with infections such as strep, Lyme, EBV, and COVID can be detected by the Cunningham Panel. Inflammatory cytokines that help “set the brain on fire” can be detected by IncellKINE. Cellular Health The 30 trillion cells in our body all affect how we feel and function. Tests such as NutrEval and Metabolomix assess mitochondrial function, oxidative stress and free radicals, methylation, omega 3 fatty acids, micronutrients, and more. Gut Microbiome The 39 trillion microbes in your body are so important that I’ve written more than 50 blog articles about them. Tests such as the Gut Zoomer and GI Effects can search for “bad bugs” (pathogens), leaky gut syndrome, inflammation, maldigestion, and lack of production of essential molecules. Immunologic and Infectious Disease Testing A variety of tests can assess whether a dysregulated immune system may be affecting mental health, depending on the patient’s history and presenting problems. To learn more about how we practice holistic psychiatry here at Potomac Psychiatry, visit our Root Cause Psychiatry page and our Nutritional Brain Health page, or feel free to contact us for a no-cost 15-minute consultation.

Cognitive distortions are irrational thoughts that can influence your emotions. Everyone experiences cognitive distortions to some degree, but in their more extreme forms they can be harmful. It is amplified through various mental issues such as depression, anxiety, OCD, PTSD, etc. Regardless of brain chemistry, human beings all experience cognitive distortions at some point in their life especially when they feel vulnerable. These distortions are also known as automatic negative thoughts, which are important to challenge as they are not reality but alter negative perspective of how we view life. Ongoing worsening cognitive distortion can worsen the trajectory of such underlying illness. It is important to recognize the maladaptive though process that offer. In my other articles, I will discuss techniques to challenge these thoughts, feelings, beliefs. Cognitive Distortions - CBT

Depression is a medical problem where feelings of sadness, distress, and other physical and emotional symptoms are long-lasting and interfere your day-to-day life. Other symptoms of depression can include a loss of interest in favorite activities, fatigue, and thinking and memory problems. After a cancer diagnosis and during cancer treatment, it is common to feel emotions like sadness, grief, anxiety, and fear at times. These feelings can come and go throughout your cancer treatment. But when these feelings are persistent most of the day, most days of the week for more than 2 weeks, and interfere with your daily routines and pleasures, it may be a sign of clinical depression. Even if you think your feelings are normal, it is important to talk to your health care team about how you are feeling. Some cancer treatments can make people feel depressed or fatigued. Diagnosing and treating depression is an important part of cancer care. If untreated, depression can affect your quality of life and it can make it harder to cope with or finish your cancer treatment. The American Society of Clinical Oncology (ASCO) recommends screening for depression at the time of a cancer diagnosis, and again during and after treatment. The symptoms of depression may appear at any of these times. Depression and cancer According to research, around 25% of people with cancer have depression. This means the symptoms (see below) go beyond distress after a cancer diagnosis or during cancer treatment. A cancer diagnosis can trigger these feelings: Fear of cancer treatment or treatment-related side effects, such as pain Changes to your body, affecting your self-image Concerns about money and finances Uncertainty Spiritual questions about life's meaning Fear of recurrence after treatment Fear of suffering Fear of death Talk with your health care team about your concerns. They will ask you to describe how you are feeling, including any specific symptoms. They have special training, expertise, and knowledge to help you cope with these strong feelings and get additional treatment if needed. What are the symptoms of depression? Depression is a type of mood disorder. The symptoms range from mild to severe. When they are severe, persistent, and include many of the mood-related symptoms listed below, they are a major depressive disorder. You can receive treatment for depression whether you have mild, moderate, or severe symptoms. Talk with your doctor if you have any of these symptoms, especially if they last 2 weeks or longer: Mood-related symptoms. People with depression can feel a range of feelings. You may feel sad or down, but anxiety, irritation and anger can also be signs of depression. Mood-related symptoms of depression include: Feeling sad, down, or hopeless most of the time Feeling irritable and angry, often without a reason you can point to Feeling numb, like nothing matters Feeling worthless Feeling guilt Thoughts of suicide Always tell your family and your doctor immediately if you are experiencing suicidal thoughts. Suicidal thoughts are when you feel like life is not worth living and you are thinking about or planning to harm or kill yourself. If you feel you’re in crisis and cannot reach your doctor or a loved one, call the National Suicide Prevention Lifeline at 1-800-273-8255 or dial the code "988" (available in the United States). Learn more about depression, suicide, and cancer. Behavioral symptoms. Often, people with depression have a hard time finding joy in the activities they used to love. Behavioral symptoms of depression include: Loss of motivation to do daily activities, including taking care of yourself Loss of interest in activities you used to enjoy Withdrawal from friends or family Frequent crying Cognitive symptoms. Depression can cause attention, thinking, and memory problems. These include: Trouble focusing Difficulty making decisions Memory problems Negative thoughts, including thoughts that life is not worth living or thoughts of hurting yourself Physical symptoms. Depression can also cause many physical symptoms. Physical symptoms of depression include: Fatigue Appetite loss Insomnia, a disorder that interferes with your ability to fall and stay asleep Hypersomnia, a disorder that makes you sleep too much or feel very sleepy during the day Sexual problems, such as a lower sexual desire Having feelings of sadness, worthlessness, emptiness, and/or numbness that last longer than 2 weeks can indicate that your symptoms are a result of clinical depression. Emotional, behavioral, physical, and cognitive symptoms can all have other causes that are not caused by depression. For example, feeling sad and not engaging in usual activities can be caused by pain, fatigue, or some medications. Because of this, your health care team will focus on finding the cause of your symptoms. Other causes of depression symptoms Common physical symptoms of depression can have causes that are not depression. For example, high levels of calcium in your body can cause fatigue, depressed mood, and even confusion. If you are experiencing symptoms of depression, be sure to tell your doctor so the exact cause can be found. Some common medical or physical causes of these symptoms include: High calcium levels or hypercalcemia Anemia Vitamin deficiency Fever Thyroid problems Sleep problems, such as insomnia and hypersomnia Uncontrolled pain Some medications, such as steroids, some antibiotics, some chemotherapy treatments, and hormone therapy treatment What are risk factors for depression? People with cancer are more likely to have depression if they have these risk factors: Previous diagnosis of depression or anxiety A history of suicide attempts or suicide in the family Family history of depression or anxiety Lack of support from friends or family Financial burdens Substance abuse However, it is important to note that depression can be experienced by anyone, especially after a cancer diagnosis. Should people with cancer be screened for depression? Yes. The American Society of Clinical Oncology (ASCO) recommends screening for anxiety and depression. Screenings should start at the time of a cancer diagnosis and be repeated regularly during your treatment and recovery. These screenings can help catch problems related to depression. Treatment for depression will depend on your specific symptoms and how often you have them. As explained above, some symptoms of depression can also be related to other problems, including side effects of cancer and cancer treatment. For example, fatigue and trouble sleeping or concentrating are common side effects of cancer and cancer treatment. Although it can be challenging, try to talk openly with your health care team about your experiences, feelings, and the topic of depression. This will help them understand your concerns and recommend a treatment plan. ASCO recommends the following techniques to help manage depression symptoms during treatment: Deep breathing. Slow, deep breathing helps lower stress in the body. It sends calming signals from your brain to the rest of your body, slowing your heart rate and how fast you are breathing. Progressive muscle relaxation. This is a technique that involves tightening and then relaxing groups of muscles. You begin at the toes or head and then slowly tense and relax the muscles across the body. Guided imagery. This is the use of words and sounds to help you imagine calming, peaceful settings, experiences, and feelings. Meditation. Meditation is a practice of focusing attention or awareness on your breath, a verbal phrase, or a part of the body. This can help you achieve a sense of well-being in the present moment and reduce stress. It can also help you to acknowledge uncomfortable emotions and prevent them from building up. One type of meditation that may be helpful in managing depression symptoms during and after treatment is called “mindfulness- based stress reduction meditation.” When practicing mindfulness, you focus on bringing your attention to the present moment and becoming aware of your feelings, thoughts, and surroundings within that moment with an attitude of openness, kindness, and acceptance. Mindfulness practices may be helpful for depression symptoms during and after cancer treatment. Music therapy. This artistic expression can help relieve anxiety. Learn more about music therapists. Reflexology. During reflexology, a specialist uses their hands to apply pressure to specific points on the body to help relieve tension. For people diagnosed with breast cancer, ASCO recommendations include the following additional guidance for reducing symptoms of depression during and/or after treatment. These techniques may be helpful for people with other types of cancer as well, but there is not yet enough research for this level of recommendation. Research is ongoing in these areas. Yoga. Yoga combines breathing and posture exercises to promote relaxation. This can be helpful during or after treatment. Tai chi and qigong. Tai chi and qigong are both types of meditation that focus on gentle movements and postures and controlled breathing. There are other techniques or practices that may help reduce symptoms of depression during or after cancer. However, there are no specific recommendations for them, so be sure to talk with your health care team about whether any additional techniques may be helpful for you. Seeking the help of a mental health professional can help you with your depression. Mental health professionals include social workers, licensed counselors, psychologists, and psychiatrists. Psychiatrists are mental health professionals who can prescribe medication. Counselors and other mental health professionals can provide tools to improve your coping skills, develop a support system, and reshape negative thoughts. You can work with a counselor on your own, through couples or family therapy, and in group therapy. Today, options exist for mental health tele-medicine so you may not need to leave your home to get help. Counselors can also lead or direct you to a peer support group. Based on ASCO guidelines: Questions to ask the mental health team - to battle depression due to cancer You may want to ask your health care team the following questions about depression: Who can I talk to if I am feeling depression, anxiety, or other mental distress? What symptoms and side effects of cancer treatment could affect my mental health? Are there counseling services at this medical center for patients? Who can I talk with if I need free or lower-cost counseling services? Do you recommend any relaxation techniques or other ways to manage my depression? Would you recommend medication for my depression? Who should I contact if my depression symptoms continue or worsen? What do I do if I feel suicidal or that life is not worth living anymore? Source: Cancer.net

As the name implies, it is about living your “one life” to its fullest potential without any psychological or psychiatric limitations. My practice is about the holistic model for mental health with medications, therapy, and alternatives. It is an integration of optimal aspects of Western medicines (avoiding potential side effects or complications) with various therapy modalities (CBT, DBT, Psychodynamic Psychotherapy, etc). One Life Psychiatry provides a unique blend of patient-driven treatment, from an educational perspective, empowering the patient to select a treatment modality that aligns with his/her values, whether it be medications (psychopharmacology), therapy, and alternatives. In addition, I will explore and find whole body alternatives (if you prefer). As a child psychiatrist, I was very attuned to over prescription of medicines that could have potentially long-term consequences, including addiction, among the least. I will integrate nutritional supplements, herbal/plant based meditation, meditation/mindfulness, and particularly important health habits such as sunlight (vitamin D3), etc. I will continue update these pages with diagnosis, treatments options (including pros and cons), alternatives, knowledge about the different types of therapy (particularly what conditions they are effective for, alternative remedies, self-help books, clips on philosophy. Anything that will give you hope for a first quality of life and a healthy transformation.

Psychiatric Times posted an article detailing the complexities of women focused-mental health and its impact on families and communities. About 1 in 4 individuals around the world will develop mental illness at some point in their lifetimes. Women are impacted at a higher rate than men, with 1 in 5 women experiencing a prevalent mental illness (eg, anxiety, depression) versus only 1 in 8 men.1,2 Perhaps this imbalance is not surprising, given that women’s mental health throughout history and around the globe has commonly been attributed to different versions of hysteria. Hysteria originates from hysterus (uterus), intimately connecting mental illness with what has for millennia defined an essential and exclusive aspect of the female gender.3 Today, across different countries and in different settings, there continue to be gender differences in the utilization of mental health services and the treatment provided.4 For example, a significant predictor of being prescribed psychotropic drugs is simply identifying as a woman.4 Furthermore, specific mental health-related risk factors that disproportionately affect women include pressures created by their multiple roles; gender discrimination and associated factors of the pay gap; and increased rates of poverty, hunger, malnutrition, domestic violence, and sexual abuse.5,6 However, these statistics and figures do not portray the more narrative data of global women’s mental health. To address this, we unite here to explore the lessons we have learned from personal and clinical experiences, and the challenges that remain in treating mental illness in patients who identify as female. We are a group of women from different ethnic heritages and cultures, working together in a psychiatry department at the largest academic safety net hospital in New England. Given that 32% of our patients do not speak English as a primary language in this diverse patient population, we have gained insight into how mental health is perceived by women from around the world. While there are cultural nuances, there are also shared universal themes contributing to women’s poor mental health, such as prohibitive cultural views that do not acknowledge mental health, shame and stigma, cultural defense mechanisms (eg, denial), and alternate explanations (“crazy,” somatization, religious punishment) that target and can ultimately cause lack of access to timely and effective diagnosis and treatment in women.5-10 Sharing Perspectives Some cultures have a prohibitive view of mental health, from ignoring that it exists to discounting it as a necessary component of wellbeing.7 Kushani Patel, DO, shared her unique perspective: “As a first-generation Indian immigrant who moved from India at an early age and lived most of her life in the United States, I can give the perspective of growing up in a family and Indian community here where mental health is often discounted and seen as not real.” Sonal Jain, DO, also shared her experience: “As a South Asian female who identifies as a second-generation Indian-American, I have struggled to engage in mental health services despite training as a psychiatrist. In high school, there were moments where I would develop racing thoughts, palpitations, and nervousness, but was unable to identify this as anxiety. Mental health was simply not discussed in our community. The idea of seeking out formal mental health services was daunting; [it] felt “wrong” and intimidating… How would I even do that? [Would] I worry my family if I did?” While rarely discussed, South Asians—defined as individuals descending from the areas of Nepal, India, or Pakistan—are experiencing high rates of untreated mental health disorders.8 South Asian female immigrants have a higher rate of depressive disorders, self-harm, and suicide than South Asian males, due to acculturative stress, gender roles, domestic violence, collectivist culture, and limited understanding of mental health services.8-10 A similar prohibitive view toward mental health is experienced within Chinese culture. Per Lucy Lan, MD, MBA, a Chinese American immigrant, mental illness is associated with shame and disregarded, seen as contrary to “saving face” for one’s family and community. Resultant mental health issues and psychiatric disorders overall are thus typically not acknowledged. In general, rates of mental illness are likely grossly underreported in research literature and official government records in China, and in communities with Chinese heritage abroad. Of the statistics that are published, the effects of female gender discrimination, institutionalized from traditional Chinese culture, still exist; however, they appear to be slightly lessened due to the effects of the Communist government policy that women are equal to men.11 Nevertheless, significant inequalities still exist, such as women occupying fewer psychiatric hospital beds and in general receiving fewer health care resources than men.11 Mental health is still a taboo subject, for both genders, within Chinese and other East Asian communities.12 Given the large extent to which culture of familial origin may affect one’s acknowledgement of mental illness, it makes sense for providers to ask patients how their culture views mental illness in general and specifically in women. This information is invaluable in understanding the wider sociocultural context of how a woman might view her illness, and how she ultimately copes with it. It is also important for us clinicians to understand our own biases, especially when there are clinical symptoms with unique presentations with cultural nuances that differ from ours. Impact of Religion Some cultures associate mental illness with stigma and cope via multiple defense mechanisms.12 Per several Haitian patients, mental health symptoms are overall discounted with statements such as “crazy, shameful, hide it, just deal with it.” Katherine Crist, MD, a fourth-generation descendent of Irish Catholics immigrants, recently spoke with a 25-year-old Haitian, Catholic, female patient who presented to the emergency room with psychosis. This patient had been struggling with auditory hallucinations, bizarre thought content, and inability to take care of herself for several months. Crist said, “When I asked about prior mental health treatments, she stared at me blankly and said, ‘my mother prays for me.’” Religiosity in the Haitian approach to mental health is not so different from that of other cultures. In reflection, Crist recalled a discussion with her uncle, a Catholic priest from Minnesota, who encouraged religious treatment for churchgoers suffering from severe mental illness. “Each of these stories helped me to realize that a core issue continues to be believing women’s experience with mental illness and treating them equitably,” Crist said. There is an opportunity for clinicians to show interest in and respect for patients’ faith-based world views while providing mental health education in order to build a therapeutic alliance and inadvertently combat stigma of mental illness. Somatization Somatization of mental health symptoms is prevalent across many cultural and ethnic groups.13 Patel recalled caring for a 28-year-old Somalian female, “Mrs Caledon,” on the consult psychiatry service who presented to the hospital multiple times for persistent nausea and uncontrolled movements. This patient found it very difficult to accept and understand her diagnosis of psychogenic nonepileptic seizures, especially in relation to her severe childhood sexual trauma. Mrs Caledon explained that it was also difficult to discuss such a diagnosis with her family. A somatic understanding and explanation of mental illness is especially common in the Latinx female community.14 Anxiety and depression show up as abdominal pain, nausea, and headaches. Lan’s 32-year-old Colombian patient who was suffering from acutely elevated anxiety and depression in the context of domestic violence presented to the emergency department many times for chest pain and nausea. She believed she was suffering from cardiac emergencies and found it culturally difficult to acknowledge the possibility of panic attacks. We suggest approaching somatization with empathy, sharing with the patient that there is strong scientific evidence for mind-body connection and that their experience is normal.15 For example, for patients who feel anxiety with gastrointestinal manifestations, we have found it helpful to explain that this is logical, given that there are more nervous cells in the gastrointestinal tract than in the central nervous system and there is a well-known gut-brain connection.16 Patients with anxiety are more likely to be open to mental health treatment, as they tend to feel their interpretation is acknowledged. Of note, there is active research in elucidating how significant biological differences between male and female brains affect cognitions, behaviors, and how our existing treatments work in light of emerging evidence. Providers should make an effort to learn how differences in female anatomy, biochemistry, and pharmacokinetics affect our understanding of women’s mental health.6 Gender Discrimination Many of our female patients and their female family members expressed a sense of mental burden secondary to gender discrimination within their culture of origin. For example, Lan shared how this affects her 59-year-old Haitian female patient, “Mrs Louis,” who said, “It is not right, the way we were brought up—hit and screamed at for the smallest thing. My brothers weren’t, but that is the way it is in Haiti. My sister and I were the girls and had to do everything, take care of everyone, and not talk back… I got married so I could get away.” Mrs Louis noted that she was encouraged by her sister, also an immigrant, to seek psychiatric care. Her primary goal of treatment was to gain confidence in “standing up to myself, to my parents, to my brothers, even to my sister. I have to learn how to say no.” Yet despite the painful, chronic conflict with her family, this patient’s parents live with her, and family is a large part of her identity and daily life. Similarly, per Patel, gender discrimination and societal pressure of women’s roles play a significant factor in women’s health in the South Asian community. Patel noted that many females in the Indian community, particularly middle-aged and elderly women, carry out the traditional Indian concept that women—not men—are largely and solely responsible for taking care of the household at the cost of caring for their own mental health. This concept is largely explained by collective culture, where the emphasis on family cohesion and interdependence is emphasized over the individual.17 Literature shows that collectivist culture and gender roles in the South Asian community can also lend themselves to increased risk of depressive disorders amongst South Asian females.17 Increasing training in ideas such as acculturative stress and gender roles within society and improving understanding amongst mental health professionals may be ways to overcome this barrier. Concluding Thoughts Women-focused mental health is not one-size-fits-all. As per the preceding narratives, there are many different factors that result in how a woman makes sense of and approaches her mental wellbeing, nuanced by ethnic, cultural, socioeconomic, and traumatic experiences. Yet despite these differences, there are many shared themes within women’s mental health across the world, such as stigma, lack of resources for treatment, and shared risk factors for mental illness.3,4,6 As providers, we have an opportunity to be inclusive of and sensitive to female patients with different world views, especially of the mind-body connection, which is more representative of how most of the world makes sense of mental illness. While there is a dearth of and need for evidence-based treatments for how to best approach women’s mental health with cultural nuance, our clinical experiences suggest simply asking patients how they make sense of their mental health symptoms: “What does this mean to you?” This basic approach opens the door to an infinity of possibilities, inclusive of cultural and gender differences. It is imperative that we listen; we may be the sole individual willing and able to lend an ear to a woman with mental health needs. Do not hesitate to ask questions from a humble position of wanting to better understand a context that differs from your own. More than ever, we as providers are uniquely positioned to make a significant impact on our female patients’ mental health—thereby positively affecting their families and communities at large. Drs Lan, Jain, Patel, and Crist are residents in psychiatry at Boston University Medical Center/Boston University School of Medicine in Boston, MA. Dr Borba is Vice Chair of Research for the Department of Psychiatry at Boston Medical Center and Associate Professor at Boston University School of Medicine in Boston, MA. References 1. Kessler RC, Angermeyer M, Anthony JC, et al. Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization's World Mental Health Survey Initiative. World Psychiatry. 2007;6(3):168-176. 2. McManus S, Bebbington PE, Jenkins R. et al. Mental health and wellbeing in England: The Adult Psychiatric Morbidity Survey 2014. NHS Digital. 2016. Accessed January 21, 2022. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/556596/apms-2014-full-rpt.pdf 3. Tasca C, Rapetti M, Carta MG, Fadda B. Women and hysteria in the history of mental health. Clin Pract Epidemiol Ment Health. 2012;8:110-119. 4. Gender and mental health. World Health Organization. 2002. Accessed January 21, 2022. https://apps.who.int/iris/handle/10665/68884 5. Karg RS, Bose J, Batts KR, et al. Past year mental disorders among adults in the United States: results from the 2008–2012 Mental Health Surveillance Study. CBHSQ Data Review. 2014:1-19. 6. Van Niel MS. Best practice highlights: female patients. American Psychiatric Association. Accessed January 21, 2022. https://www.psychiatry.org/File%20Library/Psychiatrists/Cultural-Competency/Treating-Diverse-Populations/Best-Practices-Women-Patients.pdf. 7. Gopalkrishnan N. Cultural diversity and mental health: considerations for policy and practice. Front Public Health. 2018;6:179. 8. Karasz A, Gany F, Escobar J, et al. Mental health and stress among South Asians. J Immigr Minor Health. 2019;21(Suppl 1):7-14. 9. Rehman T. Social stigma, cultural constraints, or poor policies: examining the Pakistani Muslim female population in the U.S. and unequal access to professional mental health services. Columbia Undergraduate Journal of South Asian Studies. 2010;2(1):1-21. 10. Abraham M. Fighting back: abused South Asian women’s strategies of resistance. In: Sokoloff NJ, Pratt C, eds. Domestic Violence at the Margins: Readings on Race, Class, Gender, and Culture. Rutgers University Press; 2005:253-271. 11. Pearson V. Goods on which one loses: women and mental health in China. Soc Sci Med. 1995;41(8):1159-1173. 12. Hechanova R, Waelde L. The influence of culture on disaster mental health and psychosocial support interventions in Southeast Asia. Mental Health, Religion & Culture. 2017;20(1):31-44. 13. Kirmayer LJ, Young A. Culture and somatization: clinical, epidemiological, and ethnographic perspectives. Psychosom Med. 1998;60(4):420-430. 14. Escovar EL, Craske M, Roy-Byrne P, et al. Cultural influences on mental health symptoms in a primary care sample of Latinx patients. J Anxiety Disord. 2018;55:39-47. 15. Littrell J. The mind-body connection: not just a theory anymore. Soc Work Health Care. 2008;46(4):17-37. 16. Petra AI, Panagiotidou S, Hatziagelaki E, et al. Gut-microbiota-brain axis and its effect on neuropsychiatric disorders with suspected immune dysregulation. Clin Ther. 2015;37(5):984-995. 17. Samuel E. Acculturative stress: South Asian immigrant women's experiences in Canada's Atlantic Provinces. Journal of Immigrant & Refugee Studies. 2009;7(1):16-34.

Carl Jung (1875-1961) Carl Jung was an early 20th century psychotherapist and psychiatrist who created the field of analytical psychology. He is widely considered one of the most important figures in the history of psychology. Early Life Carl Gustav Jung was born in Switzerland in 1875 to Emilie Preiswerk and Paul Jung, a pastor. Because of his father’s faith, Jung developed a keen interest in religious history, but he settled on the study of medicine at the Universit of Basel. After he completed his medical degree, Jung joined the staff at Burghoelzli Clinic in Zurich, Switzerland as an intern to Eugen Bleuler, where he explored the unconscious mind and its related complexes. He also traveled to Paris to study under Pierre Janet in 1902. In 1905, Jung was appointed to the faculty at the University of Zurich where he worked until 1913. Jung married Emma Rauschenbach in 1903. The couple had five children and remained married until Emma's death in 1955, although Jung's extramarital affairs were extensive. Jung died in Switzerland in 1961. Professional Life Jung sent a copy of his book Studies in Word Association to Sigmund Freud in 1906, and Freud reciprocated by inviting Jung to visit Vienna. Their friendship lasted until 1913, at which time they parted ways due to a difference in academic opinion. Jung agreed with Freud’s theory of the unconscious, but Jung also believed in the existence of a deeper collective unconscious and representative archetypes. Freud openly criticized Jung's theories, and this fundamental difference caused their friendship and psychological views to diverge. Jung traveled throughout the world to teach and influence others with his psychoanalytical theories. He published many books relating to psychology, and others that seemed outside the realm science, including Flying Saucers: A Modern Myth of Things Seen in the Skies, which examined and dissected the psychological significance of UFO sightings. Jung’s work embodied his belief that each person has a life purpose that is based in a spiritual self. Through his eastern, western, and mythological studies, Jung developed a theory of transformation called individuation that he explored in Psychology and Alchemy, a book in which he detailed the relationship of alchemy in the psychoanalytical process. Contribution to Psychology Carl Jung is recognized as one of the most influential psychiatrists of all time. He founded analytical psychology and was among the first experts in his field to explore the religious nature behind human psychology. He argued that empirical evidence was not the only way to arrive at psychological or scientific truths and that the soul plays a key role in the psyche. Key contributions of Jung include: The collective unconscious: A universal cultural repository of archetypes and human experiences. Dream analysis and the interpretation of symbols from the collective unconscious that show up in dreams. Extroversion and introversion: Jung was the first to identify these two personality traits, and some of his work continues to be used in the theory of personality and in personality testing. Psychological complexes: A cluster of behaviors, memories, and emotions grouped around a common theme. For example, a child who was deprived of food might grow into an adult smoker, nail biter, and compulsive eater, focusing on the theme of oral satiation. An emphasis on spirituality: Jung argued that spirituality and a sense of the connectedness of life could play a profound role in emotional health. Individuation: The integration and balancing of dual aspects of personality to achieve psychic wholeness, such as thinking and feeling, introversion and extroversion, or the personal unconscious and the collective unconscious. Jung argued that people who have individuated are happier, more ethical, and more responsible. The persona and the shadow: The persona is the public version of the self that serves as a mask for the ego, and the shadow is a set of infantile, suppressed behaviors and attitudes. Synchronicity: A phenomenon that occurs when two seemingly unrelated events occur close to one another, and the person experiencing the events interprets this correlation as meaningful. In addition, some of Jung's patients helped to found Alcoholics Anonymous, inspired by Jung's belief in an evangelic cure for alcoholism. Selected Works of Carl Jung Psychology of the Unconscious (1912) Psychological Types (1921) Essays on Contemporary Events (1947) Synchronicity: An Acausal Connecting Principle (1952) The Undiscovered Self (1957) Memories, Dreams, Reflections (1961) Man and His Symbols (1964) The Archetypes and The Collective Unconscious (2nd ed. with R. Hull, 1981) The Red Book (with Sonu Shamdasani, 2009) Source: GoodTherapy (2023)

It can be challenging, frustrating trying to find a psychiatrist that takes your insurance as more psychiatrist are opting out of insurance plans based on drops in the rate of reimbursement and various mental health legislating changes. At One Life Psychiatry, we think its very important to be able to use whatever insurance you have when you feel sick mentally or physically. We have added on approximately 15 new insurance plans to our company with ongoing additions as our contracts our finalized. Here is a list of our in-network plans. If you don't see your insurance plan please contact us at 888-855-0947 to verify if your insurance plan in now in-network, as we are continually adding new contracts. Updated: 11/3/2023 Allwell Ambetter Anthem | Elevance Blue Cross Blue Shield BlueCross and BlueShield Cenpatico Cigna and Evernorth GEHA Home State Health Plan Medicaid Medicare Optum Oscar Health Show Me Healthy Kids TRICARE TriWest UMR UnitedHealthcare UHC | UBH VA Community Care Network (CCN) WellCare We want to make mental health care affordable. If we are out-of-network, we will provide you a super-bill of the charges where you can get 50-70% reimbursement (which you should verify with your insurance company. If you don't have insurance, we have self-pay options (with discounted rates for qualified patients on a sliding scale). If prior arrangements are made, we can create an affordable payment plan. More details on our FAQ page Interested in setting up at appointment - Click here If you have any questions, please feel free to email us at support@onelifepsychiatry.com

Abstract and Introduction Abstract Purpose of the Review: To examine recently published results of randomized placebo-controlled trials investigating the clinical effects of selective serotonin reuptake inhibitors on the prevalence of clinically significant symptoms of depression and suicidal ideation after an acute stroke. Recent Findings: The prevalence of poststroke depression varies markedly according to the approach used to define depression, with recently published data suggesting that about one in every three stroke survivors will experience clinically significant symptoms of depression over a period of 12 months. The proportion of stroke survivors with clinically significant symptoms of depression decreases progressively with time, but in 30% of them symptoms persist or recur over 12 months. Routine daily treatment with 20 mg of fluoxetine for 6 months does not affect the prevalence of depression in this population, nor is it effective at treating or preventing poststroke depressive symptoms. Treatment discontinuation, gastrointestinal adverse effects, seizures and bone fractures are more frequent among stroke survivors treated with antidepressants than placebo. Moreover, current data show that thoughts about death or suicide are more frequent among adults who had a stroke than the general population, although recurring suicidal thoughts are uncommon. Routine daily treatment with 20 mg of fluoxetine for 6 months does not change the proportion of people who disclose suicidal thoughts over a period of 12 months after an acute stroke. Summary: Current evidence raises concerns about the efficacy and safety of antidepressants for the management and prevention of poststroke clinically significant symptoms of depression. It is unclear if these findings can be generalized to people with severe strokes or to stroke survivors with moderate to severe major depressive episodes. Introduction Stroke is a leading cause of disability and health burden worldwide.[1] Poststroke rehabilitation and quality of life are often hindered by the presence of depressive symptoms, so that the effective management and prevention of depression has become an integral part of strategies designed to improve the clinical outcomes of stroke survivors. Antidepressants have been used to prevent and treat clinically significant symptoms of depression after a stroke, and more recently to promote neuro-regeneration and stroke recovery. The results of several randomized controlled trials have been published over the past couple of years, and many of them have examined the effects of antidepressants on the mental and physical outcomes of people who survive a stroke. This paper will summarize the key-findings of these studies. Methods The literature search was restricted to the years 2021 to January 2023 and made use of the following search terms in PubMed: stroke AND "clinical trial" AND depression AND antidepressant. A total of 39 papers were retrieved, of which 7 reported original information and were relevant. Cited bibliography and forward citations were then reviewed, and another 33 papers were identified. Of the 40 papers available, 23 papers were deemed relevant and were included in this review. Stroke and Depression Epidemiology of Poststroke Depression Depression is common after stroke, although prevalence estimates vary widely according to the setting of the study and the approach used to define depression. Existing systematic reviews suggest that one in three stroke survivors will experience clinically significant symptoms of depression, and that the proportion of those affected does not vary much with time. In contrast, the results of the Assessment of Fluoxetine in Stroke Recovery (AFFINITY) trial found that about 19% of 1221 participants showed evidence of clinically significant symptoms of depression at the time of recruitment 2–15 days after a mild to moderate acute stroke (either ischaemic or haemorrhagic). The study defined clinically significant symptoms of depression as a score of 9 or greater on the Patient Health Questionnaire (PHQ-9). In addition, the proportion of those affected by clinically significant symptoms of depression decreased progressively with time to about 10% after 3 months and 8% after 6 months. The results of AFFINITY also showed that although the proportion of people affected by depression decreases with time, one in three survivors experienced clinically significant symptoms at some point over a period of 12 months, and in 30% of these symptoms were present both during the sub-acute (≤ 3 months) and recovery phases (3–12 months). In other words, depression was persistent or recurring in 30% of the stroke survivors who had experienced clinically significant symptoms of depression. The Efficacy of Fluoxetine on Outcomes at 12 Months After Acute Stroke (EFFECTS) recruited 1500 adults after an acute stroke. The investigators defined clinically significant depression as a physician-based diagnosis that led to the prescription of a nontrial antidepressant. At 6 months, 6% of those recruited had been offered treatment with an antidepressant, and at 12 months 8.8%. These results were remarkably like those of AFFINITY regarding the prescription of novel antidepressants over a period of 12 months. The discrepancy between the reported proportion of stroke survivors affected by clinically significant symptoms of depression and those who receive treatment is striking and raises questions about the validity of the approach most studies use to define depression (i.e., specific cut-points of various depression scales) or, alternatively, about the poor sensitivity of health professionals to identify stroke survivors with depression. A recent study of 343 stroke survivors living in Korea showed that less than half of those with depression were aware of their clinical status, and only 20% of these were receiving antidepressant treatment. History of depression before the stroke, severity of stroke-related functional impairment, and older age seem to be the most robust measures associated with the presence of clinically significant symptoms of depression, whereas sex, living arrangements, and treatment with antidepressants do not seem to mediate or modulate the emergence of depressive symptoms after a stroke. Antidepressants for the Treatment and Prevention of Poststroke Depression Two Cochrane systematic reviews and meta-analyses published in 2020 produced equivocal results about the potential benefits of antidepressants for the treatment and prevention of depression after a stroke. Novel data from the AFFINITY and EFFECTS trials have raised additional questions about the use of antidepressants for the management of stroke survivors. EFFECTS randomly assigned 1500 stroke survivors to 6-months daily treatment with 20 mg of fluoxetine or placebo. Both participants and investigators were blind to treatment assignment. After 6 months, 36 of 750 participants treated with fluoxetine and 51 of 750 treated with placebo had been prescribed treatment with an open-label antidepressant – differences between the groups were not statistically significant. By 12 months, the numbers had increase to 65 of 725 of those treated with fluoxetine and 64 of 728 of participants treated with placebo (P = 0.907). The investigators of the AFFINITY trial reported data for 607 and 614 stroke survivors randomly assigned to daily treatment with placebo or 20 mg of fluoxetine in a double-blind fashion for 6 months. By the end of this period, 8% and 7% of the participants treated with placebo and fluoxetine showed evidence of clinically significant symptoms of depression – the difference between the groups was not statistically significant (P = 0.467). In addition, of the 228 participants with clinically significant symptoms of depression at the time of enrolment, 20% and 19% of those treated with placebo and fluoxetine were still experiencing clinically significant symptoms of depression after 6 months of treatment (P = 0.840). Conversely, of the 993 participants who were free of clinically significant symptoms of depression when they joined the study (498 assigned to treatment with fluoxetine), 15% and 13% showed evidence of clinically significant symptoms of depression over the 6 months of treatment with placebo and fluoxetine (P = 0.426). Taken together, the results of the AFFINITY trial showed that routine daily treatment with 20 mg of fluoxetine is no more effective than placebo at reducing the 6-month prevalence of poststroke depression, or at treating clinically significant symptoms of depression, or at preventing the emergence of clinically significant symptoms of depression. A similar lack of clinical benefit associated with fluoxetine treatment of stroke survivors was observed in Tanzania according to the results of a small open label trial (n = 59). Of note, a systematic review of randomized controlled trials produced results suggesting that treatment with fluoxetine is associated with a small reduction in the proportion of stroke survivors who were told by a doctor that they had depression during the respective studies. A secondary analysis of a randomized, double-blind. placebo-controlled trial of treatment of stroke survivors treated with 10 mg of escitalopram daily for 3 months yielded results suggesting that scores on the Montgomery-Åsberg Depression Rating Scale (MADRS) declined more markedly among those using the antidepressant, although MADRS scores were well below a level of severity that would be considered clinically significant. The clinical relevance of this study was further compromised by the loss of over 25% of participants during the study, and the prior publication of trial data showing that treatment with escitalopram had no obvious effect on the proportion of participants affected by clinically significant symptoms of depression (MADRS ≥ 16). Other Clinical Effects of Antidepressant Treatment After a Stroke One of the driving forces supporting the running of recent trials of antidepressants was the expectation that medications such as fluoxetine could promote neuronal regeneration and recovery after a stroke. Both the EFFECTS and the AFFINITY trials reported data showing that fluoxetine did not improve functional outcomes at 6 and 12 months after 6 months of treatment (function was measured using the modified Rankin Scale). A Cochrane systematic review and meta-analysis of 6 trials that used fluoxetine for the management of stroke survivors confirmed that treatment had no effect on motor function compared with placebo. The results of the review also showed that treatment with an antidepressant increased by 57% the proportion of participants leaving the study early and was associated with a 40% increase in the risk of seizures and 71% increase in the risk of gastrointestinal complaints. Death was no more frequent among people treated with antidepressants than placebo. The trials included in the review were rated as having low risk of bias. Another systematic review and meta-analysis designed to investigate the risk of bone fractures among stroke patients treated with a selective serotonin reuptake inhibitor (SSRI) identified four randomized placebo-controlled trials that had used either fluoxetine (n = 3) or citalopram (n = 1).[16] The review found that treatment with an SSRI for 6 months more than doubled the risk of fractures among adults recovering from a stroke (risk ratio = 2.36). In this instance, the number needed to treat to cause one additional fracture was 58. The potential mechanisms supporting this increase in risk of fractures are not yet clear. There is also some concern that the introduction of antidepressants for the management of adults who had a stroke may increase the risk of stroke recurrence, although the AFFINITY trial found no evidence that treatment with fluoxetine for 6 months changed the risk of recurrence over 12 months. In fact, a slightly lower proportion of participants treated with fluoxetine than placebo had a new ischaemic stroke during follow up. A posthoc analysis of the EFFECTS trial examined the association between treatment with fluoxetine and the evolution of individual items of the MADRS over 6 months. Antidepressant treatment had no obvious effect on total MADRS scores compared with placebo, but was associated with increased lassitude, which was considered indicative of greater apathy. Stroke and Suicidal Behaviour Thoughts about death or self-harm seem to be relatively common among stroke survivors compared with the general population, with a recent systematic review of 21 studies that included 17 189 participants reporting a pooled prevalence of 12%. However, there was marked heterogeneity between the studies included in the review, in addition to differences in the time between the stroke and the assessment (from 4 days to 12 months), inconsistency in the definition of suicidal ideation, and varying study designs. Some of these shortcomings were highlighted by a secondary analyses of the AFFINITY trial, which showed that the prevalence of suicidal ideation varied according to the approach used to define its presence: 3% if these thoughts had to be recurrent and present for most of the time compared with 14% if these thoughts had to be present at least once over a period of 52 weeks. The presence of thoughts about death or self-harm was not affected by the sex of participants, but clinically significant symptoms of depression were present in nearly all of those with recurring thoughts over a 2-week period (95%). Of note, only one the participants in the AFFINITY trial died by suicide, and this person had denied suicidal thoughts at study entry and again 4–6 weeks after the stroke. These results suggest that suicidal thoughts are not infrequent, but they are not robust predictors of suicide attempt or completion when taken in isolation. In addition, if poststroke suicidal thoughts are recurrent in nature, clinicians should complete a detailed mental state examination to clarify if clinically significant symptoms of depression are also present. However, thinking about death or self-harm is not the same as attempting to kill oneself or completing suicide. A systematic review and meta-analysis of 23 observational studies found that stroke increased the risk of suicide completion by 61% and more than doubled the risk of attempted suicide. However, there was marked heterogeneity between the studies included in the analyses, as well as some evidence of bias favouring the publication of studies reporting a positive association between stroke and suicide (reported in the supplemental material of the relevant paper). Trial data to guide the potential use of antidepressants to decrease suicidal behaviour after a stroke are limited. The investigators of the AFFINITY trial used the last item of the PHQ-9 ('better off dead or wanting to self-harm') to assess suicidal ideation and found that over the 12 months of the study the cumulative proportion of participants who had reported recurring thoughts of death or self-harm was 15 of 607 and 23 of 614 of those treated with placebo and 20 mg of fluoxetine for 6 months (P = 0.200). Among participants treated with placebo, 85 (14%) reported thinking about death or self-harm at least once during the 12 months of the study compared with 90 (15%) of those treated with fluoxetine (P = 0.744). No other trial data are available to guide the management of poststroke suicidal thoughts and behaviours, but a review of all available data on this topic suggested that treating clinicians should consider the effective management of clinically significant symptoms of depression, the use of interventions that promote rehabilitation and reduce disability, and restriction of access to means that may be used in suicide attempts. Extra-vigilance regarding the use of antidepressants in this population may be required because observational data suggest that exposure to antidepressant medications may increase the risk of suicide attempts in later life. Conclusion Stroke is associated with high morbidity and mortality, including mental health morbidity. Clinically significant symptoms of depression are common among stroke survivors, but the assessment of their presence has relied almost exclusively on the use of rating scales, rather than structured interviews leading to a clinical diagnosis according to accepted classifications systems, such as the International Classification of Diseases 11th revision (ICD-11) or the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5). Consequently, the quality of available data examining the association between stroke and depression are, in this respect, sub-optimal. The results of recent large randomized controlled trials that used SSRIs for the management of stroke survivors showed that daily treatment with 20 mg of fluoxetine (which was used in most of the trials reviewed) does not change the prevalence of clinically significant symptoms of depression over 6 or 12 months. Treatment with fluoxetine is no more effective than placebo at treating clinically significant symptoms of depression in this population, or in preventing the emergence of depressive symptoms among those who were not depressed at study entry. However, the trials reviewed in this paper were not designed specifically to treat people with poststroke major depressive episodes, so that it may be premature to dismiss the potential benefits of fluoxetine, or of other antidepressants, for the management of poststroke depression. What is clear is that fluoxetine, and possibly other antidepressants, increases the risk of adverse events among stroke survivors, so that its use should be limited to those likely to benefit the most: i.e., people with moderate to severe depressive episodes. Future research should seek to determine the prevalence of depressive disorders in large community-representative samples of stroke survivors. It should also seek to establish the safest and most effective approach to managing and preventing poststroke depressive episodes and self-harm. Related Topic: One Life Psychiatry

“Are my other medications making my depression worse?” Researchers investigated associations between medications with potential depressive symptom adverse effects and the level of depressive symptoms in a large survey study. CASE VIGNETTE “Mr Mills” is a 45-year-old Caucasian male with a history of recurrent, moderate major depressive disorder (MDD). He also has significant symptoms of anxiety. He does not smoke, drink alcohol, or use illicit drugs, and his body mass index is 25. He has comorbid hyperlipidemia, but no other medical problems. His psychotropic medications include sertraline 100 mg daily for depression and propranolol 20 mg twice daily for anxiety. He also takes simvastatin 20 mg at bedtime for cholesterol. Mr Mills noticed some muscle cramps, which he attributed to the simvastatin, and started taking over-the-counter co-enzyme Q10 as a supplement. The muscle cramps improved, but over the next 2 months, he noted a steady worsening of depressive symptoms in the absence of other specific stressors. He stopped the co-enzyme Q10, and within 2 to 3 weeks his mood returned to baseline. He discussed this experience with his outpatient psychiatrist and asked about other medications that might be associated with worsening depression. Residual depressive symptoms are common in MDD. Medical comorbidities are an identified risk factor for persistent depressive symptoms. Although the mechanism(s) of this association is/are not clear, inflammation and childhood adversity—which are associated with both medical conditions and worse treatment outcomes in depression—may play a role. Patients with depressive and medical comorbidities often use non-psychiatric medications that may themselves be associated with increased risk of depressive symptoms. The Current Study Mojtabai and colleagues6 used data from the National Health and Nutrition Examination Survey (NHANES) to examine the association between medications with potential depressive symptom side effects (PDSS) and the level of depressive symptoms in antidepressant-treated patients with MDD. Data were drawn from NHANES 2013 to 2014, 2015 to 2016, and 2017 to 2018 surveys of the US general population. The sample was limited to 885 adults taking antidepressant medications for at least 6 weeks and with data on depressive symptoms. Non-psychiatric medications with PDSS were identified as those with “depression” or “depressive symptoms” listed as common or serious adverse effects using Micromedex. Respondents were asked about the “main reason” for taking each medication, and their reasons were translated into ICD-10 codes. Current depressive symptoms were measured with the Patient Health Questionnaire=9 (PHQ-9). PHQ-9 scores were dichotomized into no-to minimal (< 5) and moderate-to-severe (≥ 10) depressive symptoms. Data were also obtained on age, sex, race/ethnicity, income, education, health insurance, and common chronic medical conditions. Binary logistic regression models were used to investigate the associations between the number of medications with PDSS and a) no/minimal and b) moderate/severe depressive symptoms. The numbers of medications without PDSS were included in each model as a placebo test. Separate logistic regression models were repeated in more homogenous groups of patients with MDD and arthritis and MDD and hypertension, separately. The majority of the 885 participants were female (71%), aged ≥ 50 years (62%), and non-Hispanic white (82%), and had a college education (69%). Selective serotonin reuptake inhibitors were the most common class of antidepressants (68%). The majority of patients (79%) had been on the same antidepressant for > 1 year. Similarly, 85% used ≥ 1 medication for medical comorbidities, 67% used ≥ 1 medication with PDSS, and 75% used ≥ 1 medication without PDSS. Compared to other participants, those with arthritis and heart disease had significantly lower odds of no/minimal symptoms and significantly higher odds of moderate/severe symptoms. Patients with liver and lung disease also had significantly higher odds of moderate/severe symptoms. After adjusting for potential confounding/moderating factors, more medications with PDSS were associated with significantly lower odds of no/minimal symptoms (OR=0.75, 95% CI 0.64-0.87) and significantly higher odds of moderate/severe symptoms (OR=1.14, 95% CI 1.00-1.29). By contrast, there were no associations between medications without PDSS and depressive symptoms. Findings were similar in analyses limited to participants with arthritis and hypertension. Individual medications significantly associated with the severity of depressive symptoms included omeprazole, gabapentin, meloxicam, tramadol, ranitidine, baclofen, oxycodone, tizanidine, propranolol, and morphine. There was a dose-dependent effect of PDSS. The proportion of patients with no/minimal symptoms ranged from 51% in those not using any medications with PDSS to 5% in those using ≥ 3 such medications. Similarly, the proportion of patients with moderate/severe symptoms ranged from 22% in those not using any medications with PDSS to 63% in those using ≥ 3 such medications. Study Conclusions The authors concluded that individuals treated for MDD frequently use non-psychiatric medications for comorbid medical conditions that are associated with an increased risk of depressive symptoms. Associations of medications with PDSS and depressive symptoms are not attributable to chronic medical comorbidities associated with both medication use and worse treatment outcomes in depression. Importantly, 7 of 10 medications found to be associated with higher depressive symptoms are used for the treatment of pain or muscle spasms. Study limitations include the residual confounding by medical comorbidities or pain, detailed clinical information about MDD in participants, and the cross-sectional design and self-report nature of the survey. The Bottom Line Management of medical comorbidities, including judicious selection of medications with PDSS, could improve response to antidepressant treatment and patient outcomes. Dr Miller is a professor in the Department of Psychiatry and Health Behavior at Augusta University in Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for Psychiatric Times®. The author reports that he receives research support from Augusta University, the National Institute of Mental Health, and the Stanley Medical Research Institute. Related Topic: One life Psychiatry References 1. Mojtabai R. Nonremission and time to remission among remitters in major depressive disorder: revisiting STAR*D. Depress Anxiety. 2017;34(12):1123-1133. 2. Zisook S, Johnson GR, Tal I, et al. General predictors and moderators of depression remission: a VAST-D report. Am J Psychiatry. 2019;176(5):348-357. 3. Chan KL, Cathomas F, Russo SJ. Central and peripheral inflammation link metabolic syndrome and major depressive disorder. Physiology (Bethesda). 2019;34(2):123-133. 4. Nelson J, Klumparendt A, Doebler P, Ehring T. Childhood maltreatment and characteristics of adult depression: meta-analysis. Br J Psychiatry. 2017;210(2):96-104. 5. Botts S, Ryan M. Depression. In: Tisdale JE, Miller DA, eds. Drug-Induced Diseases: Prevention, Detection, and Management. 3rd ed. American Society of Health-System Pharmacists; 2018:375-397. 6. Mojtabai R, Amin-Esmaeili M, Spivak S, Olfson M. Use of non-psychiatric medications with potential depressive symptom side effects and level of depressive symptoms in major depressive disorder. J Clin Psychiatry. 2023;84(4):22m14705.

Examining the Evidence 77 Core Beliefs Examples Core beliefs are a person’s most central ideas about themselves, others, and the world. These beliefs act like a lens through which every situation and life experience is seen. As a person has new experiences, their core beliefs may gradually change. However, some experiences have a greater impact than others. Information that supports a core belief is easily integrated, making the belief stronger. Information that does not support a belief tends to be ignored. Core Beliefs Examining the Evidence

Trichotillomania (Hair-Pulling Disorder) Trichotillomania, or hair-pulling disorder, involves a person repeatedly pulling out their own hair, most commonly from the scalp, eyebrows, and eyelids. Many people twist and play with their hair or bite their hair, but these behaviors are not the same as trichotillomania. The hair pulling causes significant distress and problems functioning. The person may avoid work, school or other public situations. The distress can include feeling a loss of control, embarrassment, and shame. Hair pulling may be preceded or accompanied by various emotions such as an increasing sense of tension. It may be triggered by feelings of anxiety or boredom. Individuals with trichotillomania make repeated attempts to decrease or stop hair pulling. In the general population, trichotillomania affects an estimated 1%-2% of adults and adolescents in a given year and it is much more common among females. It usually begins around puberty. It may come and go over time, but usually continues if it is not treated. Treatment usually involves cognitive behavior therapy (CBT), including a technique called habit reversal therapy, which can help identify triggers and enhance awareness, disrupting habitual patterns of pulling episodes and helping patients gain more control over their behaviors. Source: Mayo Clinic - Trichotillomania

Grief is universal. People often describe grief as passing through 5 or 7 stages. The 5 stages are denial, anger, bargaining, depression, and acceptance. The 7 stages elaborate on these and aim to address the complexities of grief more effectively. They include feelings of guilt. Grief is universal. At some point, everyone will have at least one encounter with grief. It may be from the death of a loved one, the loss of a job, the end of a relationship, or any other change that alters life as you know it. Dr. Kubler Ross Grief is also very personal. It’s not very neat or linear. It doesn’t follow any timelines or schedules. You may cry, become angry, withdraw, or feel empty. None of these things are unusual or wrong. Elizabeth Kübler Ross wrote in her book “On Death and Dying” that grief could be divided into five stages. While everyone can grieve differently, there are some commonalities in these stages and the order of feelings experienced during grief. Are there 5 or 7 stages of grief? In 1969, a Swiss-American psychiatrist named Elizabeth Kübler-Ross wrote in her book “On Death and Dying” that grief could be divided into five stages. Her observations came from years of working with terminally ill individuals. In time, two more stages were added to make seven stages. This expanded model aims to better reflect the complexities of grief. Neither model will necessarily reflect an individual’s experience, however, as emotions tend to come and go. You may miss a stage or come back to it later, and that’s OK. The 5 stages of grief Kübler-Ross’s five stages were originally devised for people who were ill but have been adapted for coping with grief. Her theory of grief became known as the Kübler-Ross model. While it was originally devised for people who were ill, these stages of grief have been adapted for other experiences with loss, too. According to Kübler-Ross, the five stages of grief are: denial anger bargaining depression acceptance Here’s what to know about each one. Stage 1: Denial Grief is an overwhelming emotion. It’s not unusual to respond to the strong and often sudden feelings by pretending the loss or change isn’t happening. Denying it gives you time to more gradually absorb the news and begin to process it. This is a common defense mechanism and helps numb you to the intensity of the situation. As you move out of the denial stage, however, the emotions you’ve been hiding will begin to rise. You’ll be confronted with a lot of sorrow you’ve denied. That is also part of the journey of grief, but it can be difficult. Examples of the denial stage Breakup or divorce: “They’re just upset. This will be over tomorrow.” Job loss: “They were mistaken. They’ll call tomorrow to say they need me.” Death of a loved one: “She’s not gone. She’ll come around the corner any second.” Terminal illness diagnosis: “This isn’t happening to me. The results are wrong.” Stage 2: Anger Where denial may be considered a coping mechanism, anger is a masking effect. Anger is hiding many of the emotions and pain that you carry. This anger may be redirected at other people, such as the person who died, your ex, or your old boss. You may even aim your anger at inanimate objects. While your rational brain knows the object of your anger isn’t to blame, your feelings in that moment are too intense to act according to that. Anger may mask itself in feelings like bitterness or resentment. It may not be clear-cut fury or rage. Not everyone will experience this stage of grief. Others may linger here. As the anger subsides, however, you may begin to think more rationally about what’s happening and feel the emotions you’ve been pushing aside. Examples of the anger stage Breakup or divorce: “I hate him! He’ll regret leaving me!” Job loss: “They’re terrible bosses. I hope they fail.” Death of a loved one: “If she cared for herself more, this wouldn’t have happened.” Terminal illness diagnosis: “Where is God in this? How dare God let this happen! Stage 3: Bargaining During grief, you may feel vulnerable and helpless. In those moments of intense emotions, it’s not uncommon to look for ways to regain control or to want to feel like you can affect the outcome of an event. In the bargaining stage of grief, you may find yourself creating a lot of “what if” and “if only” statements. It’s also not uncommon for religious individuals to try to make a deal or promise to God or a higher power in return for healing or relief from the grief and pain. Bargaining is a line of defense against the emotions of grief. It helps you postpone the sadness, confusion, or hurt. Examples of the bargaining stage Breakup or divorce: “If only I had spent more time with her, she would have stayed.” Job loss: “If only I worked more weekends, they would have seen how valuable I am.” Death of a loved one: “If only I had called her that night, she wouldn’t be gone.” Terminal illness diagnosis: “If only we had gone to the doctor sooner, we could have stopped this.” Stage 4: Depression Whereas anger and bargaining can feel very active, depression disorders may feel like a quiet stage of grief. In the early stages of loss, you may be running from the emotions, trying to stay a step ahead of them. By this point, however, you may be able to embrace and work through them in a more healthful manner. You may also choose to isolate yourself from others in order to fully cope with the loss. That doesn’t mean, however, that depression is easy or well defined. Like the other stages of grief, depression can be difficult and messy. It can feel overwhelming. You may feel foggy, heavy, and confused. Depression may feel like the inevitable landing point of any loss. However, if you feel stuck here or can’t seem to move past this stage of grief, you can talk with a mental health expert. A therapist can help you work through this period of coping. Examples of the depression stage Breakup or divorce: “Why go on at all?” Job loss: “I don’t know how to go forward from here.” Death of a loved one: “What am I without her?” Terminal illness diagnosis: “My whole life comes to this terrible end.” Stage 5: Acceptance Acceptance is not necessarily a happy or uplifting stage of grief. It doesn’t mean you’ve moved past the grief or loss. It does, however, mean that you’ve accepted it and have come to understand what it means in your life now. You may feel very different in this stage. That’s entirely expected. You’ve had a major change in your life, and that upends the way you feel about many things. Look to acceptance as a way to see that there may be more good days than bad. There may still be bad — and that’s OK. Examples of the acceptance stage Breakup or divorce: “Ultimately, this was a healthy choice for me.” Job loss: “I’ll be able to find a way forward from here and can start a new path.” Death of a loved one: “I am so fortunate to have had so many wonderful years with him, and he will always be in my memories.” Terminal illness diagnosis: “I have the opportunity to tie things up and make sure I get to do what I want in these final weeks and months.” The 7 stages of grief The seven stages of grief are another popular model for explaining the many complicated experiences of loss. These seven stages include: Shock and denial: This is a state of disbelief and numbed feelings. Pain and guilt: You may feel that the loss is unbearable and that you’re making other people’s lives harder because of your feelings and needs. Anger and bargaining: You may lash out, telling God or a higher power that you’ll do anything they ask if they’ll only grant you relief from these feelings or this situation. Depression: This may be a period of isolation and loneliness during which you process and reflect on the loss. The upward turn: At this point, the stages of grief like anger and pain have died down, and you’re left in a more calm and relaxed state. Reconstruction and working through: You can begin to put pieces of your life back together and move forward. Acceptance and hope: This is a very gradual acceptance of the new way of life and a feeling of possibility for the future. As an example, this may be the presentation of stages from a breakup or divorce: Shock and denial: “She absolutely wouldn’t do this to me. She’ll realize she’s wrong and be back here tomorrow.” Pain and guilt: “How could she do this to me? How selfish is she? How did I mess this up?” Anger and bargaining: “If she’ll give me another chance, I’ll be a better boyfriend. I’ll dote on her and give her everything she asks.” Depression: “I’ll never have another relationship. I’m doomed to fail everyone.” The upward turn: “The end was hard, but there could be a place in the future where I could see myself in another relationship.” Reconstruction and working through: “I need to evaluate that relationship and learn from my mistakes.” Acceptance and hope: “I have a lot to offer another person. I just have to meet them.” What is the hardest stage of grief to go through? There’s no one stage that’s universally considered to be the hardest to endure. Grief is a very individual experience. The toughest stage of grief varies from person to person and even from situation to situation. How long does each stage of grief last? Grief is different for every person. There’s no exact time frame to adhere to. You may remain in one of the stages of grief for months but skip other stages entirely. This is typical. It takes time to go through the grieving process. Is it possible to repeat the stages of grief? Not everyone goes through the stages of grief in a linear way. You may have ups and downs and go from one stage to another, then circle back. Additionally, not everyone will experience all stages of grief, and you may not go through them in order. I didn’t go through the stages of grief — how will this affect me? Avoiding, ignoring, or denying yourself the ability to express your grief may help you dissociate from the pain of the loss you’re going through. But holding it in won’t make it disappear. And you can’t avoid grief forever. Over time, unresolved grief can turn into physical or emotional manifestations that affect your health. In order to heal from a loss and move on, you have to address it. If you’re having trouble processing grief, consider seeking out counseling to help you through it. Why is it important to understand the stages of grief? Grief is a natural emotion to experience when going through a loss. While everyone experiences grief differently, identifying the various stages of grief can help you anticipate and comprehend some of the reactions you may experience throughout the grieving process. It can also help you understand your needs when grieving and find ways to have them met. Understanding the grieving process can ultimately help you work toward acceptance and healing. Frequently asked questions What are the 5 stages of grief in order? The 5 stages of grief, in order, are: denial anger bargaining depression acceptance What are the 7 steps of grief? The 7 stages are: shock and denial pain and guilt anger and bargaining depression the upward turn reconstruction and working through acceptance and hope Are there 7 or 5 stages of grief? It depends which description you use. The 7 stages aim to address the complexity of grief more effectively. They include guilt as a second stage and divide the recovery stages into three parts. What is the hardest stage of grief? This will depend on the individual. There is no way to define the hardest stage. How long do stages of grief last? This varies widely between individuals and depends on many factors. How do you know what stage of grief you are in? The stages are not a prescribed pattern, more like a description to help you understand what you are feeling and why you might be feeling it. They can also help you accept that your feelings are not unusual or wrong. You may recognize feelings that a stage describes, and this will help you know which stage you are in. However, there is no fixed way of recognizing a stage. Stages can also come and go, and and earlier stage can return later. The takeaway The key to understanding grief is realizing that no one experiences the same thing. Grief is very personal, and you may feel something different every time. You may need several weeks, or grief may be years long. If you decide you need help coping with the feelings and changes, a mental health professional is a good resource for vetting your feelings and finding a sense of assurance in these very heavy and weighty emotions. If you need help finding a mental health professional, the click here.