Poor adherence to medication is a real challenge in healthcare. Despite evidence indicating therapeutic benefit from adhering to a prescribed regimen, it is estimated that around 50% of patients around the world don't take their medication as it is prescribed — and some simply don't take them at all. Nonadherence to medication can be primary or secondary. Primary medication nonadherence (PMN) occurs when a new medication is prescribed for a patient, but the patient does not obtain the medication or an appropriate alternative within an acceptable period after it was prescribed. Secondary nonadherence measures prescription refills among patients who previously filled their first prescriptions. With most medication adherence research to date focused on secondary nonadherence, PMN has been identified as a major research gap. Growth in electronic prescribing has partially resolved this issue, and new measures have emerged linking electronic prescribing databases with pharmacy dispensing databases. A study conducted in a network of primary care services in Canada has sought to identify the predictive factors of primary nonadherence and which drugs could be at greatest risk of primary nonadherence when prescribed by a primary care physician. Adherence Measures Measuring medication adherence is challenging but can be done using various approaches. It comprises the following approaches: subjective measurements obtained by asking patients, family members, caregivers, and physicians about the patient's medication use objective measurements obtained by counting pills, examining pharmacy refill records, or using electronic medication event monitoring systems biochemical measurements obtained by adding a nontoxic marker to the medication and detecting its presence in blood or urine or measurement of serum drug levels. Determining Factors A myriad of factors contributes to poor medication adherence. Some are related to patients (eg, suboptimal health literacy and lack of involvement in the treatment decision-making process), others are related to physicians (eg, prescription of complex drug regimens, communication barriers, ineffective communication of information about adverse effects, and provision of care by multiple physicians), and still others are related to healthcare systems (eg, office visit time limitations, limited access to care, and lack of health information technology). Primary Nonadherence The literature has reported substantial variation in primary nonadherence, with estimates ranging from as little as 1.9% of incident prescriptions never filled to as much as 75%. A study carried out using data from a primary care network in British Columbia, Canada, estimated the rate of primary nonadherence, defined as failure to dispense a new medication or its equivalent within 6 months of the prescription date, using data from 150,565 new prescriptions issued to 34,243 patients. Rate of Nonadherence The following patterns of primary nonadherence were observed: Primary nonadherence was lowest for prescriptions issued by prescribers aged 35 years or younger (17.1%) and male prescribers (15.1%). It was similar among patients of both sexes. It was lowest in the oldest subjects, decreasing with age (odds ratio [OR], 0.91 for each additional 10 years). It was highest for drugs prescribed mostly on an as-needed basis, including topical corticosteroids (35.1%) and antihistamines (23.4%). Predictors of Nonadherence The odds of primary nonadherence exhibited the following patterns: lower for prescriptions issued by male clinicians (OR, 0.66) significantly greater, compared with anti-infectives, for dermatological agents (OR, 1.36) and the lowest for cardiovascular agents (OR, 0.46). lower across therapeutic drug categories (except for respiratory agents) for those aged 65 years and older than for those younger than age 65. In conclusion, in a general medicine setting, the odds of primary nonadherence were higher for younger patients, those who received primary care services from female prescribers, and older patients who were prescribed more medications. Across therapeutic categories, the odds of primary nonadherence were lowest for cardiovascular system agents and highest for dermatological agents. To date, the lack of a standardized terminology, operational definition, and measurement methods of primary nonadherence has limited our understanding of the extent to which patients do not avail themselves of prescriber-ordered pharmaceutical treatment. These results reaffirm the need to compare the prevalence of such nonadherence in different healthcare settings.

For many of us, family is one of the most important aspects of our lives. Whether biological or chosen, it’s our family members that we rely on for support. But like all relationships, there are dynamics at play. Our family dynamics can significantly impact our mental health in both positive and negative ways. Because of this, it’s important to understand how your own family dynamics have shaped you. Let’s explore some examples of healthy and less-healthy family dynamics (even toxic ones). Then, we’ll discuss how you can work on building positive family dynamics. Our family dynamics can strongly influence how we see ourselves, others, and the world around us. Plus, they influence our behaviors, well-being, and work relationships. Our families are where we first learn to relate to others. But family isn't destiny. Once we become aware of how our family influences us, we can have more control over whether those dynamics shape our perceptions and actions. The dynamics in our families aren't limited to current, living generations. They also include previous generations, as we still feel the effects of some of their traditions, structures, and habits. To better understand the meaning of family dynamics, we need to dig a little deeper. Various factors influence our family dynamics, including: Family members’ ages Family members’ personalities The relationship between the parents of a family A parent who is relaxed or strict An absent parent Intergenerational homes The job requirements of working parents A family member with a disability or chronic illness Issues such as substance use or abusive relationships Parent and grandparent family dynamics Events such as divorce, affairs, trauma, grief, or unemployment and resulting job search depression Secure or insecure family attachments Culture, ethnicity, and family values about gender roles and responsibilities Family members’ power or status Type and level of influence from family members 6 types of family dynamics Various types of dynamics are present within each family system. They dictate how a family functions and the power roles parents and siblings play. Let’s take a closer look at six types of family dynamics: 1. Authoritarian Authoritarian dynamics can be summed up as being all about following the rules without any exceptions. In this family dynamic, one family member is very controlling. They expect others to follow them without negotiation or questioning. Other family members aren’t allowed to be involved in solving challenges and problems or to share their opinions. Failure to adhere to the rules is usually met with punishment rather than constructive feedback. For example, the head of the household sets the rules for when everyone in the family must be home for dinner. If anyone is late, they are met with aggression and punishment. 2. Authoritative Authoritative dynamics also involve rules and consequences, but not in the same way as authoritarian dynamics. One individual sets the rules while validating other family members’ feelings and respecting their opinions. The authoritative family member stays in charge. They use positive discipline such as reward systems and praise to reinforce good behavior. They don't use threatening punishment for disobeying the rules. Let’s look at an example of a nuclear family with an authoritative family dynamic. The parents set clear household rules for their children, and explain the reasons behind their rules. Rather than saying, “Eat your vegetables because I said so,” they say, “Eat your vegetables so you can help your body and your brain grow.” 3. Competitive With competitive family dynamics, family members are continuously competing with one another. There is a sense of rivalry within the household, as members try to outshine their relatives. This competition could be for many things, such as attention, recognition, or power. Competitive dynamics can take place between siblings when parents encourage their children to challenge each other. Another example is spouses competing over their professional achievements, whether that’s promotions, raises, or who has the highest salary. 4. Uninvolved When uninvolved dynamics are present, family members aren’t present to one another, even when they’re in the same room. Individuals don’t really know what the other members of the family are doing. There is often a lack of support and guidance. As an example, one person in a marriage may be totally disinterested in their spouse’s life. Rather than asking their partner how their day was or supporting them in times of need, they are dismissive and neglectful. 5. Communal The presence of communal dynamics emphasizes the family as a community in which every member makes a contribution. Individual opinions are respected, and all voices are heard. In a communal family structure, tasks are shared, and everyone helps set rules and solve problems and challenges. All family members are encouraged to actively participate in making decisions and setting rules. 6. Alliance-based Alliance-based dynamics lead to members of the family grouping together and playing off each other. Certain family members form alliances in order to gain leverage over other members of the family. They agree to work together for mutual interest. This agreement can be explicit or implied. For example, in a step family, biological siblings may form alliances against their step-siblings. Or a child may form an alliance with one parent and pit them against the other parent or their siblings. Family dynamics and self-awareness The family dynamics of our childhood, as well as our current family dynamics, can impact our behavior, relationships, and work. One of the reasons for this is that those dynamics can trigger various emotions. In some cases, it can lead to emotional labor. Those emotions can also be triggered if we find ourselves in situations with similar dynamics to what we experience in our family units. Self-awareness is a key element in understanding how our family roles impact us and our work. Many of us are unaware of how those dynamics affect our emotional well-being. Writing for Harvard Business Review, Roger Jones explained that early family life can affect leaders in various ways. For example, those early dynamics can affect leaders’ reactions to team members who vie for attention. It can also impact their relationships with people who report to them and how they respond to pressure. Sometimes, we subconsciously redirect our feelings from childhood onto someone years later. This is known as transference, and it can be positive or negative. For example, a manager or supervisor may remind a team member of a parental figure. The team member is likely to respond to the manager in the same way they responded to their parents. A lack of self-awareness makes it difficult to recognize and respond to the impact of family dynamics. Jones writes that some people who are vaguely aware of their issues might consider them as personality traits they cannot change. Others might ignore their issues completely because they are afraid of looking weak. Self-awareness offers insights into how our family influences our styles of communication and relationships. When we recognize the impact of our family dynamics on our behavior, we can work at changing traits we thought of as unchangeable. Our own self-awareness can also help us recognize when our team members and managers are acting out their own family dynamics. This can change and improve the way our teams and we perform. You can't always change your family dynamics, as they were in the past. But you can work with professional support to understand how they affected you. From here, you can reframe how you understand and interpret them in the present. You also can't change other family members and how they act. But you can alter family dynamics by addressing your own role in your close family and choosing different behaviors or responses. You have individual agency to move forward and make empowering decisions. Examples of healthy family dynamics Let’s take a closer look at some of the most common characteristics of healthy family dynamics: Open communication Each member of the family should be encouraged to speak for themselves, rather than there being one person whose word is the law. There should be open communication rather than one person acting as an interpreter or message carrier. Emotional support Emotional support is when everyone is allowed to communicate their anxieties, fears, and sorrows. Emotional support also enhances each family member’s ability to care for themselves. For example, a child who is being bullied at school feels comfortable enough to tell their family what is happening. Or an individual who has just been laid off feels comfortable asking their partner for help in looking for a new job. Shared responsibility and authority Shared responsibility and authority mean one or both parents aren’t responsible for everything. They also are not the only ones involved in making decisions. The hallmarks of shared power and responsibility include respect and inclusivity. It also means creating opportunities for children or other family members to lead. For example, parents ask their children for input when discussing the chores list or the destination for the next family vacation. Or both husband and wife share the responsibility of preparing the house for Christmas so as to avoid holiday stress. Balance between work and family A lack of balance between work and family can be a source of conflict within the family and at work. Greater balance between the two can diminish conflict and lead to healthy relationships in both areas. For example, one of the parents in a nuclear family might spend too much time dealing with work responsibilities. Their partner and children may take on more responsibilities at home. This could lead to tension between the parents and children. Expressing interest in each other’s lives By taking an interest in each other’s lives, family members make each other feel valued and included. For example, family members ask each other about their day when they eat dinner together, and they support each other’s important events. If a child is participating in a school play, all family members attend a show. Providing support and discipline to children This characteristic of healthy family dynamics sees parents taking an active role in the children’s lives. The key to this is to be loving, but also to provide a structure that supports the children’s well-being. Parents should discipline children in a positive way by replacing punishments that frighten them with strategies that encourage better behavior. For example, instead of demanding them to brush their teeth, use encouraging language. “I know you don’t want to brush your teeth, but we can do it together.” Shared respect Allowing everyone to have a voice is an important part of family dynamics. In this family culture of mutual respect, constructive conflict is embraced. If conflict does arise, family members work to resolve it rather than punishing those whose opinions differ. Creating a safe, loving environment A safe and loving environment is one in which parents set good examples, stay positive and display affection. These family dynamics help members nurture relationships and build strong human connections. How to step back from toxic family dynamics Some family dynamics are toxic and can deeply affect your emotional and mental well-being. Ways to step back from dysfunctional family dynamics include: 1. Setting boundaries in your family relationships Some behaviors are not acceptable within a family. You need to set boundaries that let family members know which behaviors are not acceptable. The key to setting boundaries is to be firm but kind. Listen to what your family members have to say, but seek to take care of yourself. 2. Expressing your concerns Each family member should communicate their feelings about the family dynamics. They also should offer possible solutions. Everyone should be able to express their feelings without being criticized or interrupted by other members. 3. Practicing self-care According to Laurel Daly, toxic family dynamics can place stress on you in various ways. Toxic family members may ignore your emotions, insult you, or gossip about you. The negative effect on your self-esteem could lead to you forgetting about self-care. One element of a self-care plan is taking time out for yourself, so you can do things that make you feel good about yourself. Another element of self-care is to identify and deal with toxic family members. 4. Seeking professional help Dealing with toxic family dynamics isn’t easy. You may experience feelings of guilt or shame. Or you may avoid dealing with confronting members of your family in an effort to keep the peace. You might not know where to begin. Seeking professional help from a counselor or family therapist can provide you with the support you need to take those first steps. In this sense, seeking family therapy is a form of self-care. 5. Developing your emotional regulation skills Toxic family dynamics can affect our emotional regulation skills. Reacting impulsively to emotions at work that mimic toxic family dynamics is one example. Emotional regulation involves regulating your actions and responses triggered by emotions. You can develop your skills through self-awareness, mindful breathing, and self-compassion. 6. Determining the root of toxic behavior Identifying toxic behaviors and communicating your concerns about them isn’t enough. You should try to determine the root of those behaviors, too. Some toxic behaviors that affect family dynamics exist because no one sets any boundaries. Other behaviors may be a result of mental health concerns. Identifying the root of that behavior could lead to positive changes. Understand your family dynamics Positive or negative, your family dynamics and the way you grew up can affect your life in various ways. If your childhood experience had toxic family dynamics, your overall well-being could suffer. Your behavior, relationships, and work performance can be affected as those dynamics resurface. If your experience was one of positive dynamics, the influence on your adult life should be positive. For many of us, our family dynamics include both positive and negative elements. Understanding past and present family dynamics is an essential part of personal transformation. Let our professional BetterUp coaches support you on that journey – get started today.

Every August, SAMHSA commemorates Overdose Awareness Week (August 27 to September 2, 2023) and International Overdose Awareness Day (August 31, 2023) to remember the individuals, families, and communities who have all been impacted by overdose. According to the latest provisional data from the Centers for Disease Control and Prevention (CDC), an estimated 110,000 lives were lost to overdose in the 12-months ending in March 2023, with fentanyl and other synthetic opioids as the main drivers of these deaths. Adding to the challenge of rising fentanyl-involved overdoses is the emergence of xylazine, a non-opioid tranquilizer, increasingly mixed with fentanyl in the illicit drug supply. Too many lives have been taken and too many people have been personally affected by overdose. Overdose can be attributed to many factors. For example, it can happen when an individual uses a substance that has been contaminated with highly potent opioids or other drugs or when the person misunderstands the dosage of the medication they are taking. Irrespective of the cause, overdose can have devastating, long lasting impacts in our communities – but we also know that overdoses can be prevented. To address the overdose crisis, the Department of Health and Human Services developed the Overdose Prevention Strategy with four main pillars: Primary Prevention - These strategies promote tiered, multidisciplinary prevention activities, ranging from population-level strategies to targeted interventions aimed at high-risk individuals. These activities engage health and human services providers directly and facilitate cross-sector collaboration on prevention to address key upstream risk and protective factors. Harm Reduction - Evidence-based harm reduction strategies minimize negative consequences of drug use. These activities further expand access to harm reduction interventions such as opioid overdose reversal medications and fentanyl and xylazine test strips and better integrate harm reduction into specialty and general medical care. Evidence-Based Treatment - These strategies focus on reducing barriers to accessing the most effective treatments, including medications for opioid use disorder, using motivational and cultural enhancements to encourage those who might be reluctant, advancing strategies to improve engagement and retention, and continuing to develop new therapeutic approaches. Recovery Support - These strategies recognize that treatment alone may not be enough to support long-term recovery. Despite the demonstrated benefits of recovery support services — such as peer supports, employment and housing services — various challenges impede their availability and uptake. Enhancing coverage and integration of recovery support services is critical to promoting access to and use of these services. Strengthening the recovery support services workforce also is essential to promoting access and quality. Preventing substance use and overdose is one of SAMHSA’s top priorities emphasized in the new SAMHSA 2023-2026 Strategic Plan. SAMHSA is working to address the overdose crisis by providing technical assistance, thought leadership and partnership with communities, and funding multiple complementary grant programs. These efforts focus on preventing opioid and substance use in the first place, increasing access to medications for opioid use disorder, supporting harm reduction services, and improving access to treatment and recovery support services. A few of these programs include Medication-Assisted Treatment – Prescription Drug and Opioid Addiction, Harm Reduction, Improving Access to Overdose Treatment, and First Responders – Comprehensive Addiction and Recovery Act. As we commemorate Overdose Awareness Week and International Overdose Awareness Day, we know there is hope. This requires a collective effort, and SAMHSA remains committed to being at the forefront of providing lifesaving information and resources to the public, health care providers, and other partners in the community. The following are resources that SAMHSA will be releasing soon to help communities address these challenges: Opioid-Overdose Reduction Continuum of Care Approach (ORCCA) Practice Guide. This Guide includes a menu of evidence-based strategies for reducing opioid overdose deaths. The ORCCA Guide has three focus areas: opioid overdose education and reversal medication distribution, medication treatment for opioid use disorder, and safer opioid prescribing and disposal. Engaging Community Coalitions to Decrease Opioid Overdose Deaths Practice Guide. This provides guidance on building and maintaining community coalitions that focus on the opioid crisis, as well as approaches for assessing how well coalitions are functioning. The final Harm Reduction Framework which will incorporate public feedback and provide a roadmap of best practices, principles, and pillars that every entity can apply to their work. Our efforts at SAMHSA are pursued through a shared collective vision and partnership with other federal, state, and community partners. This week, CDC is releasing a Morbidity and Mortality Weekly Report on the increasing role counterfeit pills that contain illicit fentanyl and other synthetic opioids are playing in the overdose crisis. In addition, CDC has a dedicated site for International Overdose Awareness Day that provides ideas on how everyone can engage and take action such as wearing a purple ribbon or sharing an IOAD message on social media to facilitate discussion. Every community across our country has been impacted by the overdose crisis. And behind all of the statistics are families, friends, and communities that will be forever changed. Everyone has a role to play and observing Overdose Awareness Week and International Overdose Awareness Day provide an important opportunity to remember those who have been lost and recommit to doing everything we can to prevent substance use and overdose.

Here is a hint – they are not psychiatrists or even physicians. They are Republicans. That may come as a shock to those of you who have absorbed all of the pharma conflict of interest stories about physicians over the past 20 years. Psychiatry in general was selected for much of that criticism. The average physician in the US had no significant conflict of interest even when trivial compensation like meals during continuing medical education (CME) courses were tallied. Some members of Congress even went so far to investigate some psychiatrist’s personal employment arrangements to point out any potential conflicts of interest when it came to pharmaceutical manufacturers. Today we finally have some clarification on who really backs Big Pharma and wants to assure their large profits. It should come as no surprise that it is Congress – specifically members of the pro-business GOP. For years, Congressional conflict-of-interest has been sanitized by their disclosures as if that somehow prevented them from passing pro-Pharma legislation and regulations. For the record the amount of lobby money to the major parties varies from year to year. For 2022 a total of $26,297,445 was donated from the pharmaceutical industry with $15,175,518 to the Democrats and $10,994,723 to the Republicans. That is an average donation of $29,159 to $105,910. By contrast the Open Payments site recording payments to health care professionals claims that drug and medical device companies gave physicians $12.59 billion in 2022, but they are counting funds used to pay for research as well as profits from ownership of patents and medical devices (a total of $8.87 billion). Looking at general payments alone, the physicians receiving any type of reimbursement averaged about $441. The current reporting rule is that any amount exceeding $10 or an aggregate of $100 in the case of meals must be reported. I previously asked the question whether a slice of pizza given to a doctor at grand rounds was more likely to get results for the pharmaceutical industry than the average donation to Congress ($46,579 at the time). I made the point that despite the continuous criticism of psychiatrists, they happen to be way down on the list of physicians getting these donations with about 37% receiving general payments and 3.6% receiving payments totaling more than $10,000. But all the corruption by trivial payments discussion was based on shaky research. It is quite easy to demonstrate that physicians want to try new drugs as they come into the marketplace and show that marketing efforts correlate with prescriptions. We had a No Free Lunch movement to prevent corruption by pizza slices. We had a great deal of agitation about ghost writers, pharmaceutical companies not publishing negative studies, faulty research, side effect reporting, etc. Almost all of that involved psychiatry and often several self-appointed critics from the field. There are undoubtedly problems with clinical trials in all specialties, but during that 20-year span from about 1998-2018 it seemed as if there was an active conspiracy to sell psychiatric medications. To some extent that continues but it has less legitimacy in the field particularly since drug detailing and sales have been eliminated from most clinics and hospitals. All of that commotion was probably good cover for Congress who was actually receiving payments that could make a difference. And during that time pharmaceutical companies recorded record profits. What is different now? The Biden administration has decided that it wants to negotiate prices for Medicare Part D prescriptions. They are on solid ground. The Veterans Administration (VA) negotiates drug prices and has 399 drugs on their formulary. A GAO study showed that they paid 54% less per unit than Medicare. HHS has already selected the drugs that will be negotiated in the initial round and as expected most of them are the high expenditure drugs in the plan. The Republicans claim that these negotiations will decrease access to care and raise drug prices although there is no evidence that the VA negotiations have done that. They also claim that there will be reduced innovation, research and development, and job losses. They seem to have missed the overall picture that pharmaceutical companies in other countries succeed – even when there are negotiated prices with the health plan in those countries. Of the top 15 pharmaceutical companies in the world 8 are in the United States and the remainder in Switzerland, UK, France, Denmark, and Japan. The numbers given for fewer new drugs, fewer new indications, and drop in R&D spending seem highly speculative to me. For example, the drop of $663B in R&D spending is the equivalent of about half of the total revenue for the top 15 companies. I seriously doubt they are spending that much on R&D. During the 20 year period that I am referring to companies left entire therapeutic areas and it was common knowledge that marketing was going to drive pharmaceutical sales. There is an entire section about decreased jobs. Are the Republicans really suggesting that Americans should pay (by far) the highest amounts for prescription drugs in order to fund a jobs program? And finally, the suggestion that the plan is “legally dubious”. Apparently Congress is set up to help industries optimize profits rather than protect people who can’t pay a thousand dollars or more for a Medicare Part D copay. This post also has implications of pharmacy benefit managers or PBMs. You remember them? They are the business entities charged with “managing” your pharmacy benefits allegedly to make medications most “cost effective”. PBMs make about $315 B annually for doing nothing more than managing prescription drug programs for employers and other large entities with health insurance programs. In practice they are a price multiplier rather than a price reducer. PBMs control the spread or difference between what the insurance pays for a medication and what they reimburse pharmacies. In some cases, their reimbursement for pharmacies is lower than the actual cost of the medication. Since they are leveraging large number of patients, local pharmacies typically do not have much of a choice if they expect to do business – even though an affiliation with a PBM is draining. PBMs can own their own pharmacies and reimburse those pharmacies more than community pharmacies. For a physician the most onerous aspect of PBMs occurs with prices for drugs and their positions on formularies for hospitals and clinics. A formulary is a restricted list of medications available for physicians in that health plan to prescribe for their patients. That can mean a patient has to change their prescription for it to be covered or some newer medication may not be covered at all. During negotiations with manufacturers, PBMs can get a rebate from the manufacturer if they get their product exclusively in the formulary. That rebate is kept by the PBM rather than shared with the people paying for the drug. The pharmaceutical landscape is a minefield that is set up to optimize corporate profits. Pharmaceutical companies are essentially guaranteed high margins based on patent exclusivity and high prices. PBMs generate a lot of revenue, add no value, and many pharmacists would add are a drain on their businesses. Let's face it - these businesses like most of healthcare in the US were essentially invented in Congress. If they are not a recipe for making money - I don't know what is. The Medicare Part D price negotiations through the Inflation Reduction Act is the first bright spot I have seen in a long time. Republicans clearly want to maintain the status quo and that means extremely expensive medications and copays for anyone who is in the Medicare Part D coverage gap. If you were ever surprised by one of these copays like I was recently – support the Biden Administration’s attempt to control high drug prices. Supplementary 1: An obvious point that I forgot in the original post in terms of backing Big Pharma is the idea that any physician would back limited access to a needed medication because of financial (rationing) restrictions. Toward the latter half of my career, if anything physicians have made extraordinary efforts to get medications for their patients including having to manage large collections of samples and try to supply some patients from those samples. Incredibly - some critics saw that as another perk from pharmaceutical companies that was corrupting physicians. Some politicians on the other hand who are getting very large donations from pharmaceutical companies have no hesitation in suggesting that American patients should continue to pay exorbitant costs for pharmaceuticals - even if it means not being able to afford medication and compromised health. Supplementary 2: Must watch video on regulatory capture or how Congress profits from disrupting free markets and establishing monopolies. Pharma and electronic health record (EHR) companies are cited examples, but there are additional examples including broadband and AI:

By the end of August 2022, overall use of mental health services was almost 40% higher than before the COVID-19 pandemic, while spending increased by 54%, according to a new study by researchers at the RAND Corporation. During the early phase of the pandemic, from mid-March to mid-December 2020, before the vaccine was available, in-person visits decreased by 40%, while telehealth visits increased by 1000%, reported Jonathan Cantor, PhD, and colleagues at RAND, and at Castlight Health, a benefit coordination provider, in a paper published online August 25 in JAMA Health Forum. Between December 2020 and August 2022, telehealth visits stayed stable, but in-person visits creeped back up, eventually reaching 80% of pre-pandemic levels. However, "total utilization was higher than before the pandemic," Cantor, a policy researcher at RAND, told Medscape Medical News. "It could be that it's easier for individuals to receive care via telehealth, but it could also just be that there's a greater demand or need since the pandemic," said Cantor. "We'll just need more research to actually unpack what's going on," he said. Initial per capita spending increased by about a third and was up overall by more than half. But it's not clear how much of that is due to utilization or to price of services, said Cantor. Spending for telehealth services remained stable in the post-vaccine period, while spending on in-person visits returned to pre-pandemic levels. Cantor and his colleagues were not able to determine whether utilization was by new or existing patients, but he said that would be good data to have. "It would be really important to know whether or not folks are initiating care because telehealth is making it easier," he said. The authors analyzed about 1.5 million claims for anxiety disorders, major depressive disorder, bipolar disorder, schizophrenia, and posttraumatic stress disorder, out of claims submitted by 7 million commercially insured adults whose self-insured employers used the Castlight benefit. Cantor noted that this is just a small subset of the US population. He said he'd like to have data from Medicare and Medicaid to fully assess the impact of the COVID-19 pandemic on mental health and of telehealth visits, also. "This is a still-burgeoning field," he said, about telehealth. "We're still trying to get a handle on how things are operating, given that there's been so much change so rapidly." Meanwhile, 152 major employers responding to a large national survey this summer said that they’ve been grappling with how COVID-19 has affected workers. The employers include 72 Fortune 100 companies and provide health coverage for more than 60 million workers, retirees, and their families. Seventy-seven percent said they are currently seeing an increase in depression, anxiety, and substance use disorders as a result of the pandemic, according to the Business Group on Health's survey. That's up from 44% in 2022. Going forward, employers will focus on increasing access to mental health services, the survey reported. "Our survey found that in 2024 and for the near future, employers will be acutely focused on addressing employees’ mental health needs while ensuring access and lowering cost barriers," said Ellen Kelsay, president and CEO of Business Group on Health, in a statement. The study was supported by grants from the National Institute of Mental Health and the National Institute on Aging. Co-author Dena Bravata, a Castlight employee, reported receiving personal fees from Castlight Health during the conduct of the study. Co-author Christopher Whaley, a RAND employee, reported receiving personal fees from Castlight Health outside the submitted work.

Self-awareness is the ability to see yourself clearly and objectively through reflection and introspection. While it may not be possible to attain total objectivity about oneself (that’s a debate that has continued to rage throughout the history of philosophy), there are certainly degrees of self-awareness. It exists on a spectrum. Although everyone has a fundamental idea of what self-awareness is, we don’t know exactly where it comes from, what its precursors are, or why some of us seem to have more or less than others. This is where the self-awareness theory comes in, offering some potential answers to questions like these. These detailed, science-based exercises will not only help you increase the compassion and kindness you show yourself but will also give you the tools to help your clients, students, or employees show more compassion to themselves. What Is Self-Awareness Theory? Self-awareness theory is based on the idea that you are not your thoughts, but the entity observing your thoughts; you are the thinker, separate and apart from your thoughts (Duval & Wicklund, 1972). We can go about our day without giving our inner self any extra thought, merely thinking and feeling and acting as we will; however, we also can focus our attention on that inner self, an ability that Duval and Wicklund (1972) termed “self-evaluation.” When we engage in self-evaluation, we can give some thought to whether we are thinking and feeling and acting as we “should” or following our standards and values. This is referred to as comparing against our standards of correctness. We do this daily, using these standards as a way to judge the rightness of our thoughts and behaviors. Using these standards is a major component of practicing self-control, as we evaluate and determine whether we are making the right choices to achieve our goals. Research on the Topic This theory has been around for several decades, giving researchers plenty of time to test its soundness. The depth of knowledge on self-awareness, its correlates, and its benefits can provide us with a healthy foundation for enhancing self-awareness in ourselves and others. According to the theory, there are two primary outcomes of comparing ourselves against our standards of correctness: We “pass,” or find alignment between ourselves and our standards. We “fail,” or find a discrepancy between ourselves and our standards (Silvia & Duval, 2001). When we find a discrepancy between the two, we find ourselves with two choices: to work toward reducing the discrepancy or avoid it entirely. Self-awareness theory (and subsequent research) suggests that there are a couple of different factors that influence how we choose to respond. Basically, it comes down to how we think it will turn out. If we believe there’s little chance of actually changing this discrepancy, we tend to avoid it. If we believe it’s likely that we can improve our alignment with our standards of correctness, we take action. Our actions will also depend on how much time and effort we believe that realignment will take; the slower progress will be, the less likely we are to take on the realignment efforts, especially if the perceived discrepancy between ourselves and our standards is large (Silvia & Duval, 2001). Essentially, this means that when faced with a significant discrepancy that will take a lot of consistent and focused work, we often simply don’t bother and stick to avoiding self-evaluation on this particular discrepancy. Further, our level of self-awareness interacts with the likelihood of success in realigning ourselves and our standards to determine how we think about the outcome. When we are self-aware and believe there is a high chance of success, we are generally quick to attribute that success or failure to our efforts. Conversely, when we are self-aware but believe there is a low chance of success, we tend to think that the outcome is more influenced by external factors than our efforts (Silvia & Duval, 2001). Of course, sometimes our success in realignment with our standards is driven in part by external factors, but we always have a role to play in our successes and failures. Interestingly, we also have some control over our standards, such that we may alter our standards if we find that we don’t measure up to them (Dana, Lalwani, & Duval, 1997). This is more likely to happen if we’re focused more on the standards than on ourselves; if we fail when we are focused on the standards more than our performance, we are more likely to blame the standards and alter them to fit our performance (Dana et al., 1997). Although it may sound like merely shifting the blame to standards and, therefore, letting yourself off the hook for a real discrepancy, there are many situations in which the standards are overly strict. Therapists’ offices are filled with people who hold themselves to impossibly high standards, effectively giving themselves no chance of success when comparing themselves to their internal standards. It’s clear from the research on self-awareness that it is an important factor in how we think, feel, act, and react to our thoughts, feelings, and actions. 4 Proven Benefits of Self-Awareness Now, let’s shift our attention to research on the outcomes of being self-aware. As you might imagine, there are many benefits to practicing self-awareness: It can make us more proactive, boost our acceptance, and encourage positive self-development (Sutton, 2016). Self-awareness allows us to see things from the perspective of others, practice self-control, work creatively and productively, and experience pride in ourselves and our work as well as general self-esteem (Silvia & O’Brien, 2004). It leads to better decision making (Ridley, Schutz, Glanz, & Weinstein, 1992). It can make us better at our jobs, better communicators in the workplace, and enhance our self-confidence and job-related wellbeing (Sutton, Williams, & Allinson, 2015). These benefits are reason enough to work on improving self-awareness, but this list is by no means exhaustive. Self-awareness has the potential to enhance virtually every experience you have, as it’s a tool and a practice that can be used anywhere, anytime, to ground yourself in the moment, realistically evaluate yourself and the situation, and help you make good choices. 3 Examples of Self-Awareness Skills So we know that self-awareness is good, but what does it look like? How does one practice self-awareness? Below are three examples of someone practicing self-awareness skills: Bob at work Bob struggles with creating a quarterly report at work, and he frequently produces subpar results. He notices the discrepancy between his standards and performance and engages in self-evaluation to determine where it comes from and how to improve. He asks himself what makes the task so hard for him, and he realizes that he never seems to have trouble doing the work that goes into the report, but rather, writing it up cohesively and clearly. Bob decides to fix the discrepancy by taking a course to improve his writing ability, having a colleague review his report before submitting it, and creating a reusable template for future reports so he is sure to include all relevant information. Monique at home Monique is having relationship problems with her boyfriend, Luis. She thinks Luis takes her for granted and doesn’t tell her he loves her or share affection enough. They fight about this frequently. Suddenly, she realizes that she may be contributing to the problem. She looks inward and sees that she doesn’t show Luis appreciation very often, overlooking the nice things he does around the house for her and little physical touches that show his affection. Monique considers her thought processes when Luis misses an opportunity to make her feel loved and notes that she assumes he purposely avoids doing things that she likes. She spends time thinking and talking with Luis about how they want to show and receive love, and they begin to work on improving their relationship. Bridget on her own Bridget struggles with low self-esteem, which causes depressive symptoms. She doesn’t feel good enough, and she doesn’t accept opportunities that come her way because of it. She begins working with a therapist to help her build self-awareness. The next time an opportunity comes her way, she thinks she doesn’t want to do it and initially decides to turn it down. Later, with the help of some self-awareness techniques, Bridget realizes that she is only telling herself she doesn’t want to do it because of her fear that she won’t be good enough. Bridget reminds herself that she is good enough and redirects her thoughts to “what if I succeed?” instead of “what if I fail?” She accepts the opportunity and continues to use self-awareness and self-love to improve her chances of success. These three stories exemplify what self-awareness can look like and what it can do for you when you tap into it. Without self-awareness, Bob would have kept turning in bad reports, Monique would have continued in an unsatisfying relationship or broken things off, and Bridget would never have taken the opportunity that helped her grow. If you look for them, you can find these stories everywhere. 5 Ways to Increase Your Self-Awareness Now we have some clearcut examples of self-awareness in mind. We know what it looks like to embrace self-awareness and grow. But how do you do it? What did our leading characters do to practice self-awareness? There are many ways to build and practice self-awareness, but here are some of the most effective: 1. Practice mindfulness and meditation Mindfulness refers to being present in the moment and paying attention to yourself and your surroundings rather than getting lost in thought or ruminating or daydreaming. Meditation is the practice of focusing your attention on one thing, such as your breath, a mantra, or a feeling, and letting your thoughts drift by instead of holding on to them. Both practices can help you become more aware of your internal state and your reactions to things. They can also help you identify your thoughts and feelings and keep from getting so caught up in them that you lose your hold on your “self.” 2. Practice yoga Yoga is a physical practice, but it’s just as much a mental practice. While your body is stretching and bending and flexing, your mind is learning discipline, self-acceptance, and awareness. You become more aware of your body and all the feelings that manifest, and you become more aware of your mind and the thoughts that crop up. You can even pair yoga with mindfulness or meditation to boost your self-awareness. 3. Make time to reflect Reflecting can be done in multiple ways (including journaling; see the next tip) and is customizable to the person reflecting, but the important thing is to go over your thoughts, feelings, and behaviors to see where you met your standards, where you failed them, and where you could improve. You can also reflect on your standards themselves to see if they are good ones for you to hold yourself to. You can try writing in a journal, talking out loud, or simply sitting quietly and thinking, whatever helps you to reflect on yourself. 4. Journal The benefit of journaling is that it allows you to identify, clarify, and accept your thoughts and feelings. It helps you discover what you want, what you value, and what works for you. It can also help you find out what you don’t want, what is not important to you, and what doesn’t work for you. Both are equally important to learn. Whether you like to write free-flowing entries, bulleted lists, or poems, writing down your thoughts and feelings helps you to become more aware and intentional. 5. Ask the people you love It’s vital to feel we know ourselves from the inside, but external feedback helps too. Ask your family and close friends about what they think about you. Have them describe you and see what rings true with you and what surprises you. Carefully consider what they say and think about it when you journal or otherwise reflect. Of course, don’t take any one person’s word as gospel; you need to talk to a variety of people to get a comprehensive view of yourself. And remember that at the end of the day, it’s your self-beliefs and feelings that matter the most to you! Importance in Counseling and Coaching Self-awareness is a powerful tool that, when practiced regularly, can do more good for coachees and clients than anything else a professional can share with them. To make real, impactful, and lasting change, people need to be able to look inward and become familiar with that internal environment. Building self-awareness should be a top priority for virtually all clients, after which the more traditional coaching and counseling work can begin. For example, you can counsel someone on their bad habits and give 1,000 ways to break their habits. Still, if they don’t understand why they tend toward these bad habits in the first place, it’s almost a guarantee that they will either never break those habits or will quit for a while and simply pick up where they left off when things get tough. Self-awareness is not only vital for the coachee or client; it is also important for the coach or counselor. In fact, self-awareness is prioritized as a core standard in the Council for Accreditation of Counseling and Related Educational Programs Standards (2017) for the profession, as both a requirement for counselors and a necessary skill to build in clients. It takes a good amount of self-awareness to give competent counsel and provide actionable advice. Plus, self-awareness will help the caring counselor from getting too wrapped up in their client’s problems or seeing the issues through their own skewed lens. To truly help someone, it’s essential to see things from their perspective, and that requires being self-aware enough to put our thoughts and feelings aside sometimes. Meditation, Mindfulness, and Self-Awareness The link between meditation, mindfulness, and self-awareness is clear, meaning it’s no surprise that practicing the first two will naturally lead to more of the third. When we meditate or practice mindfulness, we are paying attention to the things that can often get ignored in our busy day-to-day: the present moment and our own internal experience. Those who get to know their thought processes and patterns are more able to adapt and improve them, both by simply being aware of their processes and patterns and by giving themselves a mechanism for practicing and improving. Indeed, a program intended to enhance self-awareness (among other things) through yoga and meditation resulted in a range of improvements, including more positive affect, less stress, greater mindfulness, enhanced resilience, and even greater job satisfaction (Trent et al., 2019). Self-Awareness & Emotional Intelligence Emotional intelligence can be defined as the cluster of abilities that allow us to recognize and regulate emotions in ourselves and others (Goleman, 2001). According to the most popular theory of emotional intelligence from psychologist and author Daniel Goleman (2001), self-awareness is not only crucial for emotional intelligence; it’s one of the five components. These five components are: Self-awareness Self-regulation Social skills Empathy Motivation Other popular theories of emotional intelligence also include self-awareness as a core component, making it one of the factors that virtually all researchers and experts agree on (Goleman, 2001). Self-awareness is a necessary building block of emotional intelligence; it is the building block upon which the rest of the components are built. One must have self-awareness to self-regulate, and social skills will be weak and of little use if you are not aware enough about when and how to use them. If you’re looking to build your emotional intelligence, self-awareness is the first step. Make sure you have developed strong skills in self-awareness before giving the other elements your all. 4 Tips for Improving Self-Awareness in Relationships If you want to be more like post-reflection Monique than pre-reflection Monique (referring to examples of self-awareness skills in action above), or if you’re going to help your clients with their relationship woes, here are some excellent tips for introducing more self-awareness within the context of a relationship: 1. Be mindful Practice mindfulness, especially when interacting with your loved ones. Pay attention to the words they say, their tone, their body language, and their facial expressions. We often communicate far more information with the latter three than we do with our words alone. Give your loved ones your full attention. 2. Talk Have regular discussions about the relationship. It’s important to keep things in perspective and ensure that nothing is falling between the cracks. When you have regular conversations about your relationship with your loved ones, it’s much harder to avoid or ignore things that can turn into problems. It also helps you reflect on your part and come prepared to discuss your thoughts, feelings, and behaviors with your loved ones. 3. Quality time Spend quality time together and apart. This is especially important for romantic relationships, as we often find ourselves spending most or even all of our free time with our spouse or partner. However much you love and enjoy spending time with your partner, everyone needs some quality time alone. Make sure you and your partner are both getting some quality “me” time to think about what you want, what you need, and what your goals are. This will help you keep yourself from merging too much into your partner and maintaining your independence and stability. Then, since there will be two independent, stable, and healthy adults in the relationship, it will be even more fulfilling and satisfying to both partners when they spend quality time together. 4. Be considerate Share your perspective and consider theirs. It’s easy to get too caught up in our own perspective on things; however, healthy relationships require that we consider others’ needs in addition to our own. To know what our loved ones need and to deliver on those needs, we must first identify and understand them. We do this by practicing our self-awareness and sharing that awareness with our friends and family. If you never check in with your loved ones on their views or feelings, it can cause you to drift apart and inhibit real, satisfying intimacy. Ask your loved ones for their perspective on things and share your perspective with them. Role in the Workplace and Leadership As noted earlier, self-awareness improves our communication, confidence, and job performance (Sutton et al., 2015). It’s easy to see how self-awareness can lead to these outcomes in the workplace, as better self-evaluation naturally leads to improving the alignment between our actions and our standards, resulting in better performance. According to Tasha Eurich (2018), self-awareness can be divided into two categories or types: internal self-awareness and external self-awareness. Internal self-awareness is about how well we see ourselves and our strengths, weaknesses, values, etc., while external self-awareness is understanding how others view us with those same factors (Eurich, 2018). Good managers and leaders need both to perform well in their roles. Although you might think that more experience as a leader and greater power in one’s role lead to better self-awareness, that may not be the case. Experience can be positive or negative in terms of learning and improving the self. Even positive experiences can lead one to attribute success to themselves when it may have had more to do with the circumstances, leading to false confidence. In fact, only 10–15% of those in Eurich’s (2018) study displayed self-awareness, although most of us believe we are self-aware. To improve self-awareness, Eurich (2018) recommends introspection, but with a focus on asking oneself the right questions. She notes that asking “why” might not always be effective, as many of our internal processes remain shrouded in our subconscious or unconscious minds; insteadFor example, instead of asking, “Why do I fail at this task so often?” you might ask yourself, “What are the circumstances in which I fail at this task, and what can I do to change them?” It’s not a foolproof method, but it can aid you in improving your self-awareness and increasing your alignment with your standards on certain activities., asking “what” may lead to better introspection. Self-Awareness in Students and Children Self-awareness isn’t just for managers and employees; it can also substantially benefit students, children, and adolescents. The same benefits that make us more productive in the workplace can make students more productive in the classroom and at home: better communication with teachers and peers, more confidence, and more satisfaction with performance can all lead to happier, healthier students. These benefits also apply to advanced students. Increased self-awareness leads to more self-care in medical students (Saunders et al., 2007) and a better understanding of one’s strengths and capabilities along with a boost to emotional intelligence in law students (James, 2011). A Take-Home Message In short, a little extra self-awareness can be of great benefit to anyone with the will to improve. This piece includes a description of self-awareness, an exploration of the theory of self-awareness, examples, and tips and tools you can use to boost your self-awareness. We hope you find this information helpful in increasing your self-awareness or that of your clients. What exercises do you use to help build self-awareness? What are some other benefits you’ve noticed? Let us know in the comments section below. If you liked this post, head on over to our post about self-awareness books to further help you increase reflection. We hope you enjoyed reading this article. Don’t forget to download our three Self Compassion Exercises for free.

Psilocybin Reduces Symptoms, Disability in Major Depression A single dose of an experimental psilocybin drug offered significant sustained improvement in symptoms and disability in patients with major depressive disorder (MDD) over a 6-week period, a new study suggests. The randomized, phase 2 trial was conducted at 11 sites across the US and is the latest to demonstrate the psychedelic drug's potential as a treatment for depression. The project was funded by Usona Institute, a nonprofit medical research organization based in Madison, Wisconsin. The institute issued a press statement, but researchers did not comment further on the findings. "As the largest and most rigorous study conducted across a wide spectrum of individuals with major depressive disorder, the results show promise for all people struggling with this condition," lead author Charles Raison, MD, director of clinical and translational research at Usona, said in the statement. The 34 co-authors on the study are affiliated with public universities, research centers, and private companies. Eight of the investigators are identified as employees of Usona Institute. Declining further comment, an institute spokesperson told Medscape Medical News that, "Usona has chosen the approach of no interviews, and this applies for all co-authors." Largest Study to Date Usona's investigational psilocybin drug has been granted a breakthrough designation by the US Food and Drug Administration, a process designed to speed drug development and review. Previous smaller studies have suggested a rapid antidepressant response with psilocybin, but they have been small, unblinded, and have had short duration of follow-up, they write. This randomized, double-blind, phase 2 clinical trial is the largest study of psilocybin for depression to date, the researchers note. It included 104 adults aged 21-65 years with MDD who had a current depressive episode of at least 60 days and a Montgomery-Åsberg Depression Rating Scale (MADRS) total score of 28 or more at baseline. Participants had to be free of psychedelic drugs for at least 5 years, have had no active suicidal ideation or suicidal behavior in the prior 12 months, no personal or first-degree family history of psychosis or mania and no history of moderate/severe alcohol or drug use disorder. Before the study, participants had a 7- to 35-day screening period for psychiatric medication tapering, underwent baseline assessments and received 6-8 hours of preparation with two facilitators who would be with them during dosing. Dosing occurred within 7 days of baseline assessments. During the 6- to 8-hour session, participants received either a single 25-mg oral dose of psilocybin or 100-mg dose of niacin. One participant randomly assigned to receive psilocybin received the incorrect treatment, resulting in 50 participants receiving psilocybin and 54 receiving niacin. Participants returned the next day, the next week, and then every 2 weeks for assessments, for a follow-up of 6 weeks. Psychosocial Support Participants who received psilocybin reported significantly greater improvements in MDD symptoms compared with those who received niacin. MADRS scores — a scale from 0 to 60 where higher scores indicate more severe depression — showed greater reductions with treatment vs placebo at 8 days (mean difference, −12.0; 95% CI, −16.6 to −7.4; P < .001), and at day 43 (mean difference, −12.3; 95% CI, −17.5 to −7.2; P < .001). More participants receiving psilocybin had sustained depressive symptom response (42% vs 11%; P = .002) and more improvement in the Sheehan Disability Scale score, which measures functional disability, 43 days after treatment (P < .001). The effects persisted through the end of the study, although the differences between groups were no longer significant by week 6. "This is another exciting piece of evidence that adds to the current literature regarding the potential efficacy of psilocybin for the treatment of mental health conditions, particularly depression," said Greg Fonzo, MD, co-director of the Center for Psychedelic Research and Therapy at the University of Texas at Austin's Dell Medical School, who commented on the findings for Medscape Medical News. Significantly more people in the psilocybin group reported at least one treatment-related adverse event (82% vs 44%), although most were mild to moderate. Headache and nausea were the most common side effects and most resolved within one day of dosing. While those numbers are high, Fonzo said they're not out of line with AEs reported in other studies. "Particularly with the types of adverse events reported here, like headache and nausea, those are things you would typically expect to see in this treatment," said Fonzo, who was not part of the research. "But it is high, and it underscores that this is not a treatment without certain risks, even though it was good that they were primarily mild in severity," he added. A "Stepping Stone" to FDA Approval? The use of tools to measure disability in addition to symptoms of depression severity is a strength of the study, Fonzo added. The use of an active comparator and the 6-week follow-up also offer something new over previous studies. Despite the longer follow up, questions remain about the durability of response, something only a longer study could answer, Fonzo said. The small and homogenous sample-size are also a concern. Nearly 90% of participants were White and more than half had an income of $75,000 a year or higher. "It's another stepping stone in the process to FDA approval, but the next step in that process would be much larger phase 3 trials that would have much larger samples, a longer follow up, and hopefully have a more inclusive swath of the population," Fonzo said. But perhaps one of the most significant limitations is the use of niacin as an active comparator, said Caleb Alexander, MD, co-director of the Center for Drug Safety and Effectiveness at Johns Hopkins University in Baltimore, Maryland. The use of an agent that doesn't produce effects similar to those expected from a psychedelic introduced the potential for functional unblinding, Alexander told Medscape Medical News. Investigators did not ask participants to guess whether they received psilocybin or niacin, so the quality of the blinding was not assessed in the study. "We'd like to see the use of [an] active comparator that might have a chance of obscuring to people as to whether they've been randomized to the treatment arm or control arm," said Alexander, who wasn't involved in the study. "Why not use a benzodiazepine or another drug that produces a transient euphoria that would better obscure whether or not people were receiving the psilocybin?" The authors of any accompanying editorial shared these concerns, also noting that the study included "a significant number of patients who did not respond to therapy." "It is important to analyze and understand adverse outcomes in psychedelic trials and conduct longitudinal studies to determine how sustained the effects will be and what may initiate a recrudescence of symptoms," write Rachel Yehuda, PhD, and Amy Lehrner, PhD, both of the Peters VA Medical Center and Icahn School of Medicine at Mount Sinai, New York City. "Future studies will help identify who is most likely to benefit from psychedelics, whether booster or repeated treatment is safe and beneficial, and what the optimal dose and therapeutic frameworks are." A long-term follow-up of the current trial was terminated last year because of low enrollment. The spokesperson with Usona Institute did not respond to questions about that study, and the institute's statement only added that preparations are underway to launch another study that "will provide additional safety and efficacy data to support submission of a new drug application to the FDA." Usona published its manufacturing process that it used to synthesize psilocybin in an open-access journal and signed a statement on "open science and open praxis" with psilocybin and similar substances, which appears on their website. That statement was signed by 31 research and service organizations around the world and nearly 150 scientists, scholars, and practitioners. Related Article: Single Psilocybin Dose Again Shows Major Depression Benefit

— One-size-fits-all treatment approaches sometimes fail Methadone Access America's drug overdose crisis has escalated in the past few years due to several factors, including disruptions caused by the COVID-19 pandemic, driving an unprecedented rise overdose fatalities. Fentanyl, stimulants and, more recently, sedatives like xylazine in the unregulated drug supply continue to drive the worst overdose crisis in American history. We cannot effectively address this crisis without updating policies that narrow the persistent addiction treatment gap acknowledge the reality of polysubstance use, and equip addiction specialists with every tool science has to offer. While we saw important policy changes during the pandemic, one essential policy issue still lags behind: broadening access to methadone treatment. Background on Opioid Use Disorder Treatment As an addiction specialist physician, I served on the front line of this overdose crisis during the pandemic. My patients experienced lonely COVID-19 quarantines during inpatient and residential addiction treatment. Staff working in outpatient programs were pushed to deliver care remotely, including medical clinicians learning to initiate lifesaving addiction medications via telehealth. In-person requirements to receive addiction treatment were modified, and addiction treatment systems quickly adapted. We learned that remote delivery of addiction medications could be managed safely and enhanced patient access to care. New policies were enacted, like those facilitating telehealth prescribing of controlled medications. Greater flexibilities with respect to take-home methadone supplies for opioid use disorder (OUD) treatment swept the nation. Last year, federal policymakers further transformed the landscape when they passed a law ensuring that clinicians who prescribe controlled medications receive education on treating patients with substance use disorders, and eliminated antiquated restrictions on the prescribing of buprenorphine for OUD. Buprenorphine will continue to play a critical role in OUD treatment, but in the context of this unprecedented overdose crisis, we need access to additional options. One limitation of buprenorphine is that it can precipitate opioid withdrawal if a patient is actively using other opioids. In a recently published document reviewing clinical considerations surrounding the use of buprenorphine in the age of high-potency, we come to better understand synthetic opioids. As part of an effort to increase successful buprenorphine treatment of OUD, the document's authors describe emerging buprenorphine-related strategies in the age of fentanyl. For example, higher doses of buprenorphine may be required for stabilizing some patients. For other patients, the use of long-acting, injectable buprenorphine may be the best option. Still, for others, initiating buprenorphine at low doses, while continuing full agonist opioids (such as methadone) during buprenorphine escalation may be warranted. However, there's a major catch when it comes to this latter strategy: U.S. federal law is currently understood to prohibit an outpatient prescription of a full agonist opioid for the treatment of OUD. This means that some patients may continue to use illegally obtained opioids while initiating buprenorphine to avoid withdrawal. With such a strategy, it is outdated federal policy, not drug potency, that exacerbates an unnecessary patient risk. This document should prompt every American policymaker to rethink how we can modernize our policies to save more lives. In the age of fentanyl, one-size-fits-all protocols for buprenorphine sometimes fail. Options for Updating Methadone Policy Methadone remains the only full agonist opioid approved in the U.S. for OUD treatment, and current federal law largely restricts outpatient access to methadone for OUD to approximately 2,000 clinics called opioid treatment programs (OTPs). These methadone regulations create an often-insurmountable challenge for many Americans. For example, in rural America, a patient may spend a good part of each day driving to their OTP -- if their county has one, that is. Some health professionals have expressed concerns that a big increase in access to methadone could lead to new safety issues, such as low-quality care or harmful use of methadone itself. However, when methadone is managed by trained physicians who arrange for dispensing by community pharmacies, it can be handled in a medically appropriate manner. Inaction is a much greater threat to patient safety than the risk of responsibly updating decades-old policies to expand patient access to methadone when it is managed by addiction specialist physicians. The U.S. Senate should take up the Modernizing Opioid Treatment Access Act (MOTAA), as the U.S. House advances other legislation to bolster the nation's addiction treatment infrastructure. MOTAA would finally allow addiction specialist physicians, like me, to use our clinical expertise to treat OUD with methadone dispensed by a local pharmacy. MOTAA would mean the chance for more Americans with OUD to reach remission and recovery; at full scale, it could man a giant step forward to ending this human crisis. In honor of Overdose Awareness Day, Congress should pass MOTAA -- an essential policy change needed to save lives.

CASE VIGNETTE “Mr Deuce” is a 22-year-old male with no previous psychiatric history who presents to the emergency department with his family. He is a senior in college. He has not been sleeping well, with complaints of initial insomnia, and has been taking NyQuil for the past 2 weeks with minimal benefit. Per his sister, the patient has exhibited delusional thinking, stating that he thinks he is a superhero and his roommates at college are plotting to get him kicked out of school. He has also had a paranoid ideation that his dorm room is wiretapped. Upon admission to the emergency department, he told the interviewer that he would be meeting the president the next day. The patient also has periods in which his speech is mostly incoherent. His laboratory studies, including a urine drug screen, were unremarkable. He was diagnosed with a first episode of psychosis and stabilized on risperidone, titrated to 3 mg daily, during an inpatient psychiatric hospitalization. Sleep disorders are highly prevalent in patients with psychotic disorders.1 This comorbidity has a significant impact on the clinical course of illness, including worsening psychotic symptoms and cognitive impairment, as well as poorer functioning and decreased quality of life.2-4 However, the nature of the relationship between psychosis and sleep disorders is unclear, as it may be a primary component of the illness itself and/or a secondary consequence of behavioral or iatrogenic factors.5 The Current Study The Physical Health Assistance in Early Psychosis (PHAstER) study was a randomized clinical trial (RCT) of a physical health nurse intervention for patients with first-episode psychosis (FEP).6 Gannon and colleagues7 performed a prospective cohort study nested within this RCT. Patients aged 15 to 24 years with FEP and <4 weeks of exposure to antipsychotic medications attending the Early Psychosis Prevention and Intervention Centre service in Melbourne, Australia, were assessed at baseline and 6 months follow-up. Participants were diagnosed using the Structured Clinical Interview for DSM-5. Insomnia was defined by a score of ≥15 on the Insomnia Severity Index (ISI). Poor sleep quality was determined by a score of >5 on the Pittsburgh Sleep Quality Index (PSQI). Psychopathology was assessed with the Brief Psychiatric Rating Scale (BPRS) and the Schedule for Assessment of Negative Symptoms (SANS). Functioning was assessed with the Social and Occupational Function Assessment Scale (SOFAS), and the Simple Physical Health Questionnaire (SIMPAQ) was used to measure physical activity. The authors used binary logistic regression models to calculate odds ratios for demographic and clinical predictors of either insomnia or poor sleep quality. Seventy-seven individuals participated in the PHAstER trial, of whom 70 (91%) had baseline data on insomnia. The mean age was 19.4 years, 53% of participants were male, and 44% had a diagnosis of schizophreniform disorder. The prevalence of clinical insomnia at study baseline was 43% (n=30). Individuals with insomnia had more severe total psychopathology (mean BPRS total score 63 vs 55) and negative symptoms (mean SANS score 24 vs 14). Positive symptoms, demographic factors, functioning, and physical activity were not associated with baseline clinical insomnia. At 6 months, ISI data was available for 42 individuals, and the prevalence of insomnia decreased to 21%. Those individuals with insomnia at 6 months had more severe total and positive psychopathology, and lower social and occupational functioning. Poor sleep quality at baseline was present in 87% of the cohort, and there were no associated demographic, clinical, or physical health factors. At 6 months, only 43% of the cohort completed the PSQI, of whom 67% had poor sleep quality. Similar to the data for insomnia, individuals with poor sleep quality at 6 months had more severe total and positive psychopathology, and lower social and occupational functioning. Study Conclusions The authors concluded that there was a high prevalence of poor sleep quality and insomnia in patients with FEP. Study strengths included that participants had minimal antipsychotic exposure at baseline and the longitudinal design. The primary study limitation was the appreciable attrition of data on sleep at the 6-month follow-up. There is some evidence supporting sleep hygiene strategies8 and cognitive behavioral therapy for insomnia (CBT-I) in FEP.9 By contrast, there is limited evidence for use of specific psychopharmacological agents for insomnia in this patient population. The Bottom Line Findings provide evidence that sleep problems are common at the onset of psychotic illness. Sleep disorders represent a potential therapeutic target in psychosis to improve psychopathology and functioning. Dr Miller is a professor in the Department of Psychiatry and Health Behavior at Augusta University in Augusta, 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 Article: Postpartum Psychosis: Improving the Likelihood of Early Intervention

In a 1943 paper titled "A Theory of Human Motivation," American psychologist Abraham Maslow theorized that human decision-making is undergirded by a hierarchy of psychological needs. In his initial paper and a subsequent 1954 book titled Motivation and Personality, Maslow proposed that five core needs form the basis for human behavioral motivation. Hierarchy of Needs Jump To Section

Mental Health Matters Episode Summary In 2020, suicide was the 12th leading cause of death in the United States, claiming the lives of over 45,000 people. Suicide doesn't discriminate—it impacts people of different ages, races, and genders. In this episode, we talk with Dr. Arielle Sheftall, an associate professor in the Department of Psychiatry at the University of Rochester Medical Center. We learn about who is at increased risk for suicide, how it's impacting the nation's youth, and most importantly, what we're doing about this tragic and preventable issue. Transcript ARIELLE SHEFTALL: So, for our kiddos, 5 to 9 years of age, it's the 10th leading cause of death. Just to think about that, it's quite devastating to be 100% honest, to think that a child that young could even have thoughts about suicide is very devastating, but it does happen. It's the 10th leading cause of death for that age group. JOSHUA A. GORDON: In 2020, suicide was the 12th leading cause of death overall in the United States, claiming the lives of over 45,000 people. And suicide doesn't discriminate. It impacts people of different ages, races, and genders. The death of a loved one by suicide has profound impacts on a person's family, friends, and the larger community. Hello, and welcome to "Mental Health Matters," a National Institute of Mental Health Podcast. I'm Dr. Joshua Gordon, Director of NIMH. And today, we'll talk with Dr. Arielle Sheftall, an associate professor in the Department of Psychiatry at the University of Rochester Medical Center. We'll learn about who is at increased risk for suicide, how it's impacting the nation's youth, and most importantly, what we're doing about this tragic and preventable issue. Arielle, welcome, so glad to have you. ARIELLE SHEFTALL: Thank you for having me. JOSHUA A. GORDON: I'm just curious, suicide, it's a topic that can be challenging to talk about, much less devote one's career to, what made you become interested in studying suicide and suicide prevention? ARIELLE SHEFTALL: To be 100% honest, I kind of stumbled upon suicide and suicide prevention. Originally, I thought I was going to be a medical doctor, but I realized chemistry was not my forte, so I had to change that pretty quickly. I went to Penn State for my undergrad. I studied biobehavioral health and had a minor in psychology. And I really enjoyed looking at problems from a behavioral, biological, psychological perspective. And I continued to just really enjoy that, and went on to Ohio State, and got my master's in Human Development and Family Science, and had all of this combined, and learned how mental health could be associated with different systems depending on where you are and what you're doing, and who you're interacting with. And it really opened my eyes, to be honest, about mental health. That was something that really excited me. And I happened to stumble upon Dr. Jeffery Bridge, at that time, who had just joined Nationwide Children's Hospital, and he was actually studying suicide and suicidal behavior in adolescence. And it really hit a nerve, to be honest. So, when I was 14 years of age, my mother passed away from cancer. And I started living with my grandmother. And during that time, I was starting high school, I was trying to figure out my life. You know, at 14 years old, my mom who was my best friend had passed away, and I was really lost. And I love my grandmother. I mean, I love, love, love her. And still, she's the strongest person I've ever known in my entire life. But, you know, we had a really big age gap. And I think, unfortunately, she just didn't quite understand what I was experiencing. And she was very smart, though, she actually had my older cousins check-in on me very often, because she knew that it would be better coming from my cousins at that time than from her specifically. And I went into this very deep, dark space, and started to have suicidal thoughts myself. JOSHUA A. GORDON: Yeah. ARIELLE SHEFTALL: So, I could relate to this study that Dr. Jeffery Bridge was doing. And I wanted to understand what was it about suicidal behavior during this stage of lifespan? How could we help individuals? How could we get the care for these adolescents so that they don't suffer? And what could we do on our end to help them to get through this space that I had, thank goodness, been able to achieve, and to be able to get through, but I had a lot of family help to get me through that really dark, dark space in my life. And some of those individuals, unfortunately, that I interacted with during that study didn't have that. And we had to be that barrier, so to speak, and getting those kids the help that they needed, and to make sure that the quality of care that they were receiving was high so that they can move on and get better. JOSHUA A. GORDON: So, for you during your training, suicide prevention, it was professional, but also deeply personal. ARIELLE SHEFTALL: Absolutely. JOSHUA A. GORDON: I'd imagine that hasn't changed. ARIELLE SHEFTALL: No, it hasn't. It really hasn't. I am very, very committed to the field. And not only because of my own personal experiences, but all the experiences that I've heard about. I've been in this field for, which is so crazy to believe, 17 years now. And I've been able to actually study suicide from different perspectives. But that's great, but hearing the stories from the families that I work with, that's even more motivation to keep going and keep striving, and keep doing better. And that is something that I take with me every single day. And if I can help one person, then I feel that I've done a good job and that I can actually keep on moving forward to help another one and another one and another one. JOSHUA A. GORDON: Before we go any further, let's talk about language. What do we mean when we use terms like suicidal ideation or self-harm? ARIELLE SHEFTALL: Yeah. So, suicidal ideation is just thoughts about suicide. So, those can range anywhere from something that's very passive, like just wishing you were dead, or all the way up to a thought that has a specific method in mind, with intention to actually act on that method. So, they can range, but it's really just a fancy way of saying suicidal thoughts. And then when talking about self-harm behavior, that is actually different in terms of suicidal behavior, just so everyone is aware. So, self-harm behavior, is when someone actually hurts themselves on purpose, but they do not have the intent to die. And usually, these injuries occur to help someone or a person to actually get the emotions that they're experiencing out, if that makes any sense. And some people actually indicate that they self-harm, because they feel so numb on the inside that they want to see something or feel something. Suicide attempt is when an individual will actually hurt themselves on purpose with the intent to actually die. That intent is what's really important. That intent to actually want to die has to be present for it to be a suicide attempt. And then suicide is what we would call someone that dies by suicide. JOSHUA A. GORDON: We used to say someone committed suicide. ARIELLE SHEFTALL: Yes. JOSHUA A. GORDON: You use died by suicide, just then, and tell me why that's become a more preferred way of saying for either? ARIELLE SHEFTALL: Yeah. So, back in the day, suicide was actually considered a crime. And that stigma continues to be present in our field of mental health and suicidal behavior. Like, so you commit a crime. You don't commit cancer. Like, you don't commit heart disease. People die from those things, and people die from suicide. And so, we actually have changed the language, so that we can get rid of that stigma, and actually start talking about the problem freely. And that takes the onus off of that person dying by a specific method versus them actually committing a crime and making it criminal. JOSHUA A. GORDON: So, this something that happens to you because of an underlying illness. What are those underlying illnesses or risks? What increases the risk for suicide? ARIELLE SHEFTALL: So, there are a ton of risks that are associated with suicide, and they vary from person to person, though some of those can be mental health concerns. So, for instance, depression, bipolar disorder, schizophrenia, and substance use disorders, but some can be chronic health concerns, like diabetes, others can be financial concerns, divorce, relationship problems. So, risks can vary greatly. They can be genetic. So, we've seen that having a familial history of suicide and suicidal behavior has been associated with an individual having a higher risk for suicidal behavior or they can be environmental. Like, experiencing bullying, or being a bully actually puts you at higher risk for having suicidal thoughts and behaviors as well. JOSHUA A. GORDON: What about the link between suicide and depression? We often think about suicide as a potential outcome from depression. But not everyone, right, who dies by suicide is depressed. Tell me about that link. ARIELLE SHEFTALL: So, there are individuals in this world that suffer from depression. And there are individuals that unfortunately, who have depression who died by suicide, but that's not necessarily the case that once you have depression, that is going to be your cause of death. There is a higher association, yes. But individuals that suffer from depression don't necessarily have suicidal thoughts. So, there's different risks for different individuals. But there is a higher risk, unfortunately, for those who do suffer from mental health concerns. So, I focus on youth suicide, primarily. Depression is actually not the disorder that we're seeing that's associated with suicide death. What we're seeing actually is ADHD. So, Attention Deficit Hyperactive disorder. And those are in kids, you know, 5 to 12 years of age. So, it depends again, unfortunately, on what group of youth you're speaking of, or individual that you're speaking about when looking at the association between depression and suicidal behavior. JOSHUA A. GORDON: So, bottom line suicide, suicidal thoughts, these are seen, yes, in individuals who suffer from depression, but also in individuals who suffer from other mental illnesses and other environmental conditions. ARIELLE SHEFTALL: Yes, absolutely. Nobody is immune. And unfortunately, if you were to do a survey from around the world, you would find that a lot of people have had thoughts about suicide. It doesn't see race. It doesn't see age. It doesn't see sex. Anybody can suffer from suicidal thoughts and behaviors. So, I think we need to change our mindset a little bit in terms of thinking about this being a public health problem for anyone. JOSHUA A. GORDON: How many people die by suicide in the US each year? ARIELLE SHEFTALL: Yeah. So, that's a great question. How big is the problem itself? So, in 2020, suicide was the 12th leading cause of death, and it was the cause of death for about 44,000 individuals. JOSHUA A. GORDON: Forty-four thousand? That's a lot of people. ARIELLE SHEFTALL: Yes, it is a lot of people. Absolutely. JOSHUA A. GORDON: How does suicide rates in the United States compare with the rest of the world? ARIELLE SHEFTALL: Yeah. So, when you look at the rest of the world, we are not doing well. So, the World Health Organization collects data on suicide, though, for 184 countries. There's 195 in the world, so they get majority of the countries. When you compare all 184 countries, we are actually the 32nd for adults, which is pretty high. Our rate in 2019 was 14.5 per 100,000. And then when you look at Australia, it was like 11.3, United Kingdom is even lower at 6.9. And then Israel is even lower than that at 5.2 per 100,000. And when you look at youth suicide, it's even more horrifying, to be 100% honest. For the United States, we are actually 19 when you compare all the rates. Yeah, 19. JOSHUA A. GORDON: Nineteen per 184. ARIELLE SHEFTALL: A hundred and eighty-four. JOSHUA A. GORDON: So, compared to the rest of the world, we've got a lot of work to do. ARIELLE SHEFTALL: Absolutely. JOSHUA A. GORDON: Changes in rates that you described, are those changes happening differently for different people, for different demographic groups? ARIELLE SHEFTALL: So, suicide does differ depending on the age group. So, for 25 to 34-year-olds, suicide is actually the second leading cause of death. And then for our 35 to 44-year-old individuals, it's actually the third leading cause of death. And this differs even more when you start looking at youth. So, for children 5 to 19 years of age, that's the primary age group that I focus my energies on, it was actually the third leading cause of death in 2020. And it touches my heart even more now. I have young kids myself. I have a 6-year-old and a 10-year-old. And to think even that those thoughts have been on their mind is devastating. JOSHUA A. GORDON: And it's rising faster in that age group isn't it than in other age groups? Yeah. ARIELLE SHEFTALL: Yes. So, when you look at the breakdown, so over the past 20 years, for our teenagers, 13 and 19 years of age, so we've seen from 2000 to 2020, we've actually seen a 38% increase in that age group. But for our 5 to 12-year-olds, it's actually been 107%. JOSHUA A. GORDON: Wow, that's more than a doubling in the rate of death by suicide in young kids. ARIELLE SHEFTALL: Five to 12. And unfortunately, another area of my research looks at black youth suicide. JOSHUA A. GORDON: Yep. ARIELLE SHEFTALL: And unfortunately, we've seen that rate is even more drastic. For our black youth, 5 to 12 years of age, they're approximately two times more likely to die by suicide than their white counterparts. What's happening in this age group is that suicide seems to be the leading cause of death for black girls 12 to 14 years old. A lot of research to be done, a lot of work to be done. JOSHUA A. GORDON: Do we know why these changes are happening? And in particular, do we know why these changes are happening differently for people from different groups? ARIELLE SHEFTALL: The research, it's still pretty young in terms of where we are when looking at minority, so youth of color, individuals of color, to be 100% honest. Back in the day, suicide was really considered to be a white male problem, because again, the rate was the highest in white middle-aged men. So, a lot of research focused in on white men or white youth. And now we're starting to see, wait a minute, we lost a lot of opportunity here because we didn't focus in on these youth of color. So, we're still in the infancy of this research. We're trying our best. I think we have gotten a lot further than what we did in the past. But we still have a lot of research to do in order to understand what are those specific risks, and how can we actually intervene appropriately for youth of color? JOSHUA A. GORDON: It's really important this research that you are doing to try to get at the causes of suicide, particularly, in young people. Rare, as you pointed out, we know that children as young as five die by suicide, which, to me, it's just truly heartbreaking. ARIELLE SHEFTALL: Yes. JOSHUA A. GORDON: What do we know about suicide in children that young? And in particular, maybe you can tell us, what should parents do if their young child, their 5, 6, 7-year-old child says they're thinking about killing themselves, or they have other thoughts of self-harm? ARIELLE SHEFTALL: Yeah. So, I would definitely say no matter the age, we should absolutely 100% make sure we're taking every disclosure of self-harm or suicide or suicidal thoughts very, very seriously. And I know that can be very hard for parents to do even, you know, at this young age to even fathom that my kid is saying these words, actually speaking these words, and they actually mean these words. Because, you know, we never think. Never, ever would have ever thought that my five-year-old would think that they want to kill themselves or hurt themselves on purpose. We have to do something about it. As a parent, this is gonna be a very scary space that you're gonna be in, but we have to make sure that we get the kids, even at this younger age, the help that they need immediately so that we can make sure that they're okay. And that they can get off of that trajectory towards self-harm behavior, or towards suicidal behavior. So, we have to take it seriously every single time. JOSHUA A. GORDON: Your research has shown that black youth, particularly very young black youth, have a higher rate of suicide than white youth. What do we know about this? What are the circumstances in the black community that might be contributing to this difference? ARIELLE SHEFTALL: So, I will be 100% honest, black youth suicide was something that we kind of stumbled upon with myself and my colleague, Dr. Jeffrey Bridge. He received a phone call from a media outlet that asked him about a suicide death that had occurred in an 8-year-old. When we started to break the data down by race, what we found is that for our black males, they actually had a significant increase in their suicide rate versus white males. So, we started to dig a little bit more. And he did the analysis over and over and over again because couldn't believe what he was seeing. And then he asked me to do it, and it was the same results, unfortunately. And yeah, it was just something that we weren't understanding to be 100% honest, but we knew it was important for us to report. And what we found is that for black youth, specifically, 5 to 12 years of age, they were about two times more likely to die by suicide compared to their white counterparts. So again, why? That's the big question. So, when I started to think about the problem, when I started to sit down and really do some introspective work, so to speak, I started to think, what are those risk factors that black youth may actually experience that white youth don't necessarily? Well, one of them, unfortunately, is racism, discrimination, right? And recently that has been shown to be associated with suicide, death, suicidal behavior, suicidal thoughts. So, I think that is one of the risk factors that may be playing a role when you look at suicide rates and suicidal behavior in black youth. And I think, unfortunately, the environment that we live in right now is not a safe space for black youth, specifically, or youth of color, specifically. JOSHUA A. GORDON: Which the reason why we ask questions about why things are happening because we wanna do something about these disparities, and about suicide deaths in general. Are there ways that we know of now to reduce suicide deaths? ARIELLE SHEFTALL: That is absolutely the reason why we ask these questions, right? JOSHUA A. GORDON: Right. ARIELLE SHEFTALL: We wanna do something. We want to change the trajectories that we're seeing, these trends that we're seeing, and I think unfortunately, the research is still not done to be able to say, "Oh, yeah, use this prevention program, or use that prevention program." But I do think there is hope. And I think that's why I still am in this field to this day is because I think that number one, suicide is preventable. Everybody can prevent suicide no matter who you are, no matter how old you are. But I think also there are some promising avenues for preventing suicide. I think in terms of youth suicide, there have been programs that have shown good promise. So, Signs of Suicide is one of them. And they actually, I believe, are starting to take the Signs of Suicide and bring it down to elementary school age. JOSHUA A. GORDON: Tell us more about Signs of Suicide, what is it? ARIELLE SHEFTALL: So, it's a school-based program, specifically. And you educate everybody from the top to the bottom within that school setting. So, it's the principals, the counselors, the teachers, the cafeteria staff, the environmental services staff, the students. You are telling them all about what are the signs that they should be looking for in any individual that they interact with that is concerning and that they should act upon. So, these things could be, you know, isolating themselves, like not answering your text messages anymore than what they used to. Acting differently, giving away possessions. Things like that that just spark, like, this isn't right, behaviors have changed. So, it educates the entire school on these behaviors. But not only that, it tells them what to do when they see these behaviors present. But it also brings the parents to the table as well. So, it educates the parents of the students also. So, you basically are creating a system of prevention within one school setting that can go outside of the school into the family setting. JOSHUA A. GORDON: Maybe it's the fact that you've been there yourself that helps you understand that reaching out to kids and talking about suicide is a helpful thing rather than a dangerous thing. Many of us are reluctant to talk to anyone, much less children about suicide because it's a scary thing for us to think about. We worry that we're gonna cause them to think about it. We're gonna impact them that way. So, just the fact that you intuitively understand that kids wanna talk about this stuff, and they appreciate learning from you more about suicide, I mean that's powerful. ARIELLE SHEFTALL: Yeah. And there's actually research out there that says that if we talk about suicide, that does not put the thought of suicide in a child's mind. There's research out there that supports that argument. It actually gives an opportunity for a kid to feel like, oh, I can talk about these things with you. And I can actually be very honest and open with you about not only this but other kind of risky behaviors that they might be doing or might be thinking about doing, right? So, we have to break that barrier. We have to understand that this does not put those thoughts in that child's mind. If the thought's there, the thought's already there. And us not knowing that the thought is there is what actually does more damage than good. JOSHUA A. GORDON: You've now mentioned research several times throughout our conversation. NIMH has been supporting research now for 75 years. ARIELLE SHEFTALL: Yes. JOSHUA A. GORDON: A lot of that in the suicide and suicide prevention research field. What has been NIMH's role from your perspective, and how far have we come in terms of understanding or preventing suicide? ARIELLE SHEFTALL: Number one, NIMH is the number one funder in the government world when it comes to suicide prevention and research. So, if NIMH wasn't present number one, my research couldn't be. It couldn't be. So, I'm very grateful for that. And thinking even way back in the day, where suicide was this taboo topic, where we didn't want to talk about it because again, we had all these thoughts about, well, if we talk about it, it's gonna open this big can of worms, and people will become suicidal. Well, no, I think NIMH has actually made that very clear that talking about it is necessary, and that we need to continue to have this conversation. We can't just, you know, brush it under the rug. And I think unfortunately, that's been the case for many years that we've kind of brushed it under the rug, that suicide doesn't really exist, and that we don't really wanna talk about it because it'll bring up other things. So, I think NIMH is absolutely the one that's driving the conversation, and making sure that you are all working with other institutions and other organizations to make sure that people understand that suicide is a public health concern, and we have to do something about it. JOSHUA A. GORDON: Is there anything you think the field could do better when it comes to studying suicide and supporting the work necessary to study it? ARIELLE SHEFTALL: So, I think engaging community, getting community organizations to be at the table to give you input about your own research ideas, to actually listen versus just talking to, and to gain insight from the community because they're the ones that are on the ground and working with these families, and working with these youth, and understand the problem probably a little bit better than what we do. And I think they are the insiders. And having their input, and being able to hear what they have to bring to the table, and to help actually form our research ideas can be extremely beneficial, and I think will play a big role in actually changing the trajectory that we're seeing. The other thing is the youth voice, which is something we haven't done in the research field. We have not done a really good job at listening to youth that have lived experience, and understanding what we can do better. And understanding what that experience was like when they did have suicidal thoughts. What were those experiences that they had prior to suicidal thoughts? What happened when they were hospitalized for a suicide attempt? What was that experience like for them? And gaining perspective from the youth themselves is something I think, again, will help us change the way that we look at the problem, and also give us some insight on where to go in terms of intervention and prevention programming. JOSHUA A. GORDON: Have you been involved, personally, in some of this research in these kinds of evidence-based approaches? ARIELLE SHEFTALL: Yeah. Actually, I have. And that's why I say Signs of Suicide. But there are other ones out there as well. But Signs of Suicide when I was in Columbus, Ohio, at the Abigail Flexner Research Institute, we in the center have a prevention arm, which is actually educating schools in central and southeastern Ohio. So, we actually have a whole team that was dedicated to going into schools, doing the Signs of Suicide training program, and then also implementing the program, and then training the trainer's so that they could keep the program going. So, I was actually involved in that program. And we were also involved with Boys and Girls Club. So, actually taking the Signs of Suicide program and implementing it into the Boys and Girls Club in Columbus. And trying to figure out how can we take that program and make it more community-based. JOSHUA A. GORDON: What was that experience like for you to be involved in an effort to really develop something that can make a difference? ARIELLE SHEFTALL: You know, that was the best feeling. It really was. And don't get me wrong, I love that NIMH funds my research. And I love that, and I love doing what I do. But getting on the ground and actually talking to kids, and talking to individuals that are talking to kids every single day, and giving them those tools to have in their tool belt to actually prevent suicide, that is like one of the best feelings in the world. JOSHUA A. GORDON: I wish that our listeners could see your face right now, and how animated it is, but I'm sure that they can hear it in your voice. Working with kids, talking to them about suicide, it clearly drives you. ARIELLE SHEFTALL: It does. It really does. I've been there. I've been there. And I don't want people to believe that means I know everything. That's not true. I don't know everything. This was my experience. These were my circumstances. But I don't want people to feel like they're alone in those experiences that they're having. And the more that I can do, the more that I can share my own story, the more that I can be present to give individuals ideas about what they can do for their friends and their family members. I feel that goes further than anything else I can do on the research side of the world. JOSHUA A. GORDON: Dr. Sheftall, thank you for joining us today. ARIELLE SHEFTALL: Thank you for having me. I'm very honored. JOSHUA A. GORDON: This concludes this episode of Mental Health Matters. I'd like to thank our guest, Dr. Arielle Sheftall, for joining us today. And I'd like to thank you for listening. If you enjoyed this podcast, please subscribe, and tell a friend to tune in. If you'd like to know more about suicide, please visit nimh.gov. We hope you'll join us for the next podcast. 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— Significant early improvement sustained through day 43 in multicenter study Single Psilocybin Dose Just one dose of psilocybin significantly improved depression symptoms and functional disability in patients with major depressive disorder (MDD), a randomized trial found. Administered with psychological support, a 25-mg dose of synthetic psilocybin resulted in a sustained 12.3-point (95% CI -17.5 to -7.2) greater improvement versus active niacin placebo in Montgomery-Asberg Depression Rating Scale (MADRS) score on day 43, meeting the phase II study's primary endpoint, according to Charles Raison, MD, of the Usona Institute in Fitchburg, Wisconsin, and colleagues in JAMA. As early as day 8, investigators observed a 12.0-point (95% CI -16.6 to -7.4) greater reduction in MADRS score favoring the psilocybin group, meeting a key secondary outcome of the trial. Other secondary outcomes demonstrated improvements with psilocybin in disability and sustained response for depressive symptoms. Treatment was well-tolerated, with the majority of adverse events (AEs) being graded mild or moderate in severity. The most commonly occurring AEs in the psilocybin group were headache (66% vs 24% for niacin), nausea (48% vs 6%), and visual perceptual effects on dosing day (44% vs 6%). Acting as a tryptamine alkaloid, psilocybin is found in Psilocybe mushrooms, commonly known as "magic mushrooms." And this isn't the first trial to demonstrate that psilocybin eases psychiatric conditions, like depression and anorexia. Another phase IIb trial -- sponsored by COMPASS Pathway -- showed benefit in MADRS total score at 3 weeks with a single 25-mg psilocybin dose, and significant improvement was seen as early as the second day. Comparing their two findings, Raison's group noted that "[i]n contrast to prior psilocybin trials for depression, there was not a significant reduction in depressive symptoms or a psilocybin/placebo difference in depressive symptom status at the day 2 assessment." "This may reflect the fact that to maintain central rater blinding, the 7-day recall period used for all other MADRS assessments was maintained at day 2, with the result that the majority of recall period for the day 2 assessment covered the pre-dosing period during which depressive symptoms remained elevated, based on results from the Symptoms of Major Depressive Disorder Scale," they explained. The study authors also pointed out a similar rate of severe adverse events in these two trials -- 8% here and 10% in the COMPASS Pathway trial. A few patients in the COMPASS trial experienced suicidal ideation as an adverse event (all were deemed non-responders), which was not seen in this current trial. Here, 41.7% of participants who received 25-mg of psilocybin experienced a sustained response versus 20.3% of the same dose psilocybin patients in the COMPASS trial. Commenting on this, accompanying editorial authors Rachel Yehuda, PhD, and Amy Lehrner, PhD, both of James J. Peters VA Medical Center in New York City, said "it is clear that despite the enthusiasm, psychedelic therapies do not represent a panacea for every patient. There are no silver bullets in psychiatry." Because a large proportion of patients in these psilocybin trials don't respond to this kind of treatment, future studies should focus on identifying exactly who might benefit most, determine the optimal dose, and figure out if "booster" or repeated treatment might be beneficial, Yehuda and Lehrner suggested. "If psychedelic therapies do prove to have enduring effects after just a single or a few administrations in the context of a few sessions for preparation and integration, they have the potential to offer not just a new approach to mental health care, but an entirely new paradigm of care," the editorialists wrote. A total of 104 participants were involved in the current trial, half of whom were women, and the average age was 41. After randomization, 51 were assigned to psilocybin and 53 to the niacin group. Niacin was used in order to aid in blinding because it produces a flushing response. All were between the ages of 21 to 65 with DSM-5-confirmed MDD of at least 60 days in duration with moderate or higher symptom severity (MADRS score of 28+). Those with a history of psychosis or mania, active substance use disorder, or active suicidal ideation with intent were excluded. If indicated, psychiatric medications were tapered prior to treatment so participants met criteria for moderate to severe MDD at the baseline assessment. Among the secondary outcomes, participants on psilocybin also saw a significant reduction in Sheehan Disability Scale scores compared with niacin at day 43 (-2.31, 95% CI -3.50 to -1.11). This disability improvement was greater for psilocybin recipients at all other timepoints after administration, as well -- days 8, 15, and 29. Significantly more psilocybin patients had a sustained response for depressive symptom improvement compared with niacin too (41.7% vs 11.4%), defined as a 50% or greater reduction from baseline MADRS total score at days 8, 15, 29, and 43. This translated to psilocybin recipients having more than a five times higher likelihood of sustained depressive symptom response than niacin recipients (OR 5.60, 95% CI 1.87-16.74). Psilocybin also trended toward a higher chance of sustained depressive symptom remission as well, defined as a MADRS total score of 10 or less at each post-dose assessment, but this wasn't statistically significant (OR 3.37, 95% CI 0.99-11.47). Participants underwent 6 to 8 hours of preparatory sessions with two facilitators prior to dosing and a 7- to 10-hour dosing session performed in a supervised, comfortable room. Participants were encouraged to wear sunglasses and listen to a curated playlist with headphones during dosing. This was followed by a 4-hour post-dose integration session when participants could discuss their experience with facilitators. Related Articles: What is Depression? A Recent Study Linked Changes in Alcohol Consumption to Changes in Depression Symptoms Can Alternative Medicine Help Depression? Vortioxetine Improves Cognition in Patients With Depression and Early Dementia Depression, Anxiety Do Not Increase Overall Risk for Cancer Does Social Media Use Cause Depression?