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By: Lauren Mackler, Contributor Many people don't treat themselves verywell. They break promises to themselves, don't get enough sleep, are self-critical or fail to take good care of their bodies. In fact, if most people treated others the way they treat themselves, they wouldn't have many friends! A great technique for treating yourself better is by developing your Inner Nurturing Parent. Imagine you had a little child in your car. You'd make every cffort to keep them healthy and safe; to love and support them; to be forgiving of their mistakes, their inevitable slips; and to let them know how precious and important she is. That's what a loving parent does. Only, in this case, you're the parent and the child. Below are sevenways to strengthen your own Inner Nurturing Parent, and turn the goal of treating yourself better into daily, living action. Send loving messages to yourself. Tell yourself, "I love you and appreciate who you are." When you do something well, give yourself : pat on the back. Say, 'Great job! I'm so proud of you." When you're struggling or feeling low, be supportive by saying, "I'm here for you. You're not alone." Take good care of yourself. A loving parent would make sure you're nourished and get plenty of rest, sleep, fresh air and joyful movement. Practicing good self-care is an essential part of this process. Do nice things for yourself. Get into the habit of doing special things for yourself. Make yourself a cup of tea with the nurturing energy that you'd have when preparing tea for someone you love. Visit the sauna, get a massage or draw yourself a bath filled with special salts. Linger in it and relax. Make yourself a candlelight dinner -- delicious meal in a special setting. Coddle yourself. Treat yourself as a loving parent would treat you. Set healthy boundaries with others. Let people know what you want and don't want. Tell them what's okay for you and what's not. If you have a friend who's always late and you end up waiting for them and feeling annoyed, tell them how you feel. A nurturing parent wouldn't let someone treat you badly. A loving parent makes sure their child's needs are met. Become your own advocate. If someone is disrespectful or hurtful to you, speak up. Tell them you don't want to be spoken to that way. If someone was unkind, hostile or verbally abusive to your child, you'd stand up for them. Protect yourself as a nurturing parent would protect you. Believe in yourself. A nurturing parent would highlight your uniqueness, tell you how special you are, encourage you to build on your strengths and support you in a loving, nonjudgmental way. A nurturing parent says, "You can do it." "T believe in you." Become your strongest supporter, coach and cheerleader. And lastly and most important: Be compassionate with yourself. Have compassion for your humanity and your flaws. You're human and you're going to make mistakes. Look at yourself through the eyes of a loving parent; don't punish or criticize yourself. Reassure yourself. Comfort yourself. Accept yourself unconditionally. And show that same compassion for your own parents and others, because they, too, are human.

How to make your resolutions a reality. Whether it's a New Year's resolution or a resolution for new you anytime of the year, sustained change can be difficult. One study found that 24 percent of people had dropped their resolutions by the time February rolled around, and, by six months, over half of people had given up. Luckily, it is not impossible to change your ways. And the best way to make that change? Drop the perfectionism and be better than perfect. Make Changes Perfectionism, or an all-or-nothing mentality, gets in the way of maintained changes. Perfectionism sounds something like this: “I had one cookie and ruined my diet, so I might as well eat the rest of the plate.” “I don't have time to meditate as long as I want to, so I'm not going do it at all.” “I can't afford a gym membership, so I can't work out.” This all-or-nothing mindset gets in your way of making progress. The antidote to perfectionism, however, is not to give up. Giving up is actually a symptom of perfectionism. Instead, be better than perfect. Being better than perfect means you focus on the change that you want and why you want it. You take steps toward that goal, celebrating each step in the right direction. What's more, you stop judging yourself when you make a mistake. Here are five ways to make sustained change by being better than perfect: 1. Focus on your why. Frequently, when people are making a change, they focus on what they don't like about it. If your resolution is to exercise, you may focus on how much you hate running or going to the gym. The secret, however, is to focus on why you want to make that change. What are the benefits of making this change? Consider psychological, physical, relationship, purpose/work, spirituality. For example, exercise has been shown to be a great way to release stress and decrease depression. That's good for your psychological health. Regarding your physical health, exercise can help you not only lose weight and tone up your body, but also help you fight infection by boosting your immune system. Socially, research shows that people who exercise together are happier together. Regarding your work, exercise can help boost creativity and productivity, which helps you be a better worker. Financially, you can save money by being healthier. And spiritually, because exercise helps reduce stress, it can allow you to focus more on what is important to you – your values – as opposed to being overwhelmed with stress. 2. It's not failure; it's data. People often give up on a resolution or change when they revert back to their old ways. Maybe your resolution is to be more organized, and yet you realize at the end of the week that your desk is just as messy as always. Instead of beating yourself up and proclaiming, “This will never work!” use the situation as data. By data, I mean information that you can learn from to make positive changes. For example, if your desk is a mess, you may want to set a reminder every afternoon for you to take five minutes and clean it up. You can learn from what didn't work to make it work. 3. Take – and celebrate – even small steps. People often bite off huge goals for New Year's resolutions. Perhaps it is to lose a significant amount of weight or to never eat sugar again or to never fight with your partner again. While these are certainly wonderful aspirations, they are significant changes. As I often tell my clients, the way to get to the top of the Empire State building is not in one big step. There are a lot of steps that go into it. For you, celebrate each step in the right direction. And if you revert to old ways, reread number 2, and apply it. Here are some ways to take steps in the right direction without having to have things be “perfect": Don't have time to do 20 minutes of meditation? Take five deep breaths. Hate going to the gym? Try an exercise video on YouTube. Don't have the money to only eat fresh organic vegetables? Choose one or two that you will incorporate into your diet. 4. Schedule it. Sure, it sounds great to have a goal of lessening your stress, but how can you actually do it? The key is to figure out actionable steps and then schedule them. Perhaps you choose to wake up 10 minutes early to meditate. Or maybe you set a reminder midmorning, when you tend to be more stressed, to stop and just take five breaths. You can also use an association method. For example, before I became a psychologist, I was a physical therapist. During my training, one of my clinical instructors pointed out what horrible posture I had. My goal was to have good posture, to sit up straight, but it was hard for me to make that change. So, what I ended up doing was associate every time I looked at my watch with sitting up straight. The more I did that, the more automatic it became, and then my posture got better. 5. Get an accountability partner. Choose someone to whom you will be accountable—whether it's your partner, a friend, or a coach. Sure, you may want to make the change, but when we are accountable to someone else, we are more likely to stick with that new behavior.

The 988 Implementation Act was introduced on July 25. What impact will it have on care? On July 25, 2023, Congressman Jamie Raskin and Congressman Tony Cárdenas reintroduced the 988 Implementation Act with Congressmembers Brian Fitzpatrick, Lisa Blunt Rochester, Doris Matsui, Seth Moulton, Grace Napolitano, and Don Beyer. Psychiatric Times sat down with the VP of Government Affairs for Connections Health Solutions, Chris Santarsiero, MBA, to learn more. 988 Implementation Act PT: Can you tell us a bit about the reintroduction of the 988 Implementation Act? Santarsiero: It is an exciting time. A year has gone by since the transition to 988, and there is a lot more work to do to build out the infrastructure, response times, and staffing. For 988 to be truly effective, crisis services must operate in a comprehensive continuum. The 988 Implementation Act provides federal support and funding for states to enact 988 and crisis services, and to broaden awareness of available resources. This will ensure that it’s not just a number to call but a line to connect to services in every community, including trained first responders and crisis centers. Specifically, the 988 Implementation Act: -Solidifies funding for 988 regional and local call centers to ensure a timely 24/7 response to callers anywhere in the country -Provides funding for community-based crisis response, including mobile crisis teams and crisis receiving and stabilization centers -Supports crisis workforce development with increased funding for training and scholarship opportunities -Increases access to care by requiring that all health insurance plans cover crisis services -Implements a national suicide prevention awareness campaign in partnership with a wide array of stakeholders 988 has been a great catalyst to talk about mental health. The mission is a number to call, someone to respond, and a place to go. The 988 Implementation Act really charged that—we are investing in and perfecting it. The launch overall has been very successful, and now we are building out the necessary continuum, which is contingent on what each community’s needs are, what infrastructures are in place, and what needs to be improved upon. What an amazing time to be in the behavioral health arena, because people are finally willing to talk about it openly and acknowledge that more needs to be done. PT: How will this legislation impact patients utilizing Medicare and Medicaid programs? Santarsiero: The Act calls for Medicaid and Medicare coverage. Today, Medicaid is the largest payer of behavioral health services. Even still, there are gaps in care. Our organization is headquartered in Arizona, though we have expanded to and are continuing to expand to other states, and we are fortunate to have structures in place that allow for a continuum like this to take place, but most other parts of the country do not. It also expands upon certified community behavioral health clinics (CCBHCs), the great success of the bipartisan Safer Communities Act. Since the inception of the CCBHC program, in the 10 demonstration states, CCBHCs saw a 60% reduction in emergency room visits; 60% reduction in police visits, jail visits, and police holdings; 33% reduction in homelessness; and 74% reduction in overall hospitalization. It is a wonderful program and a great start. On the Medicaid side, it kind of wraps around the continuum that is needed. On the Medicare side, there is a gap. Medicare does not cover crisis services today. Once Medicare coverage and quality standards are established, then commercial insurance will follow suit—that is typically how it works. The Act also calls for commercial insurers to cover the services as well, which is long overdue. PT: What do you see as the future of 988 and crisis care? Will there be further challenges with sustaining funding? The Renaissance of Behavioral Health: 988 and Crisis Care Santarsiero: I feel great about the future of 988. Recently, a couple more states established sustainable funding through a 988 cell phone surcharge. I think that is a good step. Right now, there is a lot of federal funding for 988 to draw down from, but there are a handful of states that are looking at 988 cell phone surcharges similar to 911. NAMI just came out with some polling data that is very positive: over 80% of those polled approved of a 988 surcharge. There is clearly recognition across the continuum of voters that it is necessary to have parity there. In that regard, I am very optimistic. CMS’ Certified Community Behavioral Health Clinic Demonstration provides a path towards sustainability. Its goal is to improve access to high-quality, integrated behavioral health care for individuals with mental health and substance use disorders. There are 10 states that are already in the CCBHC program, and there are 10 more that will be announced by the middle of next year. That means there will be 20 states with a sustainable funding model directed by Medicaid, but in collaboration with the community-based providers. The Bipartisan Safer Communities Act pretty much ensures that within 8 years, any state that wants to be part of this CCBHC program will be allowed in. It is 10 states every 2 years for the next 8 years. But I also know, in talking with other state leaders and Medicaid agencies and associations, some states are going straight the state plan amendment route, regardless of if they get approved for the next demonstration round. States like Texas and Kansas have already done so. Moves like this leverage the existing structure of Medicaid. I feel good about it in terms of long-term sustainability. PT: Can you talk about the importance of specialized units for individuals experiencing behavioral health emergencies? Santarsiero: It is not easy to talk about folks that are presenting with violent behaviors or suicidal threat to self or others, aggressive behaviors, public intoxication. The system as a whole in most parts of the country has not been equipped to deal with that type of person in crisis. Individuals who are violent, threatening, and in a crisis usually end up in an emergency room or jail. What our model proves is you can have a co-responder model—a partnership with first responders and law enforcement—individuals can get the care they need when they need it most. Our Crisis Response Center (CRC) in Tucson is part of the Tucson Police Department’s Department of Justice Law Enforcement-Mental Health Learning Site Program. Usually, the first people in a community that come to visit are law enforcement, along with county commissioners and sometimes even legislators. To get buy in from first responders first like that… they see there is a better way. At Connections Health Solutions, roughly 50% to 60% of our involuntary patients convert to voluntary status. We get them engaged in their care, and I find that remarkable. Unfortunately, involuntary patients are seen as a population, when the state hospitals are dealing with them, that are just there and constantly in flux. One of the amazing things we are showing with our model is that we can get them engaged and back with their families, which helps solve the homelessness problem. If you are not engaged in your care, families sometimes may no longer want you around. Getting individuals in crisis treated, agreeing to their care, and in a better place—sometimes that is the first step for housing. Then they might agree to a plan of care postcrisis with help from ties to the community. As to maintaining care, some individuals look at readmissions like they are a terrible thing. If they must come back to us, okay—they come back, they get what they need. It is important to talk about this patient population to achieve equity in mental health and establish trust in 988. If we lose those who need us most—those with severe mental illness—we are doing a great disservice. It is important to have that continuum built out in collaboration with all community stakeholders and leaders. Our walk-in centers can treat all acuities up to LOCUS Level 6, but somebody with a LOCUS Level 1, 2, or 3 can still walk in and get behavioral health care. It is important for a community to have a space where they say, “Oh, this is where you can go if you need help,” especially for commercially insured folks who cannot otherwise be seen by a psychiatrist or therapist, and we hope to provide that. PT: What other legislation should mental health clinicians be aware of? Santarsiero: There are a lot of great proposals out there, but the 2 we really focus on are the 988 Implementation Act and the Behavior Health Crisis Services Expansion Act. The latter is going to be reintroduced to Congress by Congresswoman Blunt Rochester from Delaware and Congressman Fitzpatrick from Pennsylvania in the House, and Senator Cortez Masto from Nevada and Senator Cornyn from Texas in the Senate. Clinicians should look at those bills because there are workforce provisions in there, which is great. We are also really excited about is the Biden Administration’s proposed rule on the Mental Health Parity and Addiction Equity Act (MHPAEA). It proposes to significantly improve health plan compliance and strengthen parity enforcement to ensure that people with mental health and substance use disorders do not face arbitrary barriers from insurance providers and receive the care that they need. Connections is currently drafting a written response to address current gaps in access to and provision of a full continuum of behavioral health crisis services. It is 395 pages, but there are 2 pages that have questions and requests for information on crisis. You will have 60 days to comment. It might be good for clinicians to know about this. This is a great opportunity to engage in a rulemaking and to weigh in on a provision. We are excited about the crisis provisions, obviously, but I think overall, it really illustrates the gap in coverage and parity between physical and mental health. Kudos to the administration for doing that. PT: Any final thoughts anything you want to share? Santarsiero: Regarding 988, a few weeks ago I had a conversation with an editor who has been covering Congress since 1995 and he told me, “I think this is the best thing Congress has ever done.” But the irony of that story, is 988 did not happen easily. The legislative process is based on friction, and it took 5 years to pass. I think it's a wonderful catalyst. It is so simple to remember and promote. Now the mission is to ensure a complete continuum for each community in the nation and make it incumbent upon communities to build upon. So many communities are doing such great work now, right down to the state and local level. Communities, stakeholders, law enforcement, first responders, the medical community, the mental health community, and the continuum—as a whole—are working to realize this mission. In 5, 10, or 15 years, we may have an equivalent to 911. I think everybody by and large has confidence in the 911 system. The charge is to be as good, if not better, on the mental health or behavioral health side. There is so much to do, but we are here now, so let's capitalize on it.

My long and complicated lifelong relationship with mental health issues and mainstream psychiatry takes place across three different countries. It all started quite early in my life. I experienced severe emotional neglect and abuse by my parents while growing up. They were respected people; they both had successful careers. They were also both amateur photographers. As a child, I was mainly a prop for their many different projects. And after their divorce, just something to use for expressing their hatred towards each other. During this period, as an unprotected and physically below-average-sized child, I was an easy target for bullying at school, as well as sexual abuse by an older cousin. Then later, around the time of my parents’ divorce, I was sexually abused by the older son of a family friend. Naturally, I developed an eating disorder and OCD at an early age. This wasn’t really taken seriously by the family. I was simply told that I was a spoilt, naughty child who wanted too much attention. I tried really hard to do well at school and be a good enough child for my family, to keep the accusations at bay. Around age 11, I had a classmate commit suicide. He used to sit next to me, and some other children blamed me for his death, because he had left a letter for me. I didn’t know what to make of it, since we weren’t close friends. But after this event, I started visiting the school counsellor frequently. She caused me to blame myself more, but I didn’t see it at the time. The first time I saw a psychiatrist was around age 12. My mother was worried about some sexualised jokes she heard when I was on the phone. Because we didn’t have a close and honest relationship, she just took me to see a professional to put her mind at ease. She was worried I was being promiscuous. The session with the psychiatrist must have worked well for my mother because I only saw this professional once. I assume my mother received positive feedback from the professional and was told not to worry, since I didn’t tell this person anything of importance. Later on, as a teenager, I was subject to more violent and scary sexual abuse, and was forced to use drugs and alcohol by my abuser. I got trapped in a “relationship” and I was unable to escape him. Over time, a severe dissociation took over me. I had to split from my body to cope with what was being done to it. It didn’t feel like my body belonged to me anymore. I started self-harming, just to feel my skin and keep the emotional pain at bay. I was disgusted by my body. At age 15, I was sent to a psychiatrist when I was unable to stay awake for more than a couple of hours, or eat proper food for several days, and my self-harming with sharp objects and cigarettes got too visible and out of control. I tried to open up to the psychiatrist, but he decided that I had a chemical imbalance in my brain and told me the only treatment was medication. I believe he told my parents that I was just seeking attention from them, since my father had recently had a new son from his second marriage and I was expected to react badly to this. An attention-seeking spoilt teenager was the label I had accepted. Despite all the issues, I was still doing very well at school and never getting in trouble with teachers, so this made me look healthy. In reality, I was still being groomed and raped, but now I had the medications to cope with it better. Sadly I had nobody safe in my life who would not react to this information with something like: “How could you be so stupid and allow this to happen to you?” Or “You are lying/exaggerating.” Or “This is all your fault.” So I told no one. The anxiety disorder eventually made me afraid of ever leaving the house alone, or staying at home alone. Thanks to this, the abuser couldn’t have access to me anymore and left me alone. I stayed away from boys after this for over two years. Looking back, I clearly see that my poor body did what it could to protect me under these circumstances, since nobody in my life who had the power to protect me was interested in doing so. I hated the “anxiety disorder” back then, but now I see that it saved my life at the time. I survived to the end of high school. By then my anxiety attacks had morphed into severe agoraphobia, so I was put on antidepressants by the psychiatrist because my agoraphobia was inconvenient for my parents who were busy people. With sufficient antidepressants, my “mental illness symptoms” went away, and so did the negative feelings attached to most of my childhood memories. I didn’t feel my skin or my body much, but I wasn’t aware of this dissociation at that time. The SSRIs also gave me a lot of side effects such as digestive problems, appetite and weight loss, excessive sleepiness, unexplained bruising… But I was told I had to take these long term because apparently the only options I had were either being locked up in a psychiatric unit or taking the medication. At age 17, with enough medication in my system, I wasn’t scared of boys anymore. Thanks to not having the protective emotions I needed (because SSRIs!), I got into a horrific relationship with a drug addict. I stopped worrying about anything, and I stopped going to university. I got pregnant soon after my 18th birthday, and had a secret abortion and paid for it with what I saved from my pocket money. My “boyfriend” contributed to the payment, but he was very shaken by my abortion, so I had to be extra nice to him for a long while. A year or so later, his parents sent him away to another country. I then decided to go to Germany to study at university there, since I had two uncles there who I could stay with. Despite medication, I didn’t feel safe anymore, so I was desperate to leave the country. Germany was good to me until some of my childhood memories started catching up with me again. I tried to quit the SSRIs but the withdrawal symptoms were very severe, so I phoned up the psychiatrist who had put me on them and asked for help. He said it was my original condition coming back and that I wasn’t his patient anymore anyway and not to call him anymore. I searched for a psychotherapist, but could afford none of the ones who had space. The only available therapist that my insurance paid for was a vegan Buddhist. I tried Zen meditation with him for many months but was not getting any better with my anxiety. He was adamant it was because I was not meditating enough. I powered through all this, went to university, worked two jobs, went to the gym, tried to take care of my health. Didn’t help. At age 21, my energy levels were only getting lower and my body weaker. My brain wasn’t functioning the way it used to, which made studying very difficult. I wanted to be safe, and with somebody who would never leave me. I got married. As a result of my issues, my husband was a very controlling and possessive man. I didn’t see how abusive the relationship was, and ignored the violent incidents in his past. I thought if I could control him by behaving however he wanted me to, he would not hurt me. For years, I put all my energy into keeping him happy and his anger under control. He wanted me to give all my attention to him. I quit university again, since he always wanted to do things together and I didn’t have any time and energy left for anything else. I didn’t have any more friends. I rarely saw my relatives who lived in Germany. Eventually, with the referral of a psychiatrist, I voluntarily went into a psychiatric unit, hoping it would be a safe enough place for me to quit the SSRIs and ride out the withdrawal symptoms. Unfortunately they gave me random antipsychotic drugs, which turned me into a panicky mess, since I was not psychotic at all. I managed to get myself out of there, and even the psychiatrist who referred me to the clinic was surprised by their incompetence but he could not offer me therapy and suggested I increase the dose of the SSRIs. I refused and stuck to my usual dose, where I was at least semi-functional. A while later, I found a psychotherapist who did something called Primal Therapy, and had some sessions with him. This was the first time someone was interested in my childhood. This was also the first time I opened up slightly about some of my childhood abuse. However, around this time, due to my husband’s job, we had to move again. This time to England, UK. As a result, I was unable to continue therapy with him. So I went back on full-dose medication and buried the memories one more time. A huge culture shock expected me in England. This time, I didn’t have any relatives or friends. I was all alone. The only person I had was my husband. I tried to distract myself with two part-time jobs. I still wanted to go back to university, but I didn’t have enough money for the fees here. The longer I went without trying to quit SSRIs, the more numb I got, and the less I could remember memories of abuse. The antidepressants also helped me tolerate and normalise mistreatment in my daily life. I wasn’t aware of this at time, of course, but I still didn’t want to use them because the side effects were unbearable. I hardly felt anything, I was like a zombie. I slept too much, found it difficult to communicate with people, and just went along with life. Years went by, the doctors kept prescribing the SSRIs every month, and nobody questioned this very long-term use. I tried to talk to some doctors about quitting, but they discouraged me since I had a ‘chemical imbalance’ in my brain that needed correcting with medication. So I gave up too. Until my late twenties. By then, I was a mother. I knew in my head that I loved my children, but I didn’t feel it in my body. I also realised around this time that I hadn’t cried for years. Realising this level of numbness was too unbearable for me. I could not accept giving my children this kind of mother who did not feel. For over a decade, I had been relying purely on my intellect to live, and had no emotions. Then at age 31, I was lucky enough to come across a kind doctor who genuinely wanted to help me. He suggested that I try quitting my SSRIs extremely slowly, over a period of a year, maybe. He tried to find the medication in small doses or a liquid form to make the tapering easier, but it wasn’t available. So I started tapering by taking half a tablet one day a week, and made a plan to eventually take half two days a week, then three days and so on. After five months I was taking half a tablet every day. And at that point the withdrawal symptoms hit me. All the information I got from the doctor and the internet was that I should not be having these symptoms from simply reducing my dose over such a long period of time. I was on the brink of going back to full dose again when I discovered an American website, a peer support internet forum called “Surviving Antidepressants.” This was a godsend. I had finally found people who could help me quit SSRIs. I adjusted my tapering speed and method according to their recommendations, which was 10% reduction a month, and everything was bearable for a little while. Unfortunately the relief didn’t last long, because the speed of tapering was still too fast for me, due to the fact that I had been on psychotropic medications since age 15, had a huge amount of unprocessed trauma, was stuck in an abusive relationship in a foreign country with no family or friends, as well as having two little children to look after. I sought help from a psychotherapist, who was actually helpful for the first time in my life. I opened up again, purely about the frustrations of SSRI withdrawals, because by this time I had completely forgotten about all my childhood abuse. But I was listened to for the first time, and I was hopeful. However, about a year in, my husband lost his job. We sold our house. We weren’t happy in the new house, and my family were all asking us to move back to my home country. They said that they missed me too much and wanted to have a relationship with my children too. So, we moved back to my home country. In the new country, I wanted to continue therapy with someone local. Because some of my memories were returning due to the reduced dose of SSRIs, or due to being back in the same country and around the same people who abused me. Unfortunately, each psychotherapist or psychiatrist I tried had some method that they were insistent upon using, such as CBT, EMDR, parts work, somatic experiencing… I didn’t feel comfortable with any of those, I just really needed someone to talk to and be understood by. I tried opening up to one of them (a psychiatrist) about early childhood sexual abuse, and she kind of insinuated that sexual experiences are normal in childhood, so I put that idea to bed and decided I was exaggerating it. To be fair to her, a few sessions later, she was the only person who told me that if someone locks you in a room and they have a knife in their hand, and they try to convince the 15-year-old you that they only want to have sex with you because they love you, and when you run away they chase you and in the end you give up fighting and let them do whatever they want, this is still classed as rape. At the time I genuinely thought this experience was all my fault and classed as consensual, since he hadn’t actually stabbed me. Sadly, this psychiatrist also became unavailable, and I eventually gave up on finding someone to talk to face-to-face. Then came 2020 and my living situation became extremely stressful. Family issues were crushing me. I started becoming physically unwell. Then eventually, I developed a very severe chronic illness. Every medical treatment the doctors and hospitals tried on me made me worse. Until my nervous system became so hyper-sensitised that I could not tolerate any medications without dangerous allergic reactions. This slowly spread to different foods, chemicals, materials, temperature changes, even to tap water. I became allergic to life. This stopped me from eating, moving or living as normal people do. At that point I got very depressed and hopeless. My family blamed me as usual, and they assumed that my illness was all in my head. I repeated the mistake of seeking help from psychiatrists, since I was still tapering from a low dose of SSRIs. When I tried to explain my issues, I was told that I had no choice but to go back on a full dose of some kind of psychotropic medication if I ever wanted to get well. The last psychiatrist I saw told me that I was wrong about the side effects of SSRIs and withdrawal symptoms. He did not believe that I never took any other, non-prescribed drugs or used alcohol in over a decade. He said that any other doctors or therapists who ever agreed with me must have been manipulated by me. I had to pay a significant sum of money for the privilege of being insulted and gaslighted, so I will never forget the regret, despair and humiliation I felt after these accusations… Understandably, that was the last time I sought help from mainstream psychiatry. After all these disgusting experiences I had with the mental health system, in three different countries over 20 years, I am not in favour of seeking help from them unless one is at the brink of death. I am now in a place where life seems more hassle than it’s worth. My physical health is in a worse state than my mental health. The medical system broke me completely. The pieces of my shattered soul are waiting to be retrieved from each and every memory of abuse and exploitation. I don’t have the strength to do that alone… So today I am just surviving. I only hold on to life for my children, and nothing else. When I look back at my life, it seems that nobody was interested in actually supporting me. They just wanted me to take the drugs and keep quiet. My family and my rapists, abusers and psychiatrists all had it in common that they wanted me to “take something” to become more obedient and quiet. It is as if they were working together without even knowing each other. The worst part is, I was completely unable to see this pattern until I had a medication-free, clear mind to realise what was being done to me. It is a miracle that we, the victims of psychiatry, ever make it out alive. The system is broken beyond repair… And I hope that the same doesn’t apply to my beaten body and soul. *** Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own. *** Mad in America has made some changes to the commenting process. 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Post traumatic stress disorder (PTSD) is a disorder that develops in some people who have experienced a shocking, scary, or dangerous event. It is natural to feel afraid during and after a traumatic situation. Fear is a part of the body’s “fight-or-flight” response, which helps us avoid or respond to potential danger. People may experience a range of reactions after trauma, and most people recover from initial symptoms over time. Those who continue to experience problems may be diagnosed with PTSD. Post traumatic stress disorder Who gets PTSD? Anyone can develop PTSD at any age. This includes combat veterans and people who have experienced or witnessed a physical or sexual assault, abuse, an accident, a disaster, or other serious events. People who have PTSD may feel stressed or frightened, even when they are not in danger. Not everyone with PTSD has been through a dangerous event. Sometimes, learning that a friend or family member experienced trauma can cause PTSD. According to the National Center for PTSD , a program of the U.S. Department of Veterans Affairs, about six out of every 100 people will experience PTSD at some point in their lives. Women are more likely to develop PTSD than men. Certain aspects of the traumatic event and some biological factors (such as genes) may make some people more likely to develop PTSD. What are the signs and symptoms of PTSD? Symptoms of PTSD usually begin within 3 months of the traumatic event, but they sometimes emerge later. To meet the criteria for PTSD, a person must have symptoms for longer than 1 month, and the symptoms must be severe enough to interfere with aspects of daily life, such as relationships or work. The symptoms also must be unrelated to medication, substance use, or other illness. The course of the disorder varies. Some people recover within 6 months, while others have symptoms that last for 1 year or longer. People with PTSD often have co-occurring conditions, such as depression, substance use, or one or more anxiety disorders. After a dangerous event, it is natural to have some symptoms. For example, some people may feel detached from the experience, as though they are observing things rather than experiencing them. A mental health professional who has experience helping people with PTSD, such as a psychiatrist, psychologist, or clinical social worker, can determine whether symptoms meet the criteria for PTSD. To be diagnosed with PTSD, an adult must have all of the following for at least 1 month. At least one re-experiencing symptom At least one avoidance symptom At least two arousal and reactivity symptoms At least two cognition and mood symptoms Re-experiencing symptoms include: Experiencing flashbacks—reliving the traumatic event, including physical symptoms such as a racing heart or sweating Having recurring memories or dreams related to the event Having distressing thoughts Experiencing physical signs of stress Thoughts and feelings can trigger these symptoms, as can words, objects, or situations that are reminders of the event. Avoidance symptoms include: Staying away from places, events, or objects that are reminders of the traumatic experience Avoiding thoughts or feelings related to the traumatic event Avoidance symptoms may cause people to change their routines. For example, some people may avoid driving or riding in a car after a serious car accident. Arousal and reactivity symptoms include: Being easily startled Feeling tense, on guard, or on edge Having difficulty concentrating Having difficulty falling asleep or staying asleep Feeling irritable and having angry or aggressive outbursts Engaging in risky, reckless, or destructive behavior Arousal symptoms are often constant. They can lead to feelings of stress and anger and may interfere with parts of daily life, such as sleeping, eating, or concentrating. Cognition and mood symptoms include: Having trouble remembering key features of the traumatic event Having negative thoughts about oneself or the world Having exaggerated feelings of blame directed toward oneself or others Having ongoing negative emotions, such as fear, anger, guilt, or shame Losing interest in enjoyable activities Having feelings of social isolation Having difficulty feeling positive emotions, such as happiness or satisfaction Cognition and mood symptoms can begin or worsen after the traumatic event. They can lead a person to feel detached from friends or family members. If you or someone you know is struggling or having thoughts of suicide, call or text the 988 Suicide and Crisis Lifeline at 988 or chat at 988lifeline.org . In life-threatening situations, call 911. How do children and teens react to trauma? Children and teens can have extreme reactions to trauma, but some of their symptoms may not be the same as those seen in adults. In children younger than age 6, these symptoms can include: Wetting the bed after having learned to use the toilet Forgetting how to talk or being unable to talk Acting out the scary event during playtime Being unusually clingy with a parent or other adult Older children and teens usually show symptoms more like those seen in adults. They also may develop disruptive, disrespectful, or destructive behaviors. Older children and teens may feel guilty for not preventing injury or deaths. They may also have thoughts of revenge. Learn more about how to help children and adolescents cope with disasters and other traumatic events. What are the risk factors for PTSD? Not everyone who lives through a dangerous event develops PTSD—many factors play a part. Some of these factors are present before the trauma; others become important during and after a traumatic event. Risk factors that may increase the likelihood of developing PTSD include: Being exposed to previous traumatic experiences, particularly during childhood Getting hurt or seeing people hurt or killed Feeling horror, helplessness, or extreme fear Having little or no social support after the event Dealing with extra stress after the event, such as loss of a loved one, pain and injury, or loss of a job or home Having a personal or family history of mental illness or substance use Resilience factors that may reduce the likelihood of developing PTSD include: Seeking out support from friends, family, or support groups Learning to feel okay with one’s actions in response to a traumatic event Having a coping strategy for getting through and learning from the traumatic event Being prepared and able to respond to upsetting events as they occur, despite feeling fear How is PTSD treated? It is important for anyone with PTSD symptoms to work with a mental health professional who has experience treating PTSD. The main treatments are psychotherapy, medications, or a combination of psychotherapy and medications. A mental health professional can help people find the best treatment plan for their symptoms and needs. Some people with PTSD, such as those in abusive relationships, may be living through ongoing trauma. In these cases, treatment is usually most effective when it addresses both the traumatic situation and the symptoms of PTSD. People who experience traumatic events or who have PTSD also may experience panic disorder, depression, substance use, or suicidal thoughts. Treatment for these conditions can help with recovery after trauma. Research shows that support from family and friends also can be an important part of recovery. What is Psychotherapy: Psychotherapy (sometimes called talk therapy) includes a variety of treatment techniques that mental health professionals use to help people identify and change troubling emotions, thoughts, and behaviors. Psychotherapy can provide support, education, and guidance to people with PTSD and their families. Treatment can take place one on one or in a group and usually lasts 6 to 12 weeks but can last longer. Some types of psychotherapy target PTSD symptoms, while others focus on social, family, or job-related problems. Effective psychotherapies often emphasize a few key components, including learning skills to help identify triggers and manage symptoms. One common type of psychotherapy, called cognitive behavioral therapy, can include exposure therapy and cognitive restructuring: Exposure therapy helps people learn to manage their fear by gradually exposing them, in a safe way, to the trauma they experienced. As part of exposure therapy, people may think or write about the trauma or visit the place where it happened. This therapy can help people with PTSD reduce symptoms that cause them distress. Cognitive restructuring helps people make sense of the traumatic event. Sometimes people remember the event differently from how it happened. They may feel guilt or shame about something that is not their fault. Cognitive restructuring can help people with PTSD think about what happened in a realistic way. Medications The U.S. Food and Drug Administration (FDA) has approved two selective serotonin reuptake inhibitors (SSRIs), a type of antidepressant medication, for the treatment of PTSD. SSRIs may help manage PTSD symptoms such as sadness, worry, anger, and feeling emotionally numb. Health care providers may prescribe SSRIs and other medications along with psychotherapy. Some medications may help treat specific PTSD symptoms, such as sleep problems and nightmares. Source: National Center for PTSD

Service Dog help Veterans When Ryan, 37, returned home from two deployments with the 101st Airborne Division in Iraq from 2005 to 2008, he began withdrawing from social situations and experienced chronic anxiety. Nights brought no respite — his sleep was interrupted by punishing nightmares. "I had every calling card of a veteran in distress," he told Medscape Medical News. When his wife told him she thought he may have posttraumatic stress disorder (PTSD), he shrugged it off. "I wasn't automatically going to accept [the diagnosis] because as an infantry veteran, we're big tough guys. We don't need help with anything." Ryan's wife had heard of a program called Northwest Battle Buddies (NWBB) that pairs professionally trained dogs with veterans struggling with PTSD. The dogs, mostly recruited from rescue organizations, receive 5-7 months of specialized training to assist the veterans. Life-Changing Help While Ryan was skeptical about the program and whether it would work for him, he agreed to try it. After working with Bullet, a cream-colored golden retriever trained to help veterans with PTSD, he realized his life was improving. "I stopped self-medicating, started advocating for myself, and became more comfortable socializing in public." In his 3 years with Bullet, Ryan was able to work on his marriage, advanced his career, and became a homeowner. "The dreams I never thought were attainable started coming to fruition, and I was happy and comfortable for the first time in as long as I could remember." Unfortunately, Bullet died from a rare heart condition after a few years, and when that happened, NWBB immediately began working with Ryan to find him a new dog to fill the void left by Bullet. Soon, Ryan began working with Twitch, who, like Bullet, knew when Ryan was becoming anxious, angry, or depressed before he did, he said. "These dogs pick up on PTSD symptoms and come over and press themselves against you, push their faces into yours, and give you those big puppy dog eyes as if to say, 'I got you. Everything is going to be okay.'" The same thing happened when Ryan had night terrors and nightmares. "These dogs wake you up, and again, you're greeted with this sweet puppy dog face." NWBB founder and CEO Shannon Walker, who has been training dogs for 25 years and whose father served in the US Air Force in the 1950s, leads a 5-week training course for the veterans and their "battle buddies" so that the veterans can learn how to bond with and benefit from their new service dogs. Finding the Perfect Match Veterans are paired with a trained service dog based on their lifestyle and personality. For instance, a Vietnam veteran who is having trouble walking may be paired with a calm dog while a younger veteran who runs each morning is paired with a more active dog. NWBB operates on funds from private donors and nonprofit organizations that make it financially feasible for the veterans to travel to Washington state and stay for the time required to train with their service dogs. "Our service dogs are there in the midnight hour when no one else is," she told Medscape Medical News. "Our veterans are fighting internal battles that no one else sees but the dogs. The dogs alert on their adrenaline and bring them back to the moment of now, interrupting suicidal ideations, panic attacks, and night terrors." Joshua Morganstein, MD, who is chair of the American Psychiatric Association's Committee on the Psychiatric Dimensions of Disaster, told Medscape Medical News that "PTSD can be devastating for service members and veterans and is often associated with comorbid mental health conditions, such as anxiety and substance use." He noted that for many people, dogs and other animals can be an important source of physical, emotional, and psychological comfort. "Programs like the Northwest Battle Buddies are important for us to study and better understand the extent to which trained animals are able to help alleviate the symptoms of PTSD and associated disorders and, perhaps most importantly, enhance the ability of service members and veterans to function and live in ways that feel healthy and productive to them," said Morganstein. He added that the concept of a "battle buddy" is a term pioneered by the US Army in 2002 and describes a "formal, rather than ad hoc, system of peer support in which service members are assigned buddies." "Buddies look out for each other, encourage self-care and self-advocacy and, when needed, help their buddy to seek help. Buddies remind us that someone is looking out for us and there is someone we look out for as well, both of which are protective during difficult times," he said. Source: Medscape

The NCE’s developer has announced that it is now initiating phase 3 studies. A study of a new chemical entity (NCE) for treatment-resistant schizophrenia (TRS) found that 40% of patients improved to the point of no longer meeting TRS severity criteria after 6 months of treatment. Study 014/015—a 6-week, randomized, rater-blinded study by Newron Pharmaceuticals—evaluated the safety, tolerability, and efficacy of evenamide, an investigational NCE for the management of TRS. For study 014, investigators recruited a total of 161 patients with TRS who were consistently administered a therapeutic dose of a single antipsychotic medication, excluding clozapine, with the primary aim of assessing the safety and tolerability of orally administered evenamide at 3 predefined doses: 7.5 mg, 15 mg, and 30 mg twice a day. Preliminary efficacy was evaluated by observing changes in Positive and Negative Syndrome Scale (PANSS) scores from baseline. Secondary objectives involved the evaluation of alterations from baseline in Clinical Global Impression of Change (CGI-C), Severity of Illness (CGI-S), and Strauss-Carpenter Level of Functioning (LOF) scale scores. Study 015 served as an extension of study 014 to investigate the long-term advantages of inhibiting glutamate release, continuing with 77 patients successfully completing 1 year of treatment with evenamide. Results from study 014/015 showed a statistically significant improvement in PANSS, CGI-S, and LOF scores at 6 months (p-value < 0.001: paired t-test, LOCF). A considerable proportion of participants who experienced a > 20% reduction in symptoms compared to baseline on PANSS total score at week 6 had maintained their response upon reevaluation at month 6. No participants experienced a worsening of psychosis, and no participants relapsed. And approximately 40% of participants no longer met the protocol severity criteria used to diagnose treatment resistance upon reevaluation at 6 months. These results were recently presented at the 36th European Clinical Neuropsychopharmacology Congress (ECNP) in Barcelona, Spain. “These highly encouraging results from study 014/015…demonstrate the potential benefits of evenamide and its unique glutamatergic mechanism of action,” said Ravi Anand, Newron chief medical officer, in a press release. “The findings show that the addition of this glutamate modulation to first- and second-generation antipsychotics in patients with TRS potentiates their effects on dopamine dysfunction and can potentially produce a beneficial antipsychotic response. “What is remarkable about the effect of evenamide in this study is that treatment benefits continue to accrue overtime, and many patients who do not respond early achieve clinically important benefits later. Importantly, over the course of the study period, we found that no patients relapsed or experienced worsened psychosis, and a significant portion of patients improved to the point that they no longer met the criteria to enroll in the study to begin with.” Given these results, Newron has announced that it is moving into phase 3 studies of evenamide for the same indication. According to Anand, “Following these encouraging results, which have been assessed by our international advisory committee, we are preparing to initiate a potentially pivotal, phase 3, multinational, randomized, double-blind, placebo-controlled trial in patients with TRS and are confident that the results from that study will endorse the use of evenamide as an adjunct treatment to any other antipsychotic as a new therapeutic strategy for TRS.” Related Topic: Schizophrenia Still Linked to Early Mortality Reference 1. Newron TRS study 6 months’ results: evenamide substantially improves patients to an extent that they no longer meet protocol entry criteria. BusinessWire. October 9, 2023. Accessed October 9, 2023.

Does early improvement in insomnia predict response to pharmacotherapy in psychotic depression? Authors performed a secondary analysis of a randomized clinical trial. CASE VIGNETTE “Mr Penn” is a 34-year-old Caucasian male with a history of recurrent, severe major depressive disorder (MDD) with psychotic features. His most recent psychiatric hospitalization was preceded by a period of significant insomnia with subsequent worsening depression, suicidal ideation with a plan, and an increase in paranoia. During the hospitalization, Mr Penn was started on mirtazapine 15 mg at bedtime. Over the next 7 days, he noted significant improvement in insomnia, with resolution of his suicidal ideation and some improvements in depressive symptoms. At his hospital discharge visit, he asks about whether his dose of mirtazapine should be increased. As his psychiatrist, how would you respond? Insomnia is a common symptom and part of the diagnostic criteria for MDD. A systematic review found that treatment of insomnia improves mood symptoms in MDD. There is some evidence that early insomnia improvement (EII) within the initial weeks of treatment predicts response to antidepressants. However, the clinical utility of EII as a predictor of outcomes of antidepressant treatment remains unclear. There is evidence that psychotic depression (ie, MDD with psychotic features) has a higher severity of insomnia and depressive symptoms and a lower response to antidepressants than nonpsychotic MDD. The Current Study Vos and colleagues6 investigated whether EII predicts response and remission of psychotic depression. The authors performed a secondary analysis of the Dutch University Depression Group (DUDG),7 a double-blind randomized controlled trial of venlafaxine, imipramine, and venlafaxine plus quetiapine in psychotic depression. Participants were aged 18 to 65 years and had a DSM-IV-TR diagnosis of psychotic depression. They had a Hamilton Rating Scale for Depression (HAM-D-17) score of ≥18. Exclusion criteria were no insomnia symptoms at baseline, acute indication for ECT, IA <80, alcohol or substance use disorder in the past 3 months, serious somatic illness, somatic medication affecting mood symptoms, and contraindications for or previous treatment with venlafaxine or imipramine during the current depressive episode. Patients were randomized to 7 weeks of double-blind treatment with venlafaxine, imipramine, or venlafaxine plus quetiapine. A maximum of 3 mg lorazepam per day was also permitted. Depressive symptoms were rated weekly using the HAM-D-17. EII was defined as a ≥20% reduction of insomnia severity (sum of the 3 sleep-related HAM-D-17 items) from baseline after 2 weeks of treatment. Early response for depression was defined as ≥20% reduction in HAM-D-17 score after 2 weeks. The primary outcome measure was response for depression, defined as ≥50% reduction in HAM-D-17 score after 7 weeks (excluding the 3 sleep-related outcomes for the association with EII). Remission of depression was defined as a HAM-D-17 score <8 and the absence of hallucinations and delusions after 7 weeks. Associations between EII and outcomes were analyzed using logistic regression models controlled for age, sex, medication, benzodiazepine use, and pre-treatment insomnia and depression scores. The authors used a last observation carried forward approach for study dropouts. Approximately 114 participants (out of 122 in the original study) met the inclusion/exclusion criteria and were analyzed. Thirty-seven received venlafaxine, 38 imipramine, and 39 venlafaxine plus quetiapine. There were no significant differences in clinical or demographic factors based on the treatment group. The mean participant age was 51 years, and 48% of participants were male. Over the first 2 weeks, the average reduction in insomnia symptoms was significantly greater than other depressive symptoms. EII was achieved in 74% and early response on overall depression in 67% of patients. After 7 weeks, depression response was achieved in 57% and remission in 32%, as well as remission of psychotic symptoms in 67%. EII was a significant predictor of response on overall depression (OR=7.9, 95% CI 2.7-23.4) and depression excluding the 3 insomnia items (OR=6.3m 95% I 2.2-18.3). EII was also a significant predictor of remission of depression (OR=6.1, 95% CI 1.6-23.3) and remission of psychotic symptoms (OR=4.1, 95% CI 1.6-10.9). There were no significant interactions between EII and medications. EII had a higher sensitivity and negative predictive value than early depression response for all outcome measures. Study Conclusions The authors performed the first study of EII as a predictor of treatment outcome in psychotic depression. They found evidence that EII was associated with depression response and remission and remission of psychosis. Insomnia symptoms improved within the first weeks of pharmacotherapy, whereas depressive symptoms improved more gradually. Study strengths include a more homogeneous sample of patients with psychotic depression, and the fact that patients were free of other psychotropics (except possibly low-dose benzodiazepines). Limitations include the lack of data on pre-study benzodiazepines and the lack of a specific insomnia scale. The Bottom Line Early improvement in insomnia was associated with a higher response to depressive and psychotic symptoms in psychotic depression. Further studies are needed to investigate the generalizability of EII as a predictor of treatment response in depression. Dr Miller is a professor in the Department of Psychiatry and Health Behavior at Augusta University in Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for Psychiatric Times®. The author reports that he receives research support from Augusta University, the National Institute of Mental Health, and the Stanley Medical Research Institute. Related topic: What are Sleep/Wake Disorders? References 1. Gebara MA, Siripong N, DiNapoli EA, et al. Effect of insomnia treatments on depression: a systematic review and meta-analysis. Depress Anxiety. 2018;35(8):717-731. 2. Cao B, Park C, Rosenblat JD, et al. Changes in sleep predict changes in depressive symptoms in depressed subjects receiving vortioxetine: an open-label clinical trial. J Psychopharmacol. 2019;33(11):1388-1394. 3. Wang M, Zhang B, Zhou Y, et al. Sleep improvement is associated with the antidepressant efficacy of repeated-dose ketamine and serum BDNF levels: a post-hoc analysis. Pharmacol Rep. 2021;73(2):594-603. 4. Manber R, Buysse DJ, Edinger J, et al. Efficacy of cognitive-behavioral therapy for insomnia combined with antidepressant pharmacotherapy in patients with comorbid depression and insomnia: a randomized controlled trial. J Clin Psychiatry. 2016;77(10):e1316-e1323. 5. Jääskeläinen E, Juola T, Korpela H, et al. Epidemiology of psychotic depression - systematic review and meta-analysis. Psychol Med. 2018;48(6):905-918. 6. Vos CF, Birkenhäger TK, Nolen WA, et al. The relationship of early sleep improvement with response to pharmacotherapy in unipolar psychotic depression [published online ahead of print, 2023 Aug 31]. J Clin Psychopharmacol. 2023;10.1097/JCP.0000000000001756. 7. Wijkstra J, Burger H, van den Broek WW, et al. Treatment of unipolar psychotic depression: a randomized, double-blind study comparing imipramine, venlafaxine, and venlafaxine plus quetiapine. Acta Psychiatr Scand. 2010;121(3):190-200.

The newest class of medications to treat insomnia have many advantages. CONFERENCE REPORTER Dual orexin receptor antagonists (DORAs), the newest kid on the insomnia treatment block, do not adversely effect sleep architecture, explained Paul P. Doghramji, MD, at the 2023 Annual Psychiatric Times™ World CME Conference. He also explained DORAs do not have rebound insomnia, tolerance issues, or withdrawal symptoms. Doghramji, Senior Family Physician at Collegeville Family Practice, told attendees how orexins work, and then reviewed the currently available DORAs. Suvorexant was the first DORA on the market, approved in 2014 for difficulties with sleep onset and/or maintenance, he said. Available in 5, 10, 15, and 20 mg doses, Doghramji finds most patients do best at the 20 mg dose but suggested starting with the 10 mg dose. It has a half-life of 15 hours and a Tmax of 2 hours. The most common adverse effects in trials were somnolence, headache, abnormal dreams, dry mouth, cough, and upper respiratory infection. Interestingly, the adverse events rate were in a 2 to 1 ratio of women to men, Doghramji explained. There were no differences in psychomotor or morning driving performance when compared with placebo. Doghramji shared highlights of an interesting study, in which there were significant improvements in both total sleep time and wake after sleep for patients with insomnia and mild to moderate Alzheimer in the suvorexant group as compared with the placebo group. Next on the scene was lemborexant, Doghramji said, which was approved for difficulties with sleep onset and/or maintenance. It is available in 5 mg and 10 mg doses; Doghramji noted it is better to start with the 5 mg dose, and if the desired effect is not realized, move to the higher dose. Lemborexant has more effect on orexin 2 than orexin 1, he explained, with a Tmax of 1-3 hours and a half-life of 17-19 hours. Doghramji noted that because it induces CYP2B6, which impacts the area under the curve for bupropion, patients on both drugs will need a higher dose of bupropion. The most common adverse effects in trials were somnolence/fatigue, he said. Doghramji noted research indicates it is safe in mild obstructive sleep apnea, and no difference in middle of the night auditory awakening threshold or morning cognitive performance, body sway, and driving performance when compared with placebo. In one study, lemborexant showed an improvement in sleep latency to persistent sleep almost as good if not better than zolpidem.2 In addition to sustained efficacy, he also explained patients reported improved fatigue during the day, which he said is an important indicator of treatment success. Approved in 2022, daridorexant is the most recent DORA approved for difficulties with sleep onset and/or maintenance, Doghramji said. Daridorexant is available in 25 mg and 50 mg doses. It has a Tmax of 1-2 hours and a half-life of 8h, which he noted is about half that of the other DORAs. Compared to placebo after 4 days of treatment there was no morning driving impairment, and he said safety as been demonstrated in mild obstructive sleep apnea and moderate chronic obstructive pulmonary disease. Interestingly, the most common adverse effects are nasopharyngitis and headache, he said, but somnolence and fatigue were also reported. In addition to improving latency to persistent sleep and wake after sleep onset, Deradoorian was found to improve daytime function, Doghramji told attendees. He explained the Insomnia Daytime Symptoms and Impacts Questionnaire was created and validated according to FDA guidelines to assess and evaluate daytime functioning in individuals with insomnia disorder. At the 50 mg dose daridorexant improved the IDSIQ sleepiness domain at months 1 and 3, with clinically meaningful at month 3. Doghramji told attendees there are 2 emerging DORAs: seltorexant and vornorexant. Seltorexant is a selective orexin-2 receptor antagonist and is currently in phase 3 trials as an adjunctive therapy to antidepressants for patients with major depressive disorder and insomnia symptoms, he said. On the other hand, vornorexant is a balanced dual orexin antagonist that showed significant improvement in sleep latency to persistent sleep and wake after sleep onset. Related Topic: Orexin Receptor 2 Agonist Improves Sleepiness in Narcolepsy References 1. Herring WJ, Ceesay P, Snyder E, et al. Polysomnographic assessment of suvorexant in patients with probable Alzheimer's disease dementia and insomnia: a randomized trial. Alzheimers Dement. 2020;16(3):541-551. 2. Rosenberg R, Murphy P, Zammit G, et al. Comparison of Lemborexant With Placebo and Zolpidem Tartrate Extended Release for the Treatment of Older Adults With Insomnia Disorder: A Phase 3 Randomized Clinical Trial JAMA Netw Open. 2019;2(12):e1918254. Published 2019 Dec 2. 3. Kärppä M, Yardley J, Pinner K, et al. Long-term efficacy and tolerability of lemborexant compared with placebo in adults with insomnia disorder: results from the phase 3 randomized clinical trial SUNRISE 2. Sleep. 2020;43(9):zsaa123. 4. Chepke C, Jain R, Rosenberg R, et al. Improvement in fatigue and sleep measures with the dual orexin receptor antagonist lemborexant in adults with insomnia disorder. Postgrad Med. 2022;134(3):316-325. 5. Mignot E, Mayleben D, Fietze I, et al. Safety and efficacy of daridorexant in patients with insomnia disorder: results from two multicentre, randomised, double-blind, placebo-controlled, phase 3 trials .Lancet Neurol. 2022;21(2):125-139. 6. Hudgens S, Phillips-Beyer A, Newton L, Seboek Kinter D, Benes H. Development and Validation of the Insomnia Daytime Symptoms and Impacts Questionnaire (IDSIQ). Patient. 2021;14(2):249-268.

Over the past 2 decades, the attention-deficit/hyperactivity disorder (ADHD) treatment spectrum has expanded to include intermediate-acting and long-acting treatments. Despite the advances in drug delivery technology for stimulant medications, short-acting stimulants remain widely prescribed for adults with ADHD.1,2 Understanding the diverse mechanisms and pharmacokinetic profiles of the currently available group of long-acting stimulant formulations will help clinicians tailor treatment to individual patient needs. In a recent Psychiatric Times® Expert Perspectives video series, Greg Mattingly, MD, associate clinical professor at Washington University School of Medicine in St Louis, Missouri, and president-elect of the American Professional Society of ADHD and Related Disorders (APSARD); and Oren Mason, MD, family physician at Attention MD in Grand Rapids, Michigan; had a wide-ranging discussion highlighting key points from a presentation they delivered at the 2023 APSARD annual meeting. They examined how the landscape of stimulant medications has evolved and how to improve the patient experience with stimulants. Ahead is a summary of key points and clinical insights from the discussion. Evolving Treatment Landscape for Adult Patients With ADHD As explained by Dr Mattingly, many long- acting medications achieve their duration of action by combining various ratios of immediate-release and extended-release components, which results in 2 peaks on the pharmacokinetic (PK) curve. “That first pulse [corresponds] to an immediate-release component, and the later pulses [are] delayed-release components that [occur] throughout the day… Formulations with immediate-release components usually have what we call a biphasic pharmacokinetic profile,” said Dr Mattingly. “[This means] that patients may potentially feel the on/off periods or the [adverse] effects of medicines [in a] coming-and-going [manner] rather than feeling the full duration of coverage.” Guidance for Prescribing Stimulants in Adults Within the past 15 to 20 years, the diagnosis of ADHD has increased to a greater extent for adults than for children and adolescents. In fact, a 2021 global systematic review and meta-analysis found a global prevalence of 8.83% in adults around the world. When treating adult patients with ADHD, Dr Mattingly noted that understanding various PK profiles can optimize treatment decision-making for patients with ADHD who may have disparate needs. He explained that for agents that contain a higher proportion of immediate-release medication, patients tend to exhibit greater early medication exposure relative to total exposure. “Typically, [this] is reflected by an earlier onset of action,” he said, “but perhaps [it does not have] sustained duration of action.” In comparison, Dr Mattingly said, “Formulations that have less drug available in immediate release but have more of the [medication acting in] extended release tend to give [the patient] a longer duration of coverage.” Dr Mattingly went on to describe multiple technologies that have different PK profiles. “They all need to be understood to optimize the outcomes for your patients,” he said. According to Dr Mattingly, advantages of long-acting formulations include: improving or augmenting symptom coverage throughout the day, potentially improving treatment response, helping with adherence, and potentially improving tolerability without having the on/off effect. He also added, “It’s breaking the barriers of stigma and improving privacy.” He concluded that currently, guidance is to shift away from short-acting agents whenever appropriate. Clinician and Patient Perspectives on Stimulants for ADHD Keeping the benefits of long-acting stimulants in mind, clinicians can improve the patient experience when treating adult ADHD. According to Dr Mason, the goal of treatment is to improve symptoms and to achieve functional remission, which is when the functional impairments begin to normalize. “In my experience, [although] people understand a small bit about ADHD, [patients] may not understand the full impact of ADHD on their lives,” said Dr Mason. “When we prescribe these medications, we should literally see the changes across [their full] spectrum of symptoms.” When treating adult patients with ADHD, Dr Mason explained that despite the benefits of long-acting stimulants, many patients ask for short-acting stimulant medications. “[They may have] concerns about cost or fear of the medications, hoping to limit their exposure to something they don’t understand,” said Dr Mason. “I think we have to explore it with people. There’s a lot of reassurance we can give. [We can explain] that these medications don’t change personality when properly administered, patients have overwhelmingly positive experiences to them, and a trial of [long-acting] medication may help educate them about the [benefits] that they might see from ADHD medication therapy.” In addition, it’s important for clinicians to consider medication duration. Dr Mason said that clinicians can give patients an expectation of what the average patient might experience; they will, however, need additional education to understand when a medication is wearing off. To achieve adequate duration, clinicians should begin with prescribing long-acting medications to achieve an all-day duration, according to Dr Mason. “An all-day duration is simply not going to [be achieved] with a short-acting medication, a medication [with effects that only last] for 4 to 6 hours,” said Dr Mason. “We let patients know what we expect the duration of benefit to be, and then we actually measure it. If the duration is inadequate, [we’ll] either switch to another long-acting preparation or, in some cases, we’ll add a short-acting booster to lengthen the duration of benefit.” He went on to explain that with many longer-acting preparations, there is an improvement in duration of benefit, not just in midday effect. “Through the titration optimization, we need to ask questions about both efficacy and duration of benefit. If we’re not able to obtain adequate duration of benefit from one long-acting medication, we have others that we can try. If no long-acting preparation gives the patient the duration necessary, we can add short-acting boosters in the afternoon.” Keeping in mind the appropriate utilization of stimulants and the avoidance of the overuse of short-acting formulations, Dr Mason highlighted current stimulant prescribing practices and clinician perspectives about treating adults with ADHD, explaining that there is a trend of improvement across the medical spectrum, despite the need for more improvement in the landscape.“ ADHD management spans a range of specialties, and [there are] different practices within each. We looked at a 2017 cross-sectional study across US-based health care professionals. For the purpose of the study, we’re going to talk about 4 specialties: psychiatrists, neurologists, primary care doctors, and psychiatric nurse care practitioners. When asked to identify which pharmacotherapy they prescribe as first-line treatment, short-acting stimulants were cited by 17% of psychiatrists and 29% to 36% of the other 3 groups. This means that there [are] a lot of short-acting stimulants being used primarily for ADHD right out of the gate. Psychiatrists are more likely than the other groups to prescribe long-acting stimulants.” In addition, health care professionals were asked how strongly they agree or disagree with the following statement: It’s difficult to determine optimal ADHD treatment regimen for adult patients. According to Dr Mason, there was a resounding yes from 45% of psychiatrists and 60% of primary care physicians, neurologists, and nurse practitioners. “This is an opportunity for education,” he said. “We need more awareness about the actual benefits of the [long-acting] medications, the deficiencies of short-acting medications relative to long-acting stimulants, and the opportunity to do better for our patients.” Despite the benefit patients can yield from ADHD medications, there are unmet needs that remain. According to Dr Mason, adequate duration of effect is an area in need of improvement, especially for adults with ADHD. “Clinicians should be aware of how the method of extending duration [with short-acting agents] influences drug pharmacokinetics,” he said. “Health care professionals have identified a need for guidance regarding stimulant medications for ADHD.” Dr Mattingly added that patients who misperceive the energizing effects of stimulants for clinical benefit may drive a preference for short-acting stimulants. As the role of long-acting medications within the spectrum of ADHD treatment continues to evolve, Dr Mason said that there is a need for more education related to the benefits of long-acting medications relative to short-acting stimulants to help improve patient outcomes. References 1. Cascade E, Kalali AH, Weisler RH. Short-acting versus long-acting medications for the treatment of ADHD. Psychiatry (Edgmont). 2008;5(8):24-27. 2. Mattingly GW, Wilson J, Ugarte L, Glaser P. Individualization of attention-deficit/hyperactivity disorder treatment: pharmacotherapy considerations by age and co-occurring conditions. CNS Spectr. 2021;26(3):202-221. doi:10.1017/S1092852919001822 Related Topic: ADHD Underappreciated in Older Adults

Antidepressant ARCELONA — The typical lag between treatment initiation with selective serotonin reuptake inhibitors (SSRIs) for depression and enhanced mood may be because of the time it takes to increase brain synaptic density, new imaging data suggest. In a double-blind study, more than 30 volunteers were randomly assigned to the SSRI escitalopram or placebo for 3-5 weeks. Using PET imaging, the investigators found that over time, synaptic density significantly increased significantly in the neocortex and hippocampus but only in patients taking the active drug. The results point to two conclusions said study investigator Gitta Moos Knudsen, MD, PhD, clinical professor and chief physician at the Department of Clinical Medicine, Neurology, Psychiatry and Sensory Sciences, at Copenhagen University Hospital, Copenhagen, Denmark. First, they indicate that SSRIs increase synaptic density in brain areas critically involved in depression, a finding that would go some way to indicating that the synaptic density in the brain may be involved in how antidepressants function, "which would give us a target for developing novel drugs against depression," said Knudsen. "Secondly, our data suggest synapses build up over a period of weeks, which would explain why the effects of these drugs take time to kick-in," she added. The findings were presented here at the 36th European College of Neuropsychopharmacology (ECNP) Congress, and simultaneously published online in Molecular Psychiatry. Marked Increase in Synaptic Density SSRIs are widely used for depression as well as anxiety and obsessive-compulsive disorder. It is thought they act via neuroplasticity and synaptic remodeling to improve cognition and emotion processing. However, the investigators note clinical evidence is lacking. For the study the researchers randomly assigned healthy individuals to either 20-mg escitalopram or placebo for 3-5 weeks. They performed PET with the 11C-UCB-J tracer, which allows imaging of the synaptic vesicle glycoprotein 2A (SV2A) in the brain, synaptic density, as well as changes in density over time, in the hippocampus and neocortex. Between May 2020 and October 2021, 17 individuals were assigned to escitalopram and 15 to placebo. There were no significant differences between two groups in terms of age, sex, and PET-related variables. Serum escitalopram measurements confirmed that all participants in the active drug group were compliant. When synaptic density was assessed at a single time point, an average of 29 days after the intervention, there were no significant differences between the escitalopram and placebo groups in either the neocortex (P = .41) or in the hippocampus (P = .26). However, when they performed a secondary analysis of the time-dependent effect on SV2A levels, they found a marked difference between the two study groups. Compared with the placebo group, participants taking escitalopram had a marked increase in synaptic density in both the neocortex (rp value, 0.58; P = .003) and the hippocampus (rp value, 0.41; P = .048). In contrast, there were no significant changes in synaptic density in either the neocortex (rp value, -0.01; P = .95) or the hippocampus (rp value, -0.06; P = .62) in the hippocampus. "That is consistent with our clinical observation that it takes time to evolve synaptic density, along with clinical improvement. Does that mean that the increase in synaptic density is a precondition for improvement in symptoms? We don't know," said Knudsen. Exciting but Not Conclusive Session co-chair Oliver Howes, MD, PhD, professor of Molecular Psychiatry, King's College London, London, United Kingdom, agreed that the results do not prove the gradual increase in synaptic density the treatment response lag with SSRIs. "We definitely don't yet have all the data to know one way or the other," he told Medscape Medical News. Another potential hypothesis, he said, is that SSRIs are causing shifts in underlying brain circuits that lead to cognitive changes before there is a discernable improvement in mood. Indeed, Howes suggested increases in synaptic density and cognitive changes related to SSRI use are not necessarily dependent on each other and could even be unrelated. Also commenting on the research, David Nutt, MD, PhD, Edmond J. Safra Professor of Neuropsychopharmacology at Imperial College London, United Kingdom, said that the "delay in therapeutic action of antidepressants has been a puzzle to psychiatrists ever since they were first discerned over 50 years ago." "So, these new data in humans, that use cutting edge brain imaging to demonstrate an increase in brain connections developing over the period that the depression lifts, are very exciting." Nutt added the results provide further evidence that "enhancing serotonin function in the brain can have enduring health benefits." Funding support was provided by the Danish Council for Independent Research, the Lundbeck Foundation, Rigshospitalet, and the Swedish Research Council. Open access funding provided by Royal Library, Copenhagen University Library. Knudsen declares relationships with Sage Biogen, H. Lundbeck, Onsero, Pangea, Gilgamesh, Abbvie, and PureTechHealth. Another author declares relationships with Cambridge Cognition, and PopReach via Cambridge Enterprise. 36th European College of Neuropsychopharmacology (ECNP) Congress. Abstract S14.04 and P.0378. Presented October 8 and 9, 2023.

Disruptions TOPLINE: US adults with psychiatric illness experienced fewer disruptions in receiving psychotherapy following the transition to virtual psychiatric care that accompanied the onset of the COVID-19 pandemic, a large study has shown. METHODOLOGY: Retrospective study using electronic health records and insurance claims data from three large US health systems. Sample included 110,089 patients with mental health conditions who attended at least two psychotherapy visits during the 9 months before and 9 months after the onset of COVID-19, defined in this study as March 14, 2020. Outcome was disruption in psychotherapy, defined as a gap of more than 45 days between visits. TAKEAWAY: Before the pandemic, 96.9% of psychotherapy visits were in person and 35.4% were followed by a gap of more than 45 days. After the onset of the pandemic, more than half of visits (51.8%) were virtual, and only 17.9% were followed by a gap of more than 45 days. Prior to the pandemic, the median time between visits was 27 days and after the pandemic it dropped to 14 days, suggesting individuals were more likely to return for additional psychotherapy after the widespread shift to virtual care. Over the entire study period, individuals with depressive, anxiety, or bipolar disorders were more likely to maintain consistent psychotherapy visits, whereas those with schizophrenia, ADHD, autism, conduct or disruptive disorders, dementia, or personality disorders were more likely to have a disruption in their visits. IN PRACTICE: "These findings support continued use of virtual psychotherapy as an option for care when appropriate infrastructure is in place. In addition, these findings support the continuation of policies that provide access to and coverage for virtual psychotherapy," the authors write. SOURCE: The study, led by Brian K. Ahmedani, PhD, with the Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, Michigan, was published online October 11 in Psychiatric Services. LIMITATIONS: The study was conducted in three large health systems with virtual care infrastructure already in place. Researchers did not examine use of virtual care for medication management or for types of care other than psychotherapy, which may present different challenges. DISCLOSURES: The study was supported by the National Institute of Mental Health. The authors have no relevant disclosures. Related topic: Telehealth What Happens When There Is No Help?