Older adults with major depressive disorder (MDD) exhibit riskier driving behaviors than their nondepressed peers, including hard braking, cornering, and unpredictable driving patterns, new research showed. Data for the study came from commercial vehicle data trackers installed in participants’ vehicles. After about a year of follow-up, investigators found that MDD was associated with an increase in the amount and severity of risking driving, even after controlling for antidepressant use. Late-life depression often goes undiagnosed, and the new findings highlight the importance of routine depression screening and targeted interventions to ensure driving safety among older adults, the study team said. “By using longitudinal, real-world driving data rather than controlled settings or self-reports, the study provides robust evidence of how MDD influences driving behaviors in day-to-day contexts,” first author Ganesh M. Babulal, PhD, OTD, with the Department of Neurology, Washington University School of Medicine in St Louis, told Medscape Medical News. “By analyzing the influence of antidepressant use and overall medication load, the study disentangles the effects of MDD from those of driver-impairing medications, further clarifying the unique contributions of depression to driving behaviors,” Babulal noted. The study was published online on December 30 in JAMA Network Open . Road Risks As the number of older adults grows, safe driving practices in this age group become increasingly crucial. By 2050, one quarter of drivers in the United States will be older than 65 years. MDD affects about 8% of US adults and is linked to cognitive impairments that may compromise driving safety. Prior studies revealed a link between depression and increased car crash risk, regardless of age. And earlier research by Babulal and colleagues showed that older adults with depression were three times more likely to receive a marginal or failing score on a standardized road test. To further study the issue, Babulal and colleagues examined the impact of MDD on naturalistic driving behaviors among older adults using longitudinal data. Participants were recruited from the Driving Real-World In-Vehicle Evaluation System Project, where their daily driving behaviors were recorded using commercial vehicle data loggers installed in their personal vehicles. The cohort included 85 adults with MDD (mean age, 69 years; 71% women) and 310 adults without MDD (mean age, 70 years; 49% women). The majority of participants in both groups were non-Hispanic White individuals. Based on intercepts, adults with MDD had a propensity toward riskier driving habits with a higher frequency of speeding events and spending more time on the road than those without MDD, they found. Additionally, during a mean of 1.1 years of follow-up, compared with older adults without MDD, those with MDD exhibited significantly more hard braking (P < .001) and hard cornering events per trip (P = .04) over time. They also traveled farther from home and visited more unique destinations (P < .001 for both). Over time, older adults also displayed increased entropy in driving patterns (P < .001), indicated less predictable driving routes. “Driving unpredictability, as evidenced by increased random entropy, highlights the unique challenges posed by MDD in maintaining safe driving practices,” the researchers wrote. Adjusting for antidepressant use, which could impair driving, or total medication burden did not change the findings, suggesting MDD independently affects driving. “Most importantly, our findings demonstrate that MDD — a common and treatable illness in older adults — was associated with an increase in both the amount and magnitude of risky driving behaviors over time,” the researchers wrote. The researchers noted that the study did not account for changes in depression severity over time and other psychiatric conditions co-occurring with MDD were not adjusted for. Also, situational factors like weather or traffic conditions were not assessed. Clear Clinical Implications There is a “pressing need” for targeted interventions to manage and mitigate the driving risks associated with late-life depression, the researchers wrote. “The study emphasizes the need for interventions tailored to the mental health and driving behaviors of older adults. These could include cognitive retraining, driver rehabilitation programs, and routine depression screening to enhance road safety and preserve independence,” Babulal told Medscape Medical News. “Encouraging older adults with MDD to self-regulate their driving habits (e.g., avoiding night driving or high-traffic situations) and educating them about potential driving challenges related to their condition can enhance safety,” he added. Commenting on this study for Medscape Medical News , Ipsit Vahia, MD, McLean Hospital, Belmont, Massachusetts, and Harvard Medical School, Boston, said it “adds nuance to our understanding of how depression can impact driving among older adults.” “While the connection between depression and a higher incident of crashes is known, this study demonstrates an association with riskier driving behaviors such as speeding,” Vahia said. “It highlights the importance of clinicians proactively initiating discussion of driving and safety when working with older adults with depressive symptoms.” Note: This article originally appeared on Medscape .

Andrew N. Wilner, MD: Welcome to Medscape. I’m your host, Dr Andrew Wilner. Today, I have the privilege of speaking with Dr Jessi Gold. Dr Gold is an associate professor of psychiatry at the University of Tennessee Health Science Center and the author of How Do You Feel? Today, we’re going to talk about her book and her role as chief wellness officer at the University of Tennessee. Welcome, Dr Gold. Jessica A. Gold, MD, MS: Thank you so much for having me. Wilner: Dr Gold, let’s start with your book. Why did you write it? Tiptoeing Into Self Disclosure Gold: It’s not like there was an “aha” moment precisely, but I’ve been being a clinician who takes care of healthcare workers as a psychiatrist since the pandemic, if not before, and for the most part, I’ve been hearing the same stories over and over again. They always end with “I’ve never told anyone that before,” “No one else feels this way,” or “I feel alone in this.” For me, many of the stories have the same themes and we shouldn’t feel alone in it. To be able to tell stories of my patients and tell my own story in a way that might make this information accessible and might make people feel seen was the ultimate goal there. Wilner: I read your book and I found it very interesting. Also, it was quite intimate. There was a large amount of self-reveal. How did you feel about that? Gold: I’ve tiptoed into self-disclosure for a while, and I’ve been on social media for a while, talking about my own therapy. I wrote a piece a bit ago about my own meds and noticed that the response wasn’t that I combusted or that people thought I was a horrible person or judged me for it. As I’ve tiptoed into it, I’ve felt more comfortable and recognized the need for it. I also realized in being an expert in an article on burnout that, when they asked me how I was feeling and I said the real answer and then the article changed to me being the lead story, clearly we weren’t talking about this enough. Being a person, again, who’s like the clinician of healthcare workers, I wanted to model that and also thought if I could start the conversation, maybe other people would feel more comfortable being vulnerable. I took the leap to do that. Wilner: In your book, you talk about how COVID-19 affected you. Also, I believe you had four patients and their stories with the different mental health issues that they struggle with. COVID-19 is a little bit behind us, so has anything changed, do you think, in the mental health world? Gold: I think in many ways people want to believe that COVID-19 came down from the clouds, made us sad, went back to the clouds, and we’re fine again. It just never was going to be that way. As healthcare workers, we had high rates of burnout and mental health conditions long before COVID-19. It just gave us new stressors. COVID-19 also really exposed many of the issues in healthcare, including access and who gets access to things, people dying, ventilators, and protective equipment. All of these things were maybe new stressors or cracks in existing stressors, so it only compounded our bad baseline mental health. In my experience, just because it’s been better and those stressors are different doesn’t mean we’re okay now. I think there’s a desire to pretend that we’re okay now, but for me, it’s important that this conversation is still happening and that we’re not only talking about people who are caregivers or who work in frontline work in the height of a pandemic, but we also recognize that their jobs are always hard, that their jobs are going to be impacted by those years of their life, and that it should be a conversation we continue to have. Reducing Stigma Wilner: I’m going to read a line from your book: “People who ask for help are the subject of gossip and are judged.” What you’re talking about there is stigma. Particularly for physicians, it’s very difficult for them to ask for help. As a wellness officer, what’s going on there? Gold: There are some data about that. Basically, medical students, when they’re going into medical school, are asked if getting mental health help is a weakness. A very small percentage of them say yes to that. Then they say, well, what about all this other noise in the culture? What about your supervisors? What about your colleagues? What about residency applications? What about patients? Over 50% of them — closer to 60% in many of those cases — are saying my patients would judge me, my colleagues would judge me, my supervisors would judge me, and my next level of applications, residency programs, would judge me. It ends on this question that’s like, well then if you get help, would you talk about it? It’s a tiny number. Basically, just because we come in with our own beliefs — and maybe they aren’t even stigmatizing — maybe we actually think mental health is health, once we get into this culture of healthcare to what we’re seeing around us, to what we’re seeing modeled, that changes. Maybe we still get help but we’re not talking about it, or maybe we don’t get help, which is obviously the worst outcome. We have high rates of suicide in our profession, and the people who show up at my door tend to be quite sick by the time that they show up. It’s a little skewed because I am a psychiatrist and not a therapist, but in so many ways, it’s like, oh, it’s not interfering with my work yet. Many of my patients also say, “I haven’t hurt anyone yet,” which has never been my favorite response because I don’t think we should measure our own well-being by whether we made an error or whether we’re in a position where patients are going to notice. I think we should care about ourselves. People come pretty late. I think that is a product of stigma. It’s what we see. I think the stigma comes from what you see modeled. Nobody else is talking about it. I think it comes from even those little jokes that they make about psychiatry or mental health patients. If you see somebody who is in the emergency department for a mental health thing and the people around you make dark-humor jokes about it, then you say, well, I have that same thing. Like, I’m not going to disclose it. We also have a culture of showing up no matter what and using that as a badge of honor. If we wouldn’t show up if we were actively hemorrhaging, why wouldn’t we skip for mental health? It just doesn’t meet the criteria for not showing up. All of those things combined lead to us thinking I just have to deal with it myself, or My job is to serve other people, not to serve myself. Therefore, I just have to ignore what’s going on with me. Wilner: I know I would feel differently telling my residents, “Hey, I have to leave early today. I have a dentist appointment at 4 PM” vs “I have to leave early today. I have to see my therapist.” Gold: Do you think you feel at all better than when you started your medical career, or do you think that it has been the same for you the whole time? Wilner: I think I would be more open today, but I think that probably is related to the gray hair and wrinkles I’ve accumulated. Gold: I think when you have more power and flexibility, you care less about what all these other noises are. But I also think that as a culture, we’ve evolved to being more comfortable with mental health in general. I think people have become more comfortable talking about it out loud, but in our profession, much less than others. I feel like it’s also hard with therapy because you’re probably going every week or every other week. There are only a few things you would need to do that for, so even if you didn’t say, “I’m leaving at 4 PMbecause I have therapy,” if you left at 4 PM every week for an appointment, it’s either physical therapy or mental therapy. You don’t have many options, and residents, medical students, trainees, and other health professions don’t have the ability to take that much time off, but if they did and they had to ask for it, it would be much harder. What Does a Wellness Officer Do? Wilner: I don’t remember wellness officers when I was in medical school. Is that a new thing? Gold: It’s a newer thing. It’s developed under the concept that having somebody overseeing all of this stuff and valuing it at a higher level is important to making sure things actually get done. Places like Stanford are among the first that had chief wellness officers in the hospital system. Many hospitals have grown to have them. I’m in a different role in that I’m the University of Tennessee system, which includes the undergraduate schools, so it’s a bit different from the people who are just in health. The point is to have somebody whose goals, values, and things that they’re thinking about are always about the well-being of the people that are in the institution — students, faculty, and staff. That’s not always what the bottom line is for everybody else in administrative positions. It makes sure some stuff gets done and that you’re in the right rooms to make it happen. Wilner: Give me an example of one of those things that qualify as stuff. Gold: Much of what the chief wellness officers who work in hospitals are working on includes, how do we think about the role of the electronic medical record? How do we think about staffing? How do we think about control in your workplace, and what does that look like? Is our well-being matching up to what our productivity measures are? Are we actually measuring the right thing? You see much of the system focus from the chief wellness officers that are in the healthcare system. I have a little bit of a different bent just because I’m not exclusively in the healthcare system, so much of what I’m looking at is why we focus so much on the intervention side and are there enough things that we could be looking at, and what kind of options would we have for prevention on our campuses? It’s always going to be stopping the bleeding that’s going to take your attention, right? If there’s a crisis, you have to address the crisis, but we don’t all need to get to the crisis. When you have a little bit of breathing room and time to step back and actually look at what’s going on, how do we make sure that we have preventive options and that we have things for folks to try to do along the way that aren’t just like, oh, they got to crisis again. That’s what I’m looking at. What does that look like? Is that a peer support program? Is that a coaching program? Is that just making sure that they know of all the resources and where to access them when they need them? Is it regular screening tools for themselves that they can monitor? There are many things that people have implemented, but across the spectrum and across our whole state, we’re looking at what makes sense and what programs are working or not. Advice for Improving Wellness Wilner: We’re just about out of time. I have one more question. Apart from seeing you, do you have any advice for physicians and other healthcare workers trying to improve their own wellness? Gold: We’re people that do this job, not robots that do this job, so pretending that our job doesn’t affect us doesn’t help. It should. It’s a hard job. We listen to hard stuff; we see hard stuff. Pretending that somehow, you can see all that stuff and hear all that and be fine, doesn’t make sense. Instead, you should think about how you can deal with that and approach it that way. I’m not saying that the healthcare system is great because there are so many problems in the system, but if you’d like to stay in it for as long as you have, or you’d like to stay in it at least for a while, you do have to figure out what it looks like for you to do that. For me, it’s been things like checking in on myself and my feelings, making sure I take my vacation days, working on self-compassion and that mean voice in my head when I do things wrong or when I think I did things wrong, looking at how email takes over your life, and making really strict boundaries around certain things like talks or all those extra asks that come up in academics. There are ways that we can manage it, and this isn’t to say this is somehow a resiliency problem, because our resilience is higher than any other field. It is to say that we can do something, and I think that’s more important than doing nothing. Wilner: Dr Gold, thanks for joining me for this Medscape interview. Gold: Thanks for having me. Note: This article originally appeared on Medscape .

TOPLINE: Listening to recordings of natural soundscapes may help reduce anxiety and stress, but adding in high-traffic noise can mask the potential benefit, new research shows. METHODOLOGY: Researchers enrolled 68 adults (ages 18-42 years) from the University of the West of England Psychology participant pool. Three 3-minute soundscape files were used: A natural soundscape with bird songs and two mixed soundscapes combining natural sounds with traffic noise recorded at speed limits of 20 mi/h or 40 mi/h. Each participant was exposed to three rounds of a stressor video for 1 minute and a soundscape playback of 3 minutes, then answered questions after each exposure. Subjective stress and pleasure scores (hedonic tone) were measured using the University of Wales Institute of Science and Technology Mood Adjective Checklist, and anxiety was measured using the State-Trait Anxiety Inventory scale. TAKEAWAY: Natural soundscapes were strongly associated with the lowest levels of anxiety and stress, whereas mixed soundscapes with 40 mi/h traffic noise were associated with the highest stress (P < .01) and anxiety (P < .001) levels. Higher pleasure scores occurred after exposure to natural soundscapes, but these scores decreased when the natural soundscapes were combined with 40 mi/h traffic noise. Traffic noise masked the positive impact of a natural soundscape on stress and anxiety in participants irrespective of age, sex, or a predisposed preference for natural environments. IN PRACTICE: "Our study shows that listening to natural soundscapes can reduce stress and anxiety, and that anthropogenic sounds such as traffic noise can mask potential positive impacts," the investigators said in a press release. “Reducing traffic speeds in cities is therefore an important step toward more people experiencing the positive effects of nature on their health and well-being,” they added. Note: This article originally appeared on Medscape .

NIMH-funded study used universal screening, risk assessment, and safety planning to reduce suicide attempts among adult primary care patients Suicide is a leading cause of death in the United States and a major public health concern. Previous research has shown that identifying and helping people at risk for suicide during regular care visits can help prevent it. Primary care clinics are particularly important in this regard, as research has shown that over 40% of people who died by suicide were seen in this setting in the month before their death. A recent study funded by the National Institute of Mental Health (NIMH) found that when primary care clinics added suicide care practices to routine visits, suicide attempts dropped by 25% in the 3 months after the visit. The findings highlight how impactful it can be for primary care clinics to take an active role in preventing suicide and help empower health systems to integrate those practices into clinical care. What did the researchers do in the study? Primary care clinicians screen for depression during most care visits, and depression screeners often include questions about suicide risk. Prior NIMH-supported research found that screening for suicidal thoughts and behaviors followed by brief safety planning can reduce the risk of suicide attempts . Researchers led by Julie Angerhofer Richards, Ph.D., M.P.H. , at the Kaiser Permanente Washington Health Research Institute aimed to see if integrating suicide care into routine adult primary care visits could prevent subsequent suicide attempts. This study analyzed secondary data from a larger integrated study of the National Zero Suicide Model . The comprehensive Zero Suicide approach is the first U.S. program linked to a substantial decrease in suicides among behavioral health patients. The research team previously examined this model in a separate NIMH-funded study at six health systems across the United States. Before the intervention, providers delivered care as usual, which did not include population-based suicide screening or follow-up. The 22 participating clinics were randomly assigned to start delivering suicide care on staggered dates (4 months apart) over a 2-year period. During the study, 333,593 patients were seen for over 1.5 million primary care visits. Suicide care consisted of: Depression screening: All patients completed a brief two-question depression screener, followed by a longer depression symptom scale for those who scored positive on either question. Depression symptom scale: The screener was followed by a longer depression symptom scale for patients who scored positive on either question. Suicide risk assessment: Patients with thoughts of self-harm or suicide completed a measure of suicidal thoughts and behaviors. Suicide safety planning: Patients who reported intent or plans for suicide in the last month were referred to designated care staff, including mental health social workers, for same-day suicide safety planning. Safety planning was a collaborative process between patients and providers that involved identifying warning signs, listing coping strategies and supports, and creating safe environments to manage a suicidal crisis. Three key strategies supported the intervention: Skilled facilitators led trainings at each clinic and met with staff on an ongoing basis to offer support and solve problems. Clinical decision support, including pre-visit reminders and visit prompts, came from the clinics’ electronic medical record system. Regular performance monitoring of medical records reported on clinician rates of screening and assessment. The researchers compared clinics delivering suicide care to clinics delivering usual care on: Providers’ rates of documenting suicide risk assessment and safety planning in the medical record within 2 weeks of an at-risk patient’s primary care visit Patients’ rates of suicide attempt or death by suicide in the 90 days after their primary care visit What did the results of the study show? Integrating suicide care into routine adult primary care visits led to significantly higher rates of suicide risk screening, assessment, and collaborative safety planning. The intervention in turn resulted in a 25% decrease in suicide attempts in the 90 days after a primary care visit compared to usual care clinics. Together, the results demonstrate that integrating suicide prevention practices into adult primary care leads to more people being screened for suicidal thoughts and behaviors and fewer suicide attempts once they leave the clinic. These findings support NIMH’s prioritization of suicide prevention in health care settings , with the ultimate goal of reducing the suicide rate in the United States. The study provides the critical next steps for providers and care teams in responding to suicidal concerns during clinical practice, helping save lives in the process. Note: This article originally appeared on NIMH .

Depression and anxiety are among the most common complications of stroke, affecting 1 in 3 and about 1 in 4 survivors, respectively. These disorders are associated with higher mortality rates, often obscuring the path to recovery. The American Heart Association (AHA)/American Stroke Association (ASA) last published its scientific statement on poststroke depression (PSD) in 2016. Although this statement doesn’t cover poststroke anxiety (PSA), the 2019 Canadian Stroke Best Practices update recommends screening for PSA and apathy, which often coexist in the absence of PSD. It advises management with pharmacotherapy, psychotherapy, or nonpharmacologic interventions such as exercise or music therapy, while noting there is limited evidence for the use of psychostimulants. New research on the most effective treatments for depression and the lack of information on anxiety after stroke have prompted some neurologists to ask: Is it time for new guidance? What’s the Prevalence, Who’s at Risk? Recent data from the South London Stroke Register Study, which followed 2295 patients with PSD for 18 years, revealed that 33% of those with stroke experienced PSD in the first 3 months following the event, 55% within a year, and 88% within 5 years. The study’s investigators noted that individuals with PSD were at substantial risk for persistent depression within a year and recommended PSD screening in all patients within the first 3-6 months following stroke. “The course of PSD is dynamic,” Nada El Husseini, MD, director of the Stroke Research Fellowship Program at Duke University Medical Center, Durham, North Carolina, and a co-author of the AHA/ASA 2016 statement on PSD, told Medscape Medical News. Some people experience depression soon after a stroke and recover within a year, whereas others develop PSD a year after stroke, she noted. Risk factors for PSD in the first 3 months following stroke include previous mental illness, a family history of mental illness, female gender, being younger than 70, and stroke severity. A recent analysis in the Journal of Affective Disorders examined three cohorts from STROKOG (The Stroke and Cognition Consortium), revealing a PSA prevalence of 35%. Investigators found risk factors for PSA included female gender, co-occurrence of PSD, and poststroke cognitive impairment. Most cases of PSA surface within the first year after stroke. Phobia and generalized anxiety disorder were the most common anxiety subtypes. In addition to screening, early and aggressive intervention for PSD is necessary, Bruce Ovbiagele, MD, vice chair of the committee that developed the statement, told Medscape Medical News. “With stroke, we speak about the three dreaded Ds: death, dementia, and disability. But there is a fourth, and that is depression, and it is not addressed to the degree it should be,” said Ovbiagele, professor of neurology, health policy, and global health at the University of California, San Francisco. PSD is underdiagnosed and undertreated, he added. The same appears to be true for PSA, the authors of a commentary published in October in Stroke wrote. “While awareness of PSA has increased in recent years, research into the identification and treatment of PSA continues to receive less attention than poststroke depressive disorders,” they added. “With similar prevalence rates between PSA and poststroke depression, an increased understanding of the diagnosis and treatment of PSA disorders is needed.” What Causes PSD and PSA? Although psychosocial factors can contribute to the development of depression or anxiety after a stroke, research suggests that neurologic damage caused by the stroke itself plays a significant role. A 2023 literature review examining the potential mechanisms underlying PSD showed stroke in regions such as the prefrontal cortex, limbic area, and basal ganglia can disrupt key pathways of mood-related neurotransmitters, potentially leading to depressive disorders. The review also cited numerous studies linking PSD to neuroinflammation. Some experts theorize that inflammation from stroke causes the release of pro-inflammatory cytokines, which can lead to decreased serotonin. Serotonin deficiency is believed to play a significant role in the development of depressive symptoms. Another 2023 study revealed that more than 80% of immune proteins associated with mood were elevated among individuals with PSD, suggesting a link between an overactive immune system and the disorder. These investigators also found that several pro-inflammatory cytokines, such as interleukin-6, were associated with PSD. Experts believe that such biomarkers can be used to guide treatment. Depression and anxiety after stroke often co-occur alongside cognitive impairment, physical disability, and neurologic damage, making the conditions more challenging to treat than depression or anxiety in the general population, Ovbiagele noted. Effective treatment may require a multidisciplinary approach, he added. For instance, if depressive symptoms appear at any point as a stroke patient transitions from the acute setting to rehabilitation to primary care, there must be clear communication between the patient’s treatment team about treatment strategies. Ongoing treatment may involve a psychiatric consult and psychotherapy, he said, and all clinicians should remain informed about the treatment plan. As reported previously by Medscape Medical News, there are a few theories about what distinguishes PSD from nonstroke depression. A 2023 meta-analysis showed greater severity and prevalence of emotional dysregulation and less anhedonia in people with PSD compared with their counterparts with depression and no stroke history. People with PSD were more likely to have cognitive impairment and difficulty controlling muscle contractions, which is not uncommon after stroke. Unlike major depression, PSD is linked to the ischemic event, a 2018 review suggests. In particular, the size and number of ischemic lesions, and whether the lesions disrupt the midbrain, limbic, and medial prefrontal cortical circuitry, are implicated in depression. “In particular, white matter lesions are associated with metabolic alterations in this circuitry and are correlated with major depression,” the article states. What Works for PSD? As the authors of the 2016 AHA/ASA statement noted, there are few large studies to help guide clinical management of PSD. However, some evidence suggests that escitalopram and sertraline may be effective treatment options. A 2022 meta-analysis of seven randomized controlled trials showed a standardized mean difference of -1.25 on Hamilton Depression Scale (HAM-D) scores (P < .001) among participants allocated to escitalopram vs placebo. A 2024 study added to those findings. The randomized controlled trial of 60 stroke patients showed that treatment with sertraline (100 mg) or escitalopram (20 mg) was associated with a statistically significant decrease in HAM-D scores (P < .05) after 8 weeks of treatment. Data on fluoxetine are mixed. As previously reported by Medscape Medical News , the 2021 AFFINITY trial showed that 20 mg of fluoxetine for 26 weeks did not prevent or alleviate PSD. However, a post hoc analysis of the EFFECTS trial published in 2022 showed that stroke patients reported lower depression scores after receiving 20 mg daily for 6 months. There has also been some debate over whether the use of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) might be linked to an increased risk for bleeding in stroke patients. A study published about a decade ago showed that SSRI users experienced a higher risk for overall major bleeding that contributed to mortality rates. A subsequent study, also covered by Medscape Medical News, revealed that SSRI use in patients with intracerebral hemorrhage increased the risk for recurrence. However, other research showed no such increased risk. But new data appear to put this controversy to rest. In an analysis presented at the 2024 AHA annual meeting, researchers examined the health records of more than 650,000 stroke patients, comparing the bleeding risk among those taking SSRIs/SNRIs vs that in patients who took other antidepressants or none at all. Early use of SSRIs or SNRIs during the subacute recovery phase of acute ischemic stroke was not associated with increased bleeding risk in most patients, although a 29% higher risk for hemorrhagic stroke was observed in those who took antidepressants while also on dual antiplatelet therapy. Bleeding risk was also 15% higher with the use of other antidepressants compared with SSRIs or SNRIs. “Our findings should reassure clinicians that for most stroke survivors, it is safe to prescribe SSRI and/or SNRI antidepressants early after stroke to treat post-stroke depression and anxiety, which may help optimize their patients’ recovery,” lead investigator Kent Simmonds, DO, PhD, UT Southwestern Medical Center, Dallas, Texas, said in a press release. What Works for PSA? If research on PSD is lacking, data on the most effective treatments for PSA are even more scarce. In fact, authors of a 2021 narrative review published in Stroke found only three small trials on treatments for PSA. One study compared paroxetine or paroxetine plus psychotherapy vs standard care. Another examined buspirone hydrochloride vs standard care. The third study included data on a relaxation compact disc vs a waitlist control. Reviewers said the studies were sufficient to guide clinical practice, citing a high risk of methodological bias in all three. A fourth study, on the feasibility of a guided self-help cognitive-behavioral therapy (CBT) program delivered online and over the phone, was inconclusive. “Thus, large-scale, adequately powered, well-designed trials are needed to evaluate interventions to treat poststroke anxiety,” the authors wrote. In the absence of more defined recommendations, recent data suggest that more clinicians may be turning to benzodiazepines, often prescribing far more than the American Geriatrics Society advises. Use of these drugs in adults older than 65 years is associated with higher risk for cognitive impairment, delirium, falls, fractures, and motor vehicle accidents. In addition, some research shows that benzodiazepine use is associated with increased poststroke mortality at 90 days. Despite these warnings, investigators at Massachusetts General Hospital in Boston recently reported that nearly 5% of Medicare patients with acute ischemic stroke received a prescription for benzodiazepines within 90 days of discharge. Of these patients, 55% were prescribed benzodiazepines for durations ranging from 15 to 30 days. Guidance from the World Health Organization suggests that benzodiazepines should be prescribed for no more than 7 days. In an editorial accompanying this study, Justin J. MacKenzie, PhD, and Veronica Moreno-Gomez, MD, said the findings highlight “a concerning pattern of possible BZD [benzodiazepine] overprescription in vulnerable adults following ischemic stroke.” Some evidence suggests that various nonpharmacologic treatments are effective for PSA and PSD. A 2021 meta-analysis of 10 studies showed CBT was associated with improvement in PSD and PSA symptoms and that the benefits persisted up to 3 months after treatment. Other studies suggest potential benefits from exercise, acupuncture, and neuromodulation, although many of these trials were small or yielded inconsistent results. Time for New Guidance? Updated guidance for managing PSD and PSA would enable physicians to screen stroke patients more effectively for symptoms, Moreno-Gomez, who is an associate professor of neurology at the University of Utah in Salt Lake City, told Medscape Medical News. Any new guidance should identify the most effective and safest pharmacologic and nonpharmacologic treatments, she added. “While there is still room for improvement, the development of standardized guidelines for the short- and long-term management of anxiety will help minimize the misuse of benzodiazepines and their associated risks,” Moreno-Gomez said. The majority of studies published since the release of the statement are meta-analyses of randomized clinical trials (RCTs) with small numbers, of short duration, or with problematic diagnostic approaches, Ovbiagele said. As a result, the AHA/ASA currently has no plans to update its 2016 statement on PSD. “What we really need is a large, multidisciplinary RCT headed by neurologists, psychiatrists, and perhaps primary care physicians — all of whom play a role in the diagnosis and treatment of patients with PSD,” Ovbiagele said. The results of such large-scale research would provide a solid foundation for developing new guidance on the screening, treatment and management of PSD and PSA, he added. Amytis Towfighi, MD, chair of the AHA/ASA panel that developed the 2016 statement, told Medscape Medical News that although she could not comment on the need for updated guidance, she agreed there is a need for PSD and PSA screening. She also noted that repeated screening might be necessary because the timeline of PSD is unclear. Towfighi, chief of neurology at Los Angeles General Hospital and professor of neurology at the University of Southern California, agreed with Ovbiagele that more large-scale studies are needed to identify the most effective therapies. She highlighted the importance of including research on nonpharmacologic strategies such as music therapy, mindfulness, deep breathing, meditation, visualization, physical activity, motivational interviewing, acupuncture, and herbal remedies. Note: This article originally appeared on Medscape .

Current management of children and adolescents with long COVID was the focus of various presentations at the 3rd Long COVID Congress in Berlin in November. The congress aimed to facilitate in-depth discussions on recent research projects, diagnostic procedures, and therapeutic approaches to enhance care for long COVID patients. This year, the focus was on research into long COVID in children and adolescents and how to improve their care. Uta Behrends, MD, head of the Munich Chronic Fatigue Center, Center for Pediatric and Adolescent Medicine at the Technical University of Munich, Munich, Germany, and Nicole Toepfner, MD, a pediatrician at the University Hospital in Dresden, Germany, provided an initial overview. Prevalence Data Are Limited Data on the incidence and prevalence of the condition in children and adolescents are limited because most studies have primarily examined adults. A 2022 Swiss study estimated that it affects between 2% and 3.5% of children and adolescents who contract COVID-19. A recent study published in JAMA involving 5367 children and adolescents found that 20% of children aged 6-11 years and 14% of adolescents met the researchers’ criteria for long COVID. Impaired Mental Health Initial data from the latest wave of the population-based longitudinal COPSY (Corona and Psyche) study showed that compared with their peer group, children and adolescents diagnosed with long COVID exhibit significantly higher rates of psychological issues and depressive symptoms. Although no significant differences were found in anxiety levels, study leader Ulrike Ravens-Sieberer, PhD, from the University Medical Center Hamburg-Eppendorf, Germany, told the congress that those with long COVID do also report more frequent somatic or psychological health complaints and lower health-related quality of life than peers. Addressing Data Gaps Another study due to launch in January 2025 and run through to 2028 is the COVYOUTH data study, which aims to better understand the nature, frequency, and risk factors of COVID-related sequelae in children and adolescents. Study centers include Ruhr University Bochum, University Hospital Cologne, the Paul-Ehrlich-Institut, and University Medical Center Hamburg-Eppendorf. Using routine data from statutory health insurance and newly developed case definitions, researchers aim to investigate: Psychological stress caused by COVID-19 measures Post-COVID syndrome and myocarditis Adverse effects of COVID-19 vaccinations Specialized Diagnostics and Care The Post-COVID Kids Bavaria project offers specialized diagnostics and care for children and adolescents, including a day clinic, telemedical follow-ups, and an inpatient pain therapy module providing age-appropriate care as close to patients’ homes as possible. MOVE-COVID is a model project for patient-focused research on long COVID and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) involving university pediatric hospitals in Freiburg, Heidelberg, Tübingen, and Ulm. It also aims to establish a care network across the state of Baden-Württemberg, including the establishment of long COVID outpatient clinics at social pediatric centers in the network hospitals, as well as enhanced telemedical support and standardized diagnostic and treatment protocols. “MOVE-COVID has successfully consolidated competencies and capacities in patient care, health services research, and patient-focused studies across multiple centers,” Behrends said. Chronic Pain and Fatigue Post-COVID syndromes in children and adolescents may feature profound fatigue, unrefreshing sleep, post-exertional malaise, cognitive dysfunction, and orthostatic intolerance and overlap with conditions such as ME/CFS. According to the German patient association Fatigatio, Berlin, research and studies for these conditions in children remain limited compared with those in adults. However, the US Centers for Disease Control estimates that around 2% of ME/CFS patients are children or adolescents, with the majority being teenagers. Two inpatient treatment concepts, SHARK and TIGER, developed by Lea Höfel, PhD, head of the Centre for Pain Therapy for Young People and the Psychological Service at the Children’s Hospital in Garmisch-Partenkirchen, address chronic pain, fatigue, and ME/CFS in young people. These programs integrate structured breaks and flexible access to multiple therapists as needed. The TIGER program focuses on those with post-exertional malaise, while the SHARK program is designed for adolescents without this symptom. Both programs last 4.5 to 5 weeks and emphasize symptom reduction, education, and energy management. Preliminary Results SHARK included 30 participants (7 men; average age, 16 years), of whom 12 had a history of SARS-CoV-2 infection. TIGER involved 100 participants (24 men; average age, 16.7 years), of whom 32 had a SARS-CoV-2 infection as a triggering event. Other triggers included Epstein-Barr virus and other infections. Preliminary findings from the projects indicate that optimized management with outpatient and follow-up care can yield positive, sometimes lasting effects. No significant differences between SARS-CoV-2 and other triggers emerged, but pain proved more manageable in the SHARK group than in the TIGER group, suggesting they may involve different pathological mechanisms. Hope for Improved Outcomes “It’s important to move away from the idea that nothing can be done,” Behrends said. This is a common attitude with children and adolescents displaying these types of symptoms, but it’s simply not true. “Even in pediatrics, we have numerous therapeutic options that may offer relief, from medication to psychosocial interventions,” she concluded. This story was translated from Medscape’s German edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. Note: This article originally appeared on Medscape .

Anxiety is a normal reaction to stress. Mild levels of anxiety can be beneficial in some situations. It can alert us to dangers and help us prepare and pay attention. Anxiety disorders differ from normal feelings of nervousness or anxiousness and involve excessive fear or anxiety. Anxiety disorders are the most common of mental disorders. They affect nearly 30% of adults at some point in their lives. However, anxiety disorders are treatable with a number of psycho-therapeutic treatments (psychodynamic therapy, CBT, etc). Treatment helps most people lead normal productive lives. Anxiety refers to anticipation of a future concern and is more associated with muscle tension and avoidance behavior. Fear is an emotional response to an immediate threat and is more associated with a fight or flight reaction – either staying to fight or leaving to escape danger. Anxiety disorders can cause people to try to avoid situations that trigger or worsen their symptoms. Job performance, schoolwork and personal relationships can be affected. In general, for a person to be diagnosed with an anxiety disorder, the fear or anxiety must: Be out of proportion to the situation or be age-inappropriate Hinder their ability to function normally There are several types of anxiety disorders: generalized anxiety disorder, panic disorder with or without agoraphobia, specific phobias, agoraphobia, social anxiety disorder, separation anxiety disorder and selective mutism. How Common Are Anxiety Disorders? In any given year the estimated percent of U.S. adults with various anxiety disorders are listed below: Types of Anxiety Prevalence Specific Phobia 8% - 12% (U.S.) Social Anxiety Disorder 7% (U.S.) ​ Panic Disorder ​2% - 3% (U.S.) Agoraphobia 1-1.7% (adolescents and adults; worldwide) Generalized Anxiety Disorder 0.9% (adolescents)' 2.9% (adults) Separation Anxiety Disorder 4% (children); 1.6% (adolescents); 0.9%-1.9% (adults) Selective mutism ​0.03-1.9% (U.S., Europe, Israel) Women are more likely than men to experience anxiety disorders. Types of Anxiety Disorders Generalized Anxiety Disorder Generalized anxiety disorder involves persistent and excessive worry that interferes with daily activities. This ongoing worry and tension may be accompanied by physical symptoms, such as restlessness, feeling on edge or easily fatigued, difficulty concentrating, muscle tension or problems sleeping. Often the worries focus on everyday things such as job responsibilities, family health or minor matters such as chores, car repairs, or appointments. Panic Disorder The core symptom of panic disorder is recurrent panic attacks, an overwhelming combination of physical and psychological distress. During an attack, several of these symptoms occur in combination: Palpitations, pounding heart or rapid heart rate Sweating Trembling or shaking Feeling of shortness of breath or smothering sensations Chest pain Feeling dizzy, light-headed or faint Feeling of choking Numbness or tingling Chills or hot flashes Nausea or abdominal pains Feeling detached Fear of losing control Fear of dying Because the symptoms can be quite severe, some people who experience a panic attack may believe they are having a heart attack, fear of dying, or some other life-threatening illness. They may go to a hospital emergency department. Panic attacks may be expected, such as a response to a feared object, or unexpected, apparently occurring for no reason. A panic attack can occcur in the content of any anxiety disorder, however panic disorder is a recurrent, uncontrollable condition.The mean age for onset of panic disorder is 20-24. Panic attacks may occur with other mental disorders such as depression or PTSD. Phobias, Specific Phobia A specific phobia is excessive and persistent fear of a specific object, situation or activity that is generally not harmful. Patients know their fear is excessive , but they can't overcome it, though they can rationale understand this. These fears cause such distress that some people go to extreme lengths to avoid what they fear. Examples are public speaking, fear of flying or fear of spiders. Agoraphobia Agoraphobia is the fear of being in situations where escape may be difficult or embarrassing, or help might not be available in the event of panic symptoms. The fear is out of proportion to the actual situation and lasts generally six months or more and causes problems in functioning. A person with agoraphobia experiences this fear in two or more of the following situations: Using public transportation Being in open spaces Being in enclosed places Standing in line or being in a crowd Being outside the home alone The individual actively avoids the situation, requires a companion or endures with intense fear or anxiety. Untreated agoraphobia can become so serious that a person may be unable to leave the house. A person can only be diagnosed with agoraphobia if the fear is intensely upsetting, or if it significantly interferes with normal daily activities. Social Anxiety Disorder (previously called social phobia) A person with social anxiety disorder has significant anxiety and discomfort about being embarrassed, humiliated, rejected or looked down on in social interactions. People with this disorder will try to avoid the situation or endure it with great anxiety. Common examples are extreme fear of public speaking, meeting new people or eating/drinking in public. The fear or anxiety causes problems with daily functioning and lasts at least six months. Separation Anxiety Disorder A person with separation anxiety disorder is excessively fearful or anxious about separation from those with whom he or she is attached. The feeling is beyond what is appropriate for the person's age, persists (at least four weeks in children and six months in adults) and causes problems functioning. A person with separation anxiety disorder may be persistently worried about losing the person closest to him or her, may be reluctant or refuse to go out or sleep away from home or without that person, or may experience nightmares about separation. Physical symptoms of distress often develop in childhood, but symptoms can carry though adulthood. Selective Mutism Children with selective mutism do not speak in some social situations where they are expected to speak, such as school, even though they speak in other situations. They will speak in their home around immediate family members, but often will not speak even in front of others, such as close friends or grandparents. The lack of speech may interfere with social communication, although children with this disorder sometimes use non-spoken or nonverbal means (e.g., grunting, pointing, writing). The lack of speech can also have significant consequences in school, leading to academic problems and social isolation. Many children with selective mutism also experience excessive shyness, fear of social embarrassment and high social anxiety. However, they typically have normal language skills. Selective mutism usually begins before age 5, but it may not be formally identified until the child enters school. Many children will outgrow selective mutism. For children who also have social anxiety disorder, selective mutism may disappear, but symptoms of social anxiety disorder may remain. Risk Factors The causes of anxiety disorders are currently unknown but likely involve a combination of factors including genetic, environmental, psychological and developmental. Anxiety disorders can run in families, suggesting that a combination of genes and environmental stresses can produce the disorders. Diagnosis and Treatment The first step is to see your doctor to make sure there is no physical problem causing the symptoms. If an anxiety disorder is diagnosed, a mental health professional can work with you on finding the best treatment. Unfortunately, many people with anxiety disorders don't seek help. They don't realize that they have a condition for which there are effective treatments. Although each anxiety disorder has unique characteristics, most respond well to two types of treatment: psychotherapy or "talk therapy," and medications. These treatments can be given alone or in combination. Cognitive behavior therapy (CBT), a type of talk therapy, can help a person learn a different way of thinking, reacting and behaving to help feel less anxious. Medications will not cure anxiety disorders, but can provide significant relief from symptoms. The most commonly used medications are anti-anxiety medications (generally prescribed only for a short period of time) and antidepressants. Beta-blockers, used for heart conditions, are sometimes used to control physical symptoms of anxiety. Self-Help, Coping, and Managing There are a number of things people do to help cope with symptoms of anxiety disorders and make treatment more effective. Stress management techniques and meditation can be helpful. Support groups (in-person or online) can provide an opportunity to share experiences and coping strategies. Learning more about the specifics of a disorder and helping family and friends to understand the condition better can also be helpful. Avoid caffeine, which can worsen symptoms, and check with your doctor about any medications. Related Conditions Post-traumatic stress disorder (PTSD) Acute stress disorder Obsessive-compulsive disorder Adjustment disorder

What current events are keeping Americans up at night? The economy, gun violence, and hate crimes top the list, results from a newly released American Psychiatric Association (APA) survey showed. Anxiety about international conflicts — namely, the Russia-Ukraine and Israel-Hamas wars — also remains high. “While we like to stay informed, the news can also impact our mental health, and being mindful of that impact is important. If current events seem overwhelming it may be time to limit your news consumption,” APA CEO and Medical Director Marketa M. Wills, MD, MBD, said in a statement. Survey results also revealed the election and the holidays were common sources of stress. “Election stress is common, and it’s important to recognize that, as we’re spending more time with family around the holidays, we might need to have a strategy to manage our own mental health during these times,” Howard Liu, MD, MBA, chair of the Department of Psychiatry, University of Nebraska Medical Center, Omaha, Nebraska, told Medscape Medical News. “As with any difficult topic, we all have different levels of avoidance or desire to engage, and it’s okay to set boundaries based on past conversations with family. I think sometimes we get drawn into arguments that we don’t want to have or may not be productive for either side,” said Liu, who chairs the APA Council on Communications. In line with trends throughout 2024, adults polled by the APA in November were most anxious about the economy (75%), gun violence (64%), and hate crimes (60%). The survey included 2200 US adults as part of the APA’s Healthy Minds monthly series. Anxiety about international conflicts remained high in November at 57% — but was down from 65% in August. Election anxiety remained high in mid-November but not as high as before the election. In August, 72% of Americans said they were anxious about the 2024 election. In November, just after the election, 50% reported anxiety over the election outcome. “I think the anticipation of change can sometimes be worse than the change itself. So I think a lot of people are now taking the attitude of — let’s wait and see what actually happens,” said Liu. Half the adults (50%) anticipate the same amount of stress as the 2023 holiday season, while almost one third expect more stress (28%), and one fourth anticipate less stress (23%). When asked how the holidays generally affect their mental health, 38% said it has positive effects, and 21% said the opposite was true. Anxiety About the Future After a divisive election, most Americans are ready to avoid politics at holiday gatherings, results of a separate poll conducted by the American Psychological Association in late November showed. That poll, which included 2000 US adults, showed that more than 7 in 10 (72%) said they want to avoid talking about politics with family and friends over the holidays. In addition, nearly 2 in 5 adults (39%) reported they were stressed by the thought of politics being raised at holiday gatherings and would try to avoid family members they disagree with. Younger adults were significantly more likely than their older counterparts to report they plan to avoid family over the holidays. The future of the nation also weighs on the minds of many Americans. Another poll conducted by the American Psychological Association in August prior to the 2024 US presidential election showed that 77% of respondents said the future of the nation was a significant source of stress for them. In the postelection poll, more than one third of adults (35%) said they are more stressed about the future of the nation now than they were leading up to the election, and another third reported they are now less stressed (32%). A quarter of adults (24%) said their stress about the future of the nation was unchanged, and 9% said they were not stressed about the future of the nation then or now. “There’s still clearly a lot of uncertainty, and there’s a lot of activity right now for the president-elect,” which can contribute to anxiety, C. Vaile Wright, PhD, psychologist, researcher and spokesperson for the American Psychological Association, told Medscape Medical News . These data also show that many Americans have little or no trust in the government, with some wanting to leave the United States. “It’s a reflection of the lack of strong leadership across the board in this country. We have a governmental system in place that does not seem to serve the people, but to serve corporations and maintenance of power. I think people are disillusioned with it and that creates a lack of trust and hopelessness,” Wright noted.

Key points Exposure and response (or ritual) prevention (ERP) alone is as effective as ERP with psychiatric medication. Exposure homework compliance is extremely important for treatment success. It's important to continue ERP until a client is confident that they can manage their OCD on their own. People who struggle with obsessive-compulsive disorder (OCD) experience intrusive thoughts accompanied by urges to engage in repeated behaviors to ward off something bad from happening or to relieve distress. For example, someone might check that their front door is locked when they leave so often that they are late for work, and they may jiggle the door handle so frequently that they damage the hardware. The treatment with the most research support for OCD is exposure and response (or ritual) prevention (ERP). In ERP, people learn to trigger obsessive thoughts and resist the urges to engage in compulsive behaviors or rituals. In the example above, someone might practice turning the lock once and walking away no matter how strong the urge they feel to return and double-check. There are different therapy models for guiding exposure. Traditional exposure focuses on symptom reduction, while newer models with strong research support, such as acceptance and commitment therapy and inhibitory learning, do not. Psychiatric medication—mainly antidepressants—is also an effective treatment for OCD . Psychiatric medication tends to reduce the intensity of OCD thoughts and urges. When clients come into treatment for ERP for OCD, a frequent question they ask me is whether they should also be on medication. My response has been that ERP is effective with or without medication and that ERP may be even a little more potent than medication alone. My recommendations were based on a meta-analysis Cuijpers and colleagues published in 2013. As that study is over 10 years old, I was excited when I came across a more recent study from 2023 by Wheaton and colleagues asking similar questions. The researchers wanted to know whether ERP alone or ERP-plus-medication is more effective. Study design For this study, the researchers combined data from two separate clinical trials of ERP for OCD. One study involved participants who were already taking an antidepressant before beginning ERP. The other study consisted of participants who were not taking medication before or during ERP. As both trials used the same manualized ERP protocol, participants in each received comparable versions of ERP for OCD. The manualized ERP protocol involved 17 sessions, meeting twice weekly with phone calls between sessions. As once-weekly sessions without phone calls are more typical in most practice settings, this manualized version of ERP is more intensive than one is likely to find in the community. One limitation of this protocol is that most OCD therapists use as many sessions as needed for clients to graduate treatment rather than limit treatment to 17, as in the study protocol. What did they find? Participants appeared to improve about equally as well from ERP, whether they were taking psychiatric medication or not. One important factor was what the authors called homework adherence. In ERP, people complete exposure exercises regularly—usually daily—between appointments. The researchers defined “homework adherence” as consisting of 3 parts: (a) quantity of practice (e.g., how often they engaged in exposure); (b) quality of practice (e.g., how well they engage in exposure); (c) and ritual prevention (e.g., resisting urges to engage in compulsions between sessions). Participants with higher OCD symptom severity and/or worse quality of life at the start of treatment showed less improvement overall. The researchers suggest these individuals may need more intensive treatment or more sessions than permitted in the study. As noted above, the study protocol was limited to 17 sessions of ERP. While 17 sessions may be enough for many clients, it's important to engage in as many sessions as necessary to work through relevant exposure exercises until someone can engage in daily life without compulsions. Consequently, limiting the number of sessions may mean treatment ends prematurely for some people. Here is one example where something that strengthens the integrity of a research study design is less applicable in a real-world setting. As I tell my clients, we will continue ERP until they are confident that they can manage their OCD on their own, without the structure of regular meetings. Conclusions This study supports what I’ve told clients all along: ERP is an effective treatment whether they are taking psychiatric medication or not. Anecdotally, if someone is struggling with ERP, sometimes psychiatric medication may help to reduce OCD symptoms just enough that they can better engage in exposure work. Note: This article originally appeared on Psychology Today .

Of all the currently available pharmacological and nonpharmacological therapies for attention deficit and hyperactivity disorder (ADHD) in adults, only stimulants and atomoxetine are effective at reducing core symptoms, results of a large comprehensive meta-analysis showed. The study of 113 randomized controlled trials with nearly 15,000 adults with a formal diagnosis of ADHD also revealed that atomoxetine is less acceptable to patients and that results of efficacy of nonpharmacological strategies are inconsistent. Data on long-term efficacy of ADHD therapies are lacking, investigators noted, so these results only apply to short-term efficacy. “There is a lot of controversy about medication, so these are quite reassuring data and certainly reinforces the role of medication as a treatment for ADHD,” study investigator Samuele Cortese, MD, PhD, with University of Southampton, Southampton, England, said during a press briefing hosted by the UK Science Media Center where the findings were released. The results also point to the “possible role of nonpharmacological interventions, which are currently not well established in current guidelines. However, there is a need for better evidence to fully understand the exact effect of these nonpharmacological interventions,” Cortese noted. The study was published online on December 17 in The Lancet Psychiatry . Bridging the Knowledge Gap Once thought to be a childhood disorder only, ADHD is now well-known to persist into adulthood, affecting roughly 2.5% of the general adult population worldwide. The comparative benefits and harms of available interventions for ADHD in adults remain unclear. To address this knowledge gap, researchers did a comprehensive systematic review and component network meta-analysis comparing a broad range of drug and nondrug treatments for adults with ADHD across several outcomes. For reducing core ADHD symptoms at 12 weeks, only stimulants and atomoxetine were better than placebo in self-reported and clinician-reported rating scales, the study team found. For stimulants, the standardized mean differences (SMDs) on the self-reported and clinician-reported scales were 0.39 and 0.61, respectively. The corresponding SMDs for atomoxetine were 0.38 and 0.51. There was no evidence that ADHD medications were better than placebo in improving additional relevant outcomes such as quality of life. In terms of nondrug interventions, cognitive behavioral therapy, cognitive remediation, mindfulness, psychoeducation, and transcranial direct current stimulation were better than placebo only on clinician-reported measures, with SMDs of −1.35, −0.79, −0.77, and −0.78, respectively. However, the evidence for nondrug strategies is less conclusive overall, with “discordant results across types of raters and based on a small body of evidence,” the authors wrote in their article. And evidence for long-term efficacy (beyond 12 weeks) for ADHD interventions is “limited and under-investigated,” they said. Regarding acceptability, all strategies were similar to placebo except for atomoxetine and guanfacine which had lower acceptability than placebo. “It’s very important to emphasize that we focused on the average effect, not at an individual level,” first author Edoardo Ostinelli, MD, with University of Oxford, England, said at the briefing. “Therefore, we cannot make any recommendation at an individual level. We need studies with individual participant data so that we can personalize treatment.” Cortese said the information from this analysis may be particularly important for “psychoeducation” of the patient before actually starting with a treatment plan. Patients often ask about nonpharmacological interventions and this study provides the “best synthesis of available data to inform these discussions,” he said. Experts Weigh In Several experts weighed in on the results in a statement from the UK Science Media Center. Celso Arango, MD, PhD, psychiatrist with Gregorio Marañón General University Hospital, Madrid, Spain, noted that there is a “clear shortage of research on ADHD in adulthood, particularly regarding medium-term (beyond 12 weeks) and long-term treatment outcomes. Consequently, the findings are applicable only to short-term treatment.” Another strength of the study is that it was developed with input from people with ADHD, Arango added, making it “highly relevant.” The majority of studies available for the analysis involved pharmacological treatments, which is important to consider when interpreting the findings, noted Katya Rubia, PhD, professor of cognitive neuroscience, King’s College London, London, England. “For example, for neurostimulation, only 10 studies were included and on very heterogenous stimulation methods,” Rubia said. “The evidence on the efficacy of neurostimulation is therefore hardly conclusive and more studies are needed to establish their efficacy.” Roi Cohen Kadosh, PhD, professor of cognitive neuroscience, University of Surrey, Guildford, England, agreed. While the study is a “valuable contribution to the literature,” it sheds light on “both the scarcity of neurostimulation research and the limited exploration of combined treatment approaches for ADHD,” he said. “While novel neurostimulation methods linked to neuroplasticity — such as those we have demonstrated to be superior in children with ADHD — were not covered here, they have shown promising and lasting benefits. In contrast, research in adults remains relatively underdeveloped. Moving forward, greater emphasis on innovative, tolerable, personalized, and sustainable neurostimulation approaches is essential to meet the unmet clinical needs of adults with ADHD ,” Kadosh added. Note: This article originally appeared on Medscape .

People with psychotic disorders like schizophrenia frequently experience cognitive difficulties, including problems with attention, concentration, and memory. These cognitive difficulties are often early symptoms that appear before the onset of psychosis. In a study funded by the National Institute of Mental Health, researchers identified consistent links between brain connectivity and cognitive function in people with early stage psychosis and in people at high risk who later developed psychosis. This discovery could help researchers and clinicians better understand the factors that lead to psychosis, informing earlier intervention and improved treatments. What did the researchers look at in the study? Researchers Heather Burrell Ward, M.D. (Vanderbilt University Medical Center), Roscoe Brady, Jr., M.D., Ph.D. (Beth Israel Deaconess Medical Center), Kathryn Eve Lewandowski, Ph.D. (McLean Hospital), and colleagues examined data from two large multisite studies. The studies—the Human Connectome Project for Early Psychosis (HCP-EP) and the North American Prodrome Longitudinal Study 2 (NAPLS2)—include participants with early psychosis or at high risk for psychosis, as well as healthy participants with no known risk for psychosis. The research team performed a comprehensive analysis of participants’ neural connections, or connectome, to identify robust associations between brain connectivity and attention. Attention was measured using an auditory task specifically developed to assess sustained attention in people with or at risk for psychotic disorders. The task gauges three aspects of attention: vigilance, memory, and ability to manage interference. In total, the researchers analyzed data from 96 HCP-EP participants with early psychosis and 213 NAPLS2 participants at high risk for psychosis. What did the study find? Overall, participants with psychosis or an increased risk for psychosis performed worse on the attention task than their peers who were not at risk for psychosis . Data from participants with early psychosis revealed associations between their brain connectivity and attention, in line with the researchers’ hypothesis. Specifically, lower connectivity between an area in the medial prefrontal cortex and a region in the somatomotor cortex was associated with worse performance on the attention task. The researchers found a similar connectivity-cognition association among participants who were at increased risk for—and eventually developed—psychosis. Data from the two studies showed no connectivity-cognition associations for high-risk participants who did not develop psychosis or for participants who were not at risk for psychosis. What do the results mean? These consistent links between brain connectivity and cognition point to specific brain circuits that may contribute to cognitive difficulties in people with psychotic disorders, even before psychosis develops. However, these links do not provide evidence of a causal relationship. The researchers suggest that experimental studies using noninvasive brain stimulation techniques could help determine whether changes in these brain circuits directly impact cognitive performance. If so, these circuits may serve as specific targets for therapeutic intervention. Ward, Brady, Lewandowski, and colleagues note that recruiting participants is a particular challenge in this area of research, requiring considerable time, effort, and resources. Only a small proportion of people who are at risk for psychosis ultimately develop psychosis, and at-risk participants are often hard to identify. According to the researchers, these findings underscore how valuable large multi-site studies like HCP-EP and NAPLS2 are to improving our understanding of the factors that predict and contribute to psychosis. Note: This article originally appeared on NIHM .

Key Takeaways Negative symptoms in schizophrenia, including diminished expression and apathy, are challenging to treat and often resist conventional antipsychotics targeting positive symptoms. Distinguishing primary from secondary negative symptoms is crucial, as secondary symptoms may arise from factors like medication side effects or comorbid conditions. Pharmacological treatments, such as cariprazine and clozapine, show potential but require more evidence from randomized controlled trials. Nonpharmacological interventions, including TMS and digital phenotyping, offer promising avenues for addressing negative symptoms in schizophrenia. Emerging treatments, like psychedelics, are being investigated for their potential benefits, though their use remains controversial and requires further research. Schizophrenia is a frequently chronic and disabling disorder, marked by heterogeneous positive and negative symptom constellations. While antipsychotic medications usually manage positive symptoms effectively, there are limited treatment options for negative symptoms. Despite progress in understanding schizophrenia ’s etiology, biology, and psychopharmacology, negative symptoms remain an unmet medical need. Negative symptoms pose significant challenges for individuals with schizophrenia and their caregivers. These symptoms can be described in 5 factors. These symptoms severely impair daily functioning and can be resistant to conventional antipsychotic treatments, which primarily target positive symptoms by modulating dopamine pathways in the brain. From a phenomenological point of view, negative symptoms can be described within 2 dimensions: (1) the dimension of diminished expression, comprising alogia and blunted affect; and (2) the dimension of apathy, comprising avolition, asociality, and anhedonia. These 2 distinct dimensions are thought to have different underlying neurobiological mechanisms. Distinguishing primary negative symptoms from secondary negative symptoms is therefore an essential part of the treatment approach. Primary negative symptoms are thought to be intrinsic to the underlying pathophysiology of schizophrenia, while secondary negative symptoms are thought to be related to other factors. These factors include positive symptoms, treatment adverse effects (sedation, extrapyramidal symptoms, akathisia), anxious and depressive symptoms, environmental deprivation, substance use, other comorbid psychiatric disorders, and medical comorbidities. For instance, investigators describe a complex relationship between negative symptoms and depression in schizophrenia . Indeed, affective symptoms are commonly observed in nonaffective psychosis, affecting 50% to 80% of patients at some point during their illness. Primary evidence indicates that low mood, suicidal thoughts, and pessimism are more specifically linked to depression, while alogia and blunted affect are more closely associated with negative symptoms. Nevertheless, anhedonia, anergia, and avolition may be present in both conditions. Therefore, a thorough evaluation of clinical symptoms in individuals with schizophrenia is essential to accurately identify their nature and tailor the treatment accordingly. The causes of depressive symptoms in schizophrenia are diverse, including dysphoria induced by antipsychotic medications, psychological stressors, stigma, and traumatic life events. Addressing these causes requires a combination of nonpharmacological and pharmacological approaches. In this specific case, a switch to an antipsychotic with antidepressant properties should be considered. Add-on antidepressant is another potential option, as are cognitive behavior therapy sessions. Pharmacologic Treatments Another important point is the need to avoid first-generation antipsychotics, as these dopamine antagonists present a significant risk of inducing secondary negative symptoms due to their dose-dependent adverse effects: sedation, extrapyramidal symptoms, lower motivation, and mood. Regarding second-generation or third-generation antipsychotics, there is limited evidence based on very few randomized controlled trials (RCTs). Although amisulpride selectively blocks dopamine D2 and D3 receptors, at low doses (50 to 300 mg/day) it preferentially blocks presynaptic dopamine receptors, which may enhance dopaminergic transmission in pathways associated with negative symptoms. This contrasts with higher doses, at which it blocks postsynaptic receptors to alleviate positive symptoms. Cariprazine is also promising for the treatment of predominant and persistent negative symptoms. This second-generation antipsychotic has demonstrated efficacy in reducing negative symptoms. It acts as a partial agonist at dopamine D2 and D3 receptors with a higher affinity for D3 receptors, which are believed to play a significant role in cognitive and emotional processes. Clinical trials have shown that cariprazine not only improves positive symptoms but also has a significant impact on negative symptoms. However, current evidence is limited to a few RCTs published by the same manufacturer. Clozapine is another second-generation antipsychotic. Although clozapine presents a weak affinity for D2 receptors and antagonizes D1 and D4 receptors, it is thought to regulate glutamatergic neurotransmission, which can be beneficial for negative symptoms in schizophrenia, particularly secondary negative symptoms related to treatment-resistant positive symptoms or comorbid depression. Its efficacy for primary negative symptoms is less clear, with some studies showing modest benefits. Novel mechanism-of-action (MOA) agents such as pimavanserin are emerging for treatment of both positive and negative symptoms of schizophrenia with very interesting results. Pimavanserin is a selective serotonin 5-HT2A agonist/antagonist and a 5-HT2C receptor antagonist. In a phase 2 trial, stable patients with predominant negative symptoms of schizophrenia showed a reduction in negative symptoms after treatment with pimavanserin. However, only a small effect size was found. Therefore, further investigation with optimized dosing is warranted to determine the clinical significance of this effect. Overall, for pharmacological approaches, there is a lack of high-level evidence supporting specific interventions. Further research is necessary before recommending amisulpride or cariprazine as a treatment for negative symptoms in clinical practice. Nonpharmacological Treatments Nonpharmacological treatment methods have been found to be effective in the treatment of patients with undifferentiated negative symptoms of schizophrenia. For instance, patients with negative symptoms should have access to rehabilitation interventions such as supported employment and supported housing. We present in the Figure a decision tree for current recommendations of the treatment of negative symptoms in individuals with schizophrenia. Recent advancements in medical research have introduced potential novel treatments aimed at addressing these debilitating negative symptoms, offering new hope for improving the quality of life for those affected by this condition. The add-on of psychostimulants to concurrent antipsychotics has been studied, with various RCTs with modafinil and armodafinil. However, only limited improvement for patients with predominant negative symptoms has been found to date, which precludes current recommendation in clinical practice, pending further research.ax Transcranial magnetic stimulation (TMS) is a noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain. Research has shown that TMS can be effective in reducing negative symptoms by targeting specific brain regions involved in mood and cognition. Although many RCTs have been published, there is significant heterogeneity among included patients and stimulation parameters used. Nevertheless, in expert centers, treatment with left prefrontal repetitive TMS can be considered for patients with negative symptoms that do not improve with other interventions. Original and very recent interventions are starting to be proposed to target negative symptoms in individuals with schizophrenia, such as the use of specific serotonergic psychedelics. Arnovitz et al propose 3,4-methylenedioxymethamphetamine (MDMA) as a novel therapeutic given its ability to enhance social interactions, generate empathy, and induce a state of metaplasticity in the brain. MDMA has been shown to be an effective treatment for posttraumatic stress disorder. An open-label, ascending-dose, within-subject trial of MDMA (dose, 40-120 mg) is being conducted in the US for individuals with schizophrenia presenting negative symptoms (NCT05770375). Psilocybin, a serotonergic psychedelic, also exhibits entactogenic properties and may be of interest in addressing the negative symptoms of schizophrenia . However, the psychedelic experience or “trip” associated with these substances is controversial when considering their use as potential add-on therapies as they may trigger adverse effects in individuals with schizophrenia. Moreover, most second-generation antipsychotics (eg, risperidone, olanzapine) act as “trip stoppers,” preventing patients from experiencing the psychedelic effects that might be beneficial. Furthermore, the combination of first-generation antipsychotics with psychedelics could amplify the effects of the psychedelics, increasing the risk of worsening adverse symptoms in patients.16 It remains an open question whether the psychedelic trip is necessary to achieve the antidepressant effects of these substances. Husain et al proposed an innovative double dummy trial in patients with treatment-resistant depression to try to answer to this question. However, certain antipsychotics, such as amisulpride at moderate doses (eg, 400 mg), could theoretically be used to prevent a potential increase in positive symptoms following psychedelic use while still allowing the psychedelic experience to occur. Nevertheless, switching a stable patient’s antipsychotic regimen to accommodate the potential benefits of an add-on psychedelic treatment is also a matter of debate. Finally, the assessment of negative symptoms is also evolving with promises from digital phenotyping, offering a more precise and continuous method of monitoring than traditional assessments. By leveraging data from smartphones, wearable devices, and other digital tools, digital phenotyping can capture subtle behavioral and physiological changes that may indicate the presence or severity of negative symptoms, such as social withdrawal, reduced motivation, and diminished emotional expression. This real-time, objective data can complement clinical evaluations, providing a more comprehensive understanding of a patient’s condition and enabling personalized treatment approaches. Additionally, digital phenotyping can help in early detection of symptom exacerbation, potentially leading to timely interventions that improve outcomes for individuals with schizophrenia. Concluding Thoughts In sum, negative symptoms in schizophrenia represent a significant challenge, both in terms of patient suffering and the limitations of current treatment approaches. While advancements in pharmacological and nonpharmacological treatments show promise, particularly with novel interventions like digital phenotyping,novel MOA agents, and psychedelics, much remains to be understood and validated through rigorous research. Note: This article originally appeared on Psychiatric Times .