Excoriation (Skin-Picking) Disorder A person with excoriation (skin-picking) disorder, also known as dermatillomania, repeatedly picks at one’s own skin enough to cause lesions. The skin-picking behavior causes significant distress or problems in work, social interactions, or other activities. It can cause feelings of a loss of control, embarrassment, and shame and can lead to avoiding social situations. Individuals with excoriation disorder have usually made repeated attempts to decrease or stop skin picking. The behavior may be triggered by feelings of anxiety or boredom. It may be preceded by an increasing sense of tension and may lead to a sense of relief after, or it may be a more automatic behavior. It sometimes involves a compulsion to try to fix perceived “blemishes.” In the general population, the lifetime prevalence of excoriation disorder in adults is estimated at less than 2% and it is much more common among women than men. It most often begins in adolescence, and it may come and go over time Treatment for skin picking disorder typically involves cognitive behavioral therapy, including a technique called habit reversal therapy, which can help identify stressors and triggers, tolerate and reduce urges, and replace the behavior with one that is less harmful. People with excoriation disorder often have other psychiatric disorders, such as depression or obsessive-compulsive disorder. Source: International OCD Foundation

Dementia is a collective term used to describe neurodegenerative disorders of the brain that affect cognition. It is estimated that over 55 million people around the world have dementia. Alzheimer’s disease is the most common type of dementia (60-80% of cases) and affects 6.7 million Americans. In people with dementia, the impairment in cognition is different from the memory problems associated with normal aging. Dementia can impair their ability to take care of themselves and their daily affairs. Dementia In a person with dementia, the neurons in the regions of the brain that affect cognition progressively get damaged. Dementia is a clinical diagnosis made in individuals with a significant decline from their baseline level of cognitive performance. The decline can occur in one or more cognitive domains, including: Memory, including the ability to remember recent events and conversations. Learning new information and applying it. Ability to sustain attention on complex tasks. Language, including naming, speaking without grammatical errors and with appropriate use of words. Movement-related skills, including hand-eye coordination, body-eye coordination, and visual-auditory skills. Ability to focus attention, plan, organize and coordinate multiple tasks. Ability to perceive, understand, and judge others and one’s social behavior. The severity of the cognitive impairment can be quantified through a neuropsychological assessment or a clinical assessment. For a diagnosis of dementia, a person’s cognitive issues should be severe enough to affect their ability to perform their daily activities independently. This includes their ability to manage their finances and medications, dress appropriately, and maintain hygiene. The cognitive impairment should not be the result of another psychiatric disorder like depression or schizophrenia, or medical conditions like delirium (a temporary state of confusion occurring over a short time due to underlying medical conditions, medications, substances, or toxins). There are different types and causes of dementia. The most common types of dementia are: Alzheimer’s disease: the most common type of dementia. Alzheimer’s disease usually begins with lapses in memory for recent events, conversations, names, or faces. Vascular dementia: the second most common type of dementia. This type of dementia is caused by strokes or mini-strokes (also known as transient ischemic attacks). Each stroke or mini-stroke can cause problems in the blood supply of the brain. Individuals with vascular dementia have a progressive decline in cognition with each stroke or mini-stroke. The symptoms depend on the area of the brain being affected. Dementia with Lewy bodies: in individuals who have dementia with Lewy bodies, the main symptoms include hallucinations; sleep disturbances like nightmares; appearing sleepy or tired; and trouble with movements or balance like falls, tremors, slow movements, and difficulties in walking. Problems with memory usually occur later in the progression of the disease compared to Alzheimer's disease. Frontotemporal dementia: in frontotemporal dementia, individuals can experience personality changes (such as lack of interest or emotions, impulsive anger) and difficulties in organizing and planning daily activities like going to work and paying bills. They can also struggle with language, like difficulty naming things, making grammatical errors, using inappropriate words, and maintaining fluency of speech. Problems with memory usually occur later in the progression of the disease compared to Alzheimer's disease. Individuals can have dementia caused by more than one factor. This is called mixed dementia. Dementia can also be caused by other medical conditions, including traumatic brain injury, use of alcohol and other substances, HIV infection, Parkinson’s disease, and Huntington’s disease. In the initial stages of dementia, individuals may be able to work, drive, cook, and participate in their other daily activities with the help of friends and family. The progression of dementia and the abilities affected varies among individuals. As the disease progresses, they become increasingly dependent on their friends and family members to take care of their daily needs, like paying bills, buying groceries, and personal care, including bathing and dressing. They can also experience changes in mood, anxiety, paranoia, hallucinations, agitation, inappropriate sexual behaviors, and sleep disturbances. Individuals may wander from home and get lost or make mistakes while driving or cooking. This can cause significant concern for their safety. As the disease progresses to other parts of the brain, individuals with dementia can have problems with balance, falls, and swallowing. They may also eventually become bed-bound, requiring around-the-clock care. Treatment Currently, there is no treatment that can reverse the disease process of dementia. The U.S. Food and Drug Administration (FDA) has approved medications to slow down the progression of Alzheimer’s disease (but not other types of dementia). Some of these medications belong to the class of medications called cholinesterase inhibitors, which are prescribed for mild to moderate Alzheimer’s disease [Aricept® (donepezil), Exelon® (rivastigmine) and Razadyne® (galantamine)]. One medication, Namenda® (memantine), has been approved by the U.S. FDA for treating moderate to severe Alzheimer's disease. In 2021, Aduhelm® (aducanumab) was approved by the U.S. FDA for treating Alzheimer's disease. Several new medications are also being studied to target various processes related to dementia with the goal of one day developing medications that can stop or slow down the cognitive decline of dementia. Maintaining a healthy lifestyle can help prevent dementia from getting worse. Healthy lifestyle choices can include eating a balanced diet; being physically, socially, and mentally active; stopping smoking; cutting down alcohol consumption; getting regular health check-ups; and getting treatment for heart disease, hypertension, and diabetes. Individuals with dementia can also have related conditions like depression, anxiety, agitation, and psychosis. Primary care providers or mental health providers can help manage these conditions with psychiatric medications, non-pharmacological interventions (such as addressing the cause of distress in the patient), or making lifestyle changes (like maintaining an appropriate sleep-wake cycle). Behavioral therapists who have specialized in the care of dementia can use therapies like reminiscence therapy, validation therapy, reality orientation, and cognitive stimulation therapy to alleviate distress and related behaviors, provide comfort, and avoid boredom or loneliness. Individuals with dementia may have difficulty identifying or explaining their needs. Recognizing and addressing their needs (e.g., pain, hunger, constipation, infections, skin rash, ingrowing nails, full bladder, and appropriate room temperature) can help an individual become comfortable and decrease the risk of behavioral problems. A calm and non-stimulating environment can be helpful, especially for sleeping at night. When the individual is anxious or agitated, redirecting their attention can be helpful. Instructions should be provided in a simple manner and broken down at each step as individuals might have difficulty comprehending complex instructions. It is best to avoid being argumentative or confrontational with individuals with dementia, as they might not remember or understand the issues. As the disease progresses in severity, the medications used to treat dementia or related behavior problems can become less effective. After discussing the risks versus benefits of the medications with the treating clinician, they can be discontinued to reduce the burden of taking inappropriate and unnecessary medications. Caregiver Stress Caring for individuals with dementia can be very stressful for family and friends, especially as the severity of dementia progresses and caregivers spend more effort and time caring for the individuals. Caregivers can struggle with accepting the severity of dementia or become angry and frustrated. As caregiving takes more time and energy, the caregiver can become socially isolated and lonely. They may experience anxiety, depression, and sleeplessness as they worry about the care of the individual with dementia and their future. The chronic stress of caregiving can also have a toll on the physical health of caregivers. It’s important for caregivers to take care of themselves and to seek help when needed. If possible, caregivers should find time in the day for themselves to pursue activities that they enjoy, relax, and exercise. They should ask for help from family and friends to take turns in caring for the individual with dementia. Respite care or adult day care centers can also be considered (see the U.S. Administration on Aging’s Eldercare Locator). Caregivers should also try to not take problematic behaviors of individuals with dementia personally, as they are symptoms of the disease. Caregivers should consider psychotherapy/counseling or see their mental health provider if they feel anxious or depressed about caring for their loved ones. Attending caregiver support groups for individuals with dementia can also be helpful. Information about caregiver support groups and other caregiver resources can be obtained from local chapters of the Alzheimer’s Association. If the care for the individual with dementia is beyond the caregiver’s capabilities, long-term care facilities like assisted living facilities or memory care centers should be considered as they have nursing staff skilled in the care of individuals with dementia. Source: Alzheimer's Association

The gut-brain axis is a bidirectional communication network that links the enteric and central nervous systems. According to an article published in Integrated Medicine: A Clinicians Journal, this network is not only anatomical, but it extends to include endocrine, humoral, metabolic, and immune routes of communication as well. The autonomic nervous system, hypothalamic-pituitary-adrenal (HPA) axis, and nerves within the gastrointestinal tract, all link the gut and the brain, allowing the brain to influence intestinal activities, including activity of functional immune effector cells; and the gut to influence mood, cognition, and mental health. Gut microbiota are well known to support tight junction integrity between enterocytes. It should therefore come as no surprise that dysbiosis and associated increases in intestinal permeability are now recognized features of rheumatoid arthritis, Alzheimer’s disease, asthma, autism spectrum disorders, and other systemic conditions both inflammatory and otherwise. In recent years, there has been a tremendous amount research validating the mechanisms and role of the microbiome and probiotics in managing inflammatory conditions, particularly IBD. Depression is increasingly recognized as having an inflammatory component; indeed, anti-inflammatory drugs, such as COX-2 inhibitors, have previously demonstrated efficacy in major depression A new class of probiotics, known as psychobiotics or psychomicrobiotics, has emerged in the last decade and is being fervently embraced by many health care practitioners as a nontoxic intervention for various psychiatric conditions. Several clinical trials have now documented effects, or lack thereof, of certain probiotics for depression and anxiety. In a 2017 systematic review by Wallace and Milev of 10 clinical trials, most of the studies found positive results on measures of depressive symptoms. Because clinical trials on probiotics for depression and anxiety have been heterogeneous in terms of dosing, probiotic strain selection, and length of treatment, further randomized controlled clinical trials are warranted to validate the efficacy of this promising intervention. Studies from animal models conducted by independent research groups have corroborated findings of gut dysbiosis and its relation to monoamine disruptions seen in clinical depression, connecting gut microbiota with mood.44-48 In addition, intestinal permeability defects are thought to underlie the chronic low-grade inflammation observed in stress-related psychiatric disorders.49 Those with symptoms of depression frequently exhibit increased expression of proinflammatory cytokines, such as IL-1β, IL-6, tumor necrosis factor-α, as well as interferon gamma, and C-reactive protein.50-51,52 Gut microbiota influence transcription of these same cytokines, with dysbiosis triggering the so-called inflammasome pathway, whereas beneficial metabolites (SCFAs in particular) reduce production of proinflammatory cytokines, such as NF-κB.53

“She would never hurt her baby.” These are words commonly uttered by the partners and family members of women presenting to our facilities with postpartum psychosis (PPP) symptoms. In their reluctance to accept the presence of a mental illness and its related risks, and in their desire to get their loved one out of a psychiatric facility and back home with her baby, partners and family members of patients with PPP often minimize the severity of symptoms they have observed and place themselves at odds with the inpatient psychiatric team seeking to hold and treat the patient. Their reasons for doing so are myriad, but often rooted in a lack of understanding of the course of PPP episodes and the potential for devastating outcomes of not providing treatment. At Connections Health Solutions psychiatric crisis centers in Arizona, where I serve as medical director, we typically have at least 1 patient with PPP. By contrast, many psychiatrists in the community encounter PPP rarely, or not at all. Despite this, it is vital that we are all prepared to recognize the risk factors and early signs of a developing episode, and to provide education and guidance to patients and their supports. Given the co-occurrence of massive hormone fluctuations, sleep deprivation, and the acute psychological stress of being wholly responsible for keeping a newborn alive, it is no wonder that the postpartum period is fraught with vulnerability for the development of mood disturbances, anxiety disorders, and psychosis. Findings from some studies have shown that a woman’s risk of hospitalization for psychosis is higher in the first postpartum month than it is at any other time in her life. Helping expectant mothers and their supports prepare for these possibilities, whether it is as common and relatively benign as the so-called “baby blues” or as rare and potentially life-threatening as PPP, is the first step to improving clinical outcomes. As with most psychiatric disorders, early intervention is key to improving clinical outcomes for PPP, and this becomes more feasible when mental health clinicians, patients, and their supports are familiar with risk factors and early warning signs. A Brief Summary of the Clinical Aspects of PPP Table. Identified Risk Factors for Developing PPP3-5 PPP is relatively rare, occurring in 1 to 2 per 1000 live births, with at least half of sufferers having no psychiatric history.1,2 Identified risk factors for developing PPP are listed in the Table.3-5 Psychiatrists should take careful family histories when caring for pregnant and postpartum patients, inquiring about any history of psychiatric hospitalization, mania, psychosis, depression, and suicide. The onset of PPP is rapid and severe, with hallucinations, delusions, emotional distress, and bizarre behaviors seen as early as 2 days after, and typically within 2 weeks of, delivery.2,6 The patients whom I have encountered, presenting with their first episodes of psychosis during the postpartum period, have typically exhibited delusions that are persecutory, religious, and/or grandiose in nature and usually involve the baby (for example, believing that something “evil” is happening to the baby). This differs from patients with a history of psychosis presenting with relapse of symptoms during the postpartum period, who tend to present with psychotic symptoms similar to those exhibited during their previous episodes. Episodes of PPP can last for months, and subsequent psychotic episodes outside of the postpartum period are common.7 The association between PPP and bipolar I disorder is well established, with onset of psychosis in the immediate postpartum period being a significant predictor of a later diagnosis of bipolar I disorder, although some women do present with an isolated episode of PPP that does not develop into a chronic psychiatric disorder following the postpartum period.6,8,9 There is a significant risk of death by suicide in patients presenting with first-episode PPP, with study data demonstrating rates as high as 4% to 11%, as well as a risk of homicide, with 4% of women with PPP committing infanticide.7,10 PPP should be considered a medical emergency that necessitates rapid identification and intervention, which should always begin by ensuring the safety of the patient and her child(ren). It is recommended that patients with PPP be psychiatrically hospitalized and that they not be left alone with their child(ren) prior to stabilization. With appropriate pharmacotherapy and support, patients can make a full recovery. Tragic Outcomes of Untreated PPP Andrea Yates. Kimberlynn Bolanos. Carol Coronado. We are likely all familiar with at least 1 of these names. All 3 women live in infamy after having murdered their children while in the throes of PPP. All 3 also had romantic partners who had observed signs of mental illness in them but were not able to prevent the murder of their children. And of course, all 3 women have faced the vitriol of the US public and criminal justice system. If you have not viewed the 2019 documentary Not Carol, I suggest you do so. It tells the story of Carol Coronado, a loving and devoted mother who murdered her 3 young children and then stabbed herself in the chest during a PPP episode in 2014. Prosecutors sought the death penalty, but she ultimately received 3 life sentences. The documentary features psychiatrist Torie Sepah, MD, who treated Carol at the Twin Towers Correctional Facility in Los Angeles, California, following her arrest and testified in her criminal trial. Sepah speaks and writes passionately about the tragic loss of life that can result from untreated PPP—a tragedy that is too often compounded by a justice system that often seeks to punish rather than to treat these patients, each of whom will suffer until her last breath knowing that her child(ren) died at her hands. But the greatest tragedy of all is that PPP is treatable and these horrific outcomes are preventable when intervention is swift. Concluding Thoughts PPP is a serious psychiatric disorder with a significant risk of morbidity and mortality for the patient and her child(ren). Early and aggressive treatment is vital to improving outcomes, and we must find ways to reduce the barriers to achieving them. This starts with psychiatrists gaining expertise on PPP and sharing that knowledge with others. When it comes to the woman experiencing PPP, it may be true that she would never hurt her baby, but she is not herself. Fortunately, there is treatment and there is hope. Dr Costales serves as Arizona medical director at Connections Health Solutions, overseeing all clinical operations for Connections crisis response centers in Phoenix and Tucson. Prior to joining Connections, she spent time working with individuals designated as being seriously mentally ill in outpatient settings. References 1. Terp IM, Mortensen PB. Post-partum psychoses: clinical diagnoses and relative risk of admission after parturition. Br J Psychiatry. 1998;172:521-526. 2. Blackmore ER, Rubinow DR, O’Connor TG, et al. Reproductive outcomes and risk of subsequent illness in women diagnosed with postpartum psychosis. Bipolar Disord. 2013;15(4):394-404. 3. Videbech P, Gouliaev G. First admission with puerperal psychosis: 7-14 years of follow-up. Acta Psychiatr Scand. 1995;91(3):167-173. 4. Nonacs R, Cohen LS. Postpartum mood disorders: diagnosis and treatment guidelines. J Clin Psychiatry. 1998;59(suppl 2):34-40. 5. Jones I, Craddock N. Familiality of the puerperal trigger in bipolar disorder: results of a family study. Am J Psychiatry. 2001;158(6):913-917. 6. Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet. 2014;384(9956):1789-1799. 7. Gilden J, Kamperman AM, Munk-Olsen T, et al. Long-term outcomes of postpartum psychosis: a systematic review and meta-analysis. J Clin Psychiatry. 2020;81(2):19r12906. 8. Munk-Olsen T, Laursen TM, Meltzer-Brody S, et al. Psychiatric disorders with postpartum onset: possible early manifestations of bipolar affective disorders. Arch Gen Psychiatry. 2012;69(4):428-434. 9. Wesseloo R, Kamperman AM, Munk-Olsen T, et al. Risk of postpartum relapse in bipolar disorder and postpartum psychosis: a systematic review and meta-analysis. Am J Psychiatry. 2016;173(2):117-127. 10. Parry BL. Postpartum psychiatric syndromes. In: Kaplan HI, Sadock BJ, eds. Comprehensive Textbook of Psychiatry. 6th ed. Williams & Wilkins; 1995 Source: Psychiatric Times: Volume 40, Issue 7; Theresa Costales, MD

Self-Reflection of my life It is an amazing experience to recognize how much your growth and development is influenced by a stable, loving environment. I use to think in my teens and early 20’s that I was nothing like my parents. I would describe the contrast, as though they were born in Mercury and I was born in Pluto. But, during my late 20’s and early 30’s, I realize that I am nothing more than a reflection of the values, beliefs, and ideals that were taught to me by my parents, my extended family, mentors, etc. I think its interesting to see that I am a hybrid of these influential people, who showed me true, unconditional love through their actions and not just their words. I view children as sponges, who are very capable of absorbing positive and negative experiences based on the influence of their environment. This is a concept that I consistently discuss with my patients’ parents, to help them recognize how much of an positive influence they can be on their children. After working with children for over the years, I realize how much instability children can be exposed to. I think my mom is sometimes surprised when I give her random compliments about how great of a parent I think she is. Both of my parents sacrificed so much for the betterment of my sister and I, forgoing their happiness at times. I truly learned about sacrifice through their actions, because they believed that my sister and I would be reflections of their love and dedication. As a child, I use to recognize how much effort my parents would put into being a part of my life. They always wanted me to be well-rounded, which is why they would let me try new things. I think I was enrolled in at least 4 different sports, each year, in which my parents would try to attend each event. In addition, they emphasized pretty consistently that I needed to do well in school, otherwise I would lose a lot of such privileges. I still laugh at how they let me get 3 earrings when I was in high school/college, which I thought at the time was “super cool”. I think that’s what I love the most is they never restricted me from exploring aspects of life, within a certain limit. I still laugh about the time that I was “super into” playing the clarinet, had my mom purchase a brand new one. Then I slowly started showing interest playing the saxophone, as the clarinet was “not cool enough”. I imagine my mom might have been annoyed, but she did not get mad, based on my shift in interest. My new music interest in playing the tabla, which I have not played in a while, however I need to start practicing again. I took lessons for approximately 1.5 years, which was amazing. I think its the coolest instrument, reflecting the richness of the Indian culture, which I love. As an first generation Indian-American, my parents submerged me into the Indian culture and Hindu religion as a youth, which I did not appreciate at the time. I was more interested in running around and playing games with friends that I would met. I guess I am only a reflection of the incredible people that I was blessed with. I will always miss my father, who was an amazing human being. I can notice things that I say or do that replicate his prior actions, which I find fascinating. Source: Medium - Author Dr. Vilash Reddy

Grass isn’t greener on the other side The grass isn’t always greener on the other side. It is a false perception of reality. No grass is “perfect”. Sometimes the most important aspect that we sometimes forget is to appreciate the patch of a grass we were blessed with. In order for growth and beauty to manifest we should cultivate and add nutrients to the areas that deficient and have realistic expectations for the rates of progression. It is important to be honest about areas that we need to improve, though it can challenging. We should focus on each isolated moment that a strand of grass is green and vibrant, eventually these changes will manifest overall. At some point, take the time to reflect and appreciate how beautiful the changes in your patch of grass are, due to the foundation of honesty, effort, and cultivation.

One movie that I think was very fascinating is a movie called Happy, which is available on Netflix. It is documentary film directed, written, and co-produced by Academy Award nominated film-make Roko Belic. It discusses principles of happiness, particularly through the perspective of positive psychology, through a series of interviews of people from 14 different countries, with varying cultural, socioeconomic differences. This was created based on Belic’s interest in trying to understand the fundamental aspects of happiness, which stem from a article he read “A New Measure of Well Being From Happy Little Kingdom”, which indicated that the US was the 23rd happiest country in the world. I am not sure how this ranking was measured. Belic spent several years, meeting hundreds of people, to explore his own curiosity of what factors lead to someone being happy. The film helps deconstruct happiness from an abstract concept to a possible formula based on the principles of human psychology. It was interesting because many of the aspects of happiness that were discussed coincide with concepts that were discussed by Abraham Maslow’s hierarchy of needs illustrated below. Maslow’s theory suggests that the most basic level of needs must be met before the individual will strongly desire (or focus motivation upon) the secondary or higher level needs. Maslow also coined the term “metamotivation” to describe the motivation of people who go beyond the scope of the basic needs and strive for constant betterment. The movie reflects, that regardless of socioeconomic factors and wealth, a individual was capable of feeling happy if he/she were capable advancing their life according the hierarchy that had been stated by Maslow. I thought this was an interest parallel which was not discussed in the movie, however coincided. I think in many ways I believe that Maslow’s hierarchy applies to my life, where I try to focus on my health first and foremost. Source: Medium, Author Vilash Reddy, MD

People imagine that the lives of celebrities is amazing with wealth, prestige, status, however many celebrities suffer from various mental health issues, that can be compounded with stress life choices, little time to decompress, and mental health stigage. Here is a list of some of the celebrities that have been well recognized over the course of their lives. Actors, musicians, DJs, Athletes. There is no amount of money that can make someone happy when they are suffering with any underlying mental health, which can be disabiling. Truthfully, you can be rich and acquire wealth, however your wants (luxury) will never surpass your needs (quality health) mentally and physically. There is a multitude of risk factors that lead to suicide, however the end result can never be predicted. If you are in a crisis or concerned about your safety, dial 988. National suicide and crisis hotline.Reach out to those that can help you escape your inner demon, to avoid being the next potential victim. Celebrities Robin Williams A great American comedian and actor, Williams was widely recognized for the variety of characters he created and portrayed in films, comedies, and dramas. Williams is regarded as one of the greatest comedians of all time, having won various awards throughout his career, including five Grammy Awards and an Academy Award. In 2009 he started having a health problem and was diagnosed with Parkinson’s disease. Later his wife disclosed he had a spike in anxiety, stress, insomnia, memory loss, paranoia, and delusions. Unfortunately, on August 11, 2014, he was founded dead in his home in Paradise Cay, California. An autopsy report concluded his death was suicide by hanging. Stuart Adamson William Adamson was a Scottish rock guitarist and singer who started his music career as a founding member of the punk rock band Skids. One of his successful singles was Into the Valley, which reached 10 on the UK Singles Chart. On December 16, 2001, Adamson was found dead in a hotel room. His death was caused by hanging with an electric cord from a pole in a wardrobe. By the time of his death, a very substantial amount of alcohol was found by Coroner’s Office report at the time of his death. Marilyn Monroe Marilyn Monroe was an American singer, actress, and model who became a popular sex symbol in the 1950s and early 1960s. She remains a significant pop culture icon, and in 1999, the American Film Institute ranked her sixth on their list of the greatest female screen legends from the Golden Age of Hollywood. Monroe was found dead in her home in Los Angeles, California, on August 5, 1962. Her death was caused by an overdose of barbiturates (a drug used to treat anxiety and sleep disorders). Her death was perceived as suicide because she had a history of depression and had attempted suicide several times in the past. Avicii Born as Tim Bergling, he was a Swedish DJ, music producer, and remixer who rose to fame in 2011 for his single Levels. His debut album True in 2013 had the lead single Wake Me Up, which topped most in Europe and reached number four in the United States. In January 2012, Avicii was hospitalized with acute pancreatitis caused by excessive alcohol use, and his health continued to worsen, forcing him to retire from tours in 2016. On April 20, 2018, he died in Muscat; later, it was reported he committed suicide using a glass shard to cut himself. David Foster Wallace He was an American novelist, essayist, short story writer, and university professor of English and creative writing. He is best known for his 1996 novel Infinite Jest which was cited as one of the 100 best English-language novels from 1923 to 2005 by Time Magazine. Wallace had suffered from major depressive disorder for many years, but antidepressant medication allowed him to be productive. Unfortunately, on September 12, 2008, he committed suicide by hanging on the back porch of his house in Claremont, California. He had written a private two-page suicide note to his wife and arranged part of the manuscript for The Pale King. Junior Seau Junior Seau was an American footballer who was a linebacker in the National Football League (NFL), mostly with the San Diego Chargers. He was widely known for his passionate play, was named to the NFL 1990s All-Decade Team, and in 2015 inducted into the Pro Football Hall of Fame 2015. On May 2, 2012, he was found dead of a gunshot wound to the chest at his home in Oceanside, California. His death was ruled out as suicide. Don Cornelius Don was an American television show host and producer known as the creator and host of the music show Soul Train. In 2008 he sold the show to MadVision Entertainment. Through the show, he helped to launch the career of many R&B and soul artists. On February 1, 2012, he was found dead in his home in Los Angeles with a self-inflicted gunshot wound. Ekaterina Alexandrovskaya Ekaterina Alexandrovskaya was a Russian-Australian pair skater. At the junior level, she was the 2017 World Junior champion, the 2017 Junior Grand Prix Final champion, and the 2017 JGP Poland champion. Ekaterina and Harley Windsor began skating together, winning the 2017 CS Tallinn Trophy champion, the 2017 CS Nebelhorn Trophy bronze medalist, and the two-time Australian national champion. On July 18, 2020, she died after jumping out of the 6th-floor window of her Moscow home in a suspected suicide. Chris Benoit Chris Benoit was a Canadian professional wrestler with a wrestling career spanning 22 years. He worked for several pro-wrestling promotions such as World Wrestling Federation/ World Wrestling Entertainment (WWF/WWE), Extreme Championship Wrestling (ECW), Stampede Wrestling in Canada, World Championship Wrestling (WCW), and New Japan Pro-Wrestling (NJPW) in Japan. He held 30 championships between ECW, WWF/WWE, NJPW, WCW, and Stampede and was a two-time world champion. Chris had a long battle with depression, and chronic traumatic encephalopathy (CTE) caused by concussions he sustained during his wrestling led to him committing suicide. In a three-day double murder and suicide, he murdered his wife on June 22, 2007, murdered his 7-year-old son on June 23, 2007, and committed suicide on June 24, 2007. Source: 100 Most Famous People who Committed Suicide

Children and adults with attention-deficit/hyperactivity disorder (ADHD) show greater improvement in symptoms with viloxazine extended release (ER) compared with treatment with atomoxetine, new research suggests. Investigators studied patients who started out taking atomoxetine and, after a washout period, initiated treatment with viloxazine. Participants' ADHD symptoms were assessed prior to initiation of each treatment and after 4 weeks. Children and adults showed significantly larger improvement in inattentiveness and hyperactivity/impulsivity when taking viloxazine vs atomoxetine, with almost all patients preferring the former to the latter. ADHD In addition, close to one half of the study participants were taking a prior stimulant, and 85% were able to taper off stimulant treatment. Viloxazine's effects were also more rapid than were those of atomoxetine. "It is timely to have a rapidly acting, and highly effective non-stimulant option across the full spectrum of ADHD symptoms, for both children and adults, in light of recent stimulant shortages and the new FDA [US Food and Drug Administration] boxed warnings regarding increased mortality associated with overuse of stimulants" study investigator Maxwell Z. Price, a medical student at Hackensack Meridian School of Medicine, told Medscape Medical News. Nonstimulant Treatment Options Study co-author Richard L. Price, MD, told Medscape Medical News that the study was conducted to find a more acceptable alternative to psychostimulant treatments for ADHD, which are currently considered the "gold standard." Although they are effective, said Price, they are fraught with adverse effects, including appetite suppression, insomnia, exacerbation of mood disorders, anxiety, tics, or misuse. Atomoxetine, a nonstimulant option, has been around for a few decades and is often used in combination with a stimulant medication. However, he said, the drug has a mild effect, requires frequent dosage adjustment, takes a long time to work, and people have "soured" on its utility, Price added. Like atomoxetine, viloxazine is a selective norepinephrine inhibitor that has been used an antidepressant in Europe for 30 years. It was recently reformulated as an extended-release medication and approved by the FDA for pediatric and adult ADHD. However, unlike atomoxetine, viloxazine is associated with increased prefrontal cortex 5-hydroxytrytamine, norepinephrine, and dopamine levels in vivo.There have been no head-to-head trials comparing the two agents. However, even in head-to-head ADHD medication trials, the agents that are under investigation are typically compared in matched patients. The current investigators wanted to compare the two agents in the same patients whose insurers mandate a trial of generic atomoxetine prior to covering branded viloxazine. "We wanted to find out whether patients taking atomoxetine for ADHD combined type would experience improvement in ADHD symptoms following voluntary, open-label switch to viloxazine," said Price The researchers studied 50 patients who presented with ADHD combined type and had no other psychiatric, medical, or substance-related comorbidities or prior exposure to atomoxetine or viloxazine. The study included 35 children (mean age, 11.9 ± 2.9 years; 94.3% male) and 15 adults (mean age, 29.3 ± 9.0 years; 73.3% male). Of these, 42.9% and 73.3%, respectively, were taking concurrent stimulants. Patients received mean doses of atomoxetine once daily followed by viloxazine once daily after a 5-day washout period between the two drugs. Participants were seen weekly for titration and monitoring. At baseline, the pediatric ADHD-Rating Scale 5 (ADHD-RS-5) and the Adult Investigator Symptoms Rating Scale (AISRS) were completed, then again after 4 weeks of treatment with atomoxetine (or upon earlier response or discontinuation due to side effects, whichever came first), and 5 days after discontinuing atomoxetine, which "re-established the baseline score." The same protocol was then repeated with viloxazine. 'Paradigm Shift' At baseline, the total ADHD-RS-5 mean score was 40.3 ± 10.3. Improvements at 4 weeks were greater in viloxazine vs atomoxetine, with scores of 13.9 ± 10.2 vs 33.1 ± 12.1, respectively (t = -10.12, P < .00001). In inattention and hyperactivity/impulsivity, the t values were -8.57 and -9.87, respectively (both Ps < .0001). Similarly, from the baseline total, AISRS mean score of 37.3 ± 11.8, improvements were greater on viloxazine vs atomoxetine, with scores of 11.9 ± 9.4 vs 28.8 ± 14.9, respectively (t = −4.18, P = .0009 overall; for inattention, t = −3.50, P > .004 and for hyperactivity/impulsivity, t = 3.90, P > .002). By 2 weeks, 86% of patients taking viloxazine reported a positive response vs 14% when taking atomoxetine. Side effects were lower in viloxazine vs atomoxetine, with a total of 36% of patients discontinuing treatment with atomoxetine due to side effects that included gastrointestinal upset, irritability, fatigue, and insomnia vs 4% who discontinued viloxazine due to fatigue. Almost all participants (96%) preferred viloxazine over atomoxetine and 85% were able to taper off stimulant treatment following stabilization on viloxazine. "These were not small differences," commented Richard Price. "These were clinically and statistically meaningful differences." The findings could represent "a paradigm shift for the field" because "we always think of starting ADHD treatment with stimulants, but perhaps treatment with viloxazine could help patients to avoid stimulants entirely," he suggested. Real-World Study Commenting for Medscape Medical News, Greg Mattingly, MD, associate Clinical Professor, Washington University, St. Louis, Missouri, called it "a timely addition to the clinical literature where for the first time ever we have 2 non-stimulant options approved for adults with ADHD." This real-world clinic study "yields many answers," said Mattingly, who is also the president-elect of the American Professional Society of ADHD and Related Disorders (APSARD) and was not involved with the study. "Simply put, this real-world study of 50 clinic patients found that viloxazine ER had faster onset, was significantly more effective, and was preferred by 96% of patients as compared to atomoxetine," he said. "Another intriguing part of the study that will be of high interest to both patients and providers was that, of those initially treated concurrently with stimulant and viloxazine ER, 85% were able to discontinue their stimulant medication," Mattingly added. Source: Medscape Medical News; Batya Swift Yasgur, MA, LSW; July 21, 2023

How does schizophrenia differ between men and women, and what does this mean for developing treatment strategies Several aspects of schizophrenia differ considerably between men and women and influence treatment strategies. The most important differentiating factors are the age of onset, symptom differences, response to antipsychotic medications, parenting responsibilities, and care during the menopausal transition. Age of Onset and Differences in Symptoms The first occurrence of the symptoms and behaviors that conform with the currently accepted definition of schizophrenia occur, on average, several years earlier in men than they do in women.1 The older age of onset found in women is partially explained by the fact that many large studies include a wide range of ages, sometimes extending into older age. In women, a second peak of schizophrenia onset occurs around the time of menopause,2 which has been attributed to the decline of estrogen levels as menopause approaches.3 This hypothesis is consistent with the observation that schizophrenia symptoms can be exacerbated during other times of estrogen withdrawal not only at perimenopause,4 but also postpartum5 and during the premenstrual phase of the menstrual cycle.6 It has been suggested that the onset of psychotic symptoms in middle-aged women may have a different etiology than onset that occurs in young adulthood. One hypothesis is that a first episode in middle age predominantly relates to the social stressors that women experience at this time (Table).7 Women with schizophrenia tend to be more socially adept than their male peers, perhaps because they socially mature earlier than men and because their psychotic symptoms often begin at a later age.8 Thus, the adolescent presentation of schizophrenia in women may be less clinically obvious because women can mask early schizophrenia with appropriate affect and relatively easy therapeutic engagement. The flat affect and negative symptoms that characterize men with schizophrenia may not be present in women.9 Moreover, women with schizophrenia usually have fewer cognitive symptoms than men.10 For these reasons, it is easier to attribute symptoms such as delusions and hallucinations in these young women to depression, anxiety, post-traumatic stress disorder, dissociation, and even eating disorders. Thus, women with schizophrenia are often misdiagnosed early in the course of their illness. In contrast, the main differential diagnosis in young men presenting with psychotic symptoms is substance use.11 This means that adolescent schizophrenia is often diagnosed late in women, both because it is not expected and because the first presentation may not meet textbook specifications. Finally, a distinguishing presentation in women with schizophrenia is that symptoms often fluctuate, corresponding to the ups and downs of estrogen levels across the menstrual cycle.12,13 Response to Antipsychotic Medications Women with schizophrenia find it easier than their male peers to form therapeutic alliances with their clinicians,14 and, perhaps for this reason, tend to respond to cognitive-behavioral, psychotherapeutic, and pharmacologic treatments more robustly than men.15 Differences in antipsychotic medication effects between men and women are frequently reported for several reasons. Body build usually differs in height and in lipid storage, both of which are important for drug distribution.16 The amount of therapeutic drug that reaches the relevant neurotransmitter receptors in the brain depends on a number of factors (absorption, distribution, metabolism, elimination, protein binding, blood flow to the brain), but, in sum, at comparable oral doses, more of the drug reaches targets in the brain in women than it does in men.15 This varies somewhat depending on the specific drug and whether the enzymes responsible for the drug’s breakdown are affected by estrogen levels.17 The overall effect of differences between men and women in body habitus and metabolism is that women respond to lower doses of anti-psychotic medications. On the other hand, when receiving the same doses as men, women develop more adverse effects. Metabolic effects (leading to type 2 diabetes), cardiac effects (torsade de pointes), hyperprolactinemia effects (hirsutism and acne, osteoporosis, breast cancer), and tardive dyskinesia are important potential adverse effects that are seen more commonly in women than in men.18 Parenting Responsibilities Many women with schizophrenia want to be mothers, but many do not. Discussions about this issue are important because those who do not want children need contraceptive advice and reminders, while those who want children need psycho-education, social skills training, and preparation for pregnancy and motherhood.19 Clinicians can help female patients with schizophrenia to plan pregnancy in a few different ways. They need to address smoking and substance abuse, advising their patients to gradually wean themselves off prior to conception.20 Discussions with patients and their partners should also include the pros and cons of anti-psychotic medication use during pregnancy, as well as the risks of untreated psychiatric illness to the mother, the pregnancy, and the exposed infant. Clinicians need also to refer their patients to obstetrics/gynecology, monitor their prenatal care, and carefully titrate all medications over the course of the stages of pregnancy in order to maintain the patient’s psychiatric well-being.21 Family support is essential at this time. When the patient is in a relationship, meeting with the couple is essential. Domestic abuse is sometimes triggered by pregnancy.22 When patients are living in supported housing, new and child-appropriate living and financial arrangements are often necessary, and, because the postpartum period is a time of risk for psychotic relapse in schizophrenia,23 home visits by members of the therapeutic team are necessary. Antipsychotic doses are usually kept low during late pregnancy, but they need to be increased after delivery when estrogen levels sharply fall and when symptoms can increase in severity. Breastfeeding may or may not be the best course for mother and child, depending on the mother’s wishes and their support system, so this decision should be made with careful consideration.24 Although fewer than a third of men with schizophrenia become fathers (this varies according to country and culture), approximately 50% of women with schizophrenia are mothers, which is roughly the same percentage as in the general population.25 In many cases, women raise their children on their own, and, even when women are partnered, the responsibilities of parenthood lie primarily with mothers. Because of disability, women with schizophrenia are too often economically disadvantaged, live in poor neighborhoods, eat poorly, sleep poorly, have no childcare, and enjoy relatively little family support. Some women with this disorder believe that, due to their diagnosis, they risk losing custody of their children. Because of this belief, they mistakenly think that if they stop taking medication, they will no longer be viewed as psychiatrically ill—a decision that can prove disastrous.26 Mothers with schizophrenia need therapeutic support at home when young children make mental health visits difficult. Inexperienced mothers need support, parental education, and financial assistance. Family therapy to maintain as much familial engagement as possible is also needed. The well-being of children should come first, which means that childcare workers are ideally included in the therapeutic team. Should mothers require hospitalization, temporary surrogate parenting plans should be in place.26 The Menopausal Transition Women’s transition to menopause—known as perimenopause, which tends to begin approximately at age 40 years—can occur early in women with schizophrenia because most antipsychotic medications raise prolactin levels and, consequently, suppress ovarian production of estrogen. Low estrogen levels can be associated with acne, hirsutism, and weight gain, affecting physical appearance; cause vaginal dryness and lower sexual libido; and predispose to osteoporosis. Perimenopause is also associated with hot flashes, night sweats, and insomnia. At the same time, women at this stage of life often experience psychological concerns and psychosocial stressors, which can trigger symptomatic relapse.27 In addition, antipsychotic medications that are metabolized by enzymes that are sensitive to estrogen levels may lose their effectivenessat this time.6 In turn, if the dosage of an antipsychotic is increased, adverse effects can increase. A switch to intramuscular long-acting medication has been recommended; a series of family meetings in order to reduce stress levels is advisable as well. Medical issues such as sleep apnea, breast cancer, cardiovascular and respiratory problems, osteoporosis, and osteoarthritis may emerge at this age and ideally should be addressed early.28 A Note About Suicide As in the general population, women with schizophrenia, as a group, suffer more from depression than do men with the same diagnosis, but men with schizophrenia commit suicide much more frequently. However, it must be remembered that, when it comes to schizophrenia, the proportion of women vs men who complete suicide is significantly larger than that ratio in the general population. Women as well as men with schizophrenia are at considerable risk for suicide. Suicidal thoughts should be identified and monitored, and patients must be reassured that, should they feel desperate, a team member will always be available.29 Concluding Thoughts To summarize this report on treatment needs in women with schizophrenia, the emphasis has been on strategic approaches for women patients and how these may differ from the ones routinely used with men. It must be remembered, however, that women are individuals, each of whom has her own history and her own needs. As Sir William Osler taught, “It is important to care more particularly for the individual patient than for the special features of the disease.”30 Dr Seeman is professor emerita in the Department of Psychiatry at the University of Toronto in Toronto, Ontario, Canada. References 1. Häfner H. From onset and prodromal stage to a life-long course of schizophrenia and its symptom dimensions: how sex, age, and other risk factors influence incidence and course of illness. Psychiatry J. 2019;2019:9804836. 2. Selvendra A, Toh WL, Neill E, et al. Age of onset by sex in schizophrenia: proximal and distal characteristics. J Psychiatr Res. 2022;151:454-460. 3. Brand BA, de Boer JN, Sommer IEC. Estrogens in schizophrenia: progress, current challenges and opportunities. Curr Opin Psychiatry. 2021;34(3):228-237. 4. Sommer IE, Brand BA, Gangadin S, et al. Women with schizophrenia-spectrum disorders after menopause: a vulnerable group for relapse. Schizophr Bull. 2023;49(1):136-143. 5. Perry A, Gordon-Smith K, Jones L, Jones I. Phenomenology, epidemiology and aetiology of postpartum psychosis: a review. Brain Sci. 2021;11(1):47. 6. Reilly TJ, Sagnay de la Bastida VC, Joyce DW, et al. Exacerbation of psychosis during the perimenstrual phase of the menstrual cycle: systematic review and meta-analysis. Schizophr Bull. 2020;46(1):78-90. 7. González-Rodríguez A, Guàrdia A, Monreal JA. Peri- and post-menopausal women with schizophrenia and related disorders are a population with specific needs: a narrative review of current theories. J Pers Med. 2021;11(9):849. 8. Rochat MJ. Sex and gender differences in the development of empathy. J Neurosci Res. 2023;101(5):718-729. 9. Malaspina D, Walsh-Messinger J, Gaebel W, et al. Negative symptoms, past and present: a historical perspective and moving to DSM-5. Eur Neuropsychopharmacol. 2014;24(5):710-724. 10. Zhao N, Wang XH, Kang CY, et al. Sex differences in association between cognitive impairment and clinical correlates in Chinese patients with first-episode drug-naïve schizophrenia. Ann Gen Psychiatry. 2021;20(1):26. 11. Irving J, Colling C, Shetty H, et al. Gender differences in clinical presentation and illicit substance use during first episode psychosis: a natural language processing, electronic case register study. BMJ Open. 2021;11(4):e042949. 12. Brzezinski-Sinai NA, Brzezinski A. Schizophrenia and sex hormones: what is the link? Front Psychiatry. 2020;11:693. 13. Seeman MV. Menstrual exacerbation of schizophrenia symptoms. Acta Psychiatr Scand. 2012;125(5):363-371. 14. Browne J, Bass E, Mueser KT, et al. Client predictors of the therapeutic alliance in individual resiliency training for first episode psychosis. Schizophr Res. 2019;204:375-380. 15. Li R, Ma X, Wang G, Yang J, Wang C. Why sex differences in schizophrenia? J Transl Neurosci (Beijing). 2016;1(1):37-42. 16. Seeman MV. Antipsychotic-induced somnolence in mothers with schizophrenia. Psychiatr Q. 2012;83(1):83-89. 17. Seeman MV. The pharmacodynamics of antipsychotic drugs in women and men. Front Psychiatry. 2021;12:650904. 18. Brand BA, Haveman YRA, de Beer F, et al . Antipsychotic medication for women with schizophrenia spectrum disorders. Psychol Med. 2022;52(4):649-663. 19. Schonewille NN, van den Eijnden MJM, Jonkman NH, et al. Experiences with family planning amongst persons with mental health problems: a nationwide patient survey. Int J Environ Res Public Health. 2023;20(4):3070. 20. Azenkot T, Dove MS, Fan C, et al. Tobacco and cannabis use during and after pregnancy in California. Matern Child Health J. 2023;27(1):21-28. 21. Seeman MV. Clinical interventions for women with schizophrenia: pregnancy. Acta Psychiatr Scand. 2013;127(1):12-22. 22. Wilson CA. Mitigating the increased risk of domestic abuse among people with mental illness: challenges and opportunities of the COVID-19 pandemic. BJPsych Advances. 2022;28(5):328-329. 23. Taylor CL, Stewart RJ, Howard LM. Relapse in the first three months postpartum in women with history of serious mental illness. Schizophr Res. 2019;204:46-54. 24. Breadon C, Kulkarni J. An update on medication management of women with schizophrenia in pregnancy. Expert Opin Pharmacother. 2019;20(11):1365-1376. 25. Radley J, Barlow J, Johns LC. Sociodemographic characteristics associated with parenthood amongst patients with a psychotic diagnosis: a cross-sectional study using patient clinical records. Soc Psychiatry Psychiatr Epidemiol. 2022;57(9):1897-1906. 26. Seeman MV. Intervention to prevent child custody loss in mothers with schizophrenia. Schizophr Res Treatment. 2012;2012:796763. 27. González-Rodríguez A, Monreal JA, Seeman MV. The effect of menopause on antipsychotic response. Brain Sci. 2022;12(10):1342. 28. Solomon HV, Sinopoli M, DeLisi LE. Ageing with schizophrenia: an update. Curr Opin Psychiatry. 2021;34(3):266-274. 29. Sommer IE, Tiihonen J, van Mourik A, et al. The clinical course of schizophrenia in women and men - a nation-wide cohort study. NPJ Schizophr. 2020;6(1):12. 30. Osler W. Aequanimitas, With Other Addresses to Medical Students, Nurses and Practitioners of Medicine. Blakiston’s Son & Co; 1905. Source: Psychiatric Times: Jul 21, 2023; Mary V. Seeman, MD

Nutraceuticals are a special class of supplements that have been found by the FDA to be safe enough for sale over the counter in the US without a prescription. However it is an unregulated industry, where consumers are pretty unaware of what they are buying as the industry is filled with false advertisements. It is estimated that US citizens spend millions of dollars on supplements that they commonly find at local drug stores, which are commonly have addictive, fillers, etc. The bio-availability is limited for consumers may find limited or no benefits. It is important to find quality products that consumers have found beneficial. I will provide a list of various products that could be potentially beneficial based on bio-availability, quality of ingredients, source of product, and positive feedback by consumers. Remember, costs does not necessarily make it a better quality of product. SAM-E (S-adenosylmethionine) has been the first line, mainstream antidepressants mostly used in Europe over the past 20 years. SAMe is the essentially the same molecule that participates in hundreds of biochemical reactions. It donates molecules for the production of DNA, phosholipids, three key neurotransmitters (Serotonin, Norephriphrine, and Dopamine). In approximately 50 clinical trials it was found to be safe and effective. It has a very low side profile and has a rapid onset of action (compared to antidepressants which take 4-6 weeks, minimum). No adverse reactions have been reported with other medications. Bonus, it protects the liver from the toxic effects of other medications. It is a great augmenting agent, for antidepressant or when the medication seems to wear off. SAMe can be activating and can worsening underlying anxiety so should be closely monitored under the care of a licensed physician. This supplement has a low side effect profile compared to other antidepressants. One of the benefits is it causes no weight gain or sexual side effects (which are frequently caused by an SSRI or SNRI). Avoid taking this supplement without the guidance of physician as it could potentially (in rare cases) induce Bipolar Disorder (which can be caused by any antidepressant, if there is any genetic predisposition). Many physicians believe that depression and bipolar disorder lie on a spectrum and are not individual diagnosis, contrary to common belief. This symptoms should be taken on a empty stomach before breakfast. If experience anxiety or agitation, it would be transient, however mild anxiety medications used temporarily can help the transition. Like any medication, the start dose is between 200mg to 400mg, as tolerated. Based on level of depression, you should consult with your dose to see how much supplement you may need which is strongly correlated with the severity of underlying depression. You may augment this medication with a B-complex. B-vitamins tend to be deficit in patients struggling with depression, which can helpful reduce mental fatigue, improve levels of energy, and improve overall well-being as these molecules are used in a majority of metabolic process, particular to induce natural body energy. One of the fascinating aspects of SAMe, based on various double-blind studies is that it can help conditions arthritis, fibromyalgia, reduce the effect of cirrhosis (chronic liver disease), mood improvements in patients struggling with HIV/AIDS, and Parkinson's Disorder (one commonly used medication Levodopa reduces the natural SAMe produced in the body). There is ongoing research of its children (which are not responding to medication, or refuse to take medication). Given their age, they would need much smaller doses with a faster response. SAMe is minimal reactive with other medications, in fact can protect the liver, can be combined or augment typical antidepressants to reduce typical side effects issues. Source: How to Use Herbs, Nutrients, & Yoga in Mental Health

Alternative Medicine Help Depression? The signs and symptoms are well known, it is the most under-treated illnesses today. It is a general consensus that psychotherapy + medications are more effective that either treatment alone. Studies of antidepressants show that fewer than 1/3 of all patients achieve full remission after 8 weeks, which is a very long time when you have such severe symptoms. Approximately 1/3 are partial responders and 1/3 are non-responders. It is important to know the method of patient selection and definition of outcome in antidepressant studies which is why we don’t see patients being cured. The STAR*D trial from the NIMH reflected these similar outcomes amongst patients who were switched between antidepressants, which reflected that 60% to 80% of patients would not qualify for an antidepressant study. In most studies, the symptom reduction was 50%, reducing the disabiling affects of the illness, however not remission or fully functional. Complimentary Alternative Medicine (CAM) can be a great adjunct treatment to help them closer to total remission (however is not guarantee, but a helpful natural option). One factor that is a common cause of treatment failure is non-adherence, in which one study from Harvard found that 75% of patients were non-compliant with medications. A factor that influences non-adherence is not laziness but patients felt they good they were getting out of the pill was not worth putting up with the side effects. One of the challenges is testing the efficacy of CAM most rating systems and meta-analysis are not done for solo treatments Source: How to Use Herbs, Nutrients, and Yoga in Mental Health