Data suggests that substitution of Omega-6- Fatty Acids (O6FA) for Omega-3-Fatty Acids (O3FA) is associated with unipolar and bipolar depression. This due to loss of membrane fluidity and lack of flexibility. In one study, Omega-3FA deficiencies have been associated with increase risk of suicide. Post-morteum studies found that less O3FA content in the orbitofrontal cortex from patients with Major Depressive Disorder and age-matched normal controls. DHA, is the only fatty acid found to be different from controls, was 32% lower in the OFC of female patients with MDD and 16% lower in males with depression. Overall, there is sufficient evidence of the efficacy to support O3FA as adjunct for depression and bipolar disorders. Omega 3 fatty - EPA/DHA- reduction of pro-inflammatory eicosanoids and release of pro inflammatory cytokines; our diets tend to have more saturated fat from domestic animals and more omega 6 FA. Also Omega 6 from cultivated vegetables (corn, sunflower, and soy bean) - used common as cooking oil. Fish used to be a prime source of OM-3 until farmer started feeding then vegetable oils from 6-FA. Once a rich source of Omega-3FA, now most farm-bred fish contain higher levels of O6FA versus O3FA. Also, fish such as fatty fish such a salmon (wild) still contain an important source of O3FA. Farm raised salmon now a day contain excess amounts of PCB (polychlorinated biphenyls) or mercury that contain the fish oil in liquid or capsule form. Quality brands contains no PCBs or fishy aftertaste. - reduction of pro-inflammatory eicosanoids and release of pro inflammatory cytokines; our diets tend to have more saturated fat from domestic animals and more omega 6 FA. Also Omega 6 from cultivated vegetables (corn, sunflower, and soy bean) - used common as cooking oil. Fish used to be a prime source of OM-3 until farmer feed with then vegetable oils from 6-FA. Once a rich source of Omega-3FA, now most farm-bred fish contain higher levels of O6FA versus O3FA. This is a great product that I have researched: Omega-3-Fatty Oil gel capsule that eliminates all of this toxins. Flax seeds contain Alpha-Linolenic Acid(ALA) but they must be ground to enable the ALA to be absorbed. ALA will be converted into Omega-3, EPA and DHA, but the conversion is inefficient and varies amongst individuals. Additional sources of ALA are nuts, seeds, however avoid canola or sunflower seeds (as they have high Omega 6 FA) Source: How to Use Herbs, Nutrients, & Yoga in Mental Health

Complementary and Alternative Medicine The quality and quantity of scientific information of CAM treatment varies greatly. The lack of research often has little to do with potential benefits of an herb and more to do with whether a company would profit enough from sales to oftset the costs of doing a double-blind placebo controlled study (approximately $500,000 to $2,000,000). Many companies obtain patents on “proprietary blends” which are herbal combinations. CAM treatments have been used by large groups of people all ages and stages of health for hundreds if not thousands of years, therefore clinically we have more information about the safety and efficacy than we do synthetic drugs (which some have been pulled due to adverse side effects). Introduction Complementary Alternative Medicine. It is important to understand the pros and cons of standard and alternative treatments pertinent to side effect profile. In synthetic medication trials, the patient only responds 50-75% improvement or if there are troublesome side effects, this may be a good time to consider CAM. Help improve the level of understanding of benefits of CAM are solo treatment or adjunct treatment. Stress is the focal point that exacerbates a lot of underlying symptoms of mental illness. The main components of stress is the Sympathetic Nervous System and the Hypothalamus-Pituatary Adrenal axis (HPA). The Parasympathetic Nervous System is support to counteract these affect, however suppose it fails. This imbalance is the critical in the pathology development of anxiety, depression, and other stress related conditions. Extreme cases can lead to Panic, PTSD, Chronic fatigue syndrome, Irritable Bowel, weight gain, etc. Anxiolytics and antidepressants dampen the SNS, however underactivity of PNS can lead to umbrella of anxiety disorders. Medications have no been shown to boost the activity of PNS. Based on our research; this is a quality product: Adaptogenic herbs (Rhiodola rosea) boost the PNS, which is unique. Optimal Mental Health The goal of treatment is remission, complete relief of symptoms, and resumption of a full functional life. Source: How to Use Herbs, Nutrients, and Yoga in Mental Health

Study findings reveal parallel results for alcohol consumption and depression screenings completed in primary care Background The Alcohol Use Disorders Identification Test-Consumption version (AUDIT-C) has been robustly validated as a point-in-time screen for unhealthy alcohol use, but less is known about the significance of changes in AUDIT-C scores from routine screenings over time. Unhealthy alcohol use and depression commonly co-occur, and changes in drinking often co-occur with changes in depression symptoms. We assess the associations between changes in AUDIT-C scores and changes in depression symptoms reported on brief screens completed in routine care. Methods The study sample included 198,335 primary care patients who completed two AUDIT-C screens 11 to 24 months apart and the Patient Health Questionnaire-2 (PHQ-2) depression screen on the same day as each AUDIT-C. Both screening measures were completed as part of routine care within a large health system in Washington state. AUDIT-C scores were categorized to reflect five drinking levels at both time points, resulting in 25 subgroups with different change patterns. For each of the 25 subgroups, within-group changes in the prevalence of positive PHQ-2 depression screens were characterized using risk ratios (RRs) and McNemar's tests. Results Patient subgroups with increases in AUDIT-C risk categories generally experienced increases in the prevalence of positive depression screens (RRs ranging from 0.95 to 2.00). Patient subgroups with decreases in AUDIT-C risk categories generally experienced decreases in the prevalence of positive depression screens (RRs ranging from 0.52 to 1.01). Patient subgroups that did not have changes in AUDIT-C risk categories experienced little or no change in the prevalence of positive depression screens (RRs ranging from 0.98 to 1.15). Alcohol Consumption Conclusions As hypothesized, changes in alcohol consumption reported on AUDIT-C screens completed in routine care were associated with changes in depression screening results. Results support the validity and clinical utility of monitoring changes in AUDIT-C scores over time as a meaningful measure of changes in drinking. Source: Kevin A. Hallgren, Ph.D. Wiley Online, https://doi.org/10.1111/acer.15075 Veterans Affairs, https://www.hepatitis.va.gov/alcohol/treatment/audit-c.asp#S2X

In a recent Morbidity and Mortality Weekly Report the Centers for Disease Control Published information regarding Adverse childhood experiences (ACEs) data from all 50 states and the District of Columbia by surveying adults from 2011-2020. Surveys found that ACEs, which are associated with negative health outcomes, are highest among women, persons aged 25–34 years, non-Hispanic American Indian or Alaska Native adults, non-Hispanic multiracial adults, adults with less than a high school education, and adults who were unemployed or unable to work. Prevalence of individual and total number of ACEs varied across jurisdictions. Adverse childhood experiences (ACEs) are defined as preventable, potentially traumatic events that occur among persons aged <18 years and are associated with numerous negative outcomes; data from 25 states indicate that ACEs are common among U.S. adults (1). Disparities in ACEs are often attributable to social and economic environments in which some families live (2,3). Understanding the prevalence of ACEs, stratified by sociodemographic characteristics, is essential to addressing and preventing ACEs and eliminating disparities, but population-level ACEs data collection has been sporadic (1). Using 2011–2020 Behavioral Risk Factor Surveillance System (BRFSS) data, CDC provides estimates of ACEs prevalence among U.S. adults in all 50 states and the District of Columbia, and by key sociodemographic characteristics. Overall, 63.9% of U.S. adults reported at least one ACE; 17.3% reported four or more ACEs. Experiencing four or more ACEs was most common among females (19.2%), adults aged 25–34 years (25.2%), non-Hispanic American Indian or Alaska Native (AI/AN) adults (32.4%), non-Hispanic multiracial adults (31.5%), adults with less than a high school education (20.5%), and those who were unemployed (25.8%) or unable to work (28.8%). Prevalence of experiencing four or more ACEs varied substantially across jurisdictions, from 11.9% (New Jersey) to 22.7% (Oregon). Patterns in prevalence of individual and total number of ACEs varied by jurisdiction and sociodemographic characteristics, reinforcing the importance of jurisdiction and local collection of ACEs data to guide targeted prevention and decrease inequities. CDC has released prevention resources, including Preventing Adverse Childhood Experiences: Leveraging the Best Available Evidence, to help provide jurisdictions and communities with the best available strategies to prevent violence and other ACEs, including guidance on how to implement those strategies for maximum impact (4–6). BRFSS is an annual survey of health-related risk behaviors and chronic health conditions representative of noninstitutionalized adults collected from all 50 states, the District of Columbia, and three U.S. territories (7). In addition to core questions administered annually to all participants, jurisdictions and territories can include jurisdiction-approved optional modules, as well as jurisdiction-added questions.* From 2011 to 2020, ACEs questions were included in the BRFSS questionnaire at least once by all 50 states and the District of Columbia as either an optional module (2011–2012 and 2019–2020) or jurisdiction-added questions (2013–2018). For jurisdictions that included ACEs questions in more than 1 year, the most recent year was included. The optional ACEs module includes 11 questions to determine exposure to eight types of ACEs: physical abuse, emotional abuse, sexual abuse, witnessing intimate partner violence, household substance abuse, household mental illness, parental separation or divorce, and incarcerated household member† (1). The Arkansas and New Hampshire questionnaires differed from the optional ACEs module. Arkansas collapsed three sexual abuse questions into a single question, and New Hampshire omitted two of the three sexual abuse questions.§ The Arkansas questionnaire also combined household drug abuse and alcohol abuse questions into a single household substance abuse question. Responses to all ACE types were dichotomized**; ACE scores were calculated for participants by summing affirmative responses to all eight ACE types and then categorized into zero, one, two to three, or four or more ACEs. Four or more ACEs were selected as the upper cut-off given the volume of research linking exposure to four or more ACEs with negative health and life outcomes (1,2,8,9). The New Hampshire questionnaire did not include divorce or emotional abuse questions; therefore, the maximum ACE score in New Hampshire was six. Participants with missing data for any type of ACE were excluded (79,797), leaving 264,882 participants (72.5% of total). Weighted prevalence estimates and 95% CIs were calculated for individual ACEs and total ACE score, by jurisdiction and by sociodemographic characteristics (sex, age group, race and ethnicity, annual household income, educational attainment, and employment status). Age-stratified jurisdictional prevalence estimates for four or more ACEs were also calculated. All analyses accounted for survey design by using recommended weights and complex survey procedures in SAS software (version 9.4; SAS Institute). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.†† Survey response rate ranged by jurisdiction from 30.6% (Illinois, 2017) to 67.2% (Mississippi, 2020) (Table 1). Nearly two thirds of U.S. adults (63.9%) experienced one or more ACE: 23.1% reported one; 23.5% reported two to three; and 17.3% reported four or more ACEs (Table 2). The prevalence of four or more ACEs was highest among females (19.2%), persons aged 25–34 years (25.2%), AI/AN adults (32.4%), and multiracial adults (31.5%). The prevalence of four or more ACEs was also higher among adults with household incomes <$15,000 (24.1%), those with less than a high school education (20.5%), and those who were unable to work (28.8%). Prevalence of four or more ACEs was lowest among persons aged ≥65 years (7.7%). Emotional abuse was the most reported type of ACE (34.0%), followed by parental separation or divorce (28.4%), and household substance abuse (26.5%) (Table 3). Patterns in prevalence of individual types of ACEs differed by sociodemographic characteristics. Prevalence of individual ACEs (Table 3), total number of ACEs (Table 1), and four or more ACEs varied by jurisdiction (figure 1-suppliments table 1) For example, Alaska had one of the highest prevalences of reported emotional abuse (42.2%) but one of the lower prevalences of physical abuse (19.4%). Among jurisdictions that asked all eight types of ACE questions, the prevalence of adults reporting four or more ACEs ranged from 11.9% (New Jersey) to 22.7% (Oregon). Geographic patterns of reporting four or more ACEs also differed by age group (Supplementary Figure 2), with some consistent regional differences observed across age groups (e.g., increased prevalence of reporting 4 or more ACEs among jurisdictions in the Pacific Northwest). https://www.cdc.gov/mmwr/volumes/72/wr/mm7226a2.htm?s_cid=mm7226a2_w#T1_down Discussion This study provides the first estimates of ACEs among U.S. adults for all 50 states and the District of Columbia using BRFSS data. During 2011–2020, nearly two thirds of U.S. adults reported at least one ACE, and approximately one in six U.S. adults reported four or more ACEs. Among certain sociodemographic groups, for example, AI/AN or multiracial adults, these numbers are even higher, reflecting inequities in socioeconomic conditions that increase risk for ACEs. These numbers also highlight the potential intergenerational impact of ACEs through lost opportunities and lasting impacts on behavior and health (8). The prevalence of ACEs is strikingly lower among adults aged ≥65 years than among younger age groups; although this might be due to recall bias or differing trends over time, it might also reflect the risk of premature mortality accompanying exposure to a high number of ACEs (9). Patterns in individual and total number of ACEs varied widely by jurisdiction and among sociodemographic groups, reinforcing the importance of population-level and local collection of ACE data to inform targeted prevention and intervention strategies. Variations in ACEs can result from several factors: differing demographic patterns, jurisdiction-level policies related to domestic violence, economic supports for families, historical and ongoing trauma because of discrimination, and social conditions (4). Better understanding of the relative contributions of these factors to ACEs in individual jurisdictions can help policymakers identify the most promising areas for intervention and the populations with the greatest need for services (4). Jurisdictions could consider further contextualizing their ACEs data with other BRFSS questions, such as those examining social determinants of health. CDC has released prevention resources to help provide jurisdictions and communities with the best available strategies to prevent violence and other ACEs, including guidance on how to implement those strategies for maximum impact (4–6). Clinicians and others who work directly with families play an important role in mitigating and preventing ACEs, from primary prevention opportunities (e.g., home visitation programs), to secondary and tertiary prevention strategies that reduce harms associated with ACEs (e.g., trauma-informed care, ensuring required linkage to services, and supports for identified issues) (10). The findings in this report are subject to at least four limitations. First, data were collected over a 10-year period; prevalence might have changed in jurisdictions without recent data. In addition, jurisdiction-specific prevalences reflect the experiences of adults living in that jurisdiction, but do not necessarily represent the jurisdiction in which the ACE occurred. Second, although most jurisdictions used identical measures, two states (Arkansas and New Hampshire) collapsed or omitted sexual abuse questions, and one state (New Hampshire) omitted two types of ACEs. As a result, estimates for emotional abuse and parental separation or divorce are unavailable for New Hampshire. The reported prevalences of ACEs might be underestimated because respondents with missing ACEs data (79,797) were excluded from the analysis; these respondents reported higher prevalence of individual ACEs on the questions they did answer than those who answered all of the ACEs questions. Third, recall and social desirability biases might reduce the accuracy of self-reported ACEs, leading to underestimation, because participants might no longer remember or be willing to disclose potentially traumatic events from their childhood. Finally, BRFSS questions measure a limited set of ACEs and do not reflect the full range, severity, or frequency of ACEs. It is possible that ACEs included in BRFSS are experienced differently by certain groups, thereby shaping some of the demographic and geographic differences observed. In addition, certain limitations need to be considered when interpreting jurisdiction-specific estimates. First, BRFSS records a small subset of potential ACEs; there might be ACEs that are particularly relevant in certain parts of the country that are not included on BRFSS (e.g., experiences of racism or discrimination and community violence) and are thereby not reflected in estimates. Second, adults with six or more ACEs die approximately 20 years earlier on average than do those without ACEs (9); survivorship bias might undercount ACE prevalence in regions affected by premature mortality related to ACEs. Despite these limitations, the findings from this study update the baseline for ACEs measurement from previous estimates from 25 states (1), providing actionable data for all 50 states and the District of Columbia. ACEs are common, but not equally distributed within the population. Differing patterns by jurisdiction and sociodemographic characteristics demonstrate the importance of collecting ACEs data at the jurisdiction level to understand the scope of the problem, identify populations more affected by ACEs, and ACEs-related outcomes; to help guide prevention and mitigation interventions and policies (6). CDC has released prevention resources to help provide jurisdictions and communities with the best available strategies to prevent violence and other ACEs, and with guidance on how to implement those strategies for maximum impact (4–6). Clinicians and others who work directly with families play an important role in mitigating and preventing ACEs, from primary prevention opportunities (e.g., home visitation programs) to secondary and tertiary prevention strategies that reduce harms associated with ACEs (e.g., trauma-informed care, ensuring appropriate linkage to services, and supports for identified issues) (10). Source: Morbidity and Mortality Weekly Report

Power of Perseverance "It is in your hands, to make a better world for all who live in it.” Nelson Mandela I heard this amazing story about Nelson Mandela who was imprisoned for 27 years during the apartheid. He never turned bitter during his injustice he just used it as fuel to gain inner strength and wisdom. It's something that I admire when some can rise above their situation as life can be unfair but what it is the point of suffering let get of resistance. Suffering is pain x resistance. Concept of mindfulness which I need to practice more often. Overcoming Adversity Nelson Mandela influenced great change in South Africa that resonated around the world. He was a pioneer in ending white minority rule and fostering post-apartheid reconciliation in the early 1990s. In 1994, he became South Africa’s first democratically-elected president and its first black leader. Unlike his predecessors, Mandela stepped down at the conclusion of his term. Overcoming Adversity. Before becoming president, Mandela was imprisoned for 27 years. He was jailed for standing up to the human rights abuses committed by the apartheid government against black South Africans. When he was released from prison in 1990, Mandela addressed the crowds from Cape Town’s City Hall, saying: “I greet you all in the name of peace, democracy and freedom for all. I stand here before you not as a prophet, but as a humble servant of you, the people. Your tireless and heroic sacrifices have made it possible for me to be here today. I therefore place the remaining years of my life in your hands.” As a sign of gratitude for his selflessness, many South Africans refer to Mandela as Madiba, the African name of his tribe. When Mandela was a child, it was customary for a South African student to be assigned an English name. In school, he came to be known as Nelson. Many South Africans still refer to Mandela as Madiba as a sign of respect and endearment, paying tribute to his African roots. After his presidency, Mandela became a philanthropist with a special focus on education. Through the Nelson Mandela Foundation in 1999, he pursued noble work such as rural development, school construction, and combating HIV/AIDS. Nelson Mandela’s legacy of humility and service lives on not only in South Africa, but also around the world.

Natural and herbal remedies, also known as “alternative” or “complementary” medicines. This industry has grown tremendously in popularity over the past two decades, becoming a major component of health care and general wellness in the United States and worldwide. The ready availability of these remedies over the counter and their generally good tolerability and safety contribute to this popularity, and many people have benefited from them, often in cases when conventional treatments have failed or caused intolerable side effects. Despite many Food and Drug Administration (FDA) –approved psychotropic medications on the market, efficacy has been inconsistent for some, and many treatment responders will eventually relapse. Continued research on the efficacy and safety of these alternative therapies is, therefore, important. This article reviews six of the most commonly used natural remedies for psychiatric conditions, including the antidepressants St. John’s wort, omega-3 fatty acids, and S-adenosyl methionine (SAMe); the sedative-hypnotics valerian and melatonin; and the nootropic ginkgo biloba. Natural and herbal remedies, also known as “complementary” or “alternative” medicines (CAMs), have grown tremendously in popularity over the past two decades, becoming a major component of health care and general wellness in the United States and worldwide. Many people certainly benefit from them, often in cases when conventional treatments have failed or caused side effects. A 2007 National Health Interview Survey found that 38% of adults and 12% of children had used CAM practices and products in the past year, representing about $33.9 billion in out-of-pocket costs (1). Although there is growing evidence of efficacy and safety to support the use of these remedies, it is important for clinicians to be aware of the limitations of the evidence base and to take that into account with all the other factors that contribute to clinical decision making (2). In psychiatry, we have about 40 FDA-approved antidepressants on the market, yet their efficacy has been inconsistent (3), and many treatment responders will eventually relapse (4). Continued research on natural therapies is called for, partly because they are readily available over the counter and widely used, and also because of their generally good tolerability and safety. Source: Popular Herbal and Natural Remedies Used in Psychiatry; David Mischoulon, M.D., Ph.D.

Anxiety is a normal human emotion that everyone experiences from time to time. However, when anxiety becomes excessive or debilitating, it can become a mental health disorder. Anxiety disorders are the most common mental illness in the United States, affecting 40 million adults age 18 and older, or 18.1% of the population every year. There are many different types of anxiety disorders, including generalized anxiety disorder (GAD), panic disorder, social anxiety disorder, and specific phobias. GAD is characterized by excessive worry and anxiety that is difficult to control. Panic disorder is characterized by sudden, intense episodes of fear and anxiety that can lead to physical symptoms such as shortness of breath, chest pain, and dizziness. Social anxiety disorder is characterized by a fear of social situations that can lead to avoidance of social interactions. Specific phobias are characterized by a fear of a specific object or situation that can lead to avoidance of the feared object or situation. Anxiety disorders can have a significant impact on a person's life. They can interfere with work, school, relationships, and overall quality of life. In some cases, anxiety disorders can lead to suicide. Suicide is the 10th leading cause of death in the United States, and it is the second leading cause of death among young people ages 15-24. Anxiety disorders are a major risk factor for suicide. In fact, people with anxiety disorders are up to six times more likely to attempt suicide than people without anxiety disorders. There are a number of reasons why anxiety can lead to suicide: First, anxiety can make people feel hopeless and helpless. Second, anxiety can make people feel isolated and alone. Third, anxiety can make people feel like they're a burden to others. There are a number of things that can be done to prevent suicide in people with anxiety. These include early identification and treatment of anxiety disorders, providing support and education to families and friends of people with anxiety, and reducing access to lethal means of suicide. 7 Tips on How to Deal with Anxiety Mental health wellness is the state of being mentally healthy and well-functioning. It includes having a positive sense of self, being able to cope with stress, and having the ability to maintain healthy relationships. There are a number of things that you can do to promote mental health wellness. These include: Getting enough sleep Eating a healthy diet Exercising regularly Spending time in nature Connecting with loved ones Practicing relaxation techniques Seeking professional help if needed If you are struggling with anxiety or other mental health challenges, it is important to seek help. There are a number of resources available to you, including therapists, counselors, and support groups. You are not alone, and there is help available.

On July 16, 2022, the Lifeline transitioned away from the National Suicide Prevention Line reached through a 10-digit number to the three-digit 988 Lifeline. Psychiatric Times provides a year end review of their progress below: A year ago, the National Suicide Prevention Lifeline switched to its new 3-digit number, 988. Since its launch, the Lifeline has received a startling number of contacts: over 5 million, including more than 1.43 million calls, 416,000 chats, and 281,000 texts.1 But is it effective in saving lives? “The transition to the 988 Suicide & Crisis Lifeline has sparked a transformational moment in behavioral health care in this country. For the first time in my 26-year career history, every state and territory is talking about improving their behavioral health crisis systems,” said Monica Johnson, MA, director of the 988 & Behavioral Health Crisis Coordinating Office at the Substance Abuse and Mental Health Services Administration (SAMHSA). “While we know that there is still much work to do to achieve a robust response system for mental health and substance use crisis care across the country, we have accomplished a lot in the past year. The data show that, since the transition to 988, more people are reaching out for help, and they are getting a response much faster than ever before to get the help that they need in a time of crisis.” Figure 1. May 2023 Contacts According to SAMHSA, the Lifeline receives an average of approximately 350,000 contacts per month. During May 2023 alone, contacts increased by more than 40% in calls, chats, and texts alike compared with the previous year (Figure 1).2 “We are seeing this increase in contacts, and I do not think that is a failure of the system; I think that’s showing it’s a success. Increasing numbers means that we might be catching some folks before they get to that terrible stage,” said Scott Zeller, MD, vice president of acute psychiatry at Vituity, assistant clinical professor of psychiatry at the University of California, Riverside School of Medicine, and Psychiatric Times editorial board member. “Anything we can do to reduce suicide is a win.” Let’s take a look at the Lifeline, still in its infancy, and evaluate the current benefits and potential areas for improvement. Decreased Wait Times Figure 2. Monthly Comparison of Average Answer Speeds2 National overall answer rates have increased to 91% as of December 2022, compared with 64% from December 2021, meaning—no matter the outcome—more individuals in need of help are being connected to a counselor. Additionally, individuals who contact 988 are spending much less time waiting for a counselor; the average overall wait time decreased from 2 minutes and 52 seconds to just 44 seconds.1 Monthly average wait times are even shorter in 2023 (Figure 2).2 “Seconds count when somebody is in crisis. If someone finds themselves on a long hold, waiting for an answer, that could lead to frustration or hanging up the phone, and that is when bad things start to happen. The more quickly we can get them access, the better,” said Zeller. According to research, 24% of suicide survivors aged 13 to 24 years said it took them less than 5 minutes between deciding to attempt suicide and trying.3 Data from another study showed that of 82 patients referred to a psychiatry department post suicide attempt, nearly half (47.6%) reported their suicidal deliberation lasted 10 minutes or less.4 Better Text Response Prior to 988’s launch, the Lifeline could only sufficiently process 56% of the text messages and 30% of the chats received. In contrast, although text volume has now increased by over 700%,1 the text answer rate in May 2023 was an impressive 99%.2 Connecting via text may be more important to youth who contact the Lifeline. With the average teenager sending and receiving 5 times more text messages a day than a typical adult, this may be their preferred method of communication.5 “One of the biggest impacts that 988 is having, when you look at the data, is the dramatic increase of texting services,” said Margie Balfour, MD, PhD, chief of quality and clinical innovation at Connections Health Solutions and an associate professor of psychiatry at the University of Arizona. “You should be able to provide services in ways that people like to communicate, and it really shows that there was an unmet need in this area.” Target Group Specificity Figure 3. Lifeline Specialized Services The Lifeline also now offers specialized services for various populations (Figure 3). Other pilot programs are expected to follow, with potential Lifeline subnetworks for individuals who are hearing impaired and for American Indian/Alaska Natives.6 Area Code Issues Ideally, 988 calls should be answered as locally as possible. A national backup crisis center handles any calls that local crisis centers cannot answer, but how exactly is an individual’s local center determined? Unlike 911, 988 does not geolocate those who contact the Lifeline. Instead, 988 uses their area code to determine the closest call center.7 Unfortunately, this means if an individual living in New York has a Texas area code, the call center will be directed to the closest center in Texas, which will not be able to deploy a mobile team to a New York location. More on 988 Inside 988 Lifeline: Conversations with a Crisis Counselor Leah Kuntz; Jennifer Lang 988: The 1-Year Anniversary Bob GebbiaTherein lies the problem. Although geolocation would help in providing localized services, some callers may not want their location to be known. “I think there is a really good argument from the advocate side, saying ‘We do not want to be tracked.’ What if I just want to call and talk to you and say that I feel hopeless? It does not mean that I want you to know where I am to send cops, which is really what this all comes down to. There is not an easy solution here. Ethically and philosophically, this is one of the most interesting components of the 988 rollout so far,” said Tony Thrasher, DO, MBA, DFAPA, medical director of crisis services at Milwaukee County Behavioral Health Division, Wisconsin. Lack of Quality Consistency Every 988 call center is unique in how it responds to crisis callers. Some states had robust crisis lines prior to 988. Arizona, for example, is being looked at as an example model, Balfour told Psychiatric Times. Built on the backbone of Medicaid rather than telecommunication fees, this preexisting system has established trust in the community over the past 2 to 3 decades. However, some call centers do not have the privilege of a preexisting system. “When you ask what happens when you call 988, in Arizona, you are going to get a crisis line that has been active for years. They have the infrastructure and resources to be able to dispatch 24/7 clinician mobile crisis teams, who can do interventions in the field and then resolve many of those crises. If needed, they can bring individuals to crisis stabilization centers, or crisis receiving centers that can then provide crisis care,” said Balfour. “If you call 988 in a community that does not have that… What actually happens is very local resource dependent. Different communities carry much different loads and are at different stages of development.” Another example is Montgomery County, Ohio. Before the launch of 988, the county created Crisis Now, a 3-pronged approach to delivering crisis services that included a hotline and mobile response teams. In the initial 6 months of Crisis Now, 89% of calls to the hotline were resolved over the phone and 77% of the mobile crisis responses were resolved in the community. Upon 988’s launch in July, the already-in-place hotline also began taking local 988 calls, and felt better prepared to handle the switchover.8 Compare this with Hanover in York County, Pennsylvania. Prior to 988’s launch, the rural center, TrueNorth Wellness Services, reported difficulty hiring counselors and were uncertain they would be able to handle an influx of contacts.9 Uncertain Expectations When you call 911, you know exactly what you are getting: an ambulance, a firetruck, or police, or maybe a combination depending on the situation. What do callers get when they call 988? “It comes down to supply and demand,” said Thrasher. “What type of workers can each area find to respond to calls? There is a large push for less law enforcement presence and higher mental health presence. The hard part is, from a supply and demand focus, there are markedly more law enforcement workers, and they are paid significantly better than mental health workers. That is no knock on law enforcement—I think they earn what they get. But if we as a culture want to bring the mental health after-hours response 24/7, 365 days, on holidays, we need to pay them. One reason law enforcement and fire do that is because they are compensated to do so.” To build these expectations, we must know: Who is running that response team? What is their supply and demand? What is their funding? Do they have enough funds to have a 24/7 mental health work? The Need for More Funding The federal government has invested close to $1 billion into the 988 Lifeline, including a little more than $500 million in the federal spending bill.10 In May 2023, the US Department of Health and Human Services announced an additional $200 million in new funding for states, territories, and tribes to build local capacity for the 988 Suicide & Crisis Lifeline and related crisis services.11 Figure 4. States With Enacted Legislation to Sustain 98812 However, as contacts continue to pour in, some local Lifeline call centers may not be able to maintain their coverage when federal funding decreases. As of early June 2023, just 26 states had enacted legislation to maintain 988, and only 5 of those states had enacted legislation to sustainably fund 988 through telecommunications fees, as enabled by the National Suicide Hotline Designation Act of 2020 (Figure 4).12 “I think we need to have parity of these 4 services: fire, EMS, law enforcement, and mental health. To do so, they should all be in the same room and should all have the same sort of requirements of staffing and quality of care. But then we also must get the same degree of funding,” said Thrasher. “Mental health is not near those other 3 in anything resembling sustainable funding. The public does not see a mental health call like a fire or a police call.” Looking Ahead Comparisons are often made between 988 and 911. Notably, 911 took 13 years to reach a modicum of stability; the first 911 call was placed in 1986, but 911 was not designated the nationwide emergency telephone number until 1999.13Furthermore, there are more than 5700 primary and secondary Public Safety Answering Points to answer 911 calls, as compared with approximately 200 988 centers.1,14 911’s success was not built in a year, and to expect otherwise for 988 is irrational. Our experts agreed: “Emergency psychiatry is all about taking care of people in their most vulnerable moments on their worst days. 988 has now led to more access to services to help them with that, including services that do not necessarily culminate in the emergency department,” Thrasher told Psychiatric Times. “It is not to the scale that I think we want to see it yet, but it is a really good start.” “It is a first step in what I think is a longer journey. It has been a catalyst for both the federal government and for communities to start to look at what we need,” said Balfour. “The promise of 988 is not there yet, but I think it is effective in getting us closer.” In a Psychiatric Times online poll, 70% of responders said they had discussed 988 with their patients.15 Have you discussed 988 with patients or their families? Source: Psychiatric Times Updated 7/13/23 to reflect new statistics. References 1. Saunders H. Taking a look at 988 suicide & crisis lifeline implementation. KFF. February 23, 2023. Accessed May 31, 2023. https://www.kff.org/other/issue-brief/taking-a-look-at-988-suicide-crisis-lifeline-implementation/ 2. 988 Lifeline performance metrics. SAMHSA. Accessed May 31, 2023. https://www.samhsa.gov/find-help/988/performance-metrics 3. Simon OR, Swann AC, Powell KE, et al. Characteristics of impulsive suicide attempts and attempters. Suicide Life Threat Behav. 2001;32(suppl 1):49-59. 4. Deisenhammer EA, Ing CM, Strauss R, et al. The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt? J Clin Psychiatry. 2009;70(1):19-24. 5. Lenhart A. Part four: a comparison of cell phone attitudes & use between teens and adults. Pew Research Center. September 2, 2010. Accessed June 14, 2023. https://www.pewresearch.org/internet/2010/09/02/part-four-a-comparison-of-cell-phone-attitudes-use-between-teens-and-adults/ 6. Stracqualursi V, Howard J. Forthcoming 988 suicide prevention hotline plans pilot program specifically for LGBTQ community. CNN. July 9, 2022. Accessed June 14, 2023. https://www.cnn.com/2022/07/09/politics/988-national-suicide-prevention-lifeline-lgbtq-subnetwork-wellness/index.html 7. 988 Geolocation Report — National Suicide Hotline Designation Act of 2020. Federal Communications Commission. April 15, 2021. Accessed June 14, 2023. https://docs.fcc.gov/public/attachments/DOC-371709A1.pdf 8. Six months after launch, how is 988 doing? National Association of Counties. January 13, 2023. Accessed June 14, 2023. https://www.naco.org/articles/six-months-after-launch-how-988-doing 9. Mencia A. Pennsylvania gears up for launch of new 988 mental health hotline. Axios Philadelphia. July 13, 2022. Accessed June 14, 2023. https://www.axios.com/local/philadelphia/2022/07/13/988-mental-health-hotline-pennsylvania 10. Chatterjee R. 988 Lifeline sees boost in use and funding in first months. GBH. January 16, 2023. Accessed June 14, 2023. https://www.wgbh.org/news/national-news/2023/01/16/988-lifeline-sees-boost-in-use-and-funding-in-first-months 11. HHS announces additional $200 million in funding for 988 Suicide & Crisis Lifeline. US Department of Health and Human Services. May 17, 2023. Accessed June 14, 2023. https://www.hhs.gov/about/news/2023/05/17/hhs-announces-additional-200-million-funding-988-suicide-crisis-lifeline.html 12. State legislation to fund and implement the 988 Suicide and Crisis Lifeline. National Academy for State Health Policy. Updated June 6, 2023. Accessed June 14, 2023. https://nashp.org/state-legislation-to-fund-and-implement-988-for-the-national-suicide-prevention-lifeline/ 13. 911 and E911 Services. Federal Communications Commission. Accessed June 14, 2023. https://www.fcc.gov/general/9-1-1-and-e9-1-1-services#:~:text=The%20official%20emergency%20number%20in,States%20for%20all%20telephone%20services 14. 10 things you might not know about the United States’ 911 emergency telephone number. Walden University. Accessed June 14, 2023. https://www.waldenu.edu/online-masters-programs/ms-in-criminal-justice/resource/ten-things-you-might-not-know-about-the-united-states-911-emergency-telephone-number 15. What have you heard about 988? Psychiatric Times. May 25, 2023. https://www.psychiatrictimes.com/view/what-have-you-heard-about-988

"Dietary supplements", aka herbal remedies are not stringently regulated as medicines. Despite the regulation by the FDA, various medications have strong side effect profile so it is always important to advocate for yourself when seeing a physician (such as primary care or psychiatrist) about how your body is reacting to the medication, as various mood stabilizers and anti-psychotic medications have horrible side effects. It was very surprising that the FDA approved Abilify and Risperdal for the treatment of irritability for children with Autism Spectrum Disorder. Both of these medications having side effects such as weight gain, blunting the dopamine receptor (the happy neurotransmittor) - one potential cause of overeating as you receive dopamine responses with food. Risperdal was originally developed to treat patients with schizophrenia, which is odd how it would reduce the irritability of patients with ASD. Personally, I think there are many agents that can help control the symptoms of irritability if you understand the root cause of where it is coming from. Sorry that was a tangent, as I tend to be very cautious about use of mood stabilizers/anti-psychotics, as it seems that everyone is on it these days. I have added a link below so you can read and identify that you are not having severe or moderate side effects to your medications, as I could imagine it would be a frustrating experience. You are trying to get rid of one problem, while adding on one or more. Regardless, consumers are left in an unregulated industry, unprotected by watchdogs like the FDA there is very hard to predict which manufacturer, products, and forms would we good for our consumption. Also, there is a lot of misinformation and erroneous information on the internet so it is important to know the source of information. It is always important to use these supplements under the guidance of a clinician, as sometimes herbal remedies are not potent enough for the underlying condition or may need to be augment with a medication and/or therapy. Self-diagnosis is always frowned upon as we innately have our own biases and lack objectivity. Also, it is important to understand and recognize that there is no such thing as a "fully safe treatment", even herbal remedies. It is important to recognize that the source of herb is just as important, as there are many ways of mass producing products that are not high grade with fillers/preventatives/contaminants. A majority of the content that I use is from Herbs of the Mind, which I feel is a well written book that helps a person understand and integrate mental health from a holistic model, is from two experienced psychiatrist from Duke University Medical Center, Johnathan Davidson, MD and Kathryn Connor, MD. There is various studies that reflect simple herbs, which should be taken under the care of a physician, such as St. John's Wort (which can induce mania in patients) or 5-HTP can reduce symptoms of depression, Kava can alleviate stress and anxiety, valerian root can help with sleep issues, or ginkgo can help slow the rate of declining memory. Now, each response in on a case by case basis, again as mentioned is not full safe, therefore I would not recommend purchase these products without a physician's supervision. Did you know that Gingko Biloba can reverse the sexual side effects of SSRIs? St. John's Wort can long been used to help reduce the symptoms of depression (with caution based on concerns of inducing mania). Kava bars exist around the world, particularly in the Polynesia, but more recently into the US. The advantage of kava is can potential improve cognitive acuity unlike other anxiolytics that have a dulling effect. Valerian root is an alternative for people suffering with insomnia or mild anxiety (particular at night), compared to sleep aid (which cause sedation, which typically disrupt REM sleep). Most of data for herbal remedies comes from Europe, however there is limited long term data present in the US, as it is not typically studied as it is seen a non-lucrative, that is open to a lot of competition as it is hard to patient natural remedies, as they are hundreds, if not thousands of years old. One herb Ashwaganda has been used for thousands of years in India for anxiety, with minimal side effects. Source: Herbs of the Mind

It's no secret that alternative medical treatment is not so alternative anymore. Due to various side effects, natural ways of living it is estimated that approximately 40% of Americans are opting to try to use or augment their medical or mental health medications. Each year approximately $20 billion per year on these choices. Traditional medicine, can have its limitations, as there has been epidemic of inappropriate dispensing leading to epidemics like the opioid crisis or overuse of "benzos". Stricter regulations should have been enforced by the FDA at the time clinicians would careless prescribe such medications though it was out of their scope of practice. A lot of research is not dedicated to alternative medicine, as it is hard to patent a substance that grows from the ground, compared to prescription medications that can be patented for 10 years, priced at 30-40x times the cost of a generic medication. One question that comes to mind - how does someone without insurance or limited coverage able to pay for medication that is only name brand name. As example of such is the medication, Latuda is an expensive drug. The out-of-pocket cash price for a 30-day supply of 40 mg tablets is $1,776. That’s nearly $60 per pill, but 40 mg is on the lower end of Latuda dosages. There is a epidemic growth of popularity of herbs for mind to treat conditions, such as depression, anxiety, insomnia, memory deficits. "He that will not apply new remedies must expect new evils; for time in the great inventor" - Sir Francis Bacon. One factor that contributes to this shift in use of remedies, is ongoing issues with side effects of newly involving psychotrophic medications, despite millions, if not billions of dollars in research. Now the hard part is the internet is flood with various products that claim certain properties. I will discuss some simple well studied remedies. I will also include the supplement(s) that I would recommend based on high potency (not related to side effects) but maximum effect, but also maximum absorption and bioavailability. I think that it is important to be selective when purchasing items as a local grocery store, as it is unclear if your body is properly processing the ingredients labeled on the bottle. I have exclusive researched and created a list of supplements, which I think will be beneficial, which I recommend for my patients as well. In writing this article, I wanted to provide a disclaimer that this is only a suggestion that I am providing, as this is not a medication, it is your choice to try to supplement. I would highly recommend you do additional research to see if this is the right fit, however alternative medical treatment tend to have minimal side effects, if any at all. Regardless, if you don't feel that you are having a positive experience I would highly recommend discontinuing it. In this article and other article, I will provide an in-depth description of each herbal remedy and even discuss areas that I would be concerned about, before attempting to start the supplement. You can find more details about many herbal remedies in the book I would highly recommend. Herbal supplement(s) can be benign, however no one can truly know how it interacts with your body leading to potential allergic reaction, though a low probability. What is interesting is ask the average herbal shopper what is the actual remedy that is found in the product, often you are looked at with a blank stare, unless well read in the fundamental of herbal science. The irony of medicine in general is it has been a series of trial and errors, to this day. One interesting example, as an observation in the 1800's form a Viennese physician who was austerized to the point of having an emotional breakdown when he pointed out that women were dying during child birth because their doctors were not washing their hands. Now, it seems like a no-brainer that germs cause infection spread through unhygiene practices. Unfortunately, excessive handwashing based on this preoccupation with germs can be seen with OCD. It is important to recognize that every human being wants relief and wants to feel good and have a quality life. Depression hurts, stress kills, anxiety is unnerving, and insomnia is dangerous and unnerving, therefore it is not a mysterious that everyone is trying to find a solution that is in alignment with their values. Medication and/or therapy is not for everyone, however it should be an option to consider in the right situation. It is important to be open minded and feel free to discuss potential treatment options with your doctor, as herbal remedies can be helpful, but really dependent on your response. Check out this book that such the benefit of herbs, nutrients, and yoga in mental health care.

Gambling disorder involves repeated, problem gambling behavior. The behavior leads to problems for the individual, families, and society. Adults and adolescents with gambling disorder have trouble controlling their gambling. They will continue even when it causes significant problems. Diagnosis A diagnosis of gambling disorder requires at least four of the following during the past year: Need to gamble with increasing amounts to achieve the desired excitement. Restless or irritable when trying to cut down or stop gambling. Repeated unsuccessful efforts to control, cut back on or stop gambling. Frequent thoughts about gambling (such as reliving past gambling or planning future gambling). Often gambling when feeling distressed. After losing money gambling, often returning to get even. (This is referred to as "chasing" one's losses.) Lying to hide gambling activity. Risking or losing a close relationship, a job, or a school or job opportunity because of gambling. Relying on others to help with money problems caused by gambling People with gambling disorder can have periods where symptoms subside. The gambling may not seem a problem in between periods of more severe symptoms. Gambling disorder tends to run in families. Factors such as trauma and social inequality, particularly in women, can be risk factors. Symptoms can begin as early as adolescence or as late as older adulthood. Men are more likely to start at a younger age. Women are more likely to start later in life. Gambling Disorder Treatment Some people can stop gambling on their own. But many people need help to address their gambling problems. Only one in ten people with gambling disorder seek treatment. Gambling affects people in different ways. Different approaches may work better for different people. Several types of therapy are used to treat gambling disorders, including cognitive behavioral therapy (CBT), psychodynamic therapy, group therapy, and family therapy. Counseling can help people understand gambling and think about how gambling affects them and their family. It can also help people consider options and solve problems. There are no FDA-approved medications to treat gambling disorders. Some medications may help treat co-occurring conditions like depression or anxiety. Support from family and friends can be critical to a person's recovery from gambling. However, only the individual can decide to stop the behaviors. Counseling can help: Gain control over your gambling. Heal family relationships. Deal with your urge to gamble. Handle stress and other problems. Find other things to do with your time. Put your finances in order. Maintain recovery and avoid triggers. Support Groups and Self-Help Support groups, such as Gamblers Anonymous and Alcoholics Anonymous, use peer support to help others stop gambling. Some research has shown physical activity can help those with gambling disorder. Many states have gambling helplines and other assistance. A National Helpline is available at 1-800-662-HELP (4357). Strategies to Deal with Cravings Reach out for support. Call a trusted friend or family member. Go to a Gamblers Anonymous meeting. Distract yourself with other activities. Postpone gambling. Giving yourself time may allow the urge to pass or weaken. Stop for a moment and consider what will happen when you gamble. Avoid isolation. "Dos" and "Don'ts" for Partners, Friends, or Family Members Do Seek the support of others with similar problems; attend a self-help group for families such as Gam-Anon. Recognize your partner's good qualities. Remain calm when speaking to the person with a gambling disorder. Let them know that you are seeking help for yourself; the gambling is affecting you (and possibly children). Explain problem gambling to children. Understand the need for treatment of problem gambling and that it may take time. Set boundaries in managing money; take control of family finances; review bank and credit card statements. Don't Preach, lecture, or allow yourself to lose control of your anger Exclude the gambler from family life and activities Expect immediate recovery, or that all problems will be resolved when the gambling stops Bailout the gambler Preventing Suicide Problem gamblers are at increased risk of suicide. It’s very important to take any thoughts or talk of suicide seriously. For immediate attention, call 988, text 988, or chat at 988lifeline.org. Source: Yale Medicine - Gambling Disorder

Body Dysphoric Disorder Individuals with body dysmorphic disorder are preoccupied with what they perceive as flaws in their physical appearance. The perceived flaws are not noticeable or appear only slight to others but are seen as ugly or abnormal to the person with body dysmorphic disorder. It is not the same as the typical concerns many people have about their appearance. Body dysmorphic disorder also involves repetitive behaviors (such as checking a mirror or seeking reassurance) or repetitive thinking (such as comparing one’s appearance with others). The preoccupations can focus on one or many body areas, most commonly the skin, hair or nose. The preoccupations and behaviors are intrusive, unwanted, and time-consuming (occurring, on average, three to eight hours per day). The individual feels driven to perform them and usually has difficulty resisting or controlling them. The preoccupation causes significant distress or problems in daily activities such as work or social interactions. This can range from avoiding some social situations to being completely isolated and housebound. Body dysmorphic disorder is associated with high levels of anxiety, social anxiety, social avoidance, depressed mood and low self-esteem. Many individuals seek and too often receive cosmetic treatment, such as skin treatments or surgery, to try to fix their perceived defects. People with body dysmorphic disorder may or may not understand that their concerns about their appearance are distorted. Many individuals with body dysmorphic disorder believe that other people take special notice of them or mock them because of how they look. It affects an estimated 2% of people. It typically begins before age 18 and affects both men and women. Body dysmorphic disorder is usually treated with a combination of cognitive behavior therapy and medication, such as selective serotonin reuptake inhibitors (SSRIs). Muscle Dysphoria - subcategory of Body Dysphoria Muscle dysmorphia, a form of body dysmorphic disorder, more common in males, consists of preoccupation with the idea that one’s body is too small or too heavy, or not muscular enough. Individuals with this form of the disorder actually have a normal-looking body or are even very muscular. A majority (but not all) diet, exercise, and/or lift weights excessively. Source: Mayo Clinic - Body Dysphoric Disorder