Depression

People who follow a vegetarian lifestyle have around twice as many depressive episodes as those who eat meat, according to the Brazilian Longitudinal Study of Adult Health.

What to know

The high incidence of depression among vegetarians is not caused by nutrition but possibly by several factors, including the vegetarian social experience; depression itself may increase the likelihood of becoming vegetarian, or both vegetarianism and depression may be associated with guilt through factors involving the meat industry.

Adopting a vegetarian diet might affect one’s relationship with others and involvement in social activities and may sometimes be associated with teasing or other forms of social ostracism.

It is possible that being depressed and dwelling on negative thoughts cause people to be more likely to become vegetarian rather than the other way around.

Videos depicting violence and cruelty in the meat industry may affect depressed people, causing them to dwell on the images, feel guilty for their part in creating the demand for meat, and become vegetarian.

Survey data were collected in Brazil, a country famous for its meat-heavy diet, and while there has been a sharp increase in vegetarianism, vegetarians still account for less than 0.5%.

This is a summary of the article, “Association Between Meatless Diet and Depressive Episodes: A Cross-sectional Analysis of Baseline Data From the Longitudinal Study of Adult Health (ELSA-Brasil),” published in the Journal of Affective Disorders. The full article can be found at sciencedirect.com.

A version of this article first appeared on Medscape.com.

People who follow a vegetarian lifestyle have around twice as many depressive episodes as those who eat meat, according to the Brazilian Longitudinal Study of Adult Health.

What to know

The high incidence of depression among vegetarians is not caused by nutrition but possibly by several factors, including the vegetarian social experience; depression itself may increase the likelihood of becoming vegetarian, or both vegetarianism and depression may be associated with guilt through factors involving the meat industry.

Adopting a vegetarian diet might affect one’s relationship with others and involvement in social activities and may sometimes be associated with teasing or other forms of social ostracism.

It is possible that being depressed and dwelling on negative thoughts cause people to be more likely to become vegetarian rather than the other way around.

Videos depicting violence and cruelty in the meat industry may affect depressed people, causing them to dwell on the images, feel guilty for their part in creating the demand for meat, and become vegetarian.

Survey data were collected in Brazil, a country famous for its meat-heavy diet, and while there has been a sharp increase in vegetarianism, vegetarians still account for less than 0.5%.

This is a summary of the article, “Association Between Meatless Diet and Depressive Episodes: A Cross-sectional Analysis of Baseline Data From the Longitudinal Study of Adult Health (ELSA-Brasil),” published in the Journal of Affective Disorders. The full article can be found at sciencedirect.com.

A version of this article first appeared on Medscape.com.

People who follow a vegetarian lifestyle have around twice as many depressive episodes as those who eat meat, according to the Brazilian Longitudinal Study of Adult Health.

What to know

The high incidence of depression among vegetarians is not caused by nutrition but possibly by several factors, including the vegetarian social experience; depression itself may increase the likelihood of becoming vegetarian, or both vegetarianism and depression may be associated with guilt through factors involving the meat industry.

Adopting a vegetarian diet might affect one’s relationship with others and involvement in social activities and may sometimes be associated with teasing or other forms of social ostracism.

It is possible that being depressed and dwelling on negative thoughts cause people to be more likely to become vegetarian rather than the other way around.

Videos depicting violence and cruelty in the meat industry may affect depressed people, causing them to dwell on the images, feel guilty for their part in creating the demand for meat, and become vegetarian.

Survey data were collected in Brazil, a country famous for its meat-heavy diet, and while there has been a sharp increase in vegetarianism, vegetarians still account for less than 0.5%.

This is a summary of the article, “Association Between Meatless Diet and Depressive Episodes: A Cross-sectional Analysis of Baseline Data From the Longitudinal Study of Adult Health (ELSA-Brasil),” published in the Journal of Affective Disorders. The full article can be found at sciencedirect.com.

A version of this article first appeared on Medscape.com.

“It is one of life’s most self-evident truths that everything fades, that we fear the fading, and that we must live, nonetheless, in the face of the fear.” – Irvin D. Yalom, MD, Existential Psychotherapy, 1980

The email was titled simply, “A sorrowful note,” and I knew that someone had died. I held my breath and read as Dr. Jimmy Potash informed our entire department that Dr. Cait McFarland died in a car accident on December 7 while driving to work at West Cecil Health Center, Conowingo, Md., where she was director of psychiatry.

Sadness swelled as I remembered the outspoken resident who was interested in LGBTQ issues. Cait graduated from the Johns Hopkins residency program in 2020, she had recently married a social worker in the department, and the plan was for her to return to Hopkins full-time in July 2023 to be director of a clinic focused on mental health for people who are transgendered.

Sudden deaths are tragic and jarring and they call to the surface our losses from the past. These deaths don’t stand alone – I found myself thinking of my editor at Medscape, Dr. Bret Stetka, who died unexpectedly in August 2022, and then of Dr. Lidia Palcan Wenz, a psychiatrist I trained with, who died in a motor vehicle accident in 2004. Lidia’s husband also died in the accident, while their two young children in the back seat survived – this tragedy haunted me for some time. None of these people was close to me, but I am no stranger to the impact of unexpected death: My parents and brother all died from cardiac events, and any sudden death is a reminder of those losses.

Julia Riddle, MD, trained with Cait McFarland and was her close friend for years. “I don’t have a belief in ‘the afterlife’ but do like to think of the people that I have lost together in my memory – as if they are all suddenly in a new room together. And, with each loss, all the other occupants of that room come freshly to life again,” Dr. Riddle said.

Death is our shared destination in life, but sudden and unexpected deaths carry their own weight. There is no chance to tie up loose ends, to repair riffs, to say goodbye. Nothing is put in order, and the life that was to be lived goes on for some time as bills arrive, social and work events go unattended, vacations are canceled, and there is the awkward moment of running into someone who didn’t know your loved one has died.

Roger Lewin, MD, is a psychiatrist and writer in Towson, Md. He has both personal and professional experience with sudden death. “There is no way to prepare beforehand, so we have to get ready for what has already happened, and that is hard,” he said. “We invent a life for ourselves and others that extends into the future, and that gets interrupted.”

Most people become ill and die on a vaguely predictable schedule. There may be a chance to plan, to know and honor the wishes of the individual, and often there is the opportunity for loved ones to begin the grieving process gradually as death approaches. For those who are elderly, there may be a sense that this is the natural order of things – which may or may not temper the intensity of the grief for those who remain. If the person has suffered, the end may come with relief.

Still, I sometimes find myself surprised at the length and intensity of anguish that some people experience after losing a loved one who has lived a long and full life, who declined and suffered, but whose absence remains a gaping wound that takes years to form a scar.

Sudden death is not rare; accidents, homicide, and suicide are the top killers among young people, and cardiovascular deaths are number one among those who are older. Natural disasters and terrorist attacks can cause catastrophic numbers of sudden deaths and leave survivors to grieve not only the dead, but the loss of all that was familiar to them.

Psychiatry has been a bit lost as to how we approach grief. We often hear patients talk about anxiety surrounding death and illness, be it a fear of death or a longing for it. These fears can seem irrational – I am reminded of a patient who was afraid to eat romaine because of news reports that it was responsible for food poisoning in other states, but not Maryland, where the person lived. I found it odd that he worried about eating lettuce, but not about smoking two packs of cigarettes a day.

But our fears are like that – they move to what the media sensationalizes, or to what may be remote, because otherwise no one would get in a car or clear their walkway of snow. Life is most easily lived with a bit of denial: We shut out the reality that we can be here one moment, overscheduled and overwhelmed, with deadlines, mortgage payments, and summer vacation plans, oblivious to the fact that life may end at any moment. The early months of COVID-19 felt like a global game of Russian roulette, with each venture out a pull of the trigger and everyone’s defenses stripped bare.

While death belongs to us all, we relegate it to the disciplines of religion, philosophy, the arts, and psychology. Religion offers answers – whether a heaven, a hell, or continual reincarnation until the individual attains enlightenment, there is a destination. Perhaps it will be pleasant, perhaps not, and for some there is the hope that one gets to be the driver by having the right beliefs or doing good deeds, while others are comforted by the hope of being reunited with loved ones.

“The suddenness endures and the shock lasts – it’s like a meteor that creates a crater and we revisit it in different ways from different angles,” Dr. Lewin said. “It may leap on us unexpectedly, often many years later.”

Patients talk about death, and when their fears seem unrealistic we may long to reassure them, yet there is no reassurance and psychiatry grasps for how to help. Psychiatry has looked to draw lines for when normal grief crosses to abnormal. Is it an adjustment disorder, complicated grief, “prolonged” grief, pathology in need of medication and medicalization, or something one experiences individually, sometimes for a very long time even with treatment?

One justification for pathologizing “prolonged” reactions includes the fact that insurers will pay for treatment only if there is a diagnosis code, and shouldn’t people in distress be entitled to psychotherapy or medication? Yet there is something offensive about telling someone that they are mentally ill if they don’t grieve along a prescribed timeline, as much as there is about denying them the possible benefits of therapy or medication if they seek it, but are suffering in all the “right” ways. Psychiatry’s approach to death is inelegant at best.

In his poignant podcast series, All There Is, Anderson Cooper is tasked with sorting through his mother’s apartment after her death at age 95. In the course of packing up her belongings, he brings on other guests to talk about their emotional reactions to death. Mr. Cooper’s mother, Gloria Vanderbilt, died at an advanced age, but his father died after a brief cardiac illness when Mr. Cooper was a child, and his brother died by suicide when he was 21. He uses these experiences as a springboard to examine childhood losses, the aftermath of suicide, and the loneliness of grief.

“Loss and grief is this universal experience that we will all go through multiple times in our lives,” Mr. Cooper says, “And yet it leaves us feeling so alone and so separated from other people. At least it does me and has my entire life.”

When we talk about grief and loss, we talk about “getting over it,” or “moving on.” But loss doesn’t work that way – time usually eases the pain, leaving scars that are part of the road map for who we are on the journey that defines us.

Sudden death is hard, and the unexpected death of a young person is tragic. For Cait McFarland, there are the decades she won’t get to experience. For her family and friends, it may be excruciating, and for all the patients who have lost a psychiatrist, may time bring healing and peace.

The Dr. Caitlin McFarland Educational Fund for LGBTQI+ Mental Health is being established, and donations are being accepted at https://www.gofundme.com/f/in-memory-of-cait-mcfarland.

Dr. Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore. She has disclosed no relevant financial relationships.

“It is one of life’s most self-evident truths that everything fades, that we fear the fading, and that we must live, nonetheless, in the face of the fear.” – Irvin D. Yalom, MD, Existential Psychotherapy, 1980

The email was titled simply, “A sorrowful note,” and I knew that someone had died. I held my breath and read as Dr. Jimmy Potash informed our entire department that Dr. Cait McFarland died in a car accident on December 7 while driving to work at West Cecil Health Center, Conowingo, Md., where she was director of psychiatry.

Sadness swelled as I remembered the outspoken resident who was interested in LGBTQ issues. Cait graduated from the Johns Hopkins residency program in 2020, she had recently married a social worker in the department, and the plan was for her to return to Hopkins full-time in July 2023 to be director of a clinic focused on mental health for people who are transgendered.

Sudden deaths are tragic and jarring and they call to the surface our losses from the past. These deaths don’t stand alone – I found myself thinking of my editor at Medscape, Dr. Bret Stetka, who died unexpectedly in August 2022, and then of Dr. Lidia Palcan Wenz, a psychiatrist I trained with, who died in a motor vehicle accident in 2004. Lidia’s husband also died in the accident, while their two young children in the back seat survived – this tragedy haunted me for some time. None of these people was close to me, but I am no stranger to the impact of unexpected death: My parents and brother all died from cardiac events, and any sudden death is a reminder of those losses.

Julia Riddle, MD, trained with Cait McFarland and was her close friend for years. “I don’t have a belief in ‘the afterlife’ but do like to think of the people that I have lost together in my memory – as if they are all suddenly in a new room together. And, with each loss, all the other occupants of that room come freshly to life again,” Dr. Riddle said.

Death is our shared destination in life, but sudden and unexpected deaths carry their own weight. There is no chance to tie up loose ends, to repair riffs, to say goodbye. Nothing is put in order, and the life that was to be lived goes on for some time as bills arrive, social and work events go unattended, vacations are canceled, and there is the awkward moment of running into someone who didn’t know your loved one has died.

Roger Lewin, MD, is a psychiatrist and writer in Towson, Md. He has both personal and professional experience with sudden death. “There is no way to prepare beforehand, so we have to get ready for what has already happened, and that is hard,” he said. “We invent a life for ourselves and others that extends into the future, and that gets interrupted.”

Most people become ill and die on a vaguely predictable schedule. There may be a chance to plan, to know and honor the wishes of the individual, and often there is the opportunity for loved ones to begin the grieving process gradually as death approaches. For those who are elderly, there may be a sense that this is the natural order of things – which may or may not temper the intensity of the grief for those who remain. If the person has suffered, the end may come with relief.

Still, I sometimes find myself surprised at the length and intensity of anguish that some people experience after losing a loved one who has lived a long and full life, who declined and suffered, but whose absence remains a gaping wound that takes years to form a scar.

Sudden death is not rare; accidents, homicide, and suicide are the top killers among young people, and cardiovascular deaths are number one among those who are older. Natural disasters and terrorist attacks can cause catastrophic numbers of sudden deaths and leave survivors to grieve not only the dead, but the loss of all that was familiar to them.

Psychiatry has been a bit lost as to how we approach grief. We often hear patients talk about anxiety surrounding death and illness, be it a fear of death or a longing for it. These fears can seem irrational – I am reminded of a patient who was afraid to eat romaine because of news reports that it was responsible for food poisoning in other states, but not Maryland, where the person lived. I found it odd that he worried about eating lettuce, but not about smoking two packs of cigarettes a day.

But our fears are like that – they move to what the media sensationalizes, or to what may be remote, because otherwise no one would get in a car or clear their walkway of snow. Life is most easily lived with a bit of denial: We shut out the reality that we can be here one moment, overscheduled and overwhelmed, with deadlines, mortgage payments, and summer vacation plans, oblivious to the fact that life may end at any moment. The early months of COVID-19 felt like a global game of Russian roulette, with each venture out a pull of the trigger and everyone’s defenses stripped bare.

While death belongs to us all, we relegate it to the disciplines of religion, philosophy, the arts, and psychology. Religion offers answers – whether a heaven, a hell, or continual reincarnation until the individual attains enlightenment, there is a destination. Perhaps it will be pleasant, perhaps not, and for some there is the hope that one gets to be the driver by having the right beliefs or doing good deeds, while others are comforted by the hope of being reunited with loved ones.

“The suddenness endures and the shock lasts – it’s like a meteor that creates a crater and we revisit it in different ways from different angles,” Dr. Lewin said. “It may leap on us unexpectedly, often many years later.”

Patients talk about death, and when their fears seem unrealistic we may long to reassure them, yet there is no reassurance and psychiatry grasps for how to help. Psychiatry has looked to draw lines for when normal grief crosses to abnormal. Is it an adjustment disorder, complicated grief, “prolonged” grief, pathology in need of medication and medicalization, or something one experiences individually, sometimes for a very long time even with treatment?

One justification for pathologizing “prolonged” reactions includes the fact that insurers will pay for treatment only if there is a diagnosis code, and shouldn’t people in distress be entitled to psychotherapy or medication? Yet there is something offensive about telling someone that they are mentally ill if they don’t grieve along a prescribed timeline, as much as there is about denying them the possible benefits of therapy or medication if they seek it, but are suffering in all the “right” ways. Psychiatry’s approach to death is inelegant at best.

In his poignant podcast series, All There Is, Anderson Cooper is tasked with sorting through his mother’s apartment after her death at age 95. In the course of packing up her belongings, he brings on other guests to talk about their emotional reactions to death. Mr. Cooper’s mother, Gloria Vanderbilt, died at an advanced age, but his father died after a brief cardiac illness when Mr. Cooper was a child, and his brother died by suicide when he was 21. He uses these experiences as a springboard to examine childhood losses, the aftermath of suicide, and the loneliness of grief.

“Loss and grief is this universal experience that we will all go through multiple times in our lives,” Mr. Cooper says, “And yet it leaves us feeling so alone and so separated from other people. At least it does me and has my entire life.”

When we talk about grief and loss, we talk about “getting over it,” or “moving on.” But loss doesn’t work that way – time usually eases the pain, leaving scars that are part of the road map for who we are on the journey that defines us.

Sudden death is hard, and the unexpected death of a young person is tragic. For Cait McFarland, there are the decades she won’t get to experience. For her family and friends, it may be excruciating, and for all the patients who have lost a psychiatrist, may time bring healing and peace.

The Dr. Caitlin McFarland Educational Fund for LGBTQI+ Mental Health is being established, and donations are being accepted at https://www.gofundme.com/f/in-memory-of-cait-mcfarland.

Dr. Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore. She has disclosed no relevant financial relationships.

“It is one of life’s most self-evident truths that everything fades, that we fear the fading, and that we must live, nonetheless, in the face of the fear.” – Irvin D. Yalom, MD, Existential Psychotherapy, 1980

The email was titled simply, “A sorrowful note,” and I knew that someone had died. I held my breath and read as Dr. Jimmy Potash informed our entire department that Dr. Cait McFarland died in a car accident on December 7 while driving to work at West Cecil Health Center, Conowingo, Md., where she was director of psychiatry.

Sadness swelled as I remembered the outspoken resident who was interested in LGBTQ issues. Cait graduated from the Johns Hopkins residency program in 2020, she had recently married a social worker in the department, and the plan was for her to return to Hopkins full-time in July 2023 to be director of a clinic focused on mental health for people who are transgendered.

Sudden deaths are tragic and jarring and they call to the surface our losses from the past. These deaths don’t stand alone – I found myself thinking of my editor at Medscape, Dr. Bret Stetka, who died unexpectedly in August 2022, and then of Dr. Lidia Palcan Wenz, a psychiatrist I trained with, who died in a motor vehicle accident in 2004. Lidia’s husband also died in the accident, while their two young children in the back seat survived – this tragedy haunted me for some time. None of these people was close to me, but I am no stranger to the impact of unexpected death: My parents and brother all died from cardiac events, and any sudden death is a reminder of those losses.

Julia Riddle, MD, trained with Cait McFarland and was her close friend for years. “I don’t have a belief in ‘the afterlife’ but do like to think of the people that I have lost together in my memory – as if they are all suddenly in a new room together. And, with each loss, all the other occupants of that room come freshly to life again,” Dr. Riddle said.

Death is our shared destination in life, but sudden and unexpected deaths carry their own weight. There is no chance to tie up loose ends, to repair riffs, to say goodbye. Nothing is put in order, and the life that was to be lived goes on for some time as bills arrive, social and work events go unattended, vacations are canceled, and there is the awkward moment of running into someone who didn’t know your loved one has died.

Roger Lewin, MD, is a psychiatrist and writer in Towson, Md. He has both personal and professional experience with sudden death. “There is no way to prepare beforehand, so we have to get ready for what has already happened, and that is hard,” he said. “We invent a life for ourselves and others that extends into the future, and that gets interrupted.”

Most people become ill and die on a vaguely predictable schedule. There may be a chance to plan, to know and honor the wishes of the individual, and often there is the opportunity for loved ones to begin the grieving process gradually as death approaches. For those who are elderly, there may be a sense that this is the natural order of things – which may or may not temper the intensity of the grief for those who remain. If the person has suffered, the end may come with relief.

Still, I sometimes find myself surprised at the length and intensity of anguish that some people experience after losing a loved one who has lived a long and full life, who declined and suffered, but whose absence remains a gaping wound that takes years to form a scar.

Sudden death is not rare; accidents, homicide, and suicide are the top killers among young people, and cardiovascular deaths are number one among those who are older. Natural disasters and terrorist attacks can cause catastrophic numbers of sudden deaths and leave survivors to grieve not only the dead, but the loss of all that was familiar to them.

Psychiatry has been a bit lost as to how we approach grief. We often hear patients talk about anxiety surrounding death and illness, be it a fear of death or a longing for it. These fears can seem irrational – I am reminded of a patient who was afraid to eat romaine because of news reports that it was responsible for food poisoning in other states, but not Maryland, where the person lived. I found it odd that he worried about eating lettuce, but not about smoking two packs of cigarettes a day.

But our fears are like that – they move to what the media sensationalizes, or to what may be remote, because otherwise no one would get in a car or clear their walkway of snow. Life is most easily lived with a bit of denial: We shut out the reality that we can be here one moment, overscheduled and overwhelmed, with deadlines, mortgage payments, and summer vacation plans, oblivious to the fact that life may end at any moment. The early months of COVID-19 felt like a global game of Russian roulette, with each venture out a pull of the trigger and everyone’s defenses stripped bare.

While death belongs to us all, we relegate it to the disciplines of religion, philosophy, the arts, and psychology. Religion offers answers – whether a heaven, a hell, or continual reincarnation until the individual attains enlightenment, there is a destination. Perhaps it will be pleasant, perhaps not, and for some there is the hope that one gets to be the driver by having the right beliefs or doing good deeds, while others are comforted by the hope of being reunited with loved ones.

“The suddenness endures and the shock lasts – it’s like a meteor that creates a crater and we revisit it in different ways from different angles,” Dr. Lewin said. “It may leap on us unexpectedly, often many years later.”

Patients talk about death, and when their fears seem unrealistic we may long to reassure them, yet there is no reassurance and psychiatry grasps for how to help. Psychiatry has looked to draw lines for when normal grief crosses to abnormal. Is it an adjustment disorder, complicated grief, “prolonged” grief, pathology in need of medication and medicalization, or something one experiences individually, sometimes for a very long time even with treatment?

One justification for pathologizing “prolonged” reactions includes the fact that insurers will pay for treatment only if there is a diagnosis code, and shouldn’t people in distress be entitled to psychotherapy or medication? Yet there is something offensive about telling someone that they are mentally ill if they don’t grieve along a prescribed timeline, as much as there is about denying them the possible benefits of therapy or medication if they seek it, but are suffering in all the “right” ways. Psychiatry’s approach to death is inelegant at best.

In his poignant podcast series, All There Is, Anderson Cooper is tasked with sorting through his mother’s apartment after her death at age 95. In the course of packing up her belongings, he brings on other guests to talk about their emotional reactions to death. Mr. Cooper’s mother, Gloria Vanderbilt, died at an advanced age, but his father died after a brief cardiac illness when Mr. Cooper was a child, and his brother died by suicide when he was 21. He uses these experiences as a springboard to examine childhood losses, the aftermath of suicide, and the loneliness of grief.

“Loss and grief is this universal experience that we will all go through multiple times in our lives,” Mr. Cooper says, “And yet it leaves us feeling so alone and so separated from other people. At least it does me and has my entire life.”

When we talk about grief and loss, we talk about “getting over it,” or “moving on.” But loss doesn’t work that way – time usually eases the pain, leaving scars that are part of the road map for who we are on the journey that defines us.

Sudden death is hard, and the unexpected death of a young person is tragic. For Cait McFarland, there are the decades she won’t get to experience. For her family and friends, it may be excruciating, and for all the patients who have lost a psychiatrist, may time bring healing and peace.

The Dr. Caitlin McFarland Educational Fund for LGBTQI+ Mental Health is being established, and donations are being accepted at https://www.gofundme.com/f/in-memory-of-cait-mcfarland.

Dr. Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore. She has disclosed no relevant financial relationships.

In the treatment of depression, clinicians are commonly dealing with a mix of comorbidities that are more complex than just depression, and as such, effective treatment options may likewise require thinking outside of the box – and beyond the definitions of the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision).

“The DSM-5 isn’t handed to us on tablets from Mount Sinai,” said Charles B. Nemeroff, MD, PhD, professor and chair in the department of psychiatry and behavioral sciences at the Mulva Clinic for the Neurosciences at the University of Texas at Austin. He spoke at the 21st Annual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

“Our patients don’t fall into these very convenient buckets,” Dr. Nemeroff said. “The problem with depression is patients have very high rates of morbidity and comorbidity.”

The array of potential psychiatric comorbidities that are common in depression is somewhat staggering: As many as 70% of patients also have social anxiety disorder; 67% of patients have obsessive-compulsive disorder (OCD); up to 65% of patients have panic disorder; 48% of patients have posttraumatic stress disorder (PTSD); and 42% have generalized anxiety disorder, Dr. Nemeroff said.

And while the DSM-5 may have all those bases covered, in real world clinical practice, cracking the code of each patient’s unique and often more complicated psychiatric profile – and how to best manage it – can be a challenge. But Dr. Nemeroff said important clues can guide the clinician’s path.

A key starting point is making sure to gauge the severity of the patient’s core depression with one of the validated depression scales – whether it’s the self-reported Beck Depression Inventory, the clinician-rated Hamilton Rating Scale for Depression, the clinician-rated Montgomery Asberg Depression Rating Scale, or the Inventory of Depressive Symptoms, clinicians should pick one and track the score with each visit, Dr. Nemeroff advised.

“It doesn’t matter which tool you prefer – most tend to like the Beck Depression Scale, but the bottom line is that you have to get a measure of severity at every visit,” he said.

Among the most important comorbidities to identify as soon as possible is bipolar disorder, due to the potential worsening of the condition that can occur among those patients if treated with antidepressants, Dr. Nemeroff said.

“The question of whether the patient is bipolar should always be in the back of your mind,” he cautioned. “And if patients have been started on antidepressants, the clues may become evident very quickly.”

The most important indicator that the patient has bipolar disorder “is if they tell you that they were prescribed an antidepressant and it resulted in an increase in what we know to be hypomania – they may describe it as agitation or an inability to sleep,” Dr. Nemeroff said.

Of note, the effect is much more common with SNRIs [serotonin norepinephrine reuptake inhibitors] than SSRIs [selective serotonin reuptake inhibitors], he said.

“The effect is particularly notable with venlafaxine,” he said. “But SNRIs all have the propensity to switch people with depression into hypomania, but only patients who have bipolar disorder.”

“If you give a patient 150 mg of venlafaxine and they switch to developing hypomania, you now have the diagnosis of bipolar disorder, and you can treat them appropriately.”

Other important clues of bipolarity in depressed patients include:

• Family history: Most cases are genetically driven.
• Earlier age of onset (younger than age 25): “If the patient tells you they were depressed prepuberty, you should be thinking about the possibility of bipolar disorder, as it often presents as depression in childhood.”
• Psychotic features: As many as 80% of patients with psychotic depression end up being bipolar, Dr. Nemeroff said.
• Atypical depression: For example, depression with hypersomnia, or having an increased appetite instead of decreased, or a high amount of anxiety.

Remission should be the goal of treatment, and Dr. Nemeroff said that in efforts to accomplish that with the help of medications, psychiatrists may need to think “outside of the box” – or beyond the label.

“Many practitioners become slaves to the PDR [Physicians’ Desk Reference],” he said. “It is only a guide to what the clinical trials show, and not a mandate in terms of dosing.”

“There’s often strong data in the literature that supports going to a higher dose, if necessary, and I have [plenty] of patients, for instance, on 450 or 600 mg of venlafaxine who had not responded to 150 or even 300 mg.”
 

Treatment resistance

When patients continue to fail to respond, regardless of dosing or medication adjustments, Dr. Nemeroff suggested that clinicians should consider the potential important reasons. For instance, in addition to comorbid psychiatric conditions, practitioners should determine if there are medical conditions that they are not aware of.

“Does the patient have an underlying medical condition, such as thyroid dysfunction, early Parkinson’s disease, or even something like cancer?” he said.

There is also the inevitable question of whether the patient is indeed taking the medication. “We know that 30% of our patients do not follow their prescriptions, so of course that’s an important question to ask,” Dr. Nemeroff said.

Finally, while some pharmacogenomic tests are emerging with the suggestion of identifying which patients may or may not respond to certain drugs, Dr. Nemeroff says he’s seen little convincing evidence of their benefits.

“We have a problem in this field in that we don’t have the kinds of markers that they do in oncology, so we’re left with having to generally play trial and error,” he said.

“But when it comes to these pharmacogenomic tests, there’s just no ‘there there’,” he asserted. “From what I’ve seen so far, it’s frankly neuro-mythology.”

Dr. Nemeroff disclosed that he receives grant/research support from the National Institutes of Health and serves as a consultant for and/or on the advisory boards of multiple pharmaceutical companies.

The Psychopharmacology Update was sponsored by Medscape Live. Medscape Live and this news organization are owned by the same parent company.

In the treatment of depression, clinicians are commonly dealing with a mix of comorbidities that are more complex than just depression, and as such, effective treatment options may likewise require thinking outside of the box – and beyond the definitions of the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision).

“The DSM-5 isn’t handed to us on tablets from Mount Sinai,” said Charles B. Nemeroff, MD, PhD, professor and chair in the department of psychiatry and behavioral sciences at the Mulva Clinic for the Neurosciences at the University of Texas at Austin. He spoke at the 21st Annual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

“Our patients don’t fall into these very convenient buckets,” Dr. Nemeroff said. “The problem with depression is patients have very high rates of morbidity and comorbidity.”

The array of potential psychiatric comorbidities that are common in depression is somewhat staggering: As many as 70% of patients also have social anxiety disorder; 67% of patients have obsessive-compulsive disorder (OCD); up to 65% of patients have panic disorder; 48% of patients have posttraumatic stress disorder (PTSD); and 42% have generalized anxiety disorder, Dr. Nemeroff said.

And while the DSM-5 may have all those bases covered, in real world clinical practice, cracking the code of each patient’s unique and often more complicated psychiatric profile – and how to best manage it – can be a challenge. But Dr. Nemeroff said important clues can guide the clinician’s path.

A key starting point is making sure to gauge the severity of the patient’s core depression with one of the validated depression scales – whether it’s the self-reported Beck Depression Inventory, the clinician-rated Hamilton Rating Scale for Depression, the clinician-rated Montgomery Asberg Depression Rating Scale, or the Inventory of Depressive Symptoms, clinicians should pick one and track the score with each visit, Dr. Nemeroff advised.

“It doesn’t matter which tool you prefer – most tend to like the Beck Depression Scale, but the bottom line is that you have to get a measure of severity at every visit,” he said.

Among the most important comorbidities to identify as soon as possible is bipolar disorder, due to the potential worsening of the condition that can occur among those patients if treated with antidepressants, Dr. Nemeroff said.

“The question of whether the patient is bipolar should always be in the back of your mind,” he cautioned. “And if patients have been started on antidepressants, the clues may become evident very quickly.”

The most important indicator that the patient has bipolar disorder “is if they tell you that they were prescribed an antidepressant and it resulted in an increase in what we know to be hypomania – they may describe it as agitation or an inability to sleep,” Dr. Nemeroff said.

Of note, the effect is much more common with SNRIs [serotonin norepinephrine reuptake inhibitors] than SSRIs [selective serotonin reuptake inhibitors], he said.

“The effect is particularly notable with venlafaxine,” he said. “But SNRIs all have the propensity to switch people with depression into hypomania, but only patients who have bipolar disorder.”

“If you give a patient 150 mg of venlafaxine and they switch to developing hypomania, you now have the diagnosis of bipolar disorder, and you can treat them appropriately.”

Other important clues of bipolarity in depressed patients include:

• Family history: Most cases are genetically driven.
• Earlier age of onset (younger than age 25): “If the patient tells you they were depressed prepuberty, you should be thinking about the possibility of bipolar disorder, as it often presents as depression in childhood.”
• Psychotic features: As many as 80% of patients with psychotic depression end up being bipolar, Dr. Nemeroff said.
• Atypical depression: For example, depression with hypersomnia, or having an increased appetite instead of decreased, or a high amount of anxiety.

Remission should be the goal of treatment, and Dr. Nemeroff said that in efforts to accomplish that with the help of medications, psychiatrists may need to think “outside of the box” – or beyond the label.

“Many practitioners become slaves to the PDR [Physicians’ Desk Reference],” he said. “It is only a guide to what the clinical trials show, and not a mandate in terms of dosing.”

“There’s often strong data in the literature that supports going to a higher dose, if necessary, and I have [plenty] of patients, for instance, on 450 or 600 mg of venlafaxine who had not responded to 150 or even 300 mg.”
 

Treatment resistance

When patients continue to fail to respond, regardless of dosing or medication adjustments, Dr. Nemeroff suggested that clinicians should consider the potential important reasons. For instance, in addition to comorbid psychiatric conditions, practitioners should determine if there are medical conditions that they are not aware of.

“Does the patient have an underlying medical condition, such as thyroid dysfunction, early Parkinson’s disease, or even something like cancer?” he said.

There is also the inevitable question of whether the patient is indeed taking the medication. “We know that 30% of our patients do not follow their prescriptions, so of course that’s an important question to ask,” Dr. Nemeroff said.

Finally, while some pharmacogenomic tests are emerging with the suggestion of identifying which patients may or may not respond to certain drugs, Dr. Nemeroff says he’s seen little convincing evidence of their benefits.

“We have a problem in this field in that we don’t have the kinds of markers that they do in oncology, so we’re left with having to generally play trial and error,” he said.

“But when it comes to these pharmacogenomic tests, there’s just no ‘there there’,” he asserted. “From what I’ve seen so far, it’s frankly neuro-mythology.”

Dr. Nemeroff disclosed that he receives grant/research support from the National Institutes of Health and serves as a consultant for and/or on the advisory boards of multiple pharmaceutical companies.

The Psychopharmacology Update was sponsored by Medscape Live. Medscape Live and this news organization are owned by the same parent company.

In the treatment of depression, clinicians are commonly dealing with a mix of comorbidities that are more complex than just depression, and as such, effective treatment options may likewise require thinking outside of the box – and beyond the definitions of the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision).

“The DSM-5 isn’t handed to us on tablets from Mount Sinai,” said Charles B. Nemeroff, MD, PhD, professor and chair in the department of psychiatry and behavioral sciences at the Mulva Clinic for the Neurosciences at the University of Texas at Austin. He spoke at the 21st Annual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

“Our patients don’t fall into these very convenient buckets,” Dr. Nemeroff said. “The problem with depression is patients have very high rates of morbidity and comorbidity.”

The array of potential psychiatric comorbidities that are common in depression is somewhat staggering: As many as 70% of patients also have social anxiety disorder; 67% of patients have obsessive-compulsive disorder (OCD); up to 65% of patients have panic disorder; 48% of patients have posttraumatic stress disorder (PTSD); and 42% have generalized anxiety disorder, Dr. Nemeroff said.

And while the DSM-5 may have all those bases covered, in real world clinical practice, cracking the code of each patient’s unique and often more complicated psychiatric profile – and how to best manage it – can be a challenge. But Dr. Nemeroff said important clues can guide the clinician’s path.

A key starting point is making sure to gauge the severity of the patient’s core depression with one of the validated depression scales – whether it’s the self-reported Beck Depression Inventory, the clinician-rated Hamilton Rating Scale for Depression, the clinician-rated Montgomery Asberg Depression Rating Scale, or the Inventory of Depressive Symptoms, clinicians should pick one and track the score with each visit, Dr. Nemeroff advised.

“It doesn’t matter which tool you prefer – most tend to like the Beck Depression Scale, but the bottom line is that you have to get a measure of severity at every visit,” he said.

Among the most important comorbidities to identify as soon as possible is bipolar disorder, due to the potential worsening of the condition that can occur among those patients if treated with antidepressants, Dr. Nemeroff said.

“The question of whether the patient is bipolar should always be in the back of your mind,” he cautioned. “And if patients have been started on antidepressants, the clues may become evident very quickly.”

The most important indicator that the patient has bipolar disorder “is if they tell you that they were prescribed an antidepressant and it resulted in an increase in what we know to be hypomania – they may describe it as agitation or an inability to sleep,” Dr. Nemeroff said.

Of note, the effect is much more common with SNRIs [serotonin norepinephrine reuptake inhibitors] than SSRIs [selective serotonin reuptake inhibitors], he said.

“The effect is particularly notable with venlafaxine,” he said. “But SNRIs all have the propensity to switch people with depression into hypomania, but only patients who have bipolar disorder.”

“If you give a patient 150 mg of venlafaxine and they switch to developing hypomania, you now have the diagnosis of bipolar disorder, and you can treat them appropriately.”

Other important clues of bipolarity in depressed patients include:

• Family history: Most cases are genetically driven.
• Earlier age of onset (younger than age 25): “If the patient tells you they were depressed prepuberty, you should be thinking about the possibility of bipolar disorder, as it often presents as depression in childhood.”
• Psychotic features: As many as 80% of patients with psychotic depression end up being bipolar, Dr. Nemeroff said.
• Atypical depression: For example, depression with hypersomnia, or having an increased appetite instead of decreased, or a high amount of anxiety.

Remission should be the goal of treatment, and Dr. Nemeroff said that in efforts to accomplish that with the help of medications, psychiatrists may need to think “outside of the box” – or beyond the label.

“Many practitioners become slaves to the PDR [Physicians’ Desk Reference],” he said. “It is only a guide to what the clinical trials show, and not a mandate in terms of dosing.”

“There’s often strong data in the literature that supports going to a higher dose, if necessary, and I have [plenty] of patients, for instance, on 450 or 600 mg of venlafaxine who had not responded to 150 or even 300 mg.”
 

Treatment resistance

When patients continue to fail to respond, regardless of dosing or medication adjustments, Dr. Nemeroff suggested that clinicians should consider the potential important reasons. For instance, in addition to comorbid psychiatric conditions, practitioners should determine if there are medical conditions that they are not aware of.

“Does the patient have an underlying medical condition, such as thyroid dysfunction, early Parkinson’s disease, or even something like cancer?” he said.

There is also the inevitable question of whether the patient is indeed taking the medication. “We know that 30% of our patients do not follow their prescriptions, so of course that’s an important question to ask,” Dr. Nemeroff said.

Finally, while some pharmacogenomic tests are emerging with the suggestion of identifying which patients may or may not respond to certain drugs, Dr. Nemeroff says he’s seen little convincing evidence of their benefits.

“We have a problem in this field in that we don’t have the kinds of markers that they do in oncology, so we’re left with having to generally play trial and error,” he said.

“But when it comes to these pharmacogenomic tests, there’s just no ‘there there’,” he asserted. “From what I’ve seen so far, it’s frankly neuro-mythology.”

Dr. Nemeroff disclosed that he receives grant/research support from the National Institutes of Health and serves as a consultant for and/or on the advisory boards of multiple pharmaceutical companies.

The Psychopharmacology Update was sponsored by Medscape Live. Medscape Live and this news organization are owned by the same parent company.

CASE Depressed, anxious, and suicidal

Mr. J, age 72, is brought to the emergency department by law enforcement at his wife’s request due to worsening suicidal thoughts and anxiety. He has a history of major depressive disorder (MDD) and chronic kidney disease (CKD). Mr. J has been compliant with his medications, but they seem to no longer be effective. He is admitted to the geriatric psychiatry unit.

HISTORY Increased debilitation

Over the past several years, Mr. J has experienced increasing debilitation at home, including difficulty walking and an inability to perform activities of daily life. Recently, he has begun to ask for multiple pills in an attempt to take his own life.

Mr. J has been previously treated in a psychiatric clinic with duloxetine 60 mg/d, mirtazapine 30 mg/d at bedtime, buspirone 15 mg 3 times a day, and trazodone 50 mg/d at bedtime. He is also taking amlodipine 5 mg twice daily for hypertension, lisinopril 2.5 mg/d for hypertension, furosemide 20 mg/d orally for CKD, and potassium chloride 10 mEq/d for hypokalemia secondary to CKD and furosemide use. Over the past year, his psychiatric medications have been steadily increased to target his MDD and anxiety.

EVALUATION Disorientation and Stage 3A CKD

In the psychiatric unit, Mr. J describes panic, feelings of impending doom, and profound anxiety. He states he has increasing anxiety related to “being a burden” on his family and wife. Additionally, he describes decreased appetite, difficulty sleeping, low energy, difficulty concentrating, no interest in outside activities, and feelings of hopelessness.

Mr. J’s temperature is 39.2^o C; heart rate is 109 beats per minute; respiratory rate is 18 breaths per minute; blood pressure is 157/83 mm Hg; and pulse oximetry is 97%. Laboratory screening indicates a red blood cell count of 3.57, hemoglobin 11.2, hematocrit 33.8, red blood cell distribution width 17.5, blood urea nitrogen 45, creatinine 1.5 with no known baseline, and an estimated glomerular filtration rate (GFR) of 46 mL/min, indicating Stage 3A CKD (Table 1¹). Additional testing rules out other potential causes of delirium and psychosis.

A physical exam reveals Mr. J has a fine tremor, myoclonus, muscle rigidity, and hyperreflexia. He is oriented to name, but not to date, place, or situation, and is easily confused. Mr. J uses a walker but has significant tremors while walking and immediately asks for assistance due to profound anxiety related to a fear of falling. Mr. J’s mood and affect are labile with tearful and anxious episodes. His anxiety focuses on overvalued thoughts of minor or irrelevant concerns. Additionally, he has poor insight and judgment. When asked about the cause of his anxiety, Mr. J says, “I don’t know why I’m anxious; I’m just a worrywart.” His memory is impaired, and he does not know why he is in the hospital. Mr. J scores 24 on the Montreal Cognitive Assessment, which indicates mild impairment.

Mr. J continues to endorse suicidal ideation but denies homicidal thoughts. Based on these symptoms, the differential diagnosis includes serotonin syndrome, MDD with suicidal ideation, generalized anxiety disorder, and panic disorder.

Continue to: The authors' observations

[polldaddy:11273789]

The authors’ observations

GFR is used to determine the level of renal impairment. Mr. J’s GFR of 46 mL/min indicates Stage 3A CKD (Table 1¹ ). Additionally, he displayed anemia and increased creatinine due to CKD. Twenty percent of patients with CKD also experience MDD.² In a prospective observational cohort study, Hedayati et al³ found that Stage 2 to Stage 5 CKD with MDD leads to an increased risk of death, hospitalization, or progression to dialysis. It is important to properly manage Mr. J’s MDD and CKD to prevent future comorbidities. Renal impairment is common in people age >65.⁴ Even when GFR is normal, it is recommended to decrease dosing of medications in older adults due to age-related decreased renal excretion. As kidneys decrease in function, their ability to excrete normal amounts of medications also decreases, leading to increased serum levels and potential toxicity.

A combination of 4 serotonergic psychotropic medications may not be unusual to address treatment-resistant depression in a healthy, nongeriatric adult. However, Mr. J displayed signs of serotonin toxicity, such as hyperthermia, tachycardia, increased blood pressure, increased tremors, myoclonus, hyperreflexia, and muscle rigidity. These are classic signs of serotonin toxicity. For Mr. J, serotonin toxicity can be treated with the removal of serotonergic medications and lorazepam for symptom relief. If symptoms persist, cyproheptadine, a serotonin antagonist, can be used. Mr. J’s psychotropic medications were increased in an outpatient setting and he was unable to renally excrete higher doses of these serotonergic agents, which lead to chronic serotonin toxicity.

It is important to rule out other causes of psychosis or delirium in geriatric patients. A study by Marcantonio et al⁵ found that >40% of patients referred to a consulting psychiatrist for depression ultimately had delirium, and this was more likely in geriatric patients.

TREATMENT Adjustments to the medication regimen

The treatment team decides to taper and discontinue duloxetine, buspirone, and trazodone and reduce mirtazapine to 15 mg/d at bedtime. Additionally, oral lorazepam 1 mg as needed is prescribed to alleviate agitation and correct vital signs. Mr. J’s vital signs improve, with decreased temperature and normal cardiac and respiratory rhythms.

Mr. J’s Stage 3A CKD is treated with oral fluids, and his hypertension is managed with an increase of lisinopril from 2.5 mg/d to 10 mg/d. After 10 days on the psychiatric unit, he shows improvement, decreased anxiety, and remission of suicidal ideation.

Continue to: The authors' observations

[polldaddy:11273790]

The authors’ observations

In 2019, the American Geriatric Society (AGS) updated the Beers Criteria for potentially inappropriate medication use in older adults.⁴ The Beers Criteria were created to educate clinicians about the use of potentially inappropriate medications that have an unfavorable balance of benefits and risks compared to alternative treatments. The AGS lists medications that should be avoided or have their dosage reduced with varying levels of kidney function in older adults. Duloxetine is one of the medications listed with the recommendation to avoid for patients with a creatinine clearance <30 mL/min. Creatinine clearance is an estimation of GFR.

Although duloxetine is mentioned in the Beers Criteria, many other antidepressants have metabolites excreted by the kidneys.⁶ Potential adverse effects include increased bleeding, nausea, vomiting, and serotonin toxicity symptoms.⁷ Mr. J has Stage 3A CKD and takes 4 psychotropics, which will additively increase the serum concentration of serotonergic medications. In terms of treatment for serotonin toxicity, it is important to remove the causative medications. After discontinuing serotonergic medications, lorazepam can be administered as needed. If a patient continues to have symptoms, cyproheptadine is an option.

For patients with impaired renal function, adding nonpharmacologic options should be considered, such as cognitive-behavioral therapy, electroconvulsive therapy, and transcranial magnetic stimulation. Table 2^4,8-18 lists the minimum effective doses for well-known medications for treating MDD.

OUTCOME Improvement and discharge

Mr. J’s confusion improves, his heart rate decreases, and his feelings of panic and doom improve. He continues to have depressive symptoms, but his suicidal ideation stops. At discharge, Mr. J is receiving mirtazapine 15 mg/d, potassium chloride 10 mEq/d orally, lisinopril 20 mg/d orally at bedtime, furosemide 20 mg/d orally, and amlodipine 5 mg orally twice a day. Additionally, the treatment team recommends psychotherapy to Mr. J to address his anxiety and depression.

Bottom Line

Older patients are more sensitive to psychotropic medications, regardless of any comorbidities. It is important to review each patient’s glomerular filtration rate to better understand their renal function and adjust medications accordingly.

Related Resources

• Whittaker P, Vordenberg SE, Coe AB. Deprescribing in older adults: an overview. Current Psychiatry. 2022;21(5):40-43. doi:10.12788/cp.0246
• Gibson G, Kennedy LH, Barlow G. Polypharmacy in older adults. Current Psychiatry. 2020;19(4):40-46.
• Barr R, Miskle B, Thomas C. Management of major depressive disorder with psychotic features. Current Psychiatry. 2021;20(2):30-33. doi:10.12788/cp.0092

Drug Brand Names

Amlodipine • Norvasc
Buspirone • BuSpar
Citalopram • Celexa
Cyproheptadine • Periactin
Desvenlafaxine • Pristiq
Duloxetine • Cymbalta
Escitalopram • Lexapro
Fluoxetine • Prozac
Furosemide • Lasix
Lisinopril • Zestril
Lorazepam • Ativan
Mirtazapine • Remeron
Paroxetine • Paxil
Sertraline • Zoloft
Trazodone • Desyrel
Venlafaxine • Effexor

CASE Depressed, anxious, and suicidal

Mr. J, age 72, is brought to the emergency department by law enforcement at his wife’s request due to worsening suicidal thoughts and anxiety. He has a history of major depressive disorder (MDD) and chronic kidney disease (CKD). Mr. J has been compliant with his medications, but they seem to no longer be effective. He is admitted to the geriatric psychiatry unit.

HISTORY Increased debilitation

Over the past several years, Mr. J has experienced increasing debilitation at home, including difficulty walking and an inability to perform activities of daily life. Recently, he has begun to ask for multiple pills in an attempt to take his own life.

Mr. J has been previously treated in a psychiatric clinic with duloxetine 60 mg/d, mirtazapine 30 mg/d at bedtime, buspirone 15 mg 3 times a day, and trazodone 50 mg/d at bedtime. He is also taking amlodipine 5 mg twice daily for hypertension, lisinopril 2.5 mg/d for hypertension, furosemide 20 mg/d orally for CKD, and potassium chloride 10 mEq/d for hypokalemia secondary to CKD and furosemide use. Over the past year, his psychiatric medications have been steadily increased to target his MDD and anxiety.

EVALUATION Disorientation and Stage 3A CKD

In the psychiatric unit, Mr. J describes panic, feelings of impending doom, and profound anxiety. He states he has increasing anxiety related to “being a burden” on his family and wife. Additionally, he describes decreased appetite, difficulty sleeping, low energy, difficulty concentrating, no interest in outside activities, and feelings of hopelessness.

Mr. J’s temperature is 39.2^o C; heart rate is 109 beats per minute; respiratory rate is 18 breaths per minute; blood pressure is 157/83 mm Hg; and pulse oximetry is 97%. Laboratory screening indicates a red blood cell count of 3.57, hemoglobin 11.2, hematocrit 33.8, red blood cell distribution width 17.5, blood urea nitrogen 45, creatinine 1.5 with no known baseline, and an estimated glomerular filtration rate (GFR) of 46 mL/min, indicating Stage 3A CKD (Table 1¹). Additional testing rules out other potential causes of delirium and psychosis.

A physical exam reveals Mr. J has a fine tremor, myoclonus, muscle rigidity, and hyperreflexia. He is oriented to name, but not to date, place, or situation, and is easily confused. Mr. J uses a walker but has significant tremors while walking and immediately asks for assistance due to profound anxiety related to a fear of falling. Mr. J’s mood and affect are labile with tearful and anxious episodes. His anxiety focuses on overvalued thoughts of minor or irrelevant concerns. Additionally, he has poor insight and judgment. When asked about the cause of his anxiety, Mr. J says, “I don’t know why I’m anxious; I’m just a worrywart.” His memory is impaired, and he does not know why he is in the hospital. Mr. J scores 24 on the Montreal Cognitive Assessment, which indicates mild impairment.

Mr. J continues to endorse suicidal ideation but denies homicidal thoughts. Based on these symptoms, the differential diagnosis includes serotonin syndrome, MDD with suicidal ideation, generalized anxiety disorder, and panic disorder.

Continue to: The authors' observations

[polldaddy:11273789]

The authors’ observations

GFR is used to determine the level of renal impairment. Mr. J’s GFR of 46 mL/min indicates Stage 3A CKD (Table 1¹ ). Additionally, he displayed anemia and increased creatinine due to CKD. Twenty percent of patients with CKD also experience MDD.² In a prospective observational cohort study, Hedayati et al³ found that Stage 2 to Stage 5 CKD with MDD leads to an increased risk of death, hospitalization, or progression to dialysis. It is important to properly manage Mr. J’s MDD and CKD to prevent future comorbidities. Renal impairment is common in people age >65.⁴ Even when GFR is normal, it is recommended to decrease dosing of medications in older adults due to age-related decreased renal excretion. As kidneys decrease in function, their ability to excrete normal amounts of medications also decreases, leading to increased serum levels and potential toxicity.

A combination of 4 serotonergic psychotropic medications may not be unusual to address treatment-resistant depression in a healthy, nongeriatric adult. However, Mr. J displayed signs of serotonin toxicity, such as hyperthermia, tachycardia, increased blood pressure, increased tremors, myoclonus, hyperreflexia, and muscle rigidity. These are classic signs of serotonin toxicity. For Mr. J, serotonin toxicity can be treated with the removal of serotonergic medications and lorazepam for symptom relief. If symptoms persist, cyproheptadine, a serotonin antagonist, can be used. Mr. J’s psychotropic medications were increased in an outpatient setting and he was unable to renally excrete higher doses of these serotonergic agents, which lead to chronic serotonin toxicity.

It is important to rule out other causes of psychosis or delirium in geriatric patients. A study by Marcantonio et al⁵ found that >40% of patients referred to a consulting psychiatrist for depression ultimately had delirium, and this was more likely in geriatric patients.

TREATMENT Adjustments to the medication regimen

The treatment team decides to taper and discontinue duloxetine, buspirone, and trazodone and reduce mirtazapine to 15 mg/d at bedtime. Additionally, oral lorazepam 1 mg as needed is prescribed to alleviate agitation and correct vital signs. Mr. J’s vital signs improve, with decreased temperature and normal cardiac and respiratory rhythms.

Mr. J’s Stage 3A CKD is treated with oral fluids, and his hypertension is managed with an increase of lisinopril from 2.5 mg/d to 10 mg/d. After 10 days on the psychiatric unit, he shows improvement, decreased anxiety, and remission of suicidal ideation.

Continue to: The authors' observations

[polldaddy:11273790]

The authors’ observations

In 2019, the American Geriatric Society (AGS) updated the Beers Criteria for potentially inappropriate medication use in older adults.⁴ The Beers Criteria were created to educate clinicians about the use of potentially inappropriate medications that have an unfavorable balance of benefits and risks compared to alternative treatments. The AGS lists medications that should be avoided or have their dosage reduced with varying levels of kidney function in older adults. Duloxetine is one of the medications listed with the recommendation to avoid for patients with a creatinine clearance <30 mL/min. Creatinine clearance is an estimation of GFR.

Although duloxetine is mentioned in the Beers Criteria, many other antidepressants have metabolites excreted by the kidneys.⁶ Potential adverse effects include increased bleeding, nausea, vomiting, and serotonin toxicity symptoms.⁷ Mr. J has Stage 3A CKD and takes 4 psychotropics, which will additively increase the serum concentration of serotonergic medications. In terms of treatment for serotonin toxicity, it is important to remove the causative medications. After discontinuing serotonergic medications, lorazepam can be administered as needed. If a patient continues to have symptoms, cyproheptadine is an option.

For patients with impaired renal function, adding nonpharmacologic options should be considered, such as cognitive-behavioral therapy, electroconvulsive therapy, and transcranial magnetic stimulation. Table 2^4,8-18 lists the minimum effective doses for well-known medications for treating MDD.

OUTCOME Improvement and discharge

Mr. J’s confusion improves, his heart rate decreases, and his feelings of panic and doom improve. He continues to have depressive symptoms, but his suicidal ideation stops. At discharge, Mr. J is receiving mirtazapine 15 mg/d, potassium chloride 10 mEq/d orally, lisinopril 20 mg/d orally at bedtime, furosemide 20 mg/d orally, and amlodipine 5 mg orally twice a day. Additionally, the treatment team recommends psychotherapy to Mr. J to address his anxiety and depression.

Bottom Line

Older patients are more sensitive to psychotropic medications, regardless of any comorbidities. It is important to review each patient’s glomerular filtration rate to better understand their renal function and adjust medications accordingly.

Related Resources

• Whittaker P, Vordenberg SE, Coe AB. Deprescribing in older adults: an overview. Current Psychiatry. 2022;21(5):40-43. doi:10.12788/cp.0246
• Gibson G, Kennedy LH, Barlow G. Polypharmacy in older adults. Current Psychiatry. 2020;19(4):40-46.
• Barr R, Miskle B, Thomas C. Management of major depressive disorder with psychotic features. Current Psychiatry. 2021;20(2):30-33. doi:10.12788/cp.0092

Drug Brand Names

Amlodipine • Norvasc
Buspirone • BuSpar
Citalopram • Celexa
Cyproheptadine • Periactin
Desvenlafaxine • Pristiq
Duloxetine • Cymbalta
Escitalopram • Lexapro
Fluoxetine • Prozac
Furosemide • Lasix
Lisinopril • Zestril
Lorazepam • Ativan
Mirtazapine • Remeron
Paroxetine • Paxil
Sertraline • Zoloft
Trazodone • Desyrel
Venlafaxine • Effexor

CASE Depressed, anxious, and suicidal

Mr. J, age 72, is brought to the emergency department by law enforcement at his wife’s request due to worsening suicidal thoughts and anxiety. He has a history of major depressive disorder (MDD) and chronic kidney disease (CKD). Mr. J has been compliant with his medications, but they seem to no longer be effective. He is admitted to the geriatric psychiatry unit.

HISTORY Increased debilitation

Over the past several years, Mr. J has experienced increasing debilitation at home, including difficulty walking and an inability to perform activities of daily life. Recently, he has begun to ask for multiple pills in an attempt to take his own life.

Mr. J has been previously treated in a psychiatric clinic with duloxetine 60 mg/d, mirtazapine 30 mg/d at bedtime, buspirone 15 mg 3 times a day, and trazodone 50 mg/d at bedtime. He is also taking amlodipine 5 mg twice daily for hypertension, lisinopril 2.5 mg/d for hypertension, furosemide 20 mg/d orally for CKD, and potassium chloride 10 mEq/d for hypokalemia secondary to CKD and furosemide use. Over the past year, his psychiatric medications have been steadily increased to target his MDD and anxiety.

EVALUATION Disorientation and Stage 3A CKD

In the psychiatric unit, Mr. J describes panic, feelings of impending doom, and profound anxiety. He states he has increasing anxiety related to “being a burden” on his family and wife. Additionally, he describes decreased appetite, difficulty sleeping, low energy, difficulty concentrating, no interest in outside activities, and feelings of hopelessness.

Mr. J’s temperature is 39.2^o C; heart rate is 109 beats per minute; respiratory rate is 18 breaths per minute; blood pressure is 157/83 mm Hg; and pulse oximetry is 97%. Laboratory screening indicates a red blood cell count of 3.57, hemoglobin 11.2, hematocrit 33.8, red blood cell distribution width 17.5, blood urea nitrogen 45, creatinine 1.5 with no known baseline, and an estimated glomerular filtration rate (GFR) of 46 mL/min, indicating Stage 3A CKD (Table 1¹). Additional testing rules out other potential causes of delirium and psychosis.

A physical exam reveals Mr. J has a fine tremor, myoclonus, muscle rigidity, and hyperreflexia. He is oriented to name, but not to date, place, or situation, and is easily confused. Mr. J uses a walker but has significant tremors while walking and immediately asks for assistance due to profound anxiety related to a fear of falling. Mr. J’s mood and affect are labile with tearful and anxious episodes. His anxiety focuses on overvalued thoughts of minor or irrelevant concerns. Additionally, he has poor insight and judgment. When asked about the cause of his anxiety, Mr. J says, “I don’t know why I’m anxious; I’m just a worrywart.” His memory is impaired, and he does not know why he is in the hospital. Mr. J scores 24 on the Montreal Cognitive Assessment, which indicates mild impairment.

Mr. J continues to endorse suicidal ideation but denies homicidal thoughts. Based on these symptoms, the differential diagnosis includes serotonin syndrome, MDD with suicidal ideation, generalized anxiety disorder, and panic disorder.

Continue to: The authors' observations

[polldaddy:11273789]

The authors’ observations

GFR is used to determine the level of renal impairment. Mr. J’s GFR of 46 mL/min indicates Stage 3A CKD (Table 1¹ ). Additionally, he displayed anemia and increased creatinine due to CKD. Twenty percent of patients with CKD also experience MDD.² In a prospective observational cohort study, Hedayati et al³ found that Stage 2 to Stage 5 CKD with MDD leads to an increased risk of death, hospitalization, or progression to dialysis. It is important to properly manage Mr. J’s MDD and CKD to prevent future comorbidities. Renal impairment is common in people age >65.⁴ Even when GFR is normal, it is recommended to decrease dosing of medications in older adults due to age-related decreased renal excretion. As kidneys decrease in function, their ability to excrete normal amounts of medications also decreases, leading to increased serum levels and potential toxicity.

A combination of 4 serotonergic psychotropic medications may not be unusual to address treatment-resistant depression in a healthy, nongeriatric adult. However, Mr. J displayed signs of serotonin toxicity, such as hyperthermia, tachycardia, increased blood pressure, increased tremors, myoclonus, hyperreflexia, and muscle rigidity. These are classic signs of serotonin toxicity. For Mr. J, serotonin toxicity can be treated with the removal of serotonergic medications and lorazepam for symptom relief. If symptoms persist, cyproheptadine, a serotonin antagonist, can be used. Mr. J’s psychotropic medications were increased in an outpatient setting and he was unable to renally excrete higher doses of these serotonergic agents, which lead to chronic serotonin toxicity.

It is important to rule out other causes of psychosis or delirium in geriatric patients. A study by Marcantonio et al⁵ found that >40% of patients referred to a consulting psychiatrist for depression ultimately had delirium, and this was more likely in geriatric patients.

TREATMENT Adjustments to the medication regimen

The treatment team decides to taper and discontinue duloxetine, buspirone, and trazodone and reduce mirtazapine to 15 mg/d at bedtime. Additionally, oral lorazepam 1 mg as needed is prescribed to alleviate agitation and correct vital signs. Mr. J’s vital signs improve, with decreased temperature and normal cardiac and respiratory rhythms.

Mr. J’s Stage 3A CKD is treated with oral fluids, and his hypertension is managed with an increase of lisinopril from 2.5 mg/d to 10 mg/d. After 10 days on the psychiatric unit, he shows improvement, decreased anxiety, and remission of suicidal ideation.

Continue to: The authors' observations

[polldaddy:11273790]

The authors’ observations

In 2019, the American Geriatric Society (AGS) updated the Beers Criteria for potentially inappropriate medication use in older adults.⁴ The Beers Criteria were created to educate clinicians about the use of potentially inappropriate medications that have an unfavorable balance of benefits and risks compared to alternative treatments. The AGS lists medications that should be avoided or have their dosage reduced with varying levels of kidney function in older adults. Duloxetine is one of the medications listed with the recommendation to avoid for patients with a creatinine clearance <30 mL/min. Creatinine clearance is an estimation of GFR.

Although duloxetine is mentioned in the Beers Criteria, many other antidepressants have metabolites excreted by the kidneys.⁶ Potential adverse effects include increased bleeding, nausea, vomiting, and serotonin toxicity symptoms.⁷ Mr. J has Stage 3A CKD and takes 4 psychotropics, which will additively increase the serum concentration of serotonergic medications. In terms of treatment for serotonin toxicity, it is important to remove the causative medications. After discontinuing serotonergic medications, lorazepam can be administered as needed. If a patient continues to have symptoms, cyproheptadine is an option.

For patients with impaired renal function, adding nonpharmacologic options should be considered, such as cognitive-behavioral therapy, electroconvulsive therapy, and transcranial magnetic stimulation. Table 2^4,8-18 lists the minimum effective doses for well-known medications for treating MDD.

OUTCOME Improvement and discharge

Mr. J’s confusion improves, his heart rate decreases, and his feelings of panic and doom improve. He continues to have depressive symptoms, but his suicidal ideation stops. At discharge, Mr. J is receiving mirtazapine 15 mg/d, potassium chloride 10 mEq/d orally, lisinopril 20 mg/d orally at bedtime, furosemide 20 mg/d orally, and amlodipine 5 mg orally twice a day. Additionally, the treatment team recommends psychotherapy to Mr. J to address his anxiety and depression.

Bottom Line

Older patients are more sensitive to psychotropic medications, regardless of any comorbidities. It is important to review each patient’s glomerular filtration rate to better understand their renal function and adjust medications accordingly.

Related Resources

• Whittaker P, Vordenberg SE, Coe AB. Deprescribing in older adults: an overview. Current Psychiatry. 2022;21(5):40-43. doi:10.12788/cp.0246
• Gibson G, Kennedy LH, Barlow G. Polypharmacy in older adults. Current Psychiatry. 2020;19(4):40-46.
• Barr R, Miskle B, Thomas C. Management of major depressive disorder with psychotic features. Current Psychiatry. 2021;20(2):30-33. doi:10.12788/cp.0092

Drug Brand Names

Amlodipine • Norvasc
Buspirone • BuSpar
Citalopram • Celexa
Cyproheptadine • Periactin
Desvenlafaxine • Pristiq
Duloxetine • Cymbalta
Escitalopram • Lexapro
Fluoxetine • Prozac
Furosemide • Lasix
Lisinopril • Zestril
Lorazepam • Ativan
Mirtazapine • Remeron
Paroxetine • Paxil
Sertraline • Zoloft
Trazodone • Desyrel
Venlafaxine • Effexor

Editor’s note: This article was adapted with permission from a version originally published in the Ohio Psychiatric Physician Association’s newsletter, Insight Matters, Fall 2022.

Acknowledging and analyzing strengths, weaknesses, opportunities, and threats (SWOT) is an important tactic many organizations use to develop a strategic plan to grow, move forward, and thrive. A SWOT analysis can provide a “big picture” view of the status and the desired future directions not only for companies but for medical disciplines such as psychiatry. So here are my perspectives on psychiatry’s strengths, weaknesses, opportunities, and threats. It is a work in progress, and I welcome (and encourage) you to send additional items or comments to me at [email protected].

Strengths

• The American Psychiatric Association (APA) is the oldest medical professional organization, established in 1844 (3 years before the American Medical Association)¹
• Strong organizational structure and governance, and a “big tent” with several tiers of membership
• Effective, member-driven District Branches
• The medical identity at the core of psychiatry—we are psychiatric physicians²
• Escalating number of senior medical students choosing psychiatry as a career, far more than a decade ago
• High demand for psychiatrists in all settings around the country
• Increased compensation for psychiatrists (market forces of supply and demand)
• Psychiatry is continuously evolving and reinventing itself: seismic shifts in etiopathogenesis, disease conceptualization, terminology, and therapies (4 major shifts over the past century)³
• An abundant body of evidence supporting that all psychiatric disorders are brain disorders and transdiagnostic in nature⁴
• Many vibrant subspecialty societies
• Substantial number of Tier 1, evidence-based treatments
• Novel mechanisms of action and treatment strategies are being introduced on a regular basis for psychotic and mood disorders^5,6
• Advances in neuromodulation techniques to treat a wide spectrum of psychiatric disorders, including electroconvulsive therapy, transcranial magnetic stimulation, vagus nerve stimulation, transcranial direct current stimulation, deep brain stimulation, cranial electric stimulation, epidural cortical stimulation, focused ultrasound, low field magnetic stimulation, magnetic seizure therapy, and near infrared light therapy, with mechanisms that are electric, ultrasound, magnetic, or optical^7,8
• Psychiatric physicians develop wisdom by practicing psychiatry (ie, they become more empathic, tolerant of ambiguity, prosocial, introspective, aware of one’s strengths and limitations). Neuroplasticity in the frontal cortex is triggered by conducting psychotherapy⁹

Weaknesses

• Shrinking workforce due to a static number of residency training slots for 40 years¹⁰
• High rate of retirement by aging psychiatrists
• Persistent stigma around mental disorders despite massive scientific and medical advances¹¹
• Still no real parity! We need succinct laws with “teeth”¹²
• Demedicalization in the public sector, referring to psychiatric physicians as “providers” and labeling patients as “clients”²
• Not enough graduating residents choosing to do subspecialty fellowships (especially geriatric, addiction, psychosomatic psychiatry) to meet escalating societal needs
• Very low presence in rural areas (both psychiatrists and psychiatric hospitals)
• Persistent APA member apathy: only 10% to 15% vote in the APA national elections or volunteer to serve on committees
• Widespread member dissatisfaction with maintenance of certification
• Neuroscience advances are not being translated fast enough for practical clinical applications
• Many in the public at large do not realize psychiatric symptoms are generated from anomalous brain circuits or that psychiatric disorders are highly genetic but also have environmental and epigenetic etiologies
• The DSM diagnostic system needs a paradigm shift: it is still based on a menu of clinical signs and symptoms and is devoid of objective diagnostic measures such as biomarkers⁴
• Neuroscience literacy among busy psychiatric practitioners is insufficient at a time of explosive growth in basic and clinical neuroscience¹³
• No effective treatment for alcohol or substance use disorders despite their very high morbidity and mortality
• Major psychiatric disorders are still associated with significant disability (schizophrenia, bipolar disorder, major depressive disorder, anxiety disorders, eating disorders, substance use disorders)
• Suicide rate (other than opioid deaths) has continued to rise in the past 3 decades¹⁴

Opportunities

• Potentially momentous clinical applications of the neuroscience breakthroughs
• Collaborative care with primary care physicians and increasing colocalization
• Dramatic increase in public awareness about the importance of mental health due to the COVID-19 pandemic¹⁵
• Powerful new data management tools, including machine learning, artificial intelligence, super computers, big data, deep learning, nanotechnology, and metabolomics, all of which are expediting neurobiological discoveries¹⁶
• The potential of reclassifying psychiatric disorders as neurological disorders, which will improve reimbursement for patient health care and reduce stigma¹⁷
• Emergence of new mechanisms of action of disease etiology, such as microbiota, mitochondrial dysfunction, permeable blood-brain barrier, and neuroimmune dysregulation^18,19
• The advent and growth of “precision psychiatry”²⁰
• The tremendous potential of molecular genetics and gene therapy for psychiatric disorders, most of which are genetic in etiology
• Expanding applications of neuroimaging techniques, including morphological, spectroscopic, functional, diffusion tensor imaging, and receptor imaging²¹
• Epigenetic advances in neuropsychiatric disorders
• Remarkably powerful research methods, such as pluripotent cells (producing neurons from skin cells), optogenetics (activating genes with light), gene-wide association studies, CRISPR (clustered regularly interspaced short palindromic repeats, which serve as genetic scissors to remove and replace abnormal genes), and brain connectomics²²
• Psychiatry should develop and promote an “annual mental health checkup” for all age groups, similar to an annual physical exam²³
• Focus on the social determinants of health
• Address the unmet mental health needs of individuals who are members of minority groups
• Lobby ferociously for a much larger budget for the National Institute of Mental Health to advance funding for research of serious psychiatric brain disorders
• Remind Congress continuously that the cost of mental illness is $700 billion annually and costs can only be reduced by funding neurobiological research¹
• Partner with the pharmaceutical industry instead of demonizing them. They are the only entity that develops medication for psychiatry, where 80% of disorders have no FDA-approved drugs.²⁴ Without the pharmaceutical industry and the help of medications, many psychiatric patients would still be institutionalized and unable to lead a normal life. We must recognize the contributions of pharmaceutical companies to the health of our patients, similar to the warp speed development of vaccines for the deadly coronavirus
• Psychiatric clinicians must refer patients to clinical trials because without patients enrolling in FDA studies, no drug developments can take place
• Many “out-of-the-box” therapies are being developed, such as antiapoptotic therapy, microglia inhibition, mitochondrial repair, white matter fiber remyelination, neuroprotection, and reversing N-methyl-d-aspartate receptor hypofunction²⁵
• The emerging evidence that psychotherapy is in fact a biological treatment that induces brain changes (neuroplasticity) and can modulate the immune system²⁶
• Druggable genes, providing innovative new medications²⁷
• Reposition psychedelics as revolutionary new treatments²⁸
• Emphasize measurement-based care (rating scales), which can upgrade patient care²⁹
• Because psychosis is associated with brain tissue loss, just like heart attacks are associated with myocardium destruction, psychiatrists must act like cardiologists³⁰ and treat psychotic episodes urgently, like a stroke,³¹ to reduce the duration of untreated psychosis and improve patient outcomes

Threats

• Antipsychiatry cults continue to disparage and attack psychiatry³²
• Health delivery systems are replacing psychiatric physicians with nurse practitioners to lower costs, regardless of quality and experience, and they inappropriately lump them together as “providers”²
• Psychologists continue to seek prescribing privileges with absurdly sketchy, predominantly online training supervised by other psychologists³³
• Many legislators and policymakers, as well as the public, still don’t understand the difference between psychiatrists and psychologists, and the extensively disparate medical training in quality and quantity
• A dearth of psychiatric physician-scientists because very few residents are pursuing research fellowships after training³⁴
• Disproportionate emphasis on clinical care and generating clinical revenue (relative value units) in academic institutions, with fewer tenure-track faculty members having protected time to write grants for federal or foundation grants to support their salaries and research operations³⁵
• Meager financial support for teaching in psychiatry departments
• Many seriously psychiatrically ill persons do not have access to psychiatric medical care (and often to primary care as well)
• Many in the public falsely believe psychiatric disorders are hopeless and untreatable, which perpetuates stigma
• Long-acting injectable antipsychotic formulations are not used early enough in patients with psychosis, who are known to have a high nonadherence rate with oral medications following discharge from their first hospitalization. This leads to many recurrences with multiple devastating consequences, including progressive brain tissue loss, treatment resistance, disability, incarceration, and suicide³⁶
• Many clinicians do not have full-text access to all studies indexed in PubMed, which is vital for lifelong learning in a rapidly growing medical discipline such as psychiatry
• Psychiatrists are often unable to prescribe medications shortly after they are approved by the FDA due to the insurance companies’ outrageous preauthorization racket that enforces a fail-first policy with cheaper generics, even if generic medications are associated with safety and tolerability problems³⁷
• The continued use of decades-old first-generation antipsychotic medications despite 32 published studies reporting their neurotoxicity and the death of brain cells³⁸

Using this analysis to benefit our patients

Despite its strengths, psychiatry must overcome its weaknesses, fend off its threats, and exploit its many opportunities. The only way to do that is for psychiatrists to unify and for the APA to provide inspired leadership to achieve the aspirational goals of our field. However, we must adopt “moonshot thinking”³⁹ to magnify the Ss, diminish the Ws, exploit the Os, and stave off the Ts of our SWOT, thereby attaining all our cherished and lofty goals. Ultimately, the greatest beneficiaries will be our patients.

Editor’s note: This article was adapted with permission from a version originally published in the Ohio Psychiatric Physician Association’s newsletter, Insight Matters, Fall 2022.

Acknowledging and analyzing strengths, weaknesses, opportunities, and threats (SWOT) is an important tactic many organizations use to develop a strategic plan to grow, move forward, and thrive. A SWOT analysis can provide a “big picture” view of the status and the desired future directions not only for companies but for medical disciplines such as psychiatry. So here are my perspectives on psychiatry’s strengths, weaknesses, opportunities, and threats. It is a work in progress, and I welcome (and encourage) you to send additional items or comments to me at [email protected].

Strengths

• The American Psychiatric Association (APA) is the oldest medical professional organization, established in 1844 (3 years before the American Medical Association)¹
• Strong organizational structure and governance, and a “big tent” with several tiers of membership
• Effective, member-driven District Branches
• The medical identity at the core of psychiatry—we are psychiatric physicians²
• Escalating number of senior medical students choosing psychiatry as a career, far more than a decade ago
• High demand for psychiatrists in all settings around the country
• Increased compensation for psychiatrists (market forces of supply and demand)
• Psychiatry is continuously evolving and reinventing itself: seismic shifts in etiopathogenesis, disease conceptualization, terminology, and therapies (4 major shifts over the past century)³
• An abundant body of evidence supporting that all psychiatric disorders are brain disorders and transdiagnostic in nature⁴
• Many vibrant subspecialty societies
• Substantial number of Tier 1, evidence-based treatments
• Novel mechanisms of action and treatment strategies are being introduced on a regular basis for psychotic and mood disorders^5,6
• Advances in neuromodulation techniques to treat a wide spectrum of psychiatric disorders, including electroconvulsive therapy, transcranial magnetic stimulation, vagus nerve stimulation, transcranial direct current stimulation, deep brain stimulation, cranial electric stimulation, epidural cortical stimulation, focused ultrasound, low field magnetic stimulation, magnetic seizure therapy, and near infrared light therapy, with mechanisms that are electric, ultrasound, magnetic, or optical^7,8
• Psychiatric physicians develop wisdom by practicing psychiatry (ie, they become more empathic, tolerant of ambiguity, prosocial, introspective, aware of one’s strengths and limitations). Neuroplasticity in the frontal cortex is triggered by conducting psychotherapy⁹

Weaknesses

• Shrinking workforce due to a static number of residency training slots for 40 years¹⁰
• High rate of retirement by aging psychiatrists
• Persistent stigma around mental disorders despite massive scientific and medical advances¹¹
• Still no real parity! We need succinct laws with “teeth”¹²
• Demedicalization in the public sector, referring to psychiatric physicians as “providers” and labeling patients as “clients”²
• Not enough graduating residents choosing to do subspecialty fellowships (especially geriatric, addiction, psychosomatic psychiatry) to meet escalating societal needs
• Very low presence in rural areas (both psychiatrists and psychiatric hospitals)
• Persistent APA member apathy: only 10% to 15% vote in the APA national elections or volunteer to serve on committees
• Widespread member dissatisfaction with maintenance of certification
• Neuroscience advances are not being translated fast enough for practical clinical applications
• Many in the public at large do not realize psychiatric symptoms are generated from anomalous brain circuits or that psychiatric disorders are highly genetic but also have environmental and epigenetic etiologies
• The DSM diagnostic system needs a paradigm shift: it is still based on a menu of clinical signs and symptoms and is devoid of objective diagnostic measures such as biomarkers⁴
• Neuroscience literacy among busy psychiatric practitioners is insufficient at a time of explosive growth in basic and clinical neuroscience¹³
• No effective treatment for alcohol or substance use disorders despite their very high morbidity and mortality
• Major psychiatric disorders are still associated with significant disability (schizophrenia, bipolar disorder, major depressive disorder, anxiety disorders, eating disorders, substance use disorders)
• Suicide rate (other than opioid deaths) has continued to rise in the past 3 decades¹⁴

Opportunities

• Potentially momentous clinical applications of the neuroscience breakthroughs
• Collaborative care with primary care physicians and increasing colocalization
• Dramatic increase in public awareness about the importance of mental health due to the COVID-19 pandemic¹⁵
• Powerful new data management tools, including machine learning, artificial intelligence, super computers, big data, deep learning, nanotechnology, and metabolomics, all of which are expediting neurobiological discoveries¹⁶
• The potential of reclassifying psychiatric disorders as neurological disorders, which will improve reimbursement for patient health care and reduce stigma¹⁷
• Emergence of new mechanisms of action of disease etiology, such as microbiota, mitochondrial dysfunction, permeable blood-brain barrier, and neuroimmune dysregulation^18,19
• The advent and growth of “precision psychiatry”²⁰
• The tremendous potential of molecular genetics and gene therapy for psychiatric disorders, most of which are genetic in etiology
• Expanding applications of neuroimaging techniques, including morphological, spectroscopic, functional, diffusion tensor imaging, and receptor imaging²¹
• Epigenetic advances in neuropsychiatric disorders
• Remarkably powerful research methods, such as pluripotent cells (producing neurons from skin cells), optogenetics (activating genes with light), gene-wide association studies, CRISPR (clustered regularly interspaced short palindromic repeats, which serve as genetic scissors to remove and replace abnormal genes), and brain connectomics²²
• Psychiatry should develop and promote an “annual mental health checkup” for all age groups, similar to an annual physical exam²³
• Focus on the social determinants of health
• Address the unmet mental health needs of individuals who are members of minority groups
• Lobby ferociously for a much larger budget for the National Institute of Mental Health to advance funding for research of serious psychiatric brain disorders
• Remind Congress continuously that the cost of mental illness is $700 billion annually and costs can only be reduced by funding neurobiological research¹
• Partner with the pharmaceutical industry instead of demonizing them. They are the only entity that develops medication for psychiatry, where 80% of disorders have no FDA-approved drugs.²⁴ Without the pharmaceutical industry and the help of medications, many psychiatric patients would still be institutionalized and unable to lead a normal life. We must recognize the contributions of pharmaceutical companies to the health of our patients, similar to the warp speed development of vaccines for the deadly coronavirus
• Psychiatric clinicians must refer patients to clinical trials because without patients enrolling in FDA studies, no drug developments can take place
• Many “out-of-the-box” therapies are being developed, such as antiapoptotic therapy, microglia inhibition, mitochondrial repair, white matter fiber remyelination, neuroprotection, and reversing N-methyl-d-aspartate receptor hypofunction²⁵
• The emerging evidence that psychotherapy is in fact a biological treatment that induces brain changes (neuroplasticity) and can modulate the immune system²⁶
• Druggable genes, providing innovative new medications²⁷
• Reposition psychedelics as revolutionary new treatments²⁸
• Emphasize measurement-based care (rating scales), which can upgrade patient care²⁹
• Because psychosis is associated with brain tissue loss, just like heart attacks are associated with myocardium destruction, psychiatrists must act like cardiologists³⁰ and treat psychotic episodes urgently, like a stroke,³¹ to reduce the duration of untreated psychosis and improve patient outcomes

Threats

• Antipsychiatry cults continue to disparage and attack psychiatry³²
• Health delivery systems are replacing psychiatric physicians with nurse practitioners to lower costs, regardless of quality and experience, and they inappropriately lump them together as “providers”²
• Psychologists continue to seek prescribing privileges with absurdly sketchy, predominantly online training supervised by other psychologists³³
• Many legislators and policymakers, as well as the public, still don’t understand the difference between psychiatrists and psychologists, and the extensively disparate medical training in quality and quantity
• A dearth of psychiatric physician-scientists because very few residents are pursuing research fellowships after training³⁴
• Disproportionate emphasis on clinical care and generating clinical revenue (relative value units) in academic institutions, with fewer tenure-track faculty members having protected time to write grants for federal or foundation grants to support their salaries and research operations³⁵
• Meager financial support for teaching in psychiatry departments
• Many seriously psychiatrically ill persons do not have access to psychiatric medical care (and often to primary care as well)
• Many in the public falsely believe psychiatric disorders are hopeless and untreatable, which perpetuates stigma
• Long-acting injectable antipsychotic formulations are not used early enough in patients with psychosis, who are known to have a high nonadherence rate with oral medications following discharge from their first hospitalization. This leads to many recurrences with multiple devastating consequences, including progressive brain tissue loss, treatment resistance, disability, incarceration, and suicide³⁶
• Many clinicians do not have full-text access to all studies indexed in PubMed, which is vital for lifelong learning in a rapidly growing medical discipline such as psychiatry
• Psychiatrists are often unable to prescribe medications shortly after they are approved by the FDA due to the insurance companies’ outrageous preauthorization racket that enforces a fail-first policy with cheaper generics, even if generic medications are associated with safety and tolerability problems³⁷
• The continued use of decades-old first-generation antipsychotic medications despite 32 published studies reporting their neurotoxicity and the death of brain cells³⁸

Using this analysis to benefit our patients

Despite its strengths, psychiatry must overcome its weaknesses, fend off its threats, and exploit its many opportunities. The only way to do that is for psychiatrists to unify and for the APA to provide inspired leadership to achieve the aspirational goals of our field. However, we must adopt “moonshot thinking”³⁹ to magnify the Ss, diminish the Ws, exploit the Os, and stave off the Ts of our SWOT, thereby attaining all our cherished and lofty goals. Ultimately, the greatest beneficiaries will be our patients.

Editor’s note: This article was adapted with permission from a version originally published in the Ohio Psychiatric Physician Association’s newsletter, Insight Matters, Fall 2022.

Acknowledging and analyzing strengths, weaknesses, opportunities, and threats (SWOT) is an important tactic many organizations use to develop a strategic plan to grow, move forward, and thrive. A SWOT analysis can provide a “big picture” view of the status and the desired future directions not only for companies but for medical disciplines such as psychiatry. So here are my perspectives on psychiatry’s strengths, weaknesses, opportunities, and threats. It is a work in progress, and I welcome (and encourage) you to send additional items or comments to me at [email protected].

Strengths

• The American Psychiatric Association (APA) is the oldest medical professional organization, established in 1844 (3 years before the American Medical Association)¹
• Strong organizational structure and governance, and a “big tent” with several tiers of membership
• Effective, member-driven District Branches
• The medical identity at the core of psychiatry—we are psychiatric physicians²
• Escalating number of senior medical students choosing psychiatry as a career, far more than a decade ago
• High demand for psychiatrists in all settings around the country
• Increased compensation for psychiatrists (market forces of supply and demand)
• Psychiatry is continuously evolving and reinventing itself: seismic shifts in etiopathogenesis, disease conceptualization, terminology, and therapies (4 major shifts over the past century)³
• An abundant body of evidence supporting that all psychiatric disorders are brain disorders and transdiagnostic in nature⁴
• Many vibrant subspecialty societies
• Substantial number of Tier 1, evidence-based treatments
• Novel mechanisms of action and treatment strategies are being introduced on a regular basis for psychotic and mood disorders^5,6
• Advances in neuromodulation techniques to treat a wide spectrum of psychiatric disorders, including electroconvulsive therapy, transcranial magnetic stimulation, vagus nerve stimulation, transcranial direct current stimulation, deep brain stimulation, cranial electric stimulation, epidural cortical stimulation, focused ultrasound, low field magnetic stimulation, magnetic seizure therapy, and near infrared light therapy, with mechanisms that are electric, ultrasound, magnetic, or optical^7,8
• Psychiatric physicians develop wisdom by practicing psychiatry (ie, they become more empathic, tolerant of ambiguity, prosocial, introspective, aware of one’s strengths and limitations). Neuroplasticity in the frontal cortex is triggered by conducting psychotherapy⁹

Weaknesses

• Shrinking workforce due to a static number of residency training slots for 40 years¹⁰
• High rate of retirement by aging psychiatrists
• Persistent stigma around mental disorders despite massive scientific and medical advances¹¹
• Still no real parity! We need succinct laws with “teeth”¹²
• Demedicalization in the public sector, referring to psychiatric physicians as “providers” and labeling patients as “clients”²
• Not enough graduating residents choosing to do subspecialty fellowships (especially geriatric, addiction, psychosomatic psychiatry) to meet escalating societal needs
• Very low presence in rural areas (both psychiatrists and psychiatric hospitals)
• Persistent APA member apathy: only 10% to 15% vote in the APA national elections or volunteer to serve on committees
• Widespread member dissatisfaction with maintenance of certification
• Neuroscience advances are not being translated fast enough for practical clinical applications
• Many in the public at large do not realize psychiatric symptoms are generated from anomalous brain circuits or that psychiatric disorders are highly genetic but also have environmental and epigenetic etiologies
• The DSM diagnostic system needs a paradigm shift: it is still based on a menu of clinical signs and symptoms and is devoid of objective diagnostic measures such as biomarkers⁴
• Neuroscience literacy among busy psychiatric practitioners is insufficient at a time of explosive growth in basic and clinical neuroscience¹³
• No effective treatment for alcohol or substance use disorders despite their very high morbidity and mortality
• Major psychiatric disorders are still associated with significant disability (schizophrenia, bipolar disorder, major depressive disorder, anxiety disorders, eating disorders, substance use disorders)
• Suicide rate (other than opioid deaths) has continued to rise in the past 3 decades¹⁴

Opportunities

• Potentially momentous clinical applications of the neuroscience breakthroughs
• Collaborative care with primary care physicians and increasing colocalization
• Dramatic increase in public awareness about the importance of mental health due to the COVID-19 pandemic¹⁵
• Powerful new data management tools, including machine learning, artificial intelligence, super computers, big data, deep learning, nanotechnology, and metabolomics, all of which are expediting neurobiological discoveries¹⁶
• The potential of reclassifying psychiatric disorders as neurological disorders, which will improve reimbursement for patient health care and reduce stigma¹⁷
• Emergence of new mechanisms of action of disease etiology, such as microbiota, mitochondrial dysfunction, permeable blood-brain barrier, and neuroimmune dysregulation^18,19
• The advent and growth of “precision psychiatry”²⁰
• The tremendous potential of molecular genetics and gene therapy for psychiatric disorders, most of which are genetic in etiology
• Expanding applications of neuroimaging techniques, including morphological, spectroscopic, functional, diffusion tensor imaging, and receptor imaging²¹
• Epigenetic advances in neuropsychiatric disorders
• Remarkably powerful research methods, such as pluripotent cells (producing neurons from skin cells), optogenetics (activating genes with light), gene-wide association studies, CRISPR (clustered regularly interspaced short palindromic repeats, which serve as genetic scissors to remove and replace abnormal genes), and brain connectomics²²
• Psychiatry should develop and promote an “annual mental health checkup” for all age groups, similar to an annual physical exam²³
• Focus on the social determinants of health
• Address the unmet mental health needs of individuals who are members of minority groups
• Lobby ferociously for a much larger budget for the National Institute of Mental Health to advance funding for research of serious psychiatric brain disorders
• Remind Congress continuously that the cost of mental illness is $700 billion annually and costs can only be reduced by funding neurobiological research¹
• Partner with the pharmaceutical industry instead of demonizing them. They are the only entity that develops medication for psychiatry, where 80% of disorders have no FDA-approved drugs.²⁴ Without the pharmaceutical industry and the help of medications, many psychiatric patients would still be institutionalized and unable to lead a normal life. We must recognize the contributions of pharmaceutical companies to the health of our patients, similar to the warp speed development of vaccines for the deadly coronavirus
• Psychiatric clinicians must refer patients to clinical trials because without patients enrolling in FDA studies, no drug developments can take place
• Many “out-of-the-box” therapies are being developed, such as antiapoptotic therapy, microglia inhibition, mitochondrial repair, white matter fiber remyelination, neuroprotection, and reversing N-methyl-d-aspartate receptor hypofunction²⁵
• The emerging evidence that psychotherapy is in fact a biological treatment that induces brain changes (neuroplasticity) and can modulate the immune system²⁶
• Druggable genes, providing innovative new medications²⁷
• Reposition psychedelics as revolutionary new treatments²⁸
• Emphasize measurement-based care (rating scales), which can upgrade patient care²⁹
• Because psychosis is associated with brain tissue loss, just like heart attacks are associated with myocardium destruction, psychiatrists must act like cardiologists³⁰ and treat psychotic episodes urgently, like a stroke,³¹ to reduce the duration of untreated psychosis and improve patient outcomes

Threats

• Antipsychiatry cults continue to disparage and attack psychiatry³²
• Health delivery systems are replacing psychiatric physicians with nurse practitioners to lower costs, regardless of quality and experience, and they inappropriately lump them together as “providers”²
• Psychologists continue to seek prescribing privileges with absurdly sketchy, predominantly online training supervised by other psychologists³³
• Many legislators and policymakers, as well as the public, still don’t understand the difference between psychiatrists and psychologists, and the extensively disparate medical training in quality and quantity
• A dearth of psychiatric physician-scientists because very few residents are pursuing research fellowships after training³⁴
• Disproportionate emphasis on clinical care and generating clinical revenue (relative value units) in academic institutions, with fewer tenure-track faculty members having protected time to write grants for federal or foundation grants to support their salaries and research operations³⁵
• Meager financial support for teaching in psychiatry departments
• Many seriously psychiatrically ill persons do not have access to psychiatric medical care (and often to primary care as well)
• Many in the public falsely believe psychiatric disorders are hopeless and untreatable, which perpetuates stigma
• Long-acting injectable antipsychotic formulations are not used early enough in patients with psychosis, who are known to have a high nonadherence rate with oral medications following discharge from their first hospitalization. This leads to many recurrences with multiple devastating consequences, including progressive brain tissue loss, treatment resistance, disability, incarceration, and suicide³⁶
• Many clinicians do not have full-text access to all studies indexed in PubMed, which is vital for lifelong learning in a rapidly growing medical discipline such as psychiatry
• Psychiatrists are often unable to prescribe medications shortly after they are approved by the FDA due to the insurance companies’ outrageous preauthorization racket that enforces a fail-first policy with cheaper generics, even if generic medications are associated with safety and tolerability problems³⁷
• The continued use of decades-old first-generation antipsychotic medications despite 32 published studies reporting their neurotoxicity and the death of brain cells³⁸

Using this analysis to benefit our patients

Despite its strengths, psychiatry must overcome its weaknesses, fend off its threats, and exploit its many opportunities. The only way to do that is for psychiatrists to unify and for the APA to provide inspired leadership to achieve the aspirational goals of our field. However, we must adopt “moonshot thinking”³⁹ to magnify the Ss, diminish the Ws, exploit the Os, and stave off the Ts of our SWOT, thereby attaining all our cherished and lofty goals. Ultimately, the greatest beneficiaries will be our patients.

Groupthink is hazardous, especially when perfused with religious fervor. It can lead to adopting irrational thinking¹ and aversion to new ideas or facts. Tenaciously clinging to 1 ideology as “the absolute truth” precludes an open-minded, constructive debate with any other point of view.

Three historical examples come to mind:

• The discovery of chlorpromazine in 1952 was a scientifically and clinically seismic and transformational event for the treatment of psychosis, which for centuries had been dogmatically deemed irreversible. Jean Delay, MD, the French psychiatrist and co-discoverer of chlorpromazine, was the first physician to witness the magical and dazzling dissolution of delusions and hallucinations in chronically institutionalized patients with psychosis.² He published his landmark clinical observations and then traveled to the United States to share the great news and present his findings at a large psychiatric conference, hoping to enthrall American psychiatrists with the historic breakthrough in treating psychosis. This was an era in which psychoanalysis dominated American psychiatry (despite its dearth of empirical evidence). Dr. Delay was shocked when the audience of psycho­analysts booed him for saying that psychosis can be treated with a medication instead of with psychoanalysis (which, in the most intense groupthink in the history of psychiatry, they all believed was the only therapy for psychosis). Deeply disheartened, Dr. Delay returned to France and never returned to the United States. This groupthink was a prime example of intellectual constipation. Since then, not surprisingly, psychopharmacology grew meteorically while psychoanalysis declined precipitously.
• The monoamine hypothesis of depression, first propagated 60 years ago, became a groupthink dogma among psychiatric researchers for the next several decades, stultifying broader antidepressant medication development by focusing only on monoamines (eg, serotonin, norepinephrine, and dopamine). More recently, researchers have become more open-minded, and the monoamine hypothesis has taken a backseat to innovative new models of antidepressant therapy based on advances in the pathophysiology of depression, such as glutamatergic, opioid, and sigma pathways as well as neuroplasticity models.³ The consequence of groupthink in antidepressant research was a half-century delay in the development of effective alternative treatments that could have helped millions of patients recover from a life-threatening brain disorder such as major depressive disorder.
• Peptic ulcer and its serious gastritis were long believed to be due to stress and increased stomach acidity. So the groupthink gastroenterologists mocked 2 Australian researchers, Barry Marshall and Robin Warren, when they proposed that peptic ulcer may be due to an infection with a bacterium called Helicobacter pylori, and published their data demonstrating it.⁴ Marshall and Warren had the last laugh when they were awarded the 2005 Nobel Prize in Medicine and Physiology. It is ironic that even gastro­enterologists are not immune to the affliction of intellectual constipation!

Intellectual constipation’s effects on youth

The principle of a civilized debate of contrarian ideas must be inculcated early, especially during college years. Youth should be mentored about not cowering into an ideological cocoon and shun listening to different or opposing points of view.⁵ Institutions of higher learning are incubators of future leaders. They must provide their young students with a wide diversity of ideas and philosophies and encourage them to critique those ideas, not “shelter” or isolate them from any ideas. Youth need to recognize that the complex societies in which we all live and work are not placid or unidimensional but a hotbed of clashing ideas and perspectives. An open-minded approach to education will inoculate young minds from developing intellectual constipation in adulthood.

Avoiding or insulating oneself from the ideas of others—no matter how disagreeable—leads to cognitive cowardice and behavioral intolerance. Healthy and vibrant debate is necessary as an inoculation against extremism, hate, paranoia, and, ultimately, violence. Psychiatrists help patients to self-reflect, gain insight, and consider changing their view of themselves and the world to help them grow into mature and resilient individuals. But for the millions of people with intellectual constipation, a potent cerebral enema comprised of a salubrious concoction of insight, common sense, and compromise may be the prescription to forestall lethal intellectual ileus.

Groupthink is hazardous, especially when perfused with religious fervor. It can lead to adopting irrational thinking¹ and aversion to new ideas or facts. Tenaciously clinging to 1 ideology as “the absolute truth” precludes an open-minded, constructive debate with any other point of view.

Three historical examples come to mind:

• The discovery of chlorpromazine in 1952 was a scientifically and clinically seismic and transformational event for the treatment of psychosis, which for centuries had been dogmatically deemed irreversible. Jean Delay, MD, the French psychiatrist and co-discoverer of chlorpromazine, was the first physician to witness the magical and dazzling dissolution of delusions and hallucinations in chronically institutionalized patients with psychosis.² He published his landmark clinical observations and then traveled to the United States to share the great news and present his findings at a large psychiatric conference, hoping to enthrall American psychiatrists with the historic breakthrough in treating psychosis. This was an era in which psychoanalysis dominated American psychiatry (despite its dearth of empirical evidence). Dr. Delay was shocked when the audience of psycho­analysts booed him for saying that psychosis can be treated with a medication instead of with psychoanalysis (which, in the most intense groupthink in the history of psychiatry, they all believed was the only therapy for psychosis). Deeply disheartened, Dr. Delay returned to France and never returned to the United States. This groupthink was a prime example of intellectual constipation. Since then, not surprisingly, psychopharmacology grew meteorically while psychoanalysis declined precipitously.
• The monoamine hypothesis of depression, first propagated 60 years ago, became a groupthink dogma among psychiatric researchers for the next several decades, stultifying broader antidepressant medication development by focusing only on monoamines (eg, serotonin, norepinephrine, and dopamine). More recently, researchers have become more open-minded, and the monoamine hypothesis has taken a backseat to innovative new models of antidepressant therapy based on advances in the pathophysiology of depression, such as glutamatergic, opioid, and sigma pathways as well as neuroplasticity models.³ The consequence of groupthink in antidepressant research was a half-century delay in the development of effective alternative treatments that could have helped millions of patients recover from a life-threatening brain disorder such as major depressive disorder.
• Peptic ulcer and its serious gastritis were long believed to be due to stress and increased stomach acidity. So the groupthink gastroenterologists mocked 2 Australian researchers, Barry Marshall and Robin Warren, when they proposed that peptic ulcer may be due to an infection with a bacterium called Helicobacter pylori, and published their data demonstrating it.⁴ Marshall and Warren had the last laugh when they were awarded the 2005 Nobel Prize in Medicine and Physiology. It is ironic that even gastro­enterologists are not immune to the affliction of intellectual constipation!

Intellectual constipation’s effects on youth

The principle of a civilized debate of contrarian ideas must be inculcated early, especially during college years. Youth should be mentored about not cowering into an ideological cocoon and shun listening to different or opposing points of view.⁵ Institutions of higher learning are incubators of future leaders. They must provide their young students with a wide diversity of ideas and philosophies and encourage them to critique those ideas, not “shelter” or isolate them from any ideas. Youth need to recognize that the complex societies in which we all live and work are not placid or unidimensional but a hotbed of clashing ideas and perspectives. An open-minded approach to education will inoculate young minds from developing intellectual constipation in adulthood.

Avoiding or insulating oneself from the ideas of others—no matter how disagreeable—leads to cognitive cowardice and behavioral intolerance. Healthy and vibrant debate is necessary as an inoculation against extremism, hate, paranoia, and, ultimately, violence. Psychiatrists help patients to self-reflect, gain insight, and consider changing their view of themselves and the world to help them grow into mature and resilient individuals. But for the millions of people with intellectual constipation, a potent cerebral enema comprised of a salubrious concoction of insight, common sense, and compromise may be the prescription to forestall lethal intellectual ileus.

Groupthink is hazardous, especially when perfused with religious fervor. It can lead to adopting irrational thinking¹ and aversion to new ideas or facts. Tenaciously clinging to 1 ideology as “the absolute truth” precludes an open-minded, constructive debate with any other point of view.

Three historical examples come to mind:

• The discovery of chlorpromazine in 1952 was a scientifically and clinically seismic and transformational event for the treatment of psychosis, which for centuries had been dogmatically deemed irreversible. Jean Delay, MD, the French psychiatrist and co-discoverer of chlorpromazine, was the first physician to witness the magical and dazzling dissolution of delusions and hallucinations in chronically institutionalized patients with psychosis.² He published his landmark clinical observations and then traveled to the United States to share the great news and present his findings at a large psychiatric conference, hoping to enthrall American psychiatrists with the historic breakthrough in treating psychosis. This was an era in which psychoanalysis dominated American psychiatry (despite its dearth of empirical evidence). Dr. Delay was shocked when the audience of psycho­analysts booed him for saying that psychosis can be treated with a medication instead of with psychoanalysis (which, in the most intense groupthink in the history of psychiatry, they all believed was the only therapy for psychosis). Deeply disheartened, Dr. Delay returned to France and never returned to the United States. This groupthink was a prime example of intellectual constipation. Since then, not surprisingly, psychopharmacology grew meteorically while psychoanalysis declined precipitously.
• The monoamine hypothesis of depression, first propagated 60 years ago, became a groupthink dogma among psychiatric researchers for the next several decades, stultifying broader antidepressant medication development by focusing only on monoamines (eg, serotonin, norepinephrine, and dopamine). More recently, researchers have become more open-minded, and the monoamine hypothesis has taken a backseat to innovative new models of antidepressant therapy based on advances in the pathophysiology of depression, such as glutamatergic, opioid, and sigma pathways as well as neuroplasticity models.³ The consequence of groupthink in antidepressant research was a half-century delay in the development of effective alternative treatments that could have helped millions of patients recover from a life-threatening brain disorder such as major depressive disorder.
• Peptic ulcer and its serious gastritis were long believed to be due to stress and increased stomach acidity. So the groupthink gastroenterologists mocked 2 Australian researchers, Barry Marshall and Robin Warren, when they proposed that peptic ulcer may be due to an infection with a bacterium called Helicobacter pylori, and published their data demonstrating it.⁴ Marshall and Warren had the last laugh when they were awarded the 2005 Nobel Prize in Medicine and Physiology. It is ironic that even gastro­enterologists are not immune to the affliction of intellectual constipation!

Intellectual constipation’s effects on youth

The principle of a civilized debate of contrarian ideas must be inculcated early, especially during college years. Youth should be mentored about not cowering into an ideological cocoon and shun listening to different or opposing points of view.⁵ Institutions of higher learning are incubators of future leaders. They must provide their young students with a wide diversity of ideas and philosophies and encourage them to critique those ideas, not “shelter” or isolate them from any ideas. Youth need to recognize that the complex societies in which we all live and work are not placid or unidimensional but a hotbed of clashing ideas and perspectives. An open-minded approach to education will inoculate young minds from developing intellectual constipation in adulthood.

Avoiding or insulating oneself from the ideas of others—no matter how disagreeable—leads to cognitive cowardice and behavioral intolerance. Healthy and vibrant debate is necessary as an inoculation against extremism, hate, paranoia, and, ultimately, violence. Psychiatrists help patients to self-reflect, gain insight, and consider changing their view of themselves and the world to help them grow into mature and resilient individuals. But for the millions of people with intellectual constipation, a potent cerebral enema comprised of a salubrious concoction of insight, common sense, and compromise may be the prescription to forestall lethal intellectual ileus.

In a time of great national and global upheaval, increasing social problems, migration, climate crisis, globalization, and increasingly multicultural societies, our patients and their needs are unique, diverse, and changing. We need a new understanding of mental health to be able to adequately meet the demands of an ever-changing world. Treatment exclusively with psychotropic medications or years of psychoanalysis will not meet these needs.

Psychiatrists and psychotherapists feel (and actually have) a social responsibility, particularly in a multifaceted global society. Psychotherapeutic interventions may contribute to a more peaceful society¹ by reducing individuals’ inner stress, solving (unconscious) conflicts, and conveying a humanistic worldview. As an integrative and transcultural method, positive psychotherapy has been applied for more than 45 years in more than 60 countries and is an active force within a “positive mental health movement.”²

The term “positive psychotherapy” describes 2 different approaches³: positive psychotherapy (1977) by Nossrat Peseschkian,⁴ which is a humanistic psychodynamic approach, and positive psychotherapy (2006) by Martin E.P. Seligman, Tayyab Rashid, and Acacia C. Parks,⁵ which is a more cognitive-behavioral therapy (CBT)–based approach. This article focuses on the first approach.

Why ‘positive’ psychotherapy?

The term “positive” implies that positive psychotherapy focuses on the patient’s possibilities and capacities. Symptoms and disorders are seen as capacities to react to a conflict. The Latin term “positum” or “positivus” is applied in its original meaning—the factual, the given, the actual. Factual and given are not only the disorder, the symptoms, and the problems but also the capacity to become healthy and/or cope with this situation. This positive meaning confronts the patient (and the therapist) with a lesser-known aspect of the illness, but one that is just as important for the understanding and clinical treatment of the affliction: its function, its meaning, and, consequently, its positive aspects.⁶

Positive psychotherapy is a humanistic psychodynamic psychotherapy approach developed by Nossrat Peseschkian (1933-2010).^4,7 Positive psychotherapy has been developed since the 1970s in the clinical setting with neurotic and psychosomatic patients. It integrates approaches of the 4 main modalities of psychotherapy:

• a humanistic view of human beings
• a systemic approach toward culture, work, and environment
• a psychodynamic understanding of disorders
• a practical, goal-oriented approach with some cognitive-behavioral techniques.

The concept of balance

Based on a humanistic view of human beings and the resources every patient possesses, a key concept of positive psychotherapy is the importance of balance in one’s life. The balance model (Figure) is the core of positive psychotherapy and is applied in clinical and nonclinical settings. This model is based on the concept that there are 4 main areas of life in which a human being lives and functions. These areas influence one’s satisfaction in life, one’s feelings of self-worth, and the way one deals with conflicts and challenges. Although all 4 capacities are latent in every human being, depending on one`s education, environment, and zeitgeist, some will be more developed than others. Our life energies, activities, and reactions belong to these 4 areas of life:

• physical: eating, tenderness, sexuality, sleep, relaxation, sports, appearance, clothing
• achievement: work, job, career, money
• relationships: partner, family, friends, acquaintances and strangers, community life
• meaning and future: existential questions, spirituality, religious practices, future plans, fantasy.

A goal of treatment is to help the patient recognize their own resources and mobilize them with the goal of bringing them into a dynamic equilibrium. This goal places value on a balanced distribution of energy (25% to each area), not of time. According to positive psychotherapy, a person does not become ill because one sphere of life is overemphasized but because of the areas that have been neglected. In the case vignette described in the Box, the problem is not the patient’s work but that his physical health, family and friends, and existential questions are being neglected. That the therapist is not critical from the start of treatment is a constructive experience for the patient and is important and fruitful for building the relationship between the therapist and the patient. Instead of emphasizing the deficits or the disorders, the patient and his family hear that he has neglected other areas of life and not developed them yet.

Box

Continue to: The balance model...

The balance model also embodies the 4 potential sources of self-esteem. Usually, only 1 or 2 areas provide self-esteem, but in the therapeutic process a patient can learn to uncover the neglected areas so that their self-esteem will have additional pillars of support. By emphasizing how therapy can help to develop one’s self-esteem, many patients can be motivated for the therapeutic process. The balance model, with its concept of devoting 25% of one’s energy to each sphere of life, gives the patient a clear vision about their life and how they can be healthy over the long run by avoiding one-sidedness.⁸

The transcultural approach

In positive psychotherapy, the term “transcultural” (or cross-cultural) means not only consideration of cultural factors when the therapist and patient come from diverse cultural backgrounds (intercultural psychotherapy or “migrant psychotherapy”) but specifically the consideration of cultural factors in every therapeutic relationship, as a therapeutic attitude and consequently as a sociopolitical dimension of our thinking and behavior. This consideration of the uniqueness of each person, of the relativity of human behavior, and of “unity in diversity” is an essential reason positive psychotherapy is not a “Western” method in the sense of “psychological colonization.”⁹ Rather, this approach is a culture-sensitive method that can be modified to adapt to particular cultures and life situations.

Transcultural positive psychotherapy begins with answering 2 questions: “How are people different?” and “What do all people have in common?”⁴ During the therapeutic process, the therapist gives examples from other cultures to the patient to help them relativize their own perspective and broaden their repertoire of behavior.

The use of stories, tales, proverbs, and anecdotes

A special technique of positive psychotherapy is the therapeutic use of stories, tales, proverbs, and anecdotes.¹⁰ Often stories from other cultures are used because they offer another perspective when the patient sees none. This has been shown to be highly effective in psychiatric settings, especially in group settings. Psychiatric patients can often easily relate to the images created by stories. In psychiatry and psychotherapy, stories can be a means of changing a patient’s point of view. Such narratives can free up the listener’s feelings and thoughts and often lead to “Aha!” moments. The mirror function of storytelling leads to identification. In the narratives, the reader or listener recognizes themself as well as their needs and situation. They can reflect on the stories without personally becoming the focus of these reflections and remember their own experiences. Stories present solutions that can be models against which one’s own approach can be compared but that also leave room for broader interpretation. Storytelling is particularly useful in bringing about change in patients who are holding fast to old and outworn ideas.

The positive interpretation of disorders

Positive psychotherapy is based on a humanistic view that every human being is good by nature and endowed with unique capacities.¹¹ This positive perspective leads not only to a new quality of relationship between the therapist and patient but also to a new perspective on disorders (Table). Thus, disorders can be “interpreted” in a positive way⁶: What does the patient unconsciously want to express with their symptoms? What is the function of their disorder? The positive process brings with it a change in perspective to all those concerned: the patient, their family, and the therapist/physician. In this way, one moves from the symptom (which is the disorder and often already has been very thoroughly examined) to the conflict (and the function of the disorder). The positive interpretations are only offered to the patient (“What do you say to this explanation?” “Can you apply this to your own situation?”).

Continue to: This process also helps us...

This process also helps us focus on the “true” patient, who often is not our patient. The patient who comes to us functions as a symptom carrier and can be seen as the “weakest link” in the family chain. The “real patient” is often sitting at home. The positive interpretation of illnesses confronts the patient with the possible function and psychodynamic meaning of their illness for themself and their social milieu, encouraging the patient (and their family) to see their abilities and not merely the pathological aspects.¹²

Fields of application of positive psychotherapy

As a method positioned between manualiz­ed CBT and process-oriented analytical psychotherapy, positive psychotherapy pursues a semi-structured approach in diagnostics (first interview), treatment, posttherapeutic self-help, and training. Positive psychotherapy is applied for the treatment of mood (affective), neurotic, stress-related, and somatoform disorders; behavioral syndromes; and, to some extent, personality disorders. Positive psychotherapy has been employed successfully side-by-side with classical individual therapy as well as in the settings of couple, family, and group therapy.¹³

What makes positive psychotherapy attractive for mental health professionals?

• As a method that integrates the 4 main modalities of psychotherapy, it does not engage in the conflicts between different schools but combines effective elements into a single approach.
• As an integrative approach, it adjusts to the patient and not vice versa. It gives the therapist the possibility of focusing more on either the actual problems (supportive approach) or the basic conflict (psychodynamic approach).
• It uses vocabulary and terms that can be understood by patients from all strata of society.
• As a culturally sensitive method, it can be applied to patients from different cultures and does not require cultural adaptation.
• As a psychodynamic method, it does not stop after early life conflicts have become more conscious but helps the patient to apply the gained insights using practical techniques.
• It starts with positive affirmations and encouragement but does not later “forget” the unconscious conflicts that have led to disorders. It is not perceived as superficial.
• As a method originally coming from psychiatry and medical practice, it builds a bridge between a scientific basis and psychotherapeutic insights. It favors the biopsychosocial approach.

Bottom Line

Positive psychotherapy combines humanistic, systemic, psychodynamic, and cognitive-behavioral aspects. It is based on a resource-oriented view of human beings in which disorders are interpreted as capacities to react in a specific and unique way to life events and circumstances. Positive psychotherapy can be applied in psychiatry and psychotherapy. This short-term method is easily understood by patients from diverse cultures and social backgrounds.

Related Resources

• Peseschkian H, Remmers A. Positive psychotherapy: an introduction. In: Messias E, Peseschkian H, Cagande C, eds. Positive Psychiatry, Psychotherapy and Psychology. Springer; 2020:11-32. https://doi.org/10.1007/978-3-030-33264-8_2
• Tritt K, Loew T, Meyer M, et al. Positive psychotherapy: effectiveness of an interdisciplinary approach. Eur J Psychiatry. 1999;13(4):231-241.
• World Association for Positive and Transcultural Psychotherapy. http://www.positum.org

In a time of great national and global upheaval, increasing social problems, migration, climate crisis, globalization, and increasingly multicultural societies, our patients and their needs are unique, diverse, and changing. We need a new understanding of mental health to be able to adequately meet the demands of an ever-changing world. Treatment exclusively with psychotropic medications or years of psychoanalysis will not meet these needs.

Psychiatrists and psychotherapists feel (and actually have) a social responsibility, particularly in a multifaceted global society. Psychotherapeutic interventions may contribute to a more peaceful society¹ by reducing individuals’ inner stress, solving (unconscious) conflicts, and conveying a humanistic worldview. As an integrative and transcultural method, positive psychotherapy has been applied for more than 45 years in more than 60 countries and is an active force within a “positive mental health movement.”²

The term “positive psychotherapy” describes 2 different approaches³: positive psychotherapy (1977) by Nossrat Peseschkian,⁴ which is a humanistic psychodynamic approach, and positive psychotherapy (2006) by Martin E.P. Seligman, Tayyab Rashid, and Acacia C. Parks,⁵ which is a more cognitive-behavioral therapy (CBT)–based approach. This article focuses on the first approach.

Why ‘positive’ psychotherapy?

The term “positive” implies that positive psychotherapy focuses on the patient’s possibilities and capacities. Symptoms and disorders are seen as capacities to react to a conflict. The Latin term “positum” or “positivus” is applied in its original meaning—the factual, the given, the actual. Factual and given are not only the disorder, the symptoms, and the problems but also the capacity to become healthy and/or cope with this situation. This positive meaning confronts the patient (and the therapist) with a lesser-known aspect of the illness, but one that is just as important for the understanding and clinical treatment of the affliction: its function, its meaning, and, consequently, its positive aspects.⁶

Positive psychotherapy is a humanistic psychodynamic psychotherapy approach developed by Nossrat Peseschkian (1933-2010).^4,7 Positive psychotherapy has been developed since the 1970s in the clinical setting with neurotic and psychosomatic patients. It integrates approaches of the 4 main modalities of psychotherapy:

• a humanistic view of human beings
• a systemic approach toward culture, work, and environment
• a psychodynamic understanding of disorders
• a practical, goal-oriented approach with some cognitive-behavioral techniques.

The concept of balance

Based on a humanistic view of human beings and the resources every patient possesses, a key concept of positive psychotherapy is the importance of balance in one’s life. The balance model (Figure) is the core of positive psychotherapy and is applied in clinical and nonclinical settings. This model is based on the concept that there are 4 main areas of life in which a human being lives and functions. These areas influence one’s satisfaction in life, one’s feelings of self-worth, and the way one deals with conflicts and challenges. Although all 4 capacities are latent in every human being, depending on one`s education, environment, and zeitgeist, some will be more developed than others. Our life energies, activities, and reactions belong to these 4 areas of life:

• physical: eating, tenderness, sexuality, sleep, relaxation, sports, appearance, clothing
• achievement: work, job, career, money
• relationships: partner, family, friends, acquaintances and strangers, community life
• meaning and future: existential questions, spirituality, religious practices, future plans, fantasy.

A goal of treatment is to help the patient recognize their own resources and mobilize them with the goal of bringing them into a dynamic equilibrium. This goal places value on a balanced distribution of energy (25% to each area), not of time. According to positive psychotherapy, a person does not become ill because one sphere of life is overemphasized but because of the areas that have been neglected. In the case vignette described in the Box, the problem is not the patient’s work but that his physical health, family and friends, and existential questions are being neglected. That the therapist is not critical from the start of treatment is a constructive experience for the patient and is important and fruitful for building the relationship between the therapist and the patient. Instead of emphasizing the deficits or the disorders, the patient and his family hear that he has neglected other areas of life and not developed them yet.

Box

Continue to: The balance model...

The balance model also embodies the 4 potential sources of self-esteem. Usually, only 1 or 2 areas provide self-esteem, but in the therapeutic process a patient can learn to uncover the neglected areas so that their self-esteem will have additional pillars of support. By emphasizing how therapy can help to develop one’s self-esteem, many patients can be motivated for the therapeutic process. The balance model, with its concept of devoting 25% of one’s energy to each sphere of life, gives the patient a clear vision about their life and how they can be healthy over the long run by avoiding one-sidedness.⁸

The transcultural approach

In positive psychotherapy, the term “transcultural” (or cross-cultural) means not only consideration of cultural factors when the therapist and patient come from diverse cultural backgrounds (intercultural psychotherapy or “migrant psychotherapy”) but specifically the consideration of cultural factors in every therapeutic relationship, as a therapeutic attitude and consequently as a sociopolitical dimension of our thinking and behavior. This consideration of the uniqueness of each person, of the relativity of human behavior, and of “unity in diversity” is an essential reason positive psychotherapy is not a “Western” method in the sense of “psychological colonization.”⁹ Rather, this approach is a culture-sensitive method that can be modified to adapt to particular cultures and life situations.

Transcultural positive psychotherapy begins with answering 2 questions: “How are people different?” and “What do all people have in common?”⁴ During the therapeutic process, the therapist gives examples from other cultures to the patient to help them relativize their own perspective and broaden their repertoire of behavior.

The use of stories, tales, proverbs, and anecdotes

A special technique of positive psychotherapy is the therapeutic use of stories, tales, proverbs, and anecdotes.¹⁰ Often stories from other cultures are used because they offer another perspective when the patient sees none. This has been shown to be highly effective in psychiatric settings, especially in group settings. Psychiatric patients can often easily relate to the images created by stories. In psychiatry and psychotherapy, stories can be a means of changing a patient’s point of view. Such narratives can free up the listener’s feelings and thoughts and often lead to “Aha!” moments. The mirror function of storytelling leads to identification. In the narratives, the reader or listener recognizes themself as well as their needs and situation. They can reflect on the stories without personally becoming the focus of these reflections and remember their own experiences. Stories present solutions that can be models against which one’s own approach can be compared but that also leave room for broader interpretation. Storytelling is particularly useful in bringing about change in patients who are holding fast to old and outworn ideas.

The positive interpretation of disorders

Positive psychotherapy is based on a humanistic view that every human being is good by nature and endowed with unique capacities.¹¹ This positive perspective leads not only to a new quality of relationship between the therapist and patient but also to a new perspective on disorders (Table). Thus, disorders can be “interpreted” in a positive way⁶: What does the patient unconsciously want to express with their symptoms? What is the function of their disorder? The positive process brings with it a change in perspective to all those concerned: the patient, their family, and the therapist/physician. In this way, one moves from the symptom (which is the disorder and often already has been very thoroughly examined) to the conflict (and the function of the disorder). The positive interpretations are only offered to the patient (“What do you say to this explanation?” “Can you apply this to your own situation?”).

Continue to: This process also helps us...

This process also helps us focus on the “true” patient, who often is not our patient. The patient who comes to us functions as a symptom carrier and can be seen as the “weakest link” in the family chain. The “real patient” is often sitting at home. The positive interpretation of illnesses confronts the patient with the possible function and psychodynamic meaning of their illness for themself and their social milieu, encouraging the patient (and their family) to see their abilities and not merely the pathological aspects.¹²

Fields of application of positive psychotherapy

As a method positioned between manualiz­ed CBT and process-oriented analytical psychotherapy, positive psychotherapy pursues a semi-structured approach in diagnostics (first interview), treatment, posttherapeutic self-help, and training. Positive psychotherapy is applied for the treatment of mood (affective), neurotic, stress-related, and somatoform disorders; behavioral syndromes; and, to some extent, personality disorders. Positive psychotherapy has been employed successfully side-by-side with classical individual therapy as well as in the settings of couple, family, and group therapy.¹³

What makes positive psychotherapy attractive for mental health professionals?

• As a method that integrates the 4 main modalities of psychotherapy, it does not engage in the conflicts between different schools but combines effective elements into a single approach.
• As an integrative approach, it adjusts to the patient and not vice versa. It gives the therapist the possibility of focusing more on either the actual problems (supportive approach) or the basic conflict (psychodynamic approach).
• It uses vocabulary and terms that can be understood by patients from all strata of society.
• As a culturally sensitive method, it can be applied to patients from different cultures and does not require cultural adaptation.
• As a psychodynamic method, it does not stop after early life conflicts have become more conscious but helps the patient to apply the gained insights using practical techniques.
• It starts with positive affirmations and encouragement but does not later “forget” the unconscious conflicts that have led to disorders. It is not perceived as superficial.
• As a method originally coming from psychiatry and medical practice, it builds a bridge between a scientific basis and psychotherapeutic insights. It favors the biopsychosocial approach.

Bottom Line

Positive psychotherapy combines humanistic, systemic, psychodynamic, and cognitive-behavioral aspects. It is based on a resource-oriented view of human beings in which disorders are interpreted as capacities to react in a specific and unique way to life events and circumstances. Positive psychotherapy can be applied in psychiatry and psychotherapy. This short-term method is easily understood by patients from diverse cultures and social backgrounds.

Related Resources

• Peseschkian H, Remmers A. Positive psychotherapy: an introduction. In: Messias E, Peseschkian H, Cagande C, eds. Positive Psychiatry, Psychotherapy and Psychology. Springer; 2020:11-32. https://doi.org/10.1007/978-3-030-33264-8_2
• Tritt K, Loew T, Meyer M, et al. Positive psychotherapy: effectiveness of an interdisciplinary approach. Eur J Psychiatry. 1999;13(4):231-241.
• World Association for Positive and Transcultural Psychotherapy. http://www.positum.org

In a time of great national and global upheaval, increasing social problems, migration, climate crisis, globalization, and increasingly multicultural societies, our patients and their needs are unique, diverse, and changing. We need a new understanding of mental health to be able to adequately meet the demands of an ever-changing world. Treatment exclusively with psychotropic medications or years of psychoanalysis will not meet these needs.

Psychiatrists and psychotherapists feel (and actually have) a social responsibility, particularly in a multifaceted global society. Psychotherapeutic interventions may contribute to a more peaceful society¹ by reducing individuals’ inner stress, solving (unconscious) conflicts, and conveying a humanistic worldview. As an integrative and transcultural method, positive psychotherapy has been applied for more than 45 years in more than 60 countries and is an active force within a “positive mental health movement.”²

The term “positive psychotherapy” describes 2 different approaches³: positive psychotherapy (1977) by Nossrat Peseschkian,⁴ which is a humanistic psychodynamic approach, and positive psychotherapy (2006) by Martin E.P. Seligman, Tayyab Rashid, and Acacia C. Parks,⁵ which is a more cognitive-behavioral therapy (CBT)–based approach. This article focuses on the first approach.

Why ‘positive’ psychotherapy?

The term “positive” implies that positive psychotherapy focuses on the patient’s possibilities and capacities. Symptoms and disorders are seen as capacities to react to a conflict. The Latin term “positum” or “positivus” is applied in its original meaning—the factual, the given, the actual. Factual and given are not only the disorder, the symptoms, and the problems but also the capacity to become healthy and/or cope with this situation. This positive meaning confronts the patient (and the therapist) with a lesser-known aspect of the illness, but one that is just as important for the understanding and clinical treatment of the affliction: its function, its meaning, and, consequently, its positive aspects.⁶

Positive psychotherapy is a humanistic psychodynamic psychotherapy approach developed by Nossrat Peseschkian (1933-2010).^4,7 Positive psychotherapy has been developed since the 1970s in the clinical setting with neurotic and psychosomatic patients. It integrates approaches of the 4 main modalities of psychotherapy:

• a humanistic view of human beings
• a systemic approach toward culture, work, and environment
• a psychodynamic understanding of disorders
• a practical, goal-oriented approach with some cognitive-behavioral techniques.

The concept of balance

Based on a humanistic view of human beings and the resources every patient possesses, a key concept of positive psychotherapy is the importance of balance in one’s life. The balance model (Figure) is the core of positive psychotherapy and is applied in clinical and nonclinical settings. This model is based on the concept that there are 4 main areas of life in which a human being lives and functions. These areas influence one’s satisfaction in life, one’s feelings of self-worth, and the way one deals with conflicts and challenges. Although all 4 capacities are latent in every human being, depending on one`s education, environment, and zeitgeist, some will be more developed than others. Our life energies, activities, and reactions belong to these 4 areas of life:

• physical: eating, tenderness, sexuality, sleep, relaxation, sports, appearance, clothing
• achievement: work, job, career, money
• relationships: partner, family, friends, acquaintances and strangers, community life
• meaning and future: existential questions, spirituality, religious practices, future plans, fantasy.

A goal of treatment is to help the patient recognize their own resources and mobilize them with the goal of bringing them into a dynamic equilibrium. This goal places value on a balanced distribution of energy (25% to each area), not of time. According to positive psychotherapy, a person does not become ill because one sphere of life is overemphasized but because of the areas that have been neglected. In the case vignette described in the Box, the problem is not the patient’s work but that his physical health, family and friends, and existential questions are being neglected. That the therapist is not critical from the start of treatment is a constructive experience for the patient and is important and fruitful for building the relationship between the therapist and the patient. Instead of emphasizing the deficits or the disorders, the patient and his family hear that he has neglected other areas of life and not developed them yet.

Box

Continue to: The balance model...

The balance model also embodies the 4 potential sources of self-esteem. Usually, only 1 or 2 areas provide self-esteem, but in the therapeutic process a patient can learn to uncover the neglected areas so that their self-esteem will have additional pillars of support. By emphasizing how therapy can help to develop one’s self-esteem, many patients can be motivated for the therapeutic process. The balance model, with its concept of devoting 25% of one’s energy to each sphere of life, gives the patient a clear vision about their life and how they can be healthy over the long run by avoiding one-sidedness.⁸

The transcultural approach

In positive psychotherapy, the term “transcultural” (or cross-cultural) means not only consideration of cultural factors when the therapist and patient come from diverse cultural backgrounds (intercultural psychotherapy or “migrant psychotherapy”) but specifically the consideration of cultural factors in every therapeutic relationship, as a therapeutic attitude and consequently as a sociopolitical dimension of our thinking and behavior. This consideration of the uniqueness of each person, of the relativity of human behavior, and of “unity in diversity” is an essential reason positive psychotherapy is not a “Western” method in the sense of “psychological colonization.”⁹ Rather, this approach is a culture-sensitive method that can be modified to adapt to particular cultures and life situations.

Transcultural positive psychotherapy begins with answering 2 questions: “How are people different?” and “What do all people have in common?”⁴ During the therapeutic process, the therapist gives examples from other cultures to the patient to help them relativize their own perspective and broaden their repertoire of behavior.

The use of stories, tales, proverbs, and anecdotes

A special technique of positive psychotherapy is the therapeutic use of stories, tales, proverbs, and anecdotes.¹⁰ Often stories from other cultures are used because they offer another perspective when the patient sees none. This has been shown to be highly effective in psychiatric settings, especially in group settings. Psychiatric patients can often easily relate to the images created by stories. In psychiatry and psychotherapy, stories can be a means of changing a patient’s point of view. Such narratives can free up the listener’s feelings and thoughts and often lead to “Aha!” moments. The mirror function of storytelling leads to identification. In the narratives, the reader or listener recognizes themself as well as their needs and situation. They can reflect on the stories without personally becoming the focus of these reflections and remember their own experiences. Stories present solutions that can be models against which one’s own approach can be compared but that also leave room for broader interpretation. Storytelling is particularly useful in bringing about change in patients who are holding fast to old and outworn ideas.

The positive interpretation of disorders

Positive psychotherapy is based on a humanistic view that every human being is good by nature and endowed with unique capacities.¹¹ This positive perspective leads not only to a new quality of relationship between the therapist and patient but also to a new perspective on disorders (Table). Thus, disorders can be “interpreted” in a positive way⁶: What does the patient unconsciously want to express with their symptoms? What is the function of their disorder? The positive process brings with it a change in perspective to all those concerned: the patient, their family, and the therapist/physician. In this way, one moves from the symptom (which is the disorder and often already has been very thoroughly examined) to the conflict (and the function of the disorder). The positive interpretations are only offered to the patient (“What do you say to this explanation?” “Can you apply this to your own situation?”).

Continue to: This process also helps us...

This process also helps us focus on the “true” patient, who often is not our patient. The patient who comes to us functions as a symptom carrier and can be seen as the “weakest link” in the family chain. The “real patient” is often sitting at home. The positive interpretation of illnesses confronts the patient with the possible function and psychodynamic meaning of their illness for themself and their social milieu, encouraging the patient (and their family) to see their abilities and not merely the pathological aspects.¹²

Fields of application of positive psychotherapy

As a method positioned between manualiz­ed CBT and process-oriented analytical psychotherapy, positive psychotherapy pursues a semi-structured approach in diagnostics (first interview), treatment, posttherapeutic self-help, and training. Positive psychotherapy is applied for the treatment of mood (affective), neurotic, stress-related, and somatoform disorders; behavioral syndromes; and, to some extent, personality disorders. Positive psychotherapy has been employed successfully side-by-side with classical individual therapy as well as in the settings of couple, family, and group therapy.¹³

What makes positive psychotherapy attractive for mental health professionals?

• As a method that integrates the 4 main modalities of psychotherapy, it does not engage in the conflicts between different schools but combines effective elements into a single approach.
• As an integrative approach, it adjusts to the patient and not vice versa. It gives the therapist the possibility of focusing more on either the actual problems (supportive approach) or the basic conflict (psychodynamic approach).
• It uses vocabulary and terms that can be understood by patients from all strata of society.
• As a culturally sensitive method, it can be applied to patients from different cultures and does not require cultural adaptation.
• As a psychodynamic method, it does not stop after early life conflicts have become more conscious but helps the patient to apply the gained insights using practical techniques.
• It starts with positive affirmations and encouragement but does not later “forget” the unconscious conflicts that have led to disorders. It is not perceived as superficial.
• As a method originally coming from psychiatry and medical practice, it builds a bridge between a scientific basis and psychotherapeutic insights. It favors the biopsychosocial approach.

Bottom Line

Positive psychotherapy combines humanistic, systemic, psychodynamic, and cognitive-behavioral aspects. It is based on a resource-oriented view of human beings in which disorders are interpreted as capacities to react in a specific and unique way to life events and circumstances. Positive psychotherapy can be applied in psychiatry and psychotherapy. This short-term method is easily understood by patients from diverse cultures and social backgrounds.

Related Resources

• Peseschkian H, Remmers A. Positive psychotherapy: an introduction. In: Messias E, Peseschkian H, Cagande C, eds. Positive Psychiatry, Psychotherapy and Psychology. Springer; 2020:11-32. https://doi.org/10.1007/978-3-030-33264-8_2
• Tritt K, Loew T, Meyer M, et al. Positive psychotherapy: effectiveness of an interdisciplinary approach. Eur J Psychiatry. 1999;13(4):231-241.
• World Association for Positive and Transcultural Psychotherapy. http://www.positum.org

Weak handgrip in older adults is linked to a higher risk for depression – while a stronger handgrip may have protective benefits, new research suggests.
 

In a study of more than 115,000 adults, there was a significant association between stronger handgrip, up to 40 kg in men and 27 kg in women, and lower depression risk.

Investigators add that there was a “dose-response” association between physical strength and risk for depression.

“Being physically strong may serve as a preventive factor for depression in older adults, but this is limited to a maximum specific threshold for men and women,” Ruben Lopez-Bueno, PhD, of the department of physical medicine and nursing, University of Zaragoza, Spain, and colleagues write.

The findings were published online in the British Journal of Psychiatry.
 

Easy, fast, reliable

Depression is a major public health problem, and studies “aimed at examining preventive factors to tackle the increase in depression are required,” the investigators write.

They add that a “growing body of research” is examining the link between depression and muscle strength, with handgrip as an estimator, in healthy middle-aged and older adults.

Handgrip strength is an “easy-to-use, fast and reliable indicator of both sarcopenia (age-related loss of muscle mass) and dynapenia (age-related loss of muscle strength), both of which have been associated with depression,” the researchers note.

It is plausible that there is a “regulatory role of skeletal muscle on brain function affecting this condition,” they add.

They note that exercise seems to play a “key role” because it can improve muscle strength as well as muscle mass, downregulate systemic inflammation, and improve neuroplasticity, neuroendocrine, and oxidative stress responses.

Previous studies have relied either on cross-sectional or prospective cohort models and have focused mostly on a specific country, “not accounting for time-varying changes of both handgrip strength and relevant covariables.”

Moreover, previous evidence has been mixed regarding the “extent to which handgrip strength levels may associate with lower risk of depression, with study results ranging from weak to strong associations,” the investigators write.

So “higher-quality research with representative samples from different countries is required to better clarify the strength of such an association and to confirm directionality,” they add.
 

SHARE data

To fill this gap, the researchers turned to data from waves 1, 2, 4, 5, 6, and 7 of the Survey of Health, Ageing and Retirement in Europe (SHARE). This encompassed 115,601 individuals aged 50 years and older (mean age, 64.3 years; 54.3% women) residing in European countries and Israel (24 countries total).

Data from wave 3 were not used because handgrip measures were not used in that wave. In the other waves, a handheld dynamometer was used to measure handgrip strength.

The participants were divided into tertiles of handgrip strength, with the “first third” being the lowest tertile of strength and the “final third” representing the highest strength.

All participants were followed for a median of 7.3 years (792,459 person-years), during which 26.1% experienced a risk for depression, as reflected by scores on the EURO-D 12-item scale.

The investigators set the time scale as the months from study entry until either a first depression onset or the end of follow-up.

Covariates that the researchers accounted for included gender, age, education, country, body mass index, physical inactivity, smoking, alcohol consumption, whether living with a partner, wave of inclusion, chronic diseases, consumption of prescribed drugs, and fruit and vegetable consumption.

The researchers used two models: the first adjusted for gender and age at time of the interview, and the second adjusted for all confounders.

In the model that was adjusted only for gender and age, greater handgrip strength was associated with a significantly reduced risk for depression among participants in the second, third, and the final third in comparison with the first third (hazard ratio, 0.65; 95% confidence interval, 0.63-0.68; and HR, 0.50; 95% CI, 0.48-0.53, respectively).

The associations remained consistent in the fully adjusted model, although risk for depression was slightly attenuated in the second and final thirds compared with the first third (HR, 0.76; 95% CI, 0.71-0.81; and HR, 0.64; 95% CI, 0.59-0.69, respectively).

When the researchers conducted analyses using restricted cubic spline modeling, they found a significant association for each kilogram increase of handgrip strength and depression, up to 40 kg in men and 27 kg in women (HR, 1.39; 95% CI, 1.08-1.71; and HR, 1.28; 95% CI, 1.05-1.55, respectively).

There was no greater reduction in depression risk in those with handgrip strength above those values.
 

Potential depression screen

The investigators suggest several explanations for their findings. For example, handgrip strength has “been used as an overall indicator of health status, including sarcopenia,” they write.

Adults with sarcopenia have been found to be at greater risk for depression because of reduced muscle strength, since neurotrophins are produced by skeletal muscle, among other tissues, and are associated with improvement in mood.

From a psychological point of view, “being physically strong may lead to a sensation of psychological wellbeing,” the researchers write.

Moreover, being physically active “across the lifespan also promotes structural and functional changes in the brain, benefiting cognitive functioning and reducing the risk of neurodegeneration,” they write.

This can be important because aging adults with cognitive impairments can also experience neuromuscular impairments that “presumably will contribute to becoming weaker,” they note.

Overall, the findings “warrant strength training programmes aimed at older adults to reduce depression risk,” the investigators write. Clinicians “may consider using the observed handgrip strength thresholds to screen for potential depression risk in older adults,” they add.
 

Protective factor?

Commenting for this news organization, Julian Mutz, PhD, postdoctoral research associate at the Social, Genetic and Developmental Psychiatry Centre, King’s College, London, said the study “provides further evidence that physical strength may be a protective factor against depression in older adults.”

This confirms a “plethora of cross-sectional and longitudinal studies,” including one recently conducted by Dr. Mutz’s group.

The design of the current study “allowed the authors to address a number of key limitations of previous studies, for example, by including repeated measurements of grip strength and adjustment for potential confounding factors over time,” said Dr. Mutz, who was not involved with the research.

Additionally, “an important contribution of this study is that the authors show that higher grip strength is only associated with a lower risk of depression up to a specific threshold,” he noted.

“The clinical implication of this finding is that only individuals with grip strength below this threshold are at a higher risk of depression. These individuals especially may benefit from interventions aimed at increasing physical strength,” Dr. Mutz said.

The SHARE data collection has been funded by the European Commission and by DG Employment, Social Affairs and Inclusion. Additional funding was obtained from the German Ministry of Education and Research, the Max Planck Society for the Advancement of Science, and the U.S. National Institute on Aging. Dr. Lopez-Bueno is supported by the European Union – Next Generation EU. The other investigators and Dr. Mutz have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Weak handgrip in older adults is linked to a higher risk for depression – while a stronger handgrip may have protective benefits, new research suggests.
 

In a study of more than 115,000 adults, there was a significant association between stronger handgrip, up to 40 kg in men and 27 kg in women, and lower depression risk.

Investigators add that there was a “dose-response” association between physical strength and risk for depression.

“Being physically strong may serve as a preventive factor for depression in older adults, but this is limited to a maximum specific threshold for men and women,” Ruben Lopez-Bueno, PhD, of the department of physical medicine and nursing, University of Zaragoza, Spain, and colleagues write.

The findings were published online in the British Journal of Psychiatry.
 

Easy, fast, reliable

Depression is a major public health problem, and studies “aimed at examining preventive factors to tackle the increase in depression are required,” the investigators write.

They add that a “growing body of research” is examining the link between depression and muscle strength, with handgrip as an estimator, in healthy middle-aged and older adults.

Handgrip strength is an “easy-to-use, fast and reliable indicator of both sarcopenia (age-related loss of muscle mass) and dynapenia (age-related loss of muscle strength), both of which have been associated with depression,” the researchers note.

It is plausible that there is a “regulatory role of skeletal muscle on brain function affecting this condition,” they add.

They note that exercise seems to play a “key role” because it can improve muscle strength as well as muscle mass, downregulate systemic inflammation, and improve neuroplasticity, neuroendocrine, and oxidative stress responses.

Previous studies have relied either on cross-sectional or prospective cohort models and have focused mostly on a specific country, “not accounting for time-varying changes of both handgrip strength and relevant covariables.”

Moreover, previous evidence has been mixed regarding the “extent to which handgrip strength levels may associate with lower risk of depression, with study results ranging from weak to strong associations,” the investigators write.

So “higher-quality research with representative samples from different countries is required to better clarify the strength of such an association and to confirm directionality,” they add.
 

SHARE data

To fill this gap, the researchers turned to data from waves 1, 2, 4, 5, 6, and 7 of the Survey of Health, Ageing and Retirement in Europe (SHARE). This encompassed 115,601 individuals aged 50 years and older (mean age, 64.3 years; 54.3% women) residing in European countries and Israel (24 countries total).

Data from wave 3 were not used because handgrip measures were not used in that wave. In the other waves, a handheld dynamometer was used to measure handgrip strength.

The participants were divided into tertiles of handgrip strength, with the “first third” being the lowest tertile of strength and the “final third” representing the highest strength.

All participants were followed for a median of 7.3 years (792,459 person-years), during which 26.1% experienced a risk for depression, as reflected by scores on the EURO-D 12-item scale.

The investigators set the time scale as the months from study entry until either a first depression onset or the end of follow-up.

Covariates that the researchers accounted for included gender, age, education, country, body mass index, physical inactivity, smoking, alcohol consumption, whether living with a partner, wave of inclusion, chronic diseases, consumption of prescribed drugs, and fruit and vegetable consumption.

The researchers used two models: the first adjusted for gender and age at time of the interview, and the second adjusted for all confounders.

In the model that was adjusted only for gender and age, greater handgrip strength was associated with a significantly reduced risk for depression among participants in the second, third, and the final third in comparison with the first third (hazard ratio, 0.65; 95% confidence interval, 0.63-0.68; and HR, 0.50; 95% CI, 0.48-0.53, respectively).

The associations remained consistent in the fully adjusted model, although risk for depression was slightly attenuated in the second and final thirds compared with the first third (HR, 0.76; 95% CI, 0.71-0.81; and HR, 0.64; 95% CI, 0.59-0.69, respectively).

When the researchers conducted analyses using restricted cubic spline modeling, they found a significant association for each kilogram increase of handgrip strength and depression, up to 40 kg in men and 27 kg in women (HR, 1.39; 95% CI, 1.08-1.71; and HR, 1.28; 95% CI, 1.05-1.55, respectively).

There was no greater reduction in depression risk in those with handgrip strength above those values.
 

Potential depression screen

The investigators suggest several explanations for their findings. For example, handgrip strength has “been used as an overall indicator of health status, including sarcopenia,” they write.

Adults with sarcopenia have been found to be at greater risk for depression because of reduced muscle strength, since neurotrophins are produced by skeletal muscle, among other tissues, and are associated with improvement in mood.

From a psychological point of view, “being physically strong may lead to a sensation of psychological wellbeing,” the researchers write.

Moreover, being physically active “across the lifespan also promotes structural and functional changes in the brain, benefiting cognitive functioning and reducing the risk of neurodegeneration,” they write.

This can be important because aging adults with cognitive impairments can also experience neuromuscular impairments that “presumably will contribute to becoming weaker,” they note.

Overall, the findings “warrant strength training programmes aimed at older adults to reduce depression risk,” the investigators write. Clinicians “may consider using the observed handgrip strength thresholds to screen for potential depression risk in older adults,” they add.
 

Protective factor?

Commenting for this news organization, Julian Mutz, PhD, postdoctoral research associate at the Social, Genetic and Developmental Psychiatry Centre, King’s College, London, said the study “provides further evidence that physical strength may be a protective factor against depression in older adults.”

This confirms a “plethora of cross-sectional and longitudinal studies,” including one recently conducted by Dr. Mutz’s group.

The design of the current study “allowed the authors to address a number of key limitations of previous studies, for example, by including repeated measurements of grip strength and adjustment for potential confounding factors over time,” said Dr. Mutz, who was not involved with the research.

Additionally, “an important contribution of this study is that the authors show that higher grip strength is only associated with a lower risk of depression up to a specific threshold,” he noted.

“The clinical implication of this finding is that only individuals with grip strength below this threshold are at a higher risk of depression. These individuals especially may benefit from interventions aimed at increasing physical strength,” Dr. Mutz said.

The SHARE data collection has been funded by the European Commission and by DG Employment, Social Affairs and Inclusion. Additional funding was obtained from the German Ministry of Education and Research, the Max Planck Society for the Advancement of Science, and the U.S. National Institute on Aging. Dr. Lopez-Bueno is supported by the European Union – Next Generation EU. The other investigators and Dr. Mutz have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Weak handgrip in older adults is linked to a higher risk for depression – while a stronger handgrip may have protective benefits, new research suggests.
 

In a study of more than 115,000 adults, there was a significant association between stronger handgrip, up to 40 kg in men and 27 kg in women, and lower depression risk.

Investigators add that there was a “dose-response” association between physical strength and risk for depression.

“Being physically strong may serve as a preventive factor for depression in older adults, but this is limited to a maximum specific threshold for men and women,” Ruben Lopez-Bueno, PhD, of the department of physical medicine and nursing, University of Zaragoza, Spain, and colleagues write.

The findings were published online in the British Journal of Psychiatry.
 

Easy, fast, reliable

Depression is a major public health problem, and studies “aimed at examining preventive factors to tackle the increase in depression are required,” the investigators write.

They add that a “growing body of research” is examining the link between depression and muscle strength, with handgrip as an estimator, in healthy middle-aged and older adults.

Handgrip strength is an “easy-to-use, fast and reliable indicator of both sarcopenia (age-related loss of muscle mass) and dynapenia (age-related loss of muscle strength), both of which have been associated with depression,” the researchers note.

It is plausible that there is a “regulatory role of skeletal muscle on brain function affecting this condition,” they add.

They note that exercise seems to play a “key role” because it can improve muscle strength as well as muscle mass, downregulate systemic inflammation, and improve neuroplasticity, neuroendocrine, and oxidative stress responses.

Previous studies have relied either on cross-sectional or prospective cohort models and have focused mostly on a specific country, “not accounting for time-varying changes of both handgrip strength and relevant covariables.”

Moreover, previous evidence has been mixed regarding the “extent to which handgrip strength levels may associate with lower risk of depression, with study results ranging from weak to strong associations,” the investigators write.

So “higher-quality research with representative samples from different countries is required to better clarify the strength of such an association and to confirm directionality,” they add.
 

SHARE data

To fill this gap, the researchers turned to data from waves 1, 2, 4, 5, 6, and 7 of the Survey of Health, Ageing and Retirement in Europe (SHARE). This encompassed 115,601 individuals aged 50 years and older (mean age, 64.3 years; 54.3% women) residing in European countries and Israel (24 countries total).

Data from wave 3 were not used because handgrip measures were not used in that wave. In the other waves, a handheld dynamometer was used to measure handgrip strength.

The participants were divided into tertiles of handgrip strength, with the “first third” being the lowest tertile of strength and the “final third” representing the highest strength.

All participants were followed for a median of 7.3 years (792,459 person-years), during which 26.1% experienced a risk for depression, as reflected by scores on the EURO-D 12-item scale.

The investigators set the time scale as the months from study entry until either a first depression onset or the end of follow-up.

Covariates that the researchers accounted for included gender, age, education, country, body mass index, physical inactivity, smoking, alcohol consumption, whether living with a partner, wave of inclusion, chronic diseases, consumption of prescribed drugs, and fruit and vegetable consumption.

The researchers used two models: the first adjusted for gender and age at time of the interview, and the second adjusted for all confounders.

In the model that was adjusted only for gender and age, greater handgrip strength was associated with a significantly reduced risk for depression among participants in the second, third, and the final third in comparison with the first third (hazard ratio, 0.65; 95% confidence interval, 0.63-0.68; and HR, 0.50; 95% CI, 0.48-0.53, respectively).

The associations remained consistent in the fully adjusted model, although risk for depression was slightly attenuated in the second and final thirds compared with the first third (HR, 0.76; 95% CI, 0.71-0.81; and HR, 0.64; 95% CI, 0.59-0.69, respectively).

When the researchers conducted analyses using restricted cubic spline modeling, they found a significant association for each kilogram increase of handgrip strength and depression, up to 40 kg in men and 27 kg in women (HR, 1.39; 95% CI, 1.08-1.71; and HR, 1.28; 95% CI, 1.05-1.55, respectively).

There was no greater reduction in depression risk in those with handgrip strength above those values.
 

Potential depression screen

The investigators suggest several explanations for their findings. For example, handgrip strength has “been used as an overall indicator of health status, including sarcopenia,” they write.

Adults with sarcopenia have been found to be at greater risk for depression because of reduced muscle strength, since neurotrophins are produced by skeletal muscle, among other tissues, and are associated with improvement in mood.

From a psychological point of view, “being physically strong may lead to a sensation of psychological wellbeing,” the researchers write.

Moreover, being physically active “across the lifespan also promotes structural and functional changes in the brain, benefiting cognitive functioning and reducing the risk of neurodegeneration,” they write.

This can be important because aging adults with cognitive impairments can also experience neuromuscular impairments that “presumably will contribute to becoming weaker,” they note.

Overall, the findings “warrant strength training programmes aimed at older adults to reduce depression risk,” the investigators write. Clinicians “may consider using the observed handgrip strength thresholds to screen for potential depression risk in older adults,” they add.
 

Protective factor?

Commenting for this news organization, Julian Mutz, PhD, postdoctoral research associate at the Social, Genetic and Developmental Psychiatry Centre, King’s College, London, said the study “provides further evidence that physical strength may be a protective factor against depression in older adults.”

This confirms a “plethora of cross-sectional and longitudinal studies,” including one recently conducted by Dr. Mutz’s group.

The design of the current study “allowed the authors to address a number of key limitations of previous studies, for example, by including repeated measurements of grip strength and adjustment for potential confounding factors over time,” said Dr. Mutz, who was not involved with the research.

Additionally, “an important contribution of this study is that the authors show that higher grip strength is only associated with a lower risk of depression up to a specific threshold,” he noted.

“The clinical implication of this finding is that only individuals with grip strength below this threshold are at a higher risk of depression. These individuals especially may benefit from interventions aimed at increasing physical strength,” Dr. Mutz said.

The SHARE data collection has been funded by the European Commission and by DG Employment, Social Affairs and Inclusion. Additional funding was obtained from the German Ministry of Education and Research, the Max Planck Society for the Advancement of Science, and the U.S. National Institute on Aging. Dr. Lopez-Bueno is supported by the European Union – Next Generation EU. The other investigators and Dr. Mutz have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Outpatient behavioral health treatment (OPBHT) for patients newly diagnosed with depression, substance use disorder, or other behavioral health condition (BHC) is cost-effective.

Results of a large retrospective study showed that patients newly diagnosed with a BHC who receive OPBHT following diagnosis incur lower medical and pharmacy costs over roughly the next 1 to 2 years, compared with peers who don’t receive OPBHT.

“Our findings suggest that promoting OPBHT as part of a population health strategy is associated with improved overall medical spending, particularly among adults,” the investigators write.

The study was published online in JAMA Network Open.
 

Common, undertreated

Nearly a quarter of adults in the United States have a BHC, and they incur greater medical costs than those without a BHC. However, diagnosis of a BHC is often delayed, and most affected individuals receive little to no treatment.

In their cost analysis, Johanna Bellon, PhD, and colleagues with Evernorth Health, St. Louis, analyzed commercial insurance claims data for 203,401 U.S. individuals newly diagnosed with one or more BHCs between 2017 and 2018.

About half of participants had depression and/or anxiety, 11% had substance use or alcohol use disorder, and 6% had a higher-acuity diagnosis, such as bipolar disorder, severe depression, eating disorder, psychotic disorder, or autism spectrum disorder.

About 1 in 5 (22%) had at least one chronic medical condition along with their BHC.

The researchers found that having at least one OPBHT visit was associated with lower medical and pharmacy costs during 15- and 27-month follow-up periods.

Over 15 months, the adjusted mean per member per month (PMPM) medical/pharmacy cost was $686 with no OPBHT visit, compared with $571 with one or more OPBHT visits.

Over 27 months, the adjusted mean PMPM was $464 with no OPBHT, versus $391 with one or more OPBHT visits.
 

Dose-response effect

In addition, there was a “dose-response” relationship between OPBHT and medical/pharmacy costs, such that estimated cost savings were significantly lower in the treated versus the untreated groups at almost every level of treatment.

“Our findings were also largely age independent, especially over 15 months, suggesting that OPBHT has favorable effects among children, young adults, and adults,” the researchers report.

“This is promising given that disease etiology and progression, treatment paradigms, presence of comorbid medical conditions, and overall medical and pharmacy costs differ among the three groups,” they say.

Notably, the dataset largely encompassed in-person OPBHT, because the study period preceded the transition into virtual care that occurred in 2020.

However, overall use of OPBHT was low – older adults, adults with lower income, individuals with comorbid medical conditions, and persons of racial and ethnic minorities were less likely to receive OPBHT, they found.

“These findings support the cost-effectiveness of practitioner- and insurance-based interventions to increase OPBHT utilization, which is a critical resource as new BHC diagnoses continue to increase,” the researchers say.

“Future research should validate these findings in other populations, including government-insured individuals, and explore data by chronic disease category, over longer time horizons, by type and quality of OPBHT, by type of medical spending, within subpopulations with BHCs, and including virtual and digital behavioral health services,” they suggest.

The study had no specific funding. The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Outpatient behavioral health treatment (OPBHT) for patients newly diagnosed with depression, substance use disorder, or other behavioral health condition (BHC) is cost-effective.

Results of a large retrospective study showed that patients newly diagnosed with a BHC who receive OPBHT following diagnosis incur lower medical and pharmacy costs over roughly the next 1 to 2 years, compared with peers who don’t receive OPBHT.

“Our findings suggest that promoting OPBHT as part of a population health strategy is associated with improved overall medical spending, particularly among adults,” the investigators write.

The study was published online in JAMA Network Open.
 

Common, undertreated

Nearly a quarter of adults in the United States have a BHC, and they incur greater medical costs than those without a BHC. However, diagnosis of a BHC is often delayed, and most affected individuals receive little to no treatment.

In their cost analysis, Johanna Bellon, PhD, and colleagues with Evernorth Health, St. Louis, analyzed commercial insurance claims data for 203,401 U.S. individuals newly diagnosed with one or more BHCs between 2017 and 2018.

About half of participants had depression and/or anxiety, 11% had substance use or alcohol use disorder, and 6% had a higher-acuity diagnosis, such as bipolar disorder, severe depression, eating disorder, psychotic disorder, or autism spectrum disorder.

About 1 in 5 (22%) had at least one chronic medical condition along with their BHC.

The researchers found that having at least one OPBHT visit was associated with lower medical and pharmacy costs during 15- and 27-month follow-up periods.

Over 15 months, the adjusted mean per member per month (PMPM) medical/pharmacy cost was $686 with no OPBHT visit, compared with $571 with one or more OPBHT visits.

Over 27 months, the adjusted mean PMPM was $464 with no OPBHT, versus $391 with one or more OPBHT visits.
 

Dose-response effect

In addition, there was a “dose-response” relationship between OPBHT and medical/pharmacy costs, such that estimated cost savings were significantly lower in the treated versus the untreated groups at almost every level of treatment.

“Our findings were also largely age independent, especially over 15 months, suggesting that OPBHT has favorable effects among children, young adults, and adults,” the researchers report.

“This is promising given that disease etiology and progression, treatment paradigms, presence of comorbid medical conditions, and overall medical and pharmacy costs differ among the three groups,” they say.

Notably, the dataset largely encompassed in-person OPBHT, because the study period preceded the transition into virtual care that occurred in 2020.

However, overall use of OPBHT was low – older adults, adults with lower income, individuals with comorbid medical conditions, and persons of racial and ethnic minorities were less likely to receive OPBHT, they found.

“These findings support the cost-effectiveness of practitioner- and insurance-based interventions to increase OPBHT utilization, which is a critical resource as new BHC diagnoses continue to increase,” the researchers say.

“Future research should validate these findings in other populations, including government-insured individuals, and explore data by chronic disease category, over longer time horizons, by type and quality of OPBHT, by type of medical spending, within subpopulations with BHCs, and including virtual and digital behavioral health services,” they suggest.

The study had no specific funding. The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Outpatient behavioral health treatment (OPBHT) for patients newly diagnosed with depression, substance use disorder, or other behavioral health condition (BHC) is cost-effective.

Results of a large retrospective study showed that patients newly diagnosed with a BHC who receive OPBHT following diagnosis incur lower medical and pharmacy costs over roughly the next 1 to 2 years, compared with peers who don’t receive OPBHT.

“Our findings suggest that promoting OPBHT as part of a population health strategy is associated with improved overall medical spending, particularly among adults,” the investigators write.

The study was published online in JAMA Network Open.
 

Common, undertreated

Nearly a quarter of adults in the United States have a BHC, and they incur greater medical costs than those without a BHC. However, diagnosis of a BHC is often delayed, and most affected individuals receive little to no treatment.

In their cost analysis, Johanna Bellon, PhD, and colleagues with Evernorth Health, St. Louis, analyzed commercial insurance claims data for 203,401 U.S. individuals newly diagnosed with one or more BHCs between 2017 and 2018.

About half of participants had depression and/or anxiety, 11% had substance use or alcohol use disorder, and 6% had a higher-acuity diagnosis, such as bipolar disorder, severe depression, eating disorder, psychotic disorder, or autism spectrum disorder.

About 1 in 5 (22%) had at least one chronic medical condition along with their BHC.

The researchers found that having at least one OPBHT visit was associated with lower medical and pharmacy costs during 15- and 27-month follow-up periods.

Over 15 months, the adjusted mean per member per month (PMPM) medical/pharmacy cost was $686 with no OPBHT visit, compared with $571 with one or more OPBHT visits.

Over 27 months, the adjusted mean PMPM was $464 with no OPBHT, versus $391 with one or more OPBHT visits.
 

Dose-response effect

In addition, there was a “dose-response” relationship between OPBHT and medical/pharmacy costs, such that estimated cost savings were significantly lower in the treated versus the untreated groups at almost every level of treatment.

“Our findings were also largely age independent, especially over 15 months, suggesting that OPBHT has favorable effects among children, young adults, and adults,” the researchers report.

“This is promising given that disease etiology and progression, treatment paradigms, presence of comorbid medical conditions, and overall medical and pharmacy costs differ among the three groups,” they say.

Notably, the dataset largely encompassed in-person OPBHT, because the study period preceded the transition into virtual care that occurred in 2020.

However, overall use of OPBHT was low – older adults, adults with lower income, individuals with comorbid medical conditions, and persons of racial and ethnic minorities were less likely to receive OPBHT, they found.

“These findings support the cost-effectiveness of practitioner- and insurance-based interventions to increase OPBHT utilization, which is a critical resource as new BHC diagnoses continue to increase,” the researchers say.

“Future research should validate these findings in other populations, including government-insured individuals, and explore data by chronic disease category, over longer time horizons, by type and quality of OPBHT, by type of medical spending, within subpopulations with BHCs, and including virtual and digital behavioral health services,” they suggest.

The study had no specific funding. The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity.

Drew Ramsey, MD: Welcome back, everyone. I’m Dr. Drew Ramsey. I’m on the editorial board with Medscape Psychiatry and I’m an assistant clinical professor of psychiatry at Columbia University. We have a special guest today.

I’m here with nutritionist Jessica Bayes, who’s at the University of Technology Sydney, and she’s the lead author of the AMMEND trial. [Editor’s note: Since completing her PhD, Bayes is now at Southern Cross University.] The AMMEND trial is our most recent trial in nutritional psychiatry, finding that giving or helping young men eat a Mediterranean diet can be helpful in the treatment of depression.

Jessica, welcome to Medscape.

Jessica Bayes, PhD: Thank you for having me.

The AMMEND Trial

Dr. Ramsey: Thank you for coming on board and helping all of us as clinicians understand some of your research and some of what is suggested by your research – that young men can change their diet and it helped their depression. Tell us a little bit about the AMMEND trial.

Dr. Bayes: The AMMEND trial was a 12-week randomized controlled trial in young men, 18-25 years old, who had diagnosed moderate to severe clinical depression. They had a poor baseline diet and we got them to eat a healthy Mediterranean diet, which improved their symptoms of depression.

Dr. Ramsey: It was a remarkable trial. Jessica, if I recall, you helped individuals improve the Mediterranean dietary pattern score by 8 points on a 14-point scale. That led to a 20-point reduction in their Beck Depression Inventory. Tell us what that looked like on the ground.

Dr. Bayes: It’s a huge improvement. Obviously, they were feeling much better in the end in terms of their depressive symptoms, but we also measured their energy, sleep, and quality of life. Many of them at the end were at a score cutoff that suggests no depression or in remission.

Dr. Ramsey: There were 72 people in your total trial, so 36% in your intervention arm went into full remission.

Dr. Bayes: Which is just amazing.

Dr. Ramsey: It also follows up the SMILES trial, which was a little bit of a different trial. You had two nutritional counseling sessions and the SMILES trial had seven, but in the SMILES trial, 32.3% of the patients went into full remission when they adopted a Mediterranean-style diet.

Jessica, what is the secret that you and your team know? I think many clinicians, especially clinicians who are parents and have teens, are kind of shaking their heads in disbelief. They’ve been telling their kids to eat healthy. What do you guys know about how to help young men change their diet?

How to Aid Adherence to Mediterranean Diet

Dr. Bayes: Prior to starting this, when I would say this idea to people, everyone would say, “Great idea. There’s no way you’re going to get depressed young men to change their diet. Not going to happen.” We went to them and we asked them. We said, “We’re going to do this study. What do you want from us? What resources would you need? How many appointments would you like? What’s too little or too many?”

We really got their feedback on board when we designed the study, and that obviously paid off. We had a personalized approach and we met them where they were at. We gave them the skills, resources, recipes, meal ideas – all those things – so we could really set them up to succeed.

Dr. Ramsey: You were telling me earlier about a few of the dietary changes that you felt made a big difference for these young men. What were those?

Dr. Bayes: Increasing the vegetables, olive oil, and legumes are probably the big ones that most of them were really not doing beforehand. They were really able to take that on board and make significant improvements in those areas.

Dr. Ramsey: These are really some of the top food categories in nutritional psychiatry as we think about how we help our efforts to improve mental health by thinking about nutrition, nutritional quality, and nutritional density. Certainly, those food categories – nuts and legumes, plants, and olive oil – are really what help get us there.

You also gave the students a food hamper. If you were going to be in charge of mental health in Australia and America and you got to give every college freshman a little box with a note, what would be in that box?

Dr. Bayes: I’d want to put everything in that box! It would be full of brightly colored fruits and vegetables, different nuts and seeds, and legumes. It would be full of recipes and ideas of how to cook things and how to prepare really delicious things. It would be full of different herbs and spices and all of those things to get people really excited about food.

Dr. Ramsey: Did the young men pick up on your enthusiasm and excitement around food? Did they begin to adopt some of that, shifting their view of how they saw the food and how they saw that it is related to their depression?

Dr. Bayes: Hopefully. I do think energy is infectious. I’m sure that played a role somewhat, but trying to get them excited about food can be really quite daunting, thinking, I’ve got to change my entire diet and I’ve got to learn to cook and go out and buy groceries. I don’t even know what to do with a piece of salmon. Trying to get them curious, interested, and just reminding them that it’s not all-or-nothing. Make small changes, give it a go, and have fun.

Dr. Ramsey: You also have a unique aspect of your research that you’re interested in male mental health, and that’s not something that’s been widely researched. Can you tell us a little bit about what these men were like in terms of coming into your trial as depressed young men?

Dr. Bayes: In the context of the COVID-19 pandemic, mental health was at the forefront of many people’s minds. They joined the study saying, “I’ve never seen anything like this before. I’ve never seen myself represented in research. I wanted to contribute. I want to add to that conversation because I feel like we are overlooked.”

Dr. Ramsey: I love hearing this notion that maybe young men aren’t quite who we think they are. They are wanting to be seen around their mental health. They can learn to use olive oil and to cook, and they can engage in mental health interventions that work. We just need to ask, give them some food, encourage them, and it makes a big difference.

Jessica Bayes, thank you so much for joining us and sharing some of your research. Everyone, it’s the AMMEND trial. We will drop a link to the trial below so you can take a peek and tell us what you think.

Please, in the comments, let us know what you think about this notion of helping young men with depression through nutritional interventions. Take a peek at the great work that Jessica and Professor Sibbritt from the University of Technology Sydney have published and put out into the scientific literature for us all.

Thanks so much, Jessica. I look forward to seeing you soon.

Dr. Bayes: Thank you.

Dr. Ramsey is assistant clinical professor, department of psychiatry, Columbia University, New York. He has disclosed the following relevant financial relationships:

Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for InterContinental Hotels Group; National Kale Day 501(c)3. Received income in an amount equal to or greater than $250 from: Sharecare. Dr. Bayes is a postdoctoral research fellow; clinical nutritionist, Southern Cross University, National Center for Naturopathic Medicine, Lismore, New South Wales, Australia. She has disclosed the following relevant financial relationships: Received research grant from Endeavour College. A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity.

Drew Ramsey, MD: Welcome back, everyone. I’m Dr. Drew Ramsey. I’m on the editorial board with Medscape Psychiatry and I’m an assistant clinical professor of psychiatry at Columbia University. We have a special guest today.

I’m here with nutritionist Jessica Bayes, who’s at the University of Technology Sydney, and she’s the lead author of the AMMEND trial. [Editor’s note: Since completing her PhD, Bayes is now at Southern Cross University.] The AMMEND trial is our most recent trial in nutritional psychiatry, finding that giving or helping young men eat a Mediterranean diet can be helpful in the treatment of depression.

Jessica, welcome to Medscape.

Jessica Bayes, PhD: Thank you for having me.

The AMMEND Trial

Dr. Ramsey: Thank you for coming on board and helping all of us as clinicians understand some of your research and some of what is suggested by your research – that young men can change their diet and it helped their depression. Tell us a little bit about the AMMEND trial.

Dr. Bayes: The AMMEND trial was a 12-week randomized controlled trial in young men, 18-25 years old, who had diagnosed moderate to severe clinical depression. They had a poor baseline diet and we got them to eat a healthy Mediterranean diet, which improved their symptoms of depression.

Dr. Ramsey: It was a remarkable trial. Jessica, if I recall, you helped individuals improve the Mediterranean dietary pattern score by 8 points on a 14-point scale. That led to a 20-point reduction in their Beck Depression Inventory. Tell us what that looked like on the ground.

Dr. Bayes: It’s a huge improvement. Obviously, they were feeling much better in the end in terms of their depressive symptoms, but we also measured their energy, sleep, and quality of life. Many of them at the end were at a score cutoff that suggests no depression or in remission.

Dr. Ramsey: There were 72 people in your total trial, so 36% in your intervention arm went into full remission.

Dr. Bayes: Which is just amazing.

Dr. Ramsey: It also follows up the SMILES trial, which was a little bit of a different trial. You had two nutritional counseling sessions and the SMILES trial had seven, but in the SMILES trial, 32.3% of the patients went into full remission when they adopted a Mediterranean-style diet.

Jessica, what is the secret that you and your team know? I think many clinicians, especially clinicians who are parents and have teens, are kind of shaking their heads in disbelief. They’ve been telling their kids to eat healthy. What do you guys know about how to help young men change their diet?

How to Aid Adherence to Mediterranean Diet

Dr. Bayes: Prior to starting this, when I would say this idea to people, everyone would say, “Great idea. There’s no way you’re going to get depressed young men to change their diet. Not going to happen.” We went to them and we asked them. We said, “We’re going to do this study. What do you want from us? What resources would you need? How many appointments would you like? What’s too little or too many?”

We really got their feedback on board when we designed the study, and that obviously paid off. We had a personalized approach and we met them where they were at. We gave them the skills, resources, recipes, meal ideas – all those things – so we could really set them up to succeed.

Dr. Ramsey: You were telling me earlier about a few of the dietary changes that you felt made a big difference for these young men. What were those?

Dr. Bayes: Increasing the vegetables, olive oil, and legumes are probably the big ones that most of them were really not doing beforehand. They were really able to take that on board and make significant improvements in those areas.

Dr. Ramsey: These are really some of the top food categories in nutritional psychiatry as we think about how we help our efforts to improve mental health by thinking about nutrition, nutritional quality, and nutritional density. Certainly, those food categories – nuts and legumes, plants, and olive oil – are really what help get us there.

You also gave the students a food hamper. If you were going to be in charge of mental health in Australia and America and you got to give every college freshman a little box with a note, what would be in that box?

Dr. Bayes: I’d want to put everything in that box! It would be full of brightly colored fruits and vegetables, different nuts and seeds, and legumes. It would be full of recipes and ideas of how to cook things and how to prepare really delicious things. It would be full of different herbs and spices and all of those things to get people really excited about food.

Dr. Ramsey: Did the young men pick up on your enthusiasm and excitement around food? Did they begin to adopt some of that, shifting their view of how they saw the food and how they saw that it is related to their depression?

Dr. Bayes: Hopefully. I do think energy is infectious. I’m sure that played a role somewhat, but trying to get them excited about food can be really quite daunting, thinking, I’ve got to change my entire diet and I’ve got to learn to cook and go out and buy groceries. I don’t even know what to do with a piece of salmon. Trying to get them curious, interested, and just reminding them that it’s not all-or-nothing. Make small changes, give it a go, and have fun.

Dr. Ramsey: You also have a unique aspect of your research that you’re interested in male mental health, and that’s not something that’s been widely researched. Can you tell us a little bit about what these men were like in terms of coming into your trial as depressed young men?

Dr. Bayes: In the context of the COVID-19 pandemic, mental health was at the forefront of many people’s minds. They joined the study saying, “I’ve never seen anything like this before. I’ve never seen myself represented in research. I wanted to contribute. I want to add to that conversation because I feel like we are overlooked.”

Dr. Ramsey: I love hearing this notion that maybe young men aren’t quite who we think they are. They are wanting to be seen around their mental health. They can learn to use olive oil and to cook, and they can engage in mental health interventions that work. We just need to ask, give them some food, encourage them, and it makes a big difference.

Jessica Bayes, thank you so much for joining us and sharing some of your research. Everyone, it’s the AMMEND trial. We will drop a link to the trial below so you can take a peek and tell us what you think.

Please, in the comments, let us know what you think about this notion of helping young men with depression through nutritional interventions. Take a peek at the great work that Jessica and Professor Sibbritt from the University of Technology Sydney have published and put out into the scientific literature for us all.

Thanks so much, Jessica. I look forward to seeing you soon.

Dr. Bayes: Thank you.

Dr. Ramsey is assistant clinical professor, department of psychiatry, Columbia University, New York. He has disclosed the following relevant financial relationships:

Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for InterContinental Hotels Group; National Kale Day 501(c)3. Received income in an amount equal to or greater than $250 from: Sharecare. Dr. Bayes is a postdoctoral research fellow; clinical nutritionist, Southern Cross University, National Center for Naturopathic Medicine, Lismore, New South Wales, Australia. She has disclosed the following relevant financial relationships: Received research grant from Endeavour College. A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity.

Drew Ramsey, MD: Welcome back, everyone. I’m Dr. Drew Ramsey. I’m on the editorial board with Medscape Psychiatry and I’m an assistant clinical professor of psychiatry at Columbia University. We have a special guest today.

I’m here with nutritionist Jessica Bayes, who’s at the University of Technology Sydney, and she’s the lead author of the AMMEND trial. [Editor’s note: Since completing her PhD, Bayes is now at Southern Cross University.] The AMMEND trial is our most recent trial in nutritional psychiatry, finding that giving or helping young men eat a Mediterranean diet can be helpful in the treatment of depression.

Jessica, welcome to Medscape.

Jessica Bayes, PhD: Thank you for having me.

The AMMEND Trial

Dr. Ramsey: Thank you for coming on board and helping all of us as clinicians understand some of your research and some of what is suggested by your research – that young men can change their diet and it helped their depression. Tell us a little bit about the AMMEND trial.

Dr. Bayes: The AMMEND trial was a 12-week randomized controlled trial in young men, 18-25 years old, who had diagnosed moderate to severe clinical depression. They had a poor baseline diet and we got them to eat a healthy Mediterranean diet, which improved their symptoms of depression.

Dr. Ramsey: It was a remarkable trial. Jessica, if I recall, you helped individuals improve the Mediterranean dietary pattern score by 8 points on a 14-point scale. That led to a 20-point reduction in their Beck Depression Inventory. Tell us what that looked like on the ground.

Dr. Bayes: It’s a huge improvement. Obviously, they were feeling much better in the end in terms of their depressive symptoms, but we also measured their energy, sleep, and quality of life. Many of them at the end were at a score cutoff that suggests no depression or in remission.

Dr. Ramsey: There were 72 people in your total trial, so 36% in your intervention arm went into full remission.

Dr. Bayes: Which is just amazing.

Dr. Ramsey: It also follows up the SMILES trial, which was a little bit of a different trial. You had two nutritional counseling sessions and the SMILES trial had seven, but in the SMILES trial, 32.3% of the patients went into full remission when they adopted a Mediterranean-style diet.

Jessica, what is the secret that you and your team know? I think many clinicians, especially clinicians who are parents and have teens, are kind of shaking their heads in disbelief. They’ve been telling their kids to eat healthy. What do you guys know about how to help young men change their diet?

How to Aid Adherence to Mediterranean Diet

Dr. Bayes: Prior to starting this, when I would say this idea to people, everyone would say, “Great idea. There’s no way you’re going to get depressed young men to change their diet. Not going to happen.” We went to them and we asked them. We said, “We’re going to do this study. What do you want from us? What resources would you need? How many appointments would you like? What’s too little or too many?”

We really got their feedback on board when we designed the study, and that obviously paid off. We had a personalized approach and we met them where they were at. We gave them the skills, resources, recipes, meal ideas – all those things – so we could really set them up to succeed.

Dr. Ramsey: You were telling me earlier about a few of the dietary changes that you felt made a big difference for these young men. What were those?

Dr. Bayes: Increasing the vegetables, olive oil, and legumes are probably the big ones that most of them were really not doing beforehand. They were really able to take that on board and make significant improvements in those areas.

Dr. Ramsey: These are really some of the top food categories in nutritional psychiatry as we think about how we help our efforts to improve mental health by thinking about nutrition, nutritional quality, and nutritional density. Certainly, those food categories – nuts and legumes, plants, and olive oil – are really what help get us there.

You also gave the students a food hamper. If you were going to be in charge of mental health in Australia and America and you got to give every college freshman a little box with a note, what would be in that box?

Dr. Bayes: I’d want to put everything in that box! It would be full of brightly colored fruits and vegetables, different nuts and seeds, and legumes. It would be full of recipes and ideas of how to cook things and how to prepare really delicious things. It would be full of different herbs and spices and all of those things to get people really excited about food.

Dr. Ramsey: Did the young men pick up on your enthusiasm and excitement around food? Did they begin to adopt some of that, shifting their view of how they saw the food and how they saw that it is related to their depression?

Dr. Bayes: Hopefully. I do think energy is infectious. I’m sure that played a role somewhat, but trying to get them excited about food can be really quite daunting, thinking, I’ve got to change my entire diet and I’ve got to learn to cook and go out and buy groceries. I don’t even know what to do with a piece of salmon. Trying to get them curious, interested, and just reminding them that it’s not all-or-nothing. Make small changes, give it a go, and have fun.

Dr. Ramsey: You also have a unique aspect of your research that you’re interested in male mental health, and that’s not something that’s been widely researched. Can you tell us a little bit about what these men were like in terms of coming into your trial as depressed young men?

Dr. Bayes: In the context of the COVID-19 pandemic, mental health was at the forefront of many people’s minds. They joined the study saying, “I’ve never seen anything like this before. I’ve never seen myself represented in research. I wanted to contribute. I want to add to that conversation because I feel like we are overlooked.”

Dr. Ramsey: I love hearing this notion that maybe young men aren’t quite who we think they are. They are wanting to be seen around their mental health. They can learn to use olive oil and to cook, and they can engage in mental health interventions that work. We just need to ask, give them some food, encourage them, and it makes a big difference.

Jessica Bayes, thank you so much for joining us and sharing some of your research. Everyone, it’s the AMMEND trial. We will drop a link to the trial below so you can take a peek and tell us what you think.

Please, in the comments, let us know what you think about this notion of helping young men with depression through nutritional interventions. Take a peek at the great work that Jessica and Professor Sibbritt from the University of Technology Sydney have published and put out into the scientific literature for us all.

Thanks so much, Jessica. I look forward to seeing you soon.

Dr. Bayes: Thank you.

Dr. Ramsey is assistant clinical professor, department of psychiatry, Columbia University, New York. He has disclosed the following relevant financial relationships:

Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for InterContinental Hotels Group; National Kale Day 501(c)3. Received income in an amount equal to or greater than $250 from: Sharecare. Dr. Bayes is a postdoctoral research fellow; clinical nutritionist, Southern Cross University, National Center for Naturopathic Medicine, Lismore, New South Wales, Australia. She has disclosed the following relevant financial relationships: Received research grant from Endeavour College. A version of this article first appeared on Medscape.com.