by Devon Price, PhD; New York: Atria Books, 2021.

Editor's Note: As clinicians who treat mental illness, we have undoubtedly seen individuals who are labeled “lazy.” Some of our patients who are suffering the most may be those who have labeled themselves lazy. Fortunately, for those of us who chastise ourselves for taking even a moment away from work to focus on ourselves, and for our patients who cudgel themselves too, 

. Dr Price, a social psychologist and professor at Loyola University of Chicago’s School of Continuing and Professional Studies, recently sat for an interview, conducted via Zoom, on the topic of laziness. The interview will hopefully whet the appetite to read and recommend this truly helpful book.

Q: When I heard that you had written a book about the concept of laziness, the first question that came into my mind was: have you ever been called lazy?

A. I have only ever called myself lazy. I think I have absolutely been a workaholic in the way that I think a lot of academics are trained to be. You get this idea that you need to have a full course load, you need to be doing service to the university, you need to be doing research. And you need to be a self-starter if you want to have even a prayer of a career. They kind of drill that into you even as an undergrad. I think I have always had that bug in the back of my brain telling me that I was not doing enough. Many of us feel pressure to be a self-made individual and to be very individualistic and successful. So I am someone who has not been called lazy too often, because I have been able to check off a lot of society’s little boxes that make you look like a good little worker bee.

Q: I have always thought that when someone comes to me and tells me “my spouse is lazy” or “my employee is lazy,” they are using a lazy word, because it does not really give a useful description of what is going on. Why do you think the word lazy is used so frequently in our society?

A: The word has always had an air of moral condemnation to it. Its root words mean both feeble or weak willed and morally corrupt. A lot of times it is easier to write someone off as lacking essential qualities, lacking some drive or willpower that you need to succeed, than it is to ask what can be done to help. Does this individual have needs that are not getting met? What struggles is this individual facing that are not being taken seriously? What structural problems are getting in their way? When somebody looks lazy, maybe they just see no reason why they should be doing a task. So that is also an important question to ask. Have we failed to motivate them and empower them?

Q: Those are much more difficult questions to ask.

A: It is hard to ask those questions. It is even harder to solve those problems once the questions have been asked. It is much easier to say, “Oh, I give up on this individual. They lack that essential quality that they need for success.”

Q: Your answers make it impossible to ignore the uneven playing field that so many individuals face when trying to succeed in life, and particularly in science and academia. Do you have any thoughts on how inequities affect perceptions of laziness?

A: It is a thorny problem. When you are teaching and mentoring, it is important (as much as possible) to be flexible when you can. At the same time, I think giving honest feedback is essential. “Listen, I understand that you have things going against you. I know that this is not a reflection of some flaw or failure in you. But we do need to get you to a certain level, and I really am invested in seeing you reach that level. So, what can I do to help support you?” There is a lot of social psychology research suggesting that instructors, especially white instructors, are uncomfortable giving critical feedback to black students. Even black students who are doing really well! They are afraid of being perceived as racist, so they overcorrect, and this is true of sexism and other biases as well. If you can, try to level with them: tell them where they need to grow and give them the same critical feedback that you would give anyone else. Also be there to support them through hardships that are not their fault. I think that can really make a big difference. But it is a steep uphill battle.

A: There are so many areas of life where individuals are made to feel like they are not enough. We have already talked about racism, sexism, and things like that. But workaholism pervades almost everything in American culture and life. That affects individuals’ self-image, their depression levels, their anxiety levels, and how much they put on their plate. We know that those things are huge risk factors for all kinds of psychiatric and psychological issues. If you are doing too much, that looks a lot like an anxiety disorder, or anxiety profile, even if maybe you otherwise would not be in that situation.

is an attending psychiatrist at Montefiore Medical Center. He is the Book Review editor at 

Articles

Patients and care providers often call themselves lazy. But what are the clinical consequences and cultural meanings of this term? 

Laziness Does Not Exist

Far from being set in stone, mental well-being can be cultivated through intentional mental training. In a paper for the 

Proceedings of the National Academy of Sciences

, Cortland Dahl, PhD, and his co-authors offered a unifying framework that integrates well-being research, cognitive and affective neuroscience, and clinical psychology.

In this Mental Health Minute, Dahl discusses his paper and its clinical implications.

is Chief Contemplative Officer, Healthy Minds Innovations, and Research Scientist at the Center for Healthy Minds.

Videos

How to train your mind for happiness like you would train your body for a marathon.  

The Plasticity of Well-Being

Many psychiatrists seem to have accepted, and are content with, the narrow scope of practice imposed upon them. For myself, however, I refuse to reduce the unlimited potential of psychiatry to merely prescribing psychotropics. Medications can be quite effective, even lifesaving, but they are not the only tool we can offer our clients.

I have been reflecting on the psychosocial impact of the COVID-19 pandemic, especially on our youth, and would like to share few thoughts that might provide hope for these beautiful, little creatures.

This writing is not intended to be a naive generalization or an over-simplification; I have used an easy language here with the goal of having these tips shared with clients, especially parents and caregivers. I hope they can also help you when taking care of your family and community, and even serve your own self-care and healing.

The wounds of trauma are, for the most part, invisible. They can scar our bodies, minds, hearts, and souls. There are many hormones and chemicals involved in responding to adversity, especially protracted stress like the current pandemic. I will briefly mention 5 of those.

The hormone adrenaline (also known as epinephrine) is commonly known as the emergency hormone. It helps anticipate and prepare for threats, or activates fight or flight responses. That is helpful, and even critical short-term, but can have long-lasting negative consequences if we remain in a state of arousal, fearing an actual or a perceived threat. One way we can help children and those around us cope is to calm our mind and manage our anxiety. This can be done in many ways like meditation, mindfulness, and engaging in activities that are physically and mentally cathartic.

The hormone cortisol is commonly called the stress hormone. It helps us respond to stress, but it can also be harmful in the long run. One way to balance cortisol levels is to be kind to our bodies through mastering consistent healthy eating, sleeping, and lifestyle habits.

I want to focus now on 3 other chemicals, collectively known as the happy hormones. Dopamine (also known as the thrill hormone) is not only involved in addiction, thrill-seeking, and impulsivity, but is also a vital hormone for our emotional wellbeing. When it comes to children, we can give them a dopamine boost by simply paying attention to them. Children thrive when they feel noticed, therefore we should take every opportunity to let them know that they are seen, heard, and felt. Youth who feel safe seem to blossom, and start to believe in, and express, their beauty.

Serotonin (commonly known as the happiness hormone) is not only involved in depression, but it is also a chemical that is released when we feel valued. It is important to show appreciation to young people. When they trust in our unconditional love, they will start to believe in their own abilities, which boosts their self-esteem.

And lastly oxytocin (the love hormone) is released when children feel loved. One way to boost this hormone is to express affection towards them. Simple acts of grace and gratitude can work like magic. These can include eye contact, safe touch, smiling, kind words, and spending quality time with them.

I am a big fan and an outspoken advocate of taking care of young bodies, minds, hearts, and souls. When it comes to children, we would literally die to protect them from assaults and shield them from insults, yet many of us engage in verbal attacks and acts that verge on being abusive or neglectful towards them. I know that we are all trying our best given our circumstances, but when it comes to our loved ones, we can always do better.


To prescribe the hormones of happiness, try the Triple-A Approach:, pay attention, show appreciation, and express affection towards the people who matter most. Small moments can make all the difference.

is a practicing psychiatrist in Providence Healthcare System, Portland, OR.

One doctor gives his recommendations for attending to children’s happiness.  

Moral Duty Beyond Prescribing Medications

Ms Collins is a postgraduate researcher at the Tizard Centre, School of Social Policy, Sociology and Social Research, University of Kent, UK.

Dr Tyler is a lecturer in forensic psychology at the School of Psychology, Victoria University of Wellington, New Zealand, and Honorary Lecturer in Forensic Psychology at the University of Kent, UK.

Dr Barnoux is a chartered psychologist and lecturer in forensic psychology and intellectual and developmental disabilityat the Tizard Centre, School of Social Policy, Sociology and Social Research, University of Kent.

 in terms of the harm caused to individuals, the damage caused to property, and the financial implications for individuals and society. Between 2010-2014, an estimated 261,330 intentional fires were reported to US municipal fire departments each year, resulting in 440 deaths, and 1310 injuries, and the economic cost of fire setting was estimated to be as high as $328.5 billion per year.

 In the United States, 1 in 100 adults self-reported a lifetime history of deliberate fire setting; 38% of these fire settings persisted beyond the age of 15 years.

 Although estimations of the number of people who set fires within a population are almost certainly imprecise due to methodological limitations such as variations in study design, definition of fire setting used, data analysis techniques, ungeneralizable samples, and response bias, they do provide insight into the scale of the problem.

Various terminology, with somewhat different meanings, has been used within the literature to describe offending behavior that involves fire (

 are terms used to describe intentional fires set within specific contexts (eg, legal or psychiatric), 

 is the current preferred term in the literature to describe acts of deliberately started fires regardless of their legal or diagnostic status.

Comorbidity is common among adults who set fires. Common diagnoses include personality disorder, psychosis, substance dependence, and mood disorders.

 Reported prevalence rates of pyromania are relatively low, ranging between 0 to 10% of adults who set fires.

 Lower cognitive functioning, intellectual disabilities, and other developmental disorders (eg, autism) are also common, although exact prevalence varies widely depending upon the population sampled (ie, inpatient, community, prison samples).

Despite the development of reliable and valid assessment tools in other areas of offending behavior (eg, sexual offending), the systematic development of tools specific to fire setting has been slower to progress. Nevertheless, several tools have been developed to support the process of systematically collecting and collating clinical information from a range of sources (eg, self and informant reports, behavioral observations, file reviews and clinical assessments) in order to formulate risk and identify treatment needs and intervention plans for individuals who set fires (eg, the Tranah Firesetting Inventory,

 St Andrew’s Fire and Arson Risk Instrument,

 Northgate Firesetter Risk Assessment-2.0,

). These tools do not represent validated risk assessments for fire setting, however, a few fire-specific psychometric measures have been developed to assess fire-related factors (although they lack sufficient evaluation) (

Most recently, the properties of the Fire Interest Rating Scale, Fire Attitudes Scale and the Identification with Fire Questionnaire were analyzed using factor analysis and 4 clinically relevant constructs identified across the 3 scales (ie, the Four Factor Fire Scales): 

However, data collected to validate these measures was limited (eg, ungeneralizable/small samples). Nevertheless, despite fire specific measures not having undergone rigorous reliability and validity evaluations, they can still be used by experienced clinicians as part of a comprehensive assessment.

Those who engage in fire setting are often complex individuals with a diverse set of treatment or intervention needs warranting a specialist approach that reduces their risk of further offending. Most specialist treatment programs are underpinned by a 

approach, targeting a range of criminogenic needs and factors associated with fire setting, including cognitive distortions, poor problem solving, communication difficulties, self-regulation deficits, and relapse prevention. Treatment often includes a component on fire safety education and the consequences of fire setting, while also address­ing a range of associated interpersonal problems (eg, low self-esteem, social competence difficulties, and poor goal setting). 

 summarizes empirically evaluated treatment programs.

Existing interventions that target fire setting behavior in adults include an adapted version of the Fire Awareness Child Education UP (FACE-UP).

 More recently, a cognitive-behavioral group-based intervention for individuals with developmental disabilities called the Northgate Firesetters Treatment program was developed.

 Investigators reported follow-up data for 24 participants (16 men, 8 women) who completed the Northgate Firesetters Treatment Programme, between 4 years and 12 years, 9 months posttreatment. The majority of participants (n = 17) were living in community settings and only 1 female participant was reported to have set a further fire, although suspicions were raised concerning another 2 participants.

 Despite these positive findings, both of these treatment programs are grounded in theoretical perspectives that predate more recent advancements in the field (ie, Functional Analysis Theory,

). Furthermore, their effectiveness are limited in their comparability to other generic interventions, small sample sizes, and lack of robust evidence in terms of their effectiveness in reducing reoffending.

The Firesetting Intervention Programme for Prisoners (FIPP)

 and the Firesetting Intervention Programme for Mentally Disordered Offenders (FIP-MO)

 are based on the latest comprehensive theory of fire setting: the Multi-Trajectory Theory of Adult Firesetting (M-TTAF).

 The M-TTAF integrates parts of existing psychological theory that are supported by empirical evidence including psychological vulnerabilities, developmental factors, cultural factors, social learning factors, biological factors, and contextual factors related to fire setting into a detailed multifactorial theory.

Following a pilot evaluation of the FIPP, positive findings were reported posttreatment on measures related to fire interest/problematic associations with fire, offence supportive attitudes (ie, fire specific, violent, antisocial), locus of control, and anger regulation, which were stable at 3 month follow-up.

 However, the evaluation of the FIPP was conducted solely with adult males in a prison environment; thus, its effectiveness for women and adults with 

intellectual and developmental disabilities

 has yet to be established. Consequently, the FIP-MO was developed to address fire setting and fire-related risk behaviors for both men and women across secure forensic psychiatric hospitals in the United Kingdom. Significant improvements on self-reported interests, beliefs and attitudes about fire, as well as improvement in anger expression.

It is important to note that due to the paucity of research on fire setting by adults with intellectual and developmental disabilities, the generalizability of the M-TTAF to such groups, and the interventions underpinned by it, has yet to be established. Further, despite evidence suggesting that between 0.4% to 43.6% of adults who set fires have intellectual and developmental disabilities,

 no treatment program to date has been rigorously evaluated for this population. Yet, there is evidence to suggest this small but important group have different characteristics and offence specific treatment needs requiring a 

 Nevertheless, the FIPP and FIP-MO represent the first standardized specialist interventions for individuals who deliberately set fires and have been subject to a multisite research evaluation, with results showing that they are effective in reducing some of the fire setters’ key deficits.

Evidence suggests general recidivism is as high as 60% among adults who set fires; reoffending with fire is much lwer with estimates between 4% and 16%.

 However, the operational definition of recidivism, study methodology, setting and sample populations vary widely. Nevertheless, recidivism has been largely associated with younger age, single relationship status, a diagnosis of personality disorder, a history of criminal offending, an interest in fire, and a number of attributes suggestive of childhood disturbance.

 Furthermore, reported length of stay in hospital for adults with intellectual and other developmental 

 and history of fire setting vary from 950 days to 1725 days.

 However, very few studies have included details pertaining to length of stay, which is inevitably effected by many confounding variables, such as mental health, engagement in treatment, previous offending history that are not accounted for within the data.

Whilst there have been significant advancements in our understanding of deliberate fire setting in recent years, further research is urgently needed to understand the etiology of fire setting and to further develop specialist assessment and treatment protocols. In particular, little is known about the relationship between cultural factors and fire misuse, gender-specific factors, or the needs of individuals with intellectual and/or other developmental disabilities. In addition, research on fac­tors that influence the maintenance and desistance process for fire setting will aid the construction of valid and reliable risk assessment tools and ensure individualized treat­ment approaches are taken and practice is evidence based. Focusing on these areas will also ensure that treatment efforts evolve to meet the needs of individuals who have set fires regardless of the treatment setting.

is a postgraduate researcher at the Tizard Centre, School of Social Policy, Sociology and Social Research, University of Kent, UK. 

 is a lecturer in forensic psychology at theSchool of Psychology, Victoria University of Wellington, New Zealand, and Honorary Lecturer in Forensic Psychology at the University of Kent, UK. 

is a chartered psychologist and lecturer in forensic psychology and intellectual and developmental disabilityat the Tizard Centre, School of Social Policy, Sociology and Social Research, University of Kent. Ms Collins and Dr Barnoux have nothing to disclose regarding this article. Dr Tyler is involved in providing training and evaluating the FIPP and FIP-MO programs and has received funding from Fire and Emergency New Zealand to conduct research on their Fire Awareness Intervention Programme (FAIP) for youth.

1. Home Office. Fire statistics data tables. May 14, 2020. Accessed July 23, 2020. 

https://www.gov.uk/government/statistical-data-sets/fire-statistics-data-tables

2. Campbell R. Intentional fires. National Fire Protection Association. July 2017. Accessed July 23, 2020. https://www.nfpa.org/News-and-Research/Data-research-and-tools/US-Fire-Problem/Intentional-fires

Accessed July 23, 2020. http://www.stoparsonuk.org/arson/documents/Arson-Prevention-Forum-Booklet.pdf

4. Zhuang J, Payyappalli VM, Behrendt A, Lukasiewicz K. 

. National Fire Protection Association. October 2017. Accessed July 23, 2020. https://www.nfpa.org/News-and-Research/Data-research-and-tools/US-Fire-Problem/Total-cost-of-fire-in-the-United-States

5. Blanco C, Alegria AA, Petry NM et al. Prevalence and correlates of fire setting in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). 

6. Vaughn M, Fu Q, DeLisi M, et al. Prevalence and correlates of fire setting in the United States: results from the National Epidemiological Survey on Alcohol and Related Conditions. 

Diagnostic and Statistical Manual of Mental Disorders, DSM-V. 

8. Bell R, Doley R, Dawson D. Developmental characteristics of adults who set fires: are recidivist offenders distinctive? 

9. Geller JL, Bertsch G. (1985). Fire-setting behavior in the histories of a state hospital population. 

10. Lindberg N, Holi MM, Tani P, Virkkunen M (2005). Looking for pyromania: characteristics of a consecutive sample of Finnish male criminals with histories of recidivist fire-setting between 1973 and 1993. 

11. Lees-Warley G, Rose J. What does the evidence tell us about adults with low intellectual functioning who deliberately set fires? a systematic review

. International Journal of Developmental Disabilities

12. Tranah T, Nicholas J. Interventions for young people with intellectual disabilities who commit arson. 

13. Taylor JL, Thorne I, Slavkin ML. Treatment of fire-setting behaviour. In: Lindsay WR, Taylor JL,Sturmey , eds.

 Offenders with Developmental Disabilities

14. Long CG, Banyard E, Fulton B, Hollin CR. (2014). Developing an assessment of fire-setting to guide treatment in secure settings: The St Andrew's fire and arson risk instrument (SAFARI). 

15. Taylor JL, Thorne I. Northgate firesetter risk assessment. Unpublished manual. Northgate and Prudhoe NHS Trust; 2005.

16. Taylor JL, Thorne I, Robertson A, Avery G. (2002). Evaluation of a group intervention for convicted arsonists with mild and borderline intellectual disabilities. 

17. Murphy G, Clare I. Analysis of motivation in people with mild learning disabilities (mental handicap) who set fires. 

Firesetting: Addressing Offending Behavior.

 Redcar and Cleveland Psychological Service; 1997.

19. Gannon TA, Ó Ciardha C, Barnoux MFL. The Identification with Fire Questionnaire. CORE-FP, School of Psychology, University of Kent; 2011.

20. Gannon TA, Barrowcliffe E. Firesetting in the general population: The development and validation of the Fire Setting and Fire Proclivity Scales. 

21. Ó Ciardha C, Tyler N, Gannon TA. (2015). A practical guide to assessing adult fire setters’ fire-specific treatment needs using the Four Factor Fire Scales. 

22. Hayes A. Climbing the ladder of reform. 

23. Taylor JL, Robertson A, Thorne I, Belshaw T, Watson A. Responses of female fire‐setters with mild and borderline intellectual disabilities to a group intervention. 

Journal of Applied Research in Intellectual Disabilities. 

24. Taylor JL. Roots, referrals, risks and remedies for offenders with intellectual disabilities. Paper presented at: A Risky Business, BPS conference. October 2014. University of Manchester, UK.

25. Jackson H, Glass C, Hope S. (1987). A functional analysis of recidivistic arson. 

26. Fineman KR. Firesetting in childhood and adolescence. 

27. Fineman KR. A model for the qualitative analysis of child and adult deviant behavior. 

The Firesetting Intervention Programme for Prisoners (FIPP). 

Firesetting Intervention Programme for Mentally Disordered Offenders (FIP-MO) Version 2.0.

 CORE-FP. University of Kent and Kent Forensic Psychiatry Services, NHS; 2014.

30. Gannon TA, Ó Ciardha C, Doley RM, Alleyne E. The Multi-Trajectory Theory of Adult Firesetting (M-TTAF). 

31. Gannon TA, Alleyne E, Butler H, et al. Specialist group therapy for psychological factors associated with fire setting: Evidence of a treatment effect from a non-randomized trial with male prisoners. 

32. Tyler N, Gannon TA, Lockerbie L, Ó Ciardha C. An evaluation of a specialist fire setting treatment programmed for male and female mentally disordered offenders (the FIP-MO). 

33. Ritchie EC, Huff TG. Psychiatric aspects of arsonists. 

34. Dickens G, Sugarman P, Ahmad F, Edgar S, Hofberg, K, Tewari S. Characteristics of low IQ arsonists at psychiatric assessment. 

35. Alexander RT, Chester V, Green FN, Gunaratna I, Hoare S. Arson or fire setting in offenders with intellectual disability: clinical characteristics, forensic histories, and treatment outcomes. 

Journal of Intellectual and Developmental Disability

36. Rice ME, Harris GT. Firesetters admitted to a maximum security psychiatric institution: Offenders and offenses. 

37. Ducat L, McEwan TE, Ogloff JR. An investigation of fire setting recidivism: factors related to repeat offending. 

The development of an actuarial model for arson recidivism

39. Dickens G, Sugarman P, Edgar S, Hofberg K, Tewari S, Ahmad F. Recidivism and dangerousness in arsonists. 

The Journal of Forensic Psychiatry & Psychology

Gunaratna I, Hoare S. Arson or fire setting in offenders with intellectual disability: clinical characteristics, forensic histories, and treatment outcomes

Journal of Intellectual and Developmental Disability.

41. Edwards MJ, Grace RC. The development of an actuarial model for arson recidivism. 

42. Dickens G, Sugarman P, Edgar S, et al. Recidivism and dangerousness in arsonists. 

The Journal of Forensic psychiatry & Psychology

43. Alexander RT, Chester V, Green FN, et al. Arson or fire setting in offenders with intellectual disability: clinical characteristics, forensic histories, and treatment out-comes. 

44. Taylor JL, Thorne I, Robertson A, Avery G. Evaluation of a group intervention for convicted arsonists with mild and borderline intellectual disabilities. 

Fire setting is the current preferred term in the literature to describe acts of deliberately started fires regardless of their legal or diagnostic status.

Understanding Adult Fire Setting, Pyromania, and Arson

is an independent clinical trialist and medical device consultant in San Francisco, CA. Website: 

“An uplifting experience” is how a prominent Southern California aesthetic medicine specialist described to me the reaction from a notable number of his patients having botulinum toxin treatments during the 

 (COVID-19) pandemic. Multiple needle sticks in their face notwithstanding, these patients took particular relish in cocooning themselves (however briefly) in a 

 of self-indulgence, effectively sequestered from the barrage of unique stressors now understood to be associated with COVID-19.

This isolated anecdote may be simple serendipity or an example of a potential intervention. A recently published article might stimulate discussion about the potential of broadly effective management with neurotoxin injections.

 used the FDA Adverse Event Reporting System (FAERS) to analyze more than 40,000 botulinum toxin treatment reports across a variety of medical and cosmetic indications including hyperhidrosis, facial rhytides, migraine prophylaxis, spasticity, and spasms. They reported a significantly lower number of depression reports across all indications and injection sites compared with patients undergoing alternative treatments for the same conditions.

They also found a significantly lower incidence of depression-related adverse events (AE) with neurotoxin treatment compared with the control groups. For example, reporting odds ratios (ROR) of botulinum toxin’s depression AE frequencies were uniformly significantly lower compared with control, ranging from 0.12 (95% CI: 0.04, 0.33) to 0.60 (95% CI: 0.48, 0.74), irrespective of indication. The ROR analysis necessitates that 

k associated with neurotoxin use has a reasonable underlying pharmacodynamic hypothesis. Therefore, these findings should be considered cautiously, as they may not reflect actual number of cases or frequencies in the general population as the FAERS system is voluntary and open to the public.

Although botulinum toxin does not have regulatory approval for the treatment of depression in the United States, this information should offer food for thought that there is a possibility that neurotoxin treatment may show promise in mitigating depressive symptoms. In fact, numerous reports corroborate the efficacy of botulinum toxin in attenuating symptoms related to major depressive disorder,

 including several randomized placebo-controlled trials and observational studies.

 Some believe that the muscles involved in facial expression, such as the corrugator muscles that elicit frowning, play a pivotal role in modulating the brain’s emotional circuitry and neural activity.14-17 Put simply, it is postulated that expressive behavior can alter emotional states, likely through afferent sensory modulation.

Botulinum toxin injections have an excellent safety profile. 

 reported no significant differences in the overall incidence of AEs, including serious AEs, in almost 2000 patients treated with botulinum toxin compared with patients treated with placebo injections based on the pooled results of 9 trials. Specifically, in trials of major depression, corrugator and procerus neurotoxin injections have noted that treatment-emergent AEs were localized to the treatment site and were temporary (headache and injection site irritation).

 That said, it will remain critical to evaluate the comparative effectiveness of neurotoxin treatment versus established psychopharmacological options and psychotherapeutic strategies and determine if and where it might fit into the current treatment paradigm.

One of the barriers is training mental health professionals on how to perform freehand injections, particularly those that require dose accuracy at multiple injection sites as with neurotoxin injections. Even with extensive experience, injection dose accuracy is difficult to achieve. 

 recently calculated that the average accuracy error associated with freehand injection of 40 consecutive 0.025 mL doses from a 1.0 cc syringe was approximately 10% for 2 highly-experienced injectors. Recognizing the urgency to achieve dose accuracy, several neurotoxin-dedicated devices have been developed and are undergoing clinical and regulatory evaluation.

In conclusion, preliminary evidence suggests botulinum toxin may have a positive impact on depressive symptoms. Additional research needs to be conducted to better determine the safety and efficacy of this treatment. If the data indicate this may be a worthwhile treatment option, administration barriers also will need to be addressed

. The author reports no conflicts of interest concerning the subject matter of this article.

1. Salari N, Hosseinian-Far A, Jalali R, et al. Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: a systematic review and meta-analysis. 

2. Ettman CK, Abdalla SM, Cohen GH, et al. Prevalence of Depression Symptoms in US Adults Before and During the COVID-19 Pandemic. 

Postmarketing safety surveillance data reveals antidepressant effects of botulinum toxin across various indications and injection sites

4. Alam M, Barrett KC, Hodapp RM, Arndt KA. Botulinum toxin and the facial feedback hypothesis: can looking better make you feel happier? 

5. Finzi E. Update: Botulinum Toxin for Depression: More Than Skin Deep. 

6. Parsaik AK, Mascarenhas SS, Hashmi A, et al. Role of Botulinum Toxin in Depression. 

OnabotulinumtoxinA for the treatment of major depressive disorder: a phase 2 randomized, double-blind, placebo-controlled trial in adult females

8. Chugh S, Chhabria A, Jung S, et al. Botulinum Toxin as a Treatment for Depression in a Real-world Setting. 

9. Finzi E, Rosenthal NE. Treatment of depression with onabotulinumtoxinA: a randomized, double-blind, placebo controlled trial. 

10. Magid M, Finzi E, Kruger TH, et al. Treating depression with botulinum toxin: a pooled analysis of randomized controlled trials. 

11. Magid M, Reichenberg JS, Poth PE, et al. Treatment of major depressive disorder using botulinum toxin A: a 24-week randomized, double-blind, placebo-controlled study. 

12. Wollmer MA, de Boer C, Kalak N, et al. Facing depression with botulinum toxin: a randomized controlled trial. 

13. Zamanian A, Ghanbari Jolfaei A, Mehran G, Azizian Z. Efficacy of Botox versus Placebo for Treatment of Patients with Major Depression. Iran J Public Health. 2017;46(7):982-984.

14. Franca K, Lotti T. Botulinum toxin for the treatment of depression. 

15. Hennenlotter A, Dresel C, Castrop F, et al. The link between facial feedback and neural activity within central circuitries of emotion--new insights from botulinum toxin-induced denervation of frown muscles. 

16. Kim MJ, Neta M, Davis FC, et al. Botulinum toxin-induced facial muscle paralysis affects amygdala responses to the perception of emotional expressions: preliminary findings from an A-B-A design. Biol Mood Anxiety Disord. 2014;4:11.

17. Lewis MB. The interactions between botulinum-toxin-based facial treatments and embodied emotions. 

18. Brin MF, Boodhoo TI, Pogoda JM, et al. S

afety and tolerability of onabotulinumtoxinA in the treatment of facial lines: a meta-analysis of individual patient data from global clinical registration studies in 1678 participants

Maximizing botulinum toxin injections for cosmetic and therapeutic applications with a single use, disposable, exact dose injection assist device

20. Yoelin SG, Kwolek MS, Block JE. Commentary on Botulinum Toxin injections: a call for improved accuracy. 

Although botulinum toxin does not have regulatory approval for the treatment of depression in the United States, some reports indicate neurotoxin treatment may mitigate symptoms.

An Uplifting Experience: Can Botulinum Toxin Address Depressive Symptoms?

Adolescence is a time of mental and physical fluctuation as well as a preparation for adulthood. The rapid changes that occur during this period may impact mental health, which could continue following the transition into being an adult. An investigation in 

 looks into whether social support during the teenaged years could lead to fewer mental health issues once an individual is an adult.

The investigation was a population-based cohort and used participants from the Quebec Longitudinal Study of Child Development. The participants in the cohort were given either yearly or biennial assessments beginning at age 5 months until age 20 years. They were asked to self-report their perceived social support when they were aged 19 years using the 10-item Social Provision Scale. Then, when each participant was aged 20 years, an assessment of mental health issues such as depressive symptoms and suicide ideation was administered.

A total of 1174 adolescents were included in the study, breaking down into 574 female participants and 600 male participants. The researchers found that young adults who reported higher levels of perceived social support when they were aged 19 years subsequently reported having fewer mental health problems a year later. This remained true even following adjustment for a number of mental health problems, such as depressive symptoms and suicide attempts, in adolescence at aged 15 and 17 years as well as family characteristics such as socioeconomic status. Additionally, higher perceived social support was linked with fewer symptoms of depression (β = −0.23; 95% CI, −0.26 to −0.18; P = <.001 and odds ratio [OR], 0.53; 95% CI, 0.42-0.66 for severe depression) and anxiety (β = −0.10; 95% CI, −0.15 to −0.04; P < .001 and OR, 0.78; 95% CI, 0.62-0.98 for severe anxiety). It was also tied to lower risks for outcomes related to suicide (for suicidal ideation: OR, 0.59 [95% CI, 0.50-0.70] and for suicide attempts: OR, 0.60 [95% CI, 0.46-0.79]).

The investigators concluded that perceived social support appears to help prevent the increase of mental health problems, at least over the course of a year. Providing social support during this transition period could help promote better health in the population.

1. Scardera S, Perret L, Ouellet-Morin I. Association of social support during adolescence with depression, anxiety, and suicidal ideation in young adults. 

Support in the tender younger years may lead to fewer mental health issues in the future, according to research. 

Social Support in Teen Years Could Improve Later Mental Health

The pandemic has placed Americans under unprecedented stress. It stands to reason that suicide rates would rise across the board.

But according to Paul Nestadt, MD, early data out of Maryland suggests that suicides during the initial COVID-19 wave actually dropped, compared to previous years. At the same time, Nestadt’s research also found that suicide rates among Black Marylanders rose sharply. In this Mental Health Video, he explains his findings, and what they might mean for clinical practice.

is assistant professor in the Department of Psychiatry and Behavioral Science at the Johns Hopkins School of Medicine, with a secondary appointment in the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health. He also serves as the co-director and supervising psychiatrist for the Johns Hopkins Anxiety Disorders Clinic.

New data out of Maryland includes some surprising numbers. 

Who Is at Risk for Suicide During COVID-19?

Slideshows

A recent finding that ADHD can begin in adulthood has surprised researchers. Here are reasons why it may be wrong.

Discovery of Adult-Onset ADHD Raises Questions

Susan J. Noonan, MD, MPH, talks the move towards the positive psychological model and how having a mental illness is not an all-encompassing experience. 

is a physician consultant and Certified Peer Specialist in the Department of Psychiatry at McLean Hospital and the Massachusetts General Hospital. She is the author of four books and a blog on managing depression, most recently 

Helping Others With Depression: Words to Say, Things to Do (December 2020)

How does a patient feel about having a mental illness? 

Laziness Does Not Exist

The Plasticity of Well-Being

Moral Duty Beyond Prescribing Medications

Understanding Adult Fire Setting, Pyromania, and Arson

An Uplifting Experience: Can Botulinum Toxin Address Depressive Symptoms?

Social Support in Teen Years Could Improve Later Mental Health

Who Is at Risk for Suicide During COVID-19?

Discovery of Adult-Onset ADHD Raises Questions

What Mental Illnesses Mean to Patients

Female Veterans with PTSD at Higher Risk of Heart Disease

How Frailty in Older Adults With Depression Hinders Antidepressant Response

When a Drug Binds With a Receptor...

Psychiatry’s Gender Trouble

Blue Monday, Blue Sky

The Myth of Blue Monday