Six of America’s leading physician groups are deeply concerned about the consequences of the Texas state law that took effect yesterday, September 2, 2021, which bans abortions, medical counseling, and support related to abortion after 6 weeks of pregnancy. The American Psychiatric Association along with the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the American Osteopathic Association released a joint statement expressing their worries about this law.

“Our organizations, which represent nearly 600,000 physicians and medical students, strongly oppose any laws and regulations that interfere in the confidential relationship between a patient and their physician. This new law will endanger health by not only criminalizing physicians who perform necessary medical care, but by allowing private citizens with no medical training or expertise to insert themselves on women’s reproductive health decisions,” the statement read. “Moreover, this law jeopardizes women’s access to lawful, comprehensive care.”

The groups agreed that patients should be able to depend on their physicians, especially pertaining to critical decisions about their personal health.

“To that end, we fundamentally oppose any effort to criminalize or penalize physicians for providing necessary care for their patients,” the statement said further. “Physicians must be able to practice medicine that is informed by their years of medical education, training, experience, and the available evidence, freely and without threat of punishment.”

The groups concluded the statement by urging the US Supreme Court to swiftly strike down this law and any other similar legislation that would interfere with the patient-physician relationship.

, Jennifer Payne, MD, commented: “As a women’s mental health specialist, this law is, in my opinion, an assault not only on women’s reproductive rights and right to an educated and comprehensive medical decision making process with their physician, but is also an assault on women’s mental health. Being forced to carry an unwanted pregnancy to term is a risk factor for the development of perinatal depression and in turn is associated with adverse outcomes for the pregnancy, the mother, and the exposed child. Laws such as this one have long-reaching adverse consequences for generations and whole communities by adversely affecting mental health outcomes for women and mothers in particular.”

Do you have thoughts on the new Texas legislation? Share them with us at

1. American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American College of Physicians, American Osteopathic Association, American Psychiatric Association. Frontline physicians oppose Texas legislation that interferes in or criminalizes reproductive patient care. News release. September 2, 2021. 

https://www.psychiatry.org/newsroom/news-releases/frontline-physicians-oppose-texas-legislation-that-interferes-in-or-criminalizes-reproductive-patient-care

Articles

6 frontline physician groups expressed their concern about the Texas state law that bans abortions after 6 weeks of pregnancy. 

APA and Other Leading Physician Groups Oppose Texas Legislation That Interferes With Patient Reproductive Care

Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor in Chief Emeritus of 

 (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on

The following poem grew out of a wistful sense that the summer of 2021 has been burdened by so many sad or disturbing events in the United States and the world. The elegy is both for summer, with its wounded innocence, and for the sorry—but perhaps redeemable—state of the world. The poem was written before the tragic deaths of 13 brave US service members in Afghanistan, to whom the poem is dedicated.

brought back life to the cafes and theaters, our breath

coming easy for the first time in months. Yet a vague

of some ghost ship lost at sea, its breadth

so great we couldn’t swim free, or gauge our depth,

July brought east a bleak procession of storms.

In early August, we heard auguries and warnings,

The planet, we were told, is burning up. Fumes

from the California fires reached us each morning,

clouding the eastern sky. And the Taliban, swarming

By mid-August, the Delta strain had sliced

the neglectful or misinformed; the easily sacrificed.

to prepare for another insurrection, to secure

the Capitol from another mob. We heard obscure

A house divided against itself cannot stand,

Late August, and summer’s ebb. Haiti suffered earthquake,

then torrential rain, burying houses in rivers of mud.

Some say the world will end in fire, some say in flood.

I say, in ignorance that buries us in our own mistakes.

Kabul fell without a fight. The thousands we’ll forsake

Soon, the leaves will turn against unfaithful summer,

and vagrant geese will make their southern flight.

June will be a ghostly memory of yearning and pain.

in a world of broken vows and encroaching night,

and hope for healing summer to come around again.

is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and Editor in Chief emeritus of

The summer began with such promise. Where did it go? And what hope can we see in the future?

Elegy for a Wounded Summer

8 CMEs You Can Take Today

Slideshows

Our roundup of free CMEs features innovating strategies for diagnosing and addressing the neuropsychiatric signs of multiple sclerosis, the therapeutic potential of psilocybin, poststroke depression, and more. 

One of the biggest stories in psychopharmacology in recent years was not a very promising one. Mirtazapine, which has been used since the 1990s to augment antidepressant treatment, failed to work in the first well-designed studies to test that strategy.

 Now a new analysis offers more specific direction on when mirtazapine augmentation might still be useful in major depressive disorder (MDD).

Interest in mirtazapine augmentation began with a theory. Like selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), mirtazapine affects serotonergic and noradrenergic transmission, but it does so through a different mechanism, suggesting a potential synergy with combination therapy. Mirtazapine also has the potential to reduce SSRI side effects, including nausea, insomnia, and sexual dysfunction.

The strategy took off from there, aided by the catchy nickname 

 that Stephen Stahl, MD, PhD, coined for the venlafaxine-mirtazapine combination. But the empiric support for the strategy was always thin, mostly resting on a singular placebo-controlled trial that was significantly hindered by its 26-subject size.

After more than 20 years of clinical use, mirtazapine augmentation was finally tested in 2 high quality trials (large, double-blind, randomized, placebo-controlled), 1 from the United Kingdom (UK) and 1 from China.

 Both tested mirtazapine augmentation after unsuccessful treatment with an SSRI or SNRI, and in both mirtazapine worked no better than placebo. These were followed by a third study in which 112 patients who had not recovered on venlafaxine were randomized to either switch to imipramine or augment with mirtazapine. Unfortunately for mirtazapine, the imipramine switch was nearly twice as effective as mirtazapine augmentation.

Those 3 negative trials caused mirtazapine to slide down a few rungs on the augmentation algorithm. But a small signal in the UK trial inspired the investigators to give the data a second look. The study, dubbed the MIR trial, was the largest of the 3 negative trials, and involved 480 primary care patients whose depression did not respond to 6 weeks of an SSRI or SNRI. Although mirtazapine failed to make a difference on the primary outcome of depression, it did improve anxiety on secondary measures.

The investigators reanalyzed the data to see if patients with high levels of anxiety had a more favorable response to mirtazapine augmentation. After stratifying the sample by baseline anxiety level (mild, moderate, or severe on the GAD-7), they found that patients with severe anxiety made significant gains with mirtazapine, while those with no anxiety at baseline did not improve at all with the medication. Those gains included both depressive and anxious symptoms. Patients with moderate anxiety had gains between the 2 extremes.

To test whether anxiety was just a marker for illness severity, they stratified the sample by overall severity of depression. That analysis turned up negative, suggesting that it was the anxious symptoms themselves, and not the overall severity, that was driving the change.

The findings were significant, but are they clinically meaningful? They appear to be, at least in the severe anxiety group where the Generalized Anxiety Disorder-7 scale dropped 2.8 points (out of a max of 21) points and the Beck Depression Inventory II fell 2.8 (max of 63).

Mirtazapine is not the most effective augmentation strategy in depression, but it is worth considering in depressed patients with high anxiety.

 He has written several books on mood disorders, most recently

1. Rifkin-Zybutz R, MacNeill S, Davies SJ, et al. Does anxiety moderate the effectiveness of mirtazapine in patients with treatment-resistant depression? A secondary analysis of the MIR trial. 

2. Kessler DS, MacNeill SJ, Tallon D, et al. Mirtazapine added to SSRIs or SNRIs for treatment resistant depression in primary care: phase III randomised placebo controlled trial (MIR). 

3. Carpenter LL, Yasmin S, Price LH. A double-blind, placebo-controlled study of antidepressant augmentation with mirtazapine. 

4. Blier P, Ward HE, Tremblay P, et al. Combination of antidepressant medications from treatment initiation for major depressive disorder: a double-blind randomized study. 

5. Xiao L, Zhu X, Gillespie A, et al. Effectiveness of mirtazapine as add-on to paroxetine 

 paroxetine or mirtazapine monotherapy in patients with major depressive disorder with early non-response to paroxetine: a two-phase, multicentre, randomized, double-blind clinical trial. 

6. Navarro V, Boulahfa I, Obach A, et al. Switching to imipramine versus add-on mirtazapine in venlafaxine-resistant major depression: a 10-week randomized open study. 

After a string of disappointing results, mirtazapine gets another look in a recent study. 

When to Use Mirtazapine Augmentation

Laughter Therapy: Good Medicine to Make Your Heart Glad

Psychiatry Comic: The Best Alternative Medicine

is associate professor at the University of South Carolina School of Medicine - Greenville and medical director and division chief for Adult Inpatient and Consult-Liaison Services for the Department of Psychiatry and Behavioral Medicine at Prisma Health - Upstate. He served on the American Psychiatric Association’s Task Force to Address Structural Racism Throughout Psychiatry, and he currently serves as the Diversity and Inclusion section editor and advisory board member for

The enactment of Texas law SB8 can have deleterious impact to the health of women seeking care. Furthermore, this law, in my opinion, has the potential to fracture the physician-patient relationship. Women have, and should have, the right to be educated about their medical options in order to make an informed decision regarding their health.

I hope that we consider the mental health implications—increased anxiety, poor self-esteem, and depression—for women who are denied access to abortion, irrespective of the different perspectives on this controversial topic.

Hopefully this poem provides some food for thought.

The newest law in Texas dictating women's health brings with it many issues for consideration. 

Reflections on Women’s Health 

What's in a Nickname? The Clevand Indians To Become the Cleveland Guardians

A Mantra for Our Time: Be Flexible and Agreeable, and a Thinker, a Learner and a Good Person

H. Steven Moffic, MD, broaches the topic of risk and its assessment. Should a man, at 100 years old, be allowed to skydive? Why not? 

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues relate to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

Videos

Would You Recommend Skydiving at the Age 100? Formulating Risk Decisions

The US Food and Drug Administration (FDA) has approved Janssen Pharmaceutical’s long-acting atypical antipsychotic Invega Hayfera (6-month paliperidone palmitate), a one-of-a-kind twice-yearly injectable for the treatment of adults with schizophrenia.

 Patients wishing to take Invega Hayfera must first be treated with Invega Sustenna (1-month paliperidone palmitate) for at least 4 months, or Invega Trinza (3-month paliperidone palmitate) for at least 1 injection cycle.

“The approval of Invega Hayfera builds on our 60-year legacy of delivering transformational medicines for adults living with schizophrenia,” said Mathai Mammen, MD, PhD, Global Head of Janssen Research & Development at Johnson & Johnson. “This approval further underscores our steadfast commitment to addressing critical unmet needs, including treatment adherence concerns, faced by adults living with schizophrenia.”

Invega Hayfera is a long-acting injectable treatment administered by a health care provider in the upper buttocks area every 6 months, which dissolves slowly into the bloodstream.

FDA approval was based on the results of a 12-month, randomized, double-blind, noninferiority phase 3 global study. The study enrolled 702 adults from 20 countries, aged 18 to 70, living with schizophrenia. The results showed noninferiority of Invega Hayfera compared to Invega Trinza on the primary endpoint of time to first relapse at the end of the 12-month period, with relapse defined as psychiatric hospitalization, increase in Positive and Negative Syndrome Scale [PANSS] total score, increase in individual PANSS item scores, self-injury, violent behavior, or suicidal/homicidal ideation. Results also found that 92.5% of patients treated with Invega Hayfera and 95% treated with Invega Trinza were relapse-free at 12 months.

“For too long, we’ve accepted relapse as a normal part of living with schizophrenia, while research continues to demonstrate that stronger medication adherence means better patient outcomes,” said Gustavo Alva, MD, DFAPA, the Medical Director at ATP Clinical Research and 6-month paliperidone palmitate clinical trial investigator. “The Phase 3 trial results provide compelling evidence that 6-month paliperidone palmitate offers longer-term symptom control with the fewest doses per year, which may support greater patient adherence.”

The safety profile observed was consistent with previous studies of Invega Sustenna and Invega Trinza. The most common adverse reactions (≥5%) were upper respiratory tract infection (12%), injection site reaction (11%), weight increase (9%), headache (7%), and parkinsonism (5%).

“Long-acting injectable treatments offer a number of advantages compared to oral medication for schizophrenia, including relief from needing to remember to take medication daily, lower discontinuation rates, and sustained treatment over longer periods,” said Bill Martin, PhD, Global Therapeutic Area Head of Neuroscience at Janssen Research & Development. “Today’s approval enables us to rethink how we manage this chronic disease by offering patients and caregivers the potential for a life less defined by schizophrenia medication.”

1. Janssen Pharmaceutical Companies of Johnson & Johnson. Janssen announces US FDA approval of INVEGA HAFYERA™ (6-month paliperidone palmitate), first and only twice-yearly treatment for adults with schizophrenia. News release. September 1, 2021. 

https://www.prnewswire.com/news-releases/janssen-announces-us-fda-approval-of-invega-hafyera-6-month-paliperidone-palmitate-first-and-only-twice-yearly-treatment-for-adults-with-schizophrenia-301366768.html

The one-of-its-kind 6-month paliperidone palmitate treatment for schizophrenia has received FDA approval. 

First and Only Twice-Yearly Treatment for Schizophrenia Receives FDA Approval

a coaching and consulting psychiatrist, is board-certified in psychiatry, addiction medicine, and coaching (BCC). He launched 

after 8 years directing Physician Health Services, Inc. On the faculty of the University of Massachusetts Medical School, he is a consultant in psychiatry in the Division of Alcohol and Drug Abuse of McLean Hospital, an affiliate of Harvard Medical School.

The question: Why don't we hear about the opioid crisis in America anymore? Did it go away during COVID?

This week, Steve Adelman, MD, takes on the question about opioids in the US. 

Fighting the Opioid Crisis

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)

mental health and wellness virtual coaching practice, opening in July 2021, known as 

and can be confidentially reached through her website at 

Susan J. Noonan, MD, MPH shares strategies to assist patients in overcoming their fears about the COVID-19 pandemic.

To see the previous video on reentry anxiety, watch 

Reentry Anxiety: The Challenge of Returning to "Normal"

mental health and wellness virtual coaching practice, opening in July 2021, known as Noonan Wellness Coaching,and can be confidentially reached through her website at 

What are some ways to overcome anxieties about returning to "normal"?


Tackling Reentry Anxiety: Strategies for Coping

The US Food and Drug Administration (FDA) has approved Impel NeuroPharma’s Trudhesa (dihydroergotamine mesylate [DHE]) nasal spray for the acute treatment of migraine with or without aura in adults.

Trudhesa is the first and only therapeutic to use Impel’s proprietary precision olfactory delivery (POD) technology to deliver DHE quickly to the bloodstream through the upper nasal canal, thus offering rapid and sustained symptom relief without injection or infusion. Symptom relief is consistent even when administered long after the onset of a migraine attack.

“We are delighted with the approval of Trudhesa and are proud to offer the millions of Americans with migraine a non-oral, acute treatment option that may provide rapid, sustained, and consistent relief, even when taken late into a 

 attack,” said Adrian Adams, Chairman and Chief Executive Officer of Impel NeuroPharma. “The approval of TRUDHESA marks the culmination of more than a decade of research and advanced engineering to pair the proven efficacy of DHE with our innovative POD technology.”

In the phase 3, open-label, pivotal safety study, STOP 301, which is the largest longitudinal study ever conducted with DHE using nasal spray delivery, two-thirds of 360 participants with migraine had pain relief 2 hours after being treated with Trudhesa with more than 5650 migraine attacks treated. For 1 in 6 patients, pain relief started as early as 15 minutes.

 is a disease that impacts the whole body and is the second leading cause of disability,” said Kevin Lenaburg, executive director of the Coalition for Headache and Migraine Patients. “Historically there have not been enough effective treatments for treating migraine attacks, especially treatments that are not oral medicines, which can be challenging due to nausea, vomiting and other GI symptoms that can occur during a migraine. We welcome an important new treatment that combines the long-established efficacy of DHE with a non-oral, innovative delivery system that allows patients to self-administer wherever they are and at any point within a migraine attack.”

Stephanie J. Nahas-Geiger, MD, MSEd, Associate Professor in the Department of Neurology and Program Director of the Headache Medicine Fellowship Program at Thomas Jefferson University, commented: “Many of my patients need more from their migraine treatment, and TRUDHESA offers a non-oral, fast-acting, reliable option that overcomes many current medication challenges. Its upper nasal delivery circumvents the GI tract and common phenomena associated with migraine, such as nausea and gastroparesis, that can impact the effectiveness of oral treatments. And, importantly, it is a self-administered, single dose that can be taken anytime during a migraine attack, so patients don’t need to worry about missing the opportunity to benefit from using TRUDHESA within a certain timeframe. I think patients will be very receptive to this treatment, because it pairs the long-proven benefits of DHE with a patient-friendly delivery system.”

 are often comorbid with psychiatric disorders, especially mood and anxiety disorders.

 Although the exact nature of the comorbidity is unknown, several mechanistic hypotheses have been considered, including serotonergic dysfunction, ovarian hormone influences in women, and processes perpetuating central sensitization. Similarly, behavioral factors can influence the onset and course of headaches. 

The Commercial launch of TRUDHESA is planned for early October 2021.

1. Impel Neuropharma. Impel NeuroPharma announces US FDA approval of Trudhesa (dihydroergotamine mesylate) nasal spray for the acute treatment of migraine. News release. September 3, 2021. 

https://www.globenewswire.com/news-release/2021/09/03/2291459/0/en/Impel-NeuroPharma-Announces-U-S-FDA-Approval-of-TRUDHESA-Dihydroergotamine-Mesylate-Nasal-Spray-for-the-Acute-Treatment-of-Migraine.html

2. Smith TR, Winner P, Aurora SK, et al. 

STOP 301: a phase 3, open-label study of safety, tolerability, and exploratory efficacy of INP104, Precision Olfactory Delivery (POD®) of dihydroergotamine mesylate, over 24/52 weeks in acute treatment of migraine attacks in adult patients.

3. Smitherman TA, Penzien DB, Rains JC. Migraine and psychiatric comorbidity. 

 2013;(30)1. Accessed September 3, 2021. 

www.psychiatrictimes.com/view/migraine-and-psychiatric-comorbidity

The first and only treatment to use proprietary precision olfactory delivery technology to deliver DHE to the upper nasal cavity just received FDA approval. 

Nasal Spray for Treatment of Migraine Approved by FDA

Antidepressant augmentation is a common practice, and there are many strategies from which to choose. The 

 recommends a menu approach that encourages patients to collaboratively choose an option that best fits their needs.

 In addition to psychotherapy and lifestyle approaches like aerobic exercise, they recommend augmentation with:

1. Natural treatments: omega-3 fatty acids, L-methylfolate, or light therapy

2. Antipsychotics: aripiprazole, risperidone, or quetiapine

3. Antidepressants: bupropion, imipramine, or mirtazapine

When rapid relief is the priority, an antipsychotic might be the best choice. For favorable tolerability, there is bupropion or a natural therapy, and lithium has strong antisuicide effects, if that is a concern. But what if insomnia is the chief complaint? Mirtazapine is tempting here, but this medication carries a risk of weight gain and did not perform well in several recent, well-designed augmentation trials.

 Instead, a standard hypnotic may be a good option when patients continue to have depression and insomnia on an antidepressant, but not just any hypnotic.

Eszopiclone: The Science Behind Its Potential Effect on Depression

In the early 2000s, a group of sleep researchers set out to investigate whether hypnotics could improve mood in patients with depression and insomnia. The results did not pan out exactly as expected, but they point the way toward a medication with unique potential in depression.

But first, investigators had to overcome a hurdle. At the time, it was thought that hypnotics might cause depression through their sedative effects. That concern was partly put to rest in a 1999 study that tested whether zolpidem could relieve selective serotonin reuptake inhibitor [SSRI]-induced insomnia in patients who had otherwise recovered on the antidepressant. The sleep problems improved with zolpidem and, to the investigators’ relief, the sedating medication did not worsen depression.

Buoyed by this result, the manufacturer of eszopiclone funded a large trial to see if depression might actually improve with their hypnotic. Five hundred and forty-five patients with depression and insomnia were randomized to receive either eszopiclone 3mg or placebo while simultaneously starting a trial of fluoxetine. As expected, the hypnotic improved sleep, but it also improved mood symptoms that were unrelated to sleep. Compared to placebo, those who received eszopiclone experienced a more rapid and complete recovery from depression.

The same group repeated the study with zolpidem ER in a large trial of similar design. Once again, the hypnotic improved sleep, but this time there was no change in mood.

 Replication in China brought the same negative results, and last year zolpidem failed again to lift mood or reduce suicidality when added to an SSRI in a randomized trial of patients with depression, insomnia, and suicidality.

Meanwhile, eszopiclone repeated its success, improving mood and insomnia in 2 additional trials, 1 of which involved peri- and postmenopausal women with insomnia and depressive symptoms.

 Generalized anxiety disorder also improved when eszopiclone was added to an SSRI in a large manufacturer-supported trial that replicated the design of eszopiclone’s pivotal depression trial.

Both the zolpidem and eszopiclone studies involved many of the same investigators, who had pursued this work with the idea that any hypnotic that improved sleep would indirectly improve mood. But to this day eszopiclone remains the only hypnotic with distinct antidepressant effects (ramelteon has mild preventative benefits in bipolar disorder but is not known to treat depression).

 Whether this is a statistical fluke or a true difference is difficult to say, as eszopiclone has not gone head-to-head against other hypnotics in depression. However, eszopiclone does have a unique mechanism of action that might explain its antidepressant effects. To understand that we need to turn to the GABAA receptor.

Compared to the benzodiazepines, the z-hypnotics have more limited effects on GABAA, which is thought to explain why they treat sleep but not anxiety. Specifically, the z-hypnotics are selective for the sleep-inducing GABAA α-1 subunit, while benzodiazepines have additional effects on the α-2 and -3 subunits that are involved in anxiety and depression. But eszopiclone is an exception. It acts at all of the α subunits, and may actually be a little more selective for the anxiolytic α-2 and-3.

 This effect is furthered by eszopiclone’s active metabolite, desmethylzopiclone, which is a selective partial agonist at α-2 and -3 with very little α-1 activity (that is a good thing, as it would otherwise cause a lot of daytime sedation).

 In animal models, desmethylzopiclone reduced anxiety without causing sedation or motor impairment.

 Its effects in humans are not well described, but the trials above give us a hint, and the company that launched eszopiclone has patented this metabolite as a potential anxiolytic.

In this way, eszopiclone resembles the benzodiazepines, which have been used to treat depression and hasten the response to antidepressants in over 3 dozen controlled trials.

 In most of those trials, their antidepressant effects were independent of their anxiolytic effects, just as eszopiclone treated symptoms of depression that were unrelated to sleep.

Despite this research, benzodiazepines are not used routinely for depression because of their risk of tolerance and abuse. Those risks may also apply to eszopiclone, but the trials above provide some reassurance. In several of them, eszopiclone was replaced with a placebo after 2 months of treatment without any loss of the antidepressant and anxiolytic gains. Nor was there any rebound insomnia and, in some studies, it stabilized sleep patterns in a way that continued after the hypnotic was stopped.

Does all this elevate eszopiclone to the level of antidepressant augmentation? Possibly. It does have more positive results than some the augmentation strategies that are endorsed by evidence-based guidelines.1 But there are 2 caveats. First, eszopiclone was only studied in patients with comorbid insomnia, but this is not a major hurdle as it is the rare patient with depression who does not struggle with sleep (about 15%).

 More significantly, eszopiclone was started in tandem with an antidepressant in these augmentation trials, so we do not know if it could turn things around when added later, after a few antidepressant failures.

When selecting a hypnotic in depression or generalized anxiety disorder, eszopiclone should be on the list. The treatment need not be long-term. Most patients were able to taper off the hypnotic after recovery. To bolster those odds, start out with the expectation of short-term use and guide the patient toward 

is the Mood Disorders Section Editor for 

 with his cohost Kellie Newsome, PMH-NP. The author does not accept honoraria from pharmaceutical companies but receives royalties from PESI for

The psychopharmacology algorithm project at the Harvard South Shore Program: an update on unipolar nonpsychotic depression.

Mirtazapine augmentation: Running low on rocket fuel.

. September 2019. Accessed August 27, 2021.

3. Asnis GM, Chakraburtty A, DuBoff EA, et al. 

Zolpidem for persistent insomnia in SSRI-treated depressed patients.

Efficacy and tolerability of Z-drug adjunction to antidepressant treatment for major depressive disorder: a systematic review and meta-analysis of randomized controlled trials.

5. McCall WV, Benca RM, Rosenquist PB, et al. 

Reducing suicidal ideation through insomnia treatment (rest-it): a randomized clinical trial.

6. McCall WV, Blocker JN, D'Agostino R Jr, et al. 

Treatment of insomnia in depressed insomniacs: effects on health-related quality of life, objective and self-reported sleep, and depression.

7. Joffe H, Petrillo L, Viguera A, et al. 

Eszopiclone improves insomnia and depressive and anxious symptoms in perimenopausal and postmenopausal women with hot flashes: a randomized, double-blinded, placebo-controlled crossover trial.

. Eszopiclone coadministered with escitalopram in patients with insomnia and comorbid generalized anxiety disorder.

Melatonin receptor agonists-ramelteon and melatonin-for bipolar disorder: a systematic review and meta-analysis of double-blind, randomized, placebo-controlled trials.

. Searching for perfect sleep: the continuing evolution of GABAA receptor modulators as hypnotics.

Molecular actions of (S)-desmethylzopiclone (SEP-174559), an anxiolytic metabolite of zopiclone.

12. Carlson JN, Haskew R, Wacker J, et al. 

Sedative and anxiolytic effects of zopiclone's enantiomers and metabolite.

13. Benasi G, Guidi J, Offidani E, et al. 

Benzodiazepines as a monotherapy in depressive disorders: a systematic review.

Wisniewski SR, et al. Insomnia in patients with depression: a STAR*D report.

A hypnotic might be a good option for augmenting depression treatment, but which hypnotic has the best evidence for efficacy? 

An Overlooked Strategy for Antidepressant Augmentation?

Richard Berlin, MD, recites Francisco X. Alarcón's poem, 

has been writing a poem about his experience of being a doctor every month for the past 23 years in 

in a column called “Poetry of the Times.” He is instructor in psychiatry, University of Massachusetts Medical School, Worcester, MA

Prayer/Oracion

The first days of September seemed to be “flooded” with societal news with psychiatric implications. For instance, there was the unprecedented and unanticipated flash flooding in New York, New Jersey, and connected areas as Hurricane Ida made its destructive way from Louisiana out to sea again. On the other end of the country, the wildfire approaching Lake Tahoe is still not under enough control.

Then, of course, the startling news that the Supreme Court will not engage or comment on the new ban on abortions in Texas. (As strangely connected as it may seem, the Women’s Mental Health Conference scheduled for Dubai from February 6-9, 2022, was just cancelled because of the COVID-19 pandemic uncertainties.) As far as I know, there are no mental health exceptions to these new abortion restrictions. At least these were available during my residency training in the fall of 1972 when I screened pregnant women—and I approved all requests for such exceptions for abortion due to mental health risk.

 have been trying to keep up with such news with our once-a-week brief Psychiatry & Society videos that are released each Wednesday, as well as other periodic postings, including the poems of 

. With all that is going on, however, it seems like that is not enough. Thus, we will be trying out an additional series, brief written pieces on society and psychiatry on Mondays, Tuesdays, Thursdays, and Fridays. Such is the unique blessing of psychiatry that we can apply our knowledge to so many events in life.

Look for these columns to begin next week, following the unusual confluence of Labor Day in the United States and the first night of Rosh Hashanah. Interestingly, although Rosh Hashanah is the Jewish New Year and the beginning of our High Holy Days, it is also thought to be the celebration of the beginning of the world. In other words, it is really a global ecological anniversary. What this confluence may be telling us is that we have our work cut out for us to make the world a better place. Meeting some of the goals of Rosh Hashanah—forgiveness, social justice, and turning to our best selves—can provide hope that we can ultimately succeed in this challenge.

Comments and suggestions on this and future columns are welcomed and will be shared with Dr Moffic. Please email us at PTEditor@mmhgroup.com.

In this new series, you will find reflections on psychiatry and society as seen in—and inspired by—current events. 

When We’re Flooded With News

1. Make a Diagnosis with Appropriate Differential

Patients complaining of anxiety and/or insomnia may have an underlying substance use disorder (SUD) that mimics an anxiety disorder. They may be experiencing drug side effects that may be ameliorated without adding a BZD. 

2. Comprehensive Assessment Including Risk of Substance Use Disorders and/or Chronic Pain, including Family h/o SUDs

The cornerstone of a good comprehensive assessment is a thorough and careful clinical history, including a family history of SUDs. Patient-centered urine drug screening should be the rule, along with review of the state’s prescription monitoring program. Standardized risk assessment surveys may also be utilized.

The possibility of synergistic side effects, including somnolence and respiratory depression, should routinely be covered.

The range of aberrant drug-seeking behaviors should be covered in the treatment agreement (eg, lost prescriptions, early refills), with clarity regarding the standard response to such behaviors. When patients balk at the signing of a treatment agreement regarding controlled substance use and misuse, that often represents a red flag to be kept in mind as treatment decisions are made going forward.

5. Careful Consideration of Nonpharmacological Anxiety Reduction Strategies; and, non-BZD Alternatives Without Addiction Liability

Modalities like cognitive behavioral therapy, dialectical behavioral therapy, and meditation should be considered; as should less risky pharmacological options like buspirone, selective serotonin reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors.

6. Pre- and Post-Intervention Assessment of Anxiety Symptoms and Level of Functioning

Are benzodiazepine prescriptions contributing to the opioid overdose epidemic? 