Not surprisingly, many patients are struggling with quarantine and other aspects of the 

 virus and the uncertainty it brings. Some people with no mental health history are struggling and even harboring suicidal thoughts. A 

reported that 45% of respondents said their mental health had suffered, roughly 10% more than reported a month earlier.

Chinenye Onyemaechi, MD, a consultation-liaison psychiatrist, discusses signs and symptoms of depression and suicidal ideation that may be present in your patients. She notes that people who may never have sought help for mental health problems are dying by suicide. 

Other risk factors, such as depression, bipolar disorder, and alcohol or substance use, can also play a role. Additionally, health professionals who are facing pay cuts, furloughs, and job loss, as well as social issues such as the rising unemployment rate, may be at be risk for suicide. 

 by Dr Onyemaechi reminds us: "The good news is most people who are faced with traumatic situations or disasters fully recover psychologically, and psychiatrists can serve as a reminder that we all have the inner reserve to eventually get back to who we were before COVID-19."

Videos

More than ever, psychiatrists are encountering patients who may have never experienced mental health issues.

Facing Anxiety and Depression

 is rapidly expanding, fueled in part by patients seeking natural remedies over conventional pharmaceuticals. A 2010 

demonstrates that the majority of integrative medicine visits involve a mental health condition, of which depression is the most common.

 As psychiatrists trained in Western medicine, we are disconnected from such therapeutic modalities and their evidence basis, often struggling to provide appropriate psychoeducation to our patients. Here, we adopted an “open-minded” approach and examined the evidence behind the use of saffron in patients with depressive disorders.

 plant and has been used in Eastern medicine for centuries for various ailments including mood.

 Cultivation of the stigmas, which contain the components believed to have therapeutic properties, is extremely labor intensive. Stigmas contain 4 bioactive compounds: crocins and crocetins, which are responsible for the characteristic deep yellow color of saffron; picrocrocin, responsible for the characteristic bitter taste; and safranin, responsible for the hay-like aroma.

 These compounds exert antioxidant, anti-inflammatory, serotonergic, neuroendocrine, and neuroprotective effects. 

of 6 double-blind RCTs, all conducted in Iran, encompassing 230 adults with major depressive disorder (MDD) brought forward compelling evidence for the efficacy of saffron as an antidepressant.

 All studies compared saffron dosed 30 mg per day against conventional antidepressants, or placebo. Two studies compared saffron with placebo treatment; 3 compared it with fluoxetine 20 mg daily; and 1 with imipramine 100 mg daily. Overall, there was a significant reduction in the 

, without statistical significance between groups.

Since then, additional studies have emerged. A randomized controlled trial (RCT) comparing citalopram to saffron, showed improvements in both depression and anxiety over 6 weeks as measured by the HAMD and the Hamilton Anxiety Rating Scale (HAMA) in patients with mild to moderate symptoms.

 Another double-blind RCT used a slightly higher dose of saffron at 50 mg daily against placebo in mild to moderate MDD patients over 12 weeks. A statistically significant reduction in depression was found, as measured by the Beck Depression Inventory (BDI).

 looked specifically at the stigma component crocin dosed at 15 mg twice daily as an adjunct to SSRI treatment in 40 patients and found significant score improvement on the BDI after 4 weeks when compared with placebo. More recently, Kashani and colleagues

 compared saffron dosed at 15 mg twice daily against fluoxetine 20 mg daily in the treatment of mild to moderate postpartum depression over 6 weeks and found equal efficacy among the 2 treatments. Remission and partial response rates were almost identical between the groups. A 2019 study restricted to a patient population aged 60 years and older compared reduction in HAMD with daily treatment of saffron 60 mg against sertraline 100 mg for 6 weeks.

 In line with previous studies of wider patient populations, the researchers concluded that both agents were equally effective at reducing depressive symptoms.

 analyzed 23 studies and demonstrated saffron had a large positive effect size over placebo for depressive symptoms (g = 0.99) and anxiety symptoms (g = 0.95) and when used as an adjunct (g = 1.23) to traditional antidepressant medications. The authors went as far to conclude saffron appeared superior to placebo, both interdependently and as an adjunct, but a potential publication bias was noted. Two more recent meta-analyses have found similar results. In a 2018 meta-analysis of 7 RCTs, saffron was of comparable efficacy to traditional antidepressants and without any reports of serious adverse events reported.

 Most recently, Khaksarian and colleagues concluded that saffron was as effective as fluoxetine in the treatment of MDD upon review of 8 RCTs.

Importantly, no serious adverse effects were reported in any of these saffron studies. In fact, one study even evaluated its cardio protective effects in patients with comorbid depression and prior histories of post-percutaneous coronary interventions.

 The underlying mechanism for this was hypothesized to be attributed to crocin scavenging free radicals, exerting antioxidant effects, and inducing hypotensive effects.

Thus far, in several small studies, saffron dosed at 15 mg twice daily has shown similar efficacy to conventional antidepressants. This finding, however, was only demonstrated in patients with mild to moderate severity of unipolar depression. The exact adverse effects, long-term outcomes, as well as feasibility for use in populations with comorbidities or on complex regimens have not been explored. It is important to note that in all studies, 4 to 6 weeks were required for any demonstrable improvement. It is also relevant to note that studies of cognitive behavioral therapy (CBT) in mild to moderate depression have shown results on par with conventional antidepressants, and with the studies of saffron.

 are selling it for $120 per ounce, equating to 280 doses and about 86 cents per day or $26 per month—

Current evidence is intriguing regarding the potential antidepressant effects of saffron. We certainly do not consider this to be ready for clinical implementation and do not advocate for its endorsement by physicians in replacement of the current standard of care. However, it is likely that in our practices, we will encounter patients who have questions concerning integrative therapeutic modalities, and it is important to know the existing evidence as well as limitations of recent studies. Potentially, if saffron is to undergo rigorous large trials for safety and efficacy and obtain FDA approval, it could serve as an option for patients with unipolar mild-moderate depression who are resistant to conventional antidepressants or CBT.

is Assistant Professor of Psychiatry at Dartmouth’s Geisel School of Medicine and Director of Addiction Services at New Hampshire Hospital, Concord, NH. He is the Addiction Section Editor for 

is an upcoming PGY-5 Addiction Psychiatry Fellow at Dartmouth’s Geisel School of Medicine, Hanover, NH. The authors report no conflicts of interest concerning the subject matter of this article.

1. Horrigan B, Lewis S, Abrams DI, Pechura C. 

Integrative Medicine in America—How Integrative Medicine Is Being Practiced in Clinical Centers Across the United States

 2012;1(3):18-94. doi:10.7453/gahmj.2012.1.3.006

2. Dwyer A V, Whitten DL, Hawrelak JA. Herbal medicines, other than St. John’s Wort, in the treatment of depression: a systematic review. 

3. Christodoulou E, Kadoglou NPE, Kostomitsopoulos N, Valsami G. Saffron: a natural product with potential pharmaceutical applications. 

 2015;67(12):1634-1649. doi:10.1111/jphp.12456

4. Hausenblas HA, Heekin K, Mutchie HL, Anton S. A systematic review of randomized controlled trials examining the effectiveness of saffron (Crocus sativus L.) on psychological and behavioral outcomes. 

2015;13(4):231-240. doi:10.1016/S2095-4964(15)60176-5

5. Ghajar A, Neishabouri SM, Velayati N, et al. 

Crocus sativus L. versus Citalopram in the Treatment of Major Depressive Disorder with Anxious Distress: A Double-Blind, Controlled Clinical Trial

. 2017;50(4):152-160. doi:10.1055/s-0042-116159

6. Mazidi M, Shemshian M, Mousavi SH, et al. A double-blind, randomized and placebo-controlled trial of Saffron (Crocus sativus L.) in the treatment of anxiety and depression. 

 2016;13(2):195-199. doi:10.1515/jcim-2015-0043

7. Talaei A, Moghadam MH, Tabassi SAS, Mohajeri SA. 

Crocin, the main active saffron constituent, as an adjunctive treatment in major depressive disorder: a randomized, double-blind, placebo-controlled, pilot clinical trial

8. Kashani L, Eslatmanesh S, Saedi N, et al. Comparison of Saffron versus Fluoxetine in Treatment of Mild to Moderate Postpartum Depression: A Double-Blind, Randomized Clinical Trial. 

. 2017;50(2):64-68. doi:10.1055/s-0042-115306

9. Ahmadpanah M, Ramezanshams F, Ghaleiha A, et al. Crocus Sativus L. (saffron) versus sertraline on symptoms of depression among older people with major depressive disorders–a double-blind, randomized intervention study. 

 2019;282:112613. doi:10.1016/j.psychres.2019.112613

Effect of saffron supplementation on symptoms of depression and anxiety: a systematic review and meta-analysis

 2019;77(8):557-571. doi:10.1093/nutrit/nuz023

11. Yang X, Chen X, Fu Y, et al. Comparative efficacy and safety of Crocus sativus L. for treating mild to moderate major depressive disorder in adults: a meta-analysis of randomized controlled trials. 

 2018;14:1297-1305. doi:10.2147/NDT.S157550

12. Khaksarian M, Behzadifar M, Behzadifar M, et al. The efficacy of Crocus sativus (Saffron) versus placebo and Fluoxetine in treatingdepression: a systematic review and meta-analysis. 

2019;12:297-305. doi:10.2147/PRBM.S199343

13. Shahmansouri N, Farokhnia M, Abbasi S-H, et al. A randomized, double-blind, clinical trial comparing the efficacy and safety of Crocus sativus L. with fluoxetine for improving mild to moderate depression in post percutaneous coronary intervention patients. 

 2014;155:216-222. doi:10.1016/j.jad.2013.11.003

14. Farabaugh A, Fisher L, Nyer M, et al. Similar changes in cognitions following cognitive-behavioral therapy or escitalopramfor major depressive disorder: Implications for mechanisms of change. 

15. Hollon SD, DeRubeis RJ, Fawcett J, et al. Effect of cognitive therapy with antidepressant medications vs antidepressants alone on the rate of recovery in major depressive disorder: a randomized clinical trial. 

 2014;71(10):1157-1164. doi:10.1001/jamapsychiatry.2014.1054

16. Shahnoushi N, Abolhassani L, Kavakebi V, et al. Chapter 21 - Economic analysis of saffron production. In: Koocheki A, Khajeh-Hosseini M, eds. 

 Woodhead Publishing; 2020:337-356. doi:https://doi.org/10.1016/B978-0-12-818638-1.00021-6

Articles

Patients often have questions concerning integrative therapeutic modalities, and it is important to know the existing evidence as well as limitations of current research. 

Is There a Role for Saffron Phytotherapy in Treating Depression?

During times of stress and anxiety, it is natural to look for something to “take the edge off.” Fortunately, there is an option that is low cost with relatively no adverse effects that can be used as often you deem it necessary, explains Philip R. Muskin, MD, MA, DLFAPA, LFACLP, Professor of Psychiatry and Senior Consultant in C-L Psychiatry at Columbia University Irving Medical Center in New York City.

In this video, Dr Muskin shares his approach to “chill out” using hypnosis and imagery. Find a comfortable chair, and get ready to take this journey to relaxation.

, MD, is considered one of the first people to use the ideas associated with hypnosis. In late 1700s, he developed a system of therapeutics known as mesmerism, which he practiced first in Germany and later in Paris. Mesmerism was based on the idea that there were fluids in the body that were influenced by “animal magnetism.” Disease, he believed, was caused by obstacles that blocked the fluids. The obstacles, in turn, could be broken via trance states, which would return the harmonious flow of fluids. Although his patients were loyal supporters, the medical profession was critical of his ideas and practices. After a commission appointed by King Louis XVI was unable to find support for his claims, the mesmerist movement declined.

In an ironic twist of fate, a skeptic attempting to discredit the ideals of mesmerism actually became the father of hypnosis after observing a traveling mesmerist. Scottish neurosurgeon 

 conducted trials and experiments on himself and others; he eventually developed a technique of relaxation and eye-fixation that resulted in a trance-like state that could also be achieved by suggestions alone. Braid published “Neurypnology or The Rationale of Nervous Sleep Considered In Relation With Animal Magnetism” in 1842. He coined the terms 

, since he believed the trance-like state was related to sleep. His ideas continued to spread and gain popularity through the late 1800s.

Acceptance for its use often came from odd places. The 

 decreed it was not morally forbidden in 1847. And, in 1956, 

 indicated it was useful in treating pain, including during childbirth.

 issued a report endorsing hypnosis, stating there can be “definite and proper uses of hypnosis in medical and dental practice.” The 

 followed suit, and approved its use in 1958. Last to the party, the American Psychiatric Association issued a position statement in 1961 noting that “hypnosis has definite application in the various fields of medicine.”

, hypnosis is used for relaxation as well as to relieve pain and for psychotherapeutic purposes.

A simple exercise and tools to "find your Zen." 

A Journey To Relaxation

Schizophrenia is associated with substantial economic costs. According to the most recently published estimates, the total cost associated with schizophrenia in the US in 2013 was $155.7 billion.

 While this number is staggering in itself, even more striking is that the indirect costs such as those related to lost productivity, unemployment, premature mortality, and caregiving made up 75% ($117.3 billion) of this burden, dramatically overshadowing the direct costs of inpatient hospital stays, emergency room visits, outpatient visits, and prescription medications.

 These statistics speak to the enormity of the toll that schizophrenia and related psychotic disorders have on the whole spectrum of patients’ lives. Psychiatry, not unlike other areas of medicine, tends to take a reactive approach to treatment. Especially in the US, health insurance does not pay for treatment unless a condition is sufficiently severe or disabling, and we typically wait for a serious problem to arise before we take action. By the same token, psychiatric clinicians tend to focus somewhat narrowly on stabilization. 

We may think our jobs are done once a distressing symptom, behavior, or other crisis has been sufficiently reduced or stabilized. However, the disproportionately high burden of schizophrenia’s indirect costs suggests that our reactive approach is not working so well for our patients. These data serve as a call to action for psychiatry to shift from the traditionally reactive to a more proactive approach to patient care—one that does more to meet patients where they are. In the US, the biomedical framework has dominated how we view schizophrenia. In 2019, the National Institutes of Health spent $263 billion on schizophrenia research,

 with funding awarded primarily to studies investigating genetic, molecular, or circuit related mechanisms underlying the illness. Although such research is important for identifying new and better treatment targets, uncovering biomedical insights alone is insufficient to help our patients. Despite the vast research conducted in the past several decades to better understand biological mechanisms underlying psychosis, people with psychotic disorders continue to suffer, and so much about schizophrenia remains unknown.

Critically, we do not have a clear understanding of what causes schizophrenia or even what constitutes the main gestalt of the illness. Rather, we often resort to describing the illness in roundabout ways, such as by listing its assorted symptoms. How many scientific articles and book chapters on schizophrenia start with a sentence describing schizophrenia as a “devastating illness characterized by hallucinations, delusions, disorganized thinking, and bizarre behavior”? Sentences like these mirror the way schizophrenia is conceptualized in the DSM, but they do not provide a clear sense of what causes these myriad symptoms or how the symptoms relate to one another. Importantly, as anyone who has worked with patients knows, people are much more than a collection of their symptoms. Symptom remission is the primary outcome measure used in many clinical trials. Likewise, clinicians are trained to think operationally about what symptoms or behaviors they seek to target with a particular intervention—whether it is a specific medication, dose change, or hospitalization. However, the disproportionate impact of schizophrenia on indirect costs highlights the urgent need for psychiatry to go beyond the relatively narrow scope of symptom remission to focus more attention and effort on improving functional recovery and quality of life.

How can we accomplish this? The challenge is that there is no single algorithm for achieving this goal. Heterogeneity is inherent among people with psychotic disorders, and one size does not—and will not—fit all. We can, however, leverage one guiding principle—the importance of meeting people where they are. The 4 articles in this Special Report provide valuable perspectives on some of the ways we can meet people where they are.

on stage-specific treatment of psychotic disorders, Patrick D. McGorry, MD, PhD, highlights the differing needs of individuals across the various stages of illness. The philosophy is akin to treating patients with cancer; these patients are not uniformly treated with chemotherapy but rather are prescribed individually tailored treatment based on the specific stage of illness. In psychiatry, we need to consider psychotic disorders not as a single monolithic disorder, but rather a disorder that unfolds in stages. As such, we need to focus our efforts on preventing or delaying progression to subsequent stages, from which recovery may be more challenging. This stage-specific framework for understanding and treating psychotic disorders incorporates important public health principles, including aims for primary and secondary prevention.

 by Patricia E. Deegan, PhD, we hear the voice of someone who is not only an academic expert and pioneer in the topic of recovery, but also someone with lived experience. Dr Deegan is uniquely positioned to help clinicians understand how to effectively engage and empower individuals with psychosis to find hope and meaning by incorporating goals and preferences that matter to them. Everyone has dreams, hopes, values, preferences, and interests. Dr Deegan reminds us that symptom reduction might be helpful, but only in the service of personally meaningful goals.

The article on phenomenology and disordered selfhood by Josef Parnas, MD, and Maja Zandersen, MSc, PhD, highlights the importance of going beyond symptom checklists to understand the subjective experience of individuals with schizophrenia. They remind us that we must listen to what our patients tell us to appreciate the phenomenological essence and experience of schizophrenia spectrum disorders. This kind of careful listening and exploration, which involves joint collaboration as well as putting oneself in the mindset of the patient, can lead not only to improved understanding and prediction of schizophrenia, but may also be therapeutic in itself.

Last but not least, Antonio Waldo Zuardi MD, PhD, and José Alexandre Crippa, MD, inform us about the therapeutic potential of cannabidiol in individuals with psychotic disorders. Many patients look to and experiment with complementary and alternative products, whether for recreational use or perceived health benefits. Given the abundant evidence of the detrimental effects of cannabis on psychosis and psychosis risk, clinicians may be wary of any ingredients in cannabis. The authors differentiate the potentially anxiolytic and antipsychotic effects of cannabidiol from the psychotomimetic effects of THC. While cannabidiol is not approved for clinical use, Dr Zuardi and Dr Crippa summarize the research, which may be controversial and confusing for clinicians.

I am thrilled that the knowledge and perspectives of these experts could be brought together for clinicians. The hope is that the insights and recommendations in this Special Report can help psychiatry to go beyond what the biomedical model has traditionally prescribed for schizophrenia and proactively meet people where they are. We cannot afford not to, as underscored by $155.7 billion in economic costs associated with schizophrenia. Above all, meeting people where they are is a matter of public health—the health and quality of people’s lives depend on it.

Dr Shinn is Director of Clinical Research of the Schizophrenia and Bipolar Disorder Research Program at McLean Hospital and Assistant Professor of Psychiatry at Harvard Medical School. Dr Shinn has nothing to disclose regarding the subject matter of this Special Report.

Cloutier M, Aigbogun MS, Guerin A, et al. The economic burden of schizophrenia in the United States in 2013. 

 National Institutes of Health (NIH). Estimates of Research Funding for Various Research, Condition, and Disease Categories (RCDC). Feb. 24, 2020; 

https://report.nih.gov/categorical_spending.aspx

Despite the vast research conducted to better understand biological mechanisms underlying psychosis, people with psychotic disorders continue to suffer.

Meeting Patients Where They Are: A Public Health Imperative

When I was a teenager, I received a diagnosis of schizophrenia. My psychiatrist told me schizophrenia was a disease from which no one can get well. He told me to take high-dose antipsychotics for the rest of my life. At discharge, he told me to take my meds religiously and to avoid stress: no college, no romance, and no work.

After discharge I returned to my parents’ house and for many months sat in a chair in the living room, staring blankly into a cloud of cigarette smoke. My despair was palpable, but it was misunderstood as negative signs of schizophrenia. As the months passed by in a meaningless succession of minutes and hours punctuated only by the next med check visit and the next, it seemed to me the treatment was worse than the disorder. And so I stopped taking the antipsychotic.

Abruptly rejecting antipsychotic medicine was a resilient act of self-affirmation. I am a person, not an illness. I am a person, not a schizophrenic. I do not lack insight into the fact that I am unwell. My psychiatrist lacks insight into ME. I want to live my life, not my diagnosis.

Like so many who abruptly discontinue antipsychotics, I was rehospitalized within a few months. Looking back, I know progress in my recovery did not begin until my psychiatrist and I learned a new way of working together. Distilled from my personal experience, as well as from 3 decades of work articulating the journey of recovery and building pragmatic tools to support it, I offer the following thoughts.

A prescription for noncompliance arises when a message of hopeless chronicity is paired with a psychiatric medication. You have schizophrenia. You will be sick for the rest of your life. You must use medication for the rest of your life. This common message is a prognosis of doom. Many people will reject this hopeless forecast by rejecting the medicine. In rejecting the medication, they reject the prognosis of doom as well.

A prescription is more than what is written on a pad of paper. It is an interpersonal process. It includes the one who prescribes and the one who will try out and explore the prescription and its fit with the self. From day one, prescribe hope for recovery. Let people know that with effort and support it is possible to live a full and meaningful life beyond the diagnosis. Never mistake the person for the illness. Never tell people they will have to use medications for the rest of their life. Instead, take a pragmatic approach. Focus on how and if medication is helpful in supporting goal achievement in the present and the near future. Remember that using medication is not the goal. Medication is a means to get and to keep the life we want for ourselves.

Those of us who have a diagnosis of a psychotic disorder are, above all, human beings. We are more than the disorder. We are not passive objects to be fixed or cured. Even when experiencing psychosis, we are actively problem solving and trying to do something about it (eg, listening to music to distract ourselves from distressing voices). This active subject, the person, is our recovery partner. This is the person with whom we must develop the therapeutic alliance. Engagement and activation strategies should be used even during initial encounters, such as admissions or emergency department visits.

A simple question can be used to discover our recovery partner: “What do you already know how to do that helps?” A person may not have all the answers, but everyone tries something in an effort to manage psychosis. For instance, during my early psychosis, I told myself I had taken LSD (even though I had not). This was not a delusion. It was a strategy that helped me manage acute episodes of psychosis because an LSD trip is time limited. Knowing the experience would end helped me endure it.

Another powerful engagement and activation strategy is introducing 

 as part of recovery. Do this very early on in treatment. Personal Medicine

 is what we do to get well and stay well. It is self-initiated, nonpharmaceutical self-care activities that serve to decrease symptoms and improve thinking, mood behavior, and well-being, while also helping to avoid unwanted outcomes such as hospitalization. Examples include: reading Scripture at night helps me feel safe; working on car engines helps me ignore my voices; singing in my choir helps me forget my troubles; walking my dog gives me a reason to get up in the morning. All these strategies are Personal Medicine. “Smoking cigarettes helps me relax” is not, however. Tobacco is something we take, it is not what we do. Also, notice that Personal Medicine is different from generic coping strategies. Personal Medicine is personal.

Encouraging its use in psychiatric care underscores the importance of actively engaging in self-care during recovery. It elevates self-care to the status of medicine, which can be just as important as pharmaceutical medicine for recovery. Passively waiting for psychiatric medicine to make us well is usually futile. Personal Medicine does not compete with psychiatric medicine. The key is finding a synergy between the two. For many, the pathway into recovery involves finding the right balance between the things we do to be well and the pills we may take. Over time, Personal Medicine can grow into an entire toolkit of self-care strategies.

 Psychiatric medicine then becomes one tool among the many we use to support our recovery.

Use a simple, 2-part template to help people discover their Personal Medicine: “What do you do that helps you feel better and how does it help?” In some settings, certified peer supporters, therapists, and rehabilitation specialists help people discover their Personal Medicine prior to med visits. At each clinic visit ask, “Have you been using your Personal Medicine?”

Be sure to adjust psychopharmacology if it is interfering with Personal Medicine and the things that give life its meaning, purpose, and joy. If medications are causing a woman’s hands to tremble so much that she cannot do her job stitching flags (her Personal Medicine), then who would be surprised if she stopped taking those drugs? In a recovery-oriented approach, pharmacology must support—not disable—the things that matter, such as work. Finding the right balance between psychiatric medicine and personal medicine is the pathway to recovery for many patents.

From “What’s the matter?” to “What matters to you?”

It can be challenging to take an antipsychotic each day; over time, people need a sense of how the medication helps them. There is no sense in taking pills that do not seem to work. Clinical phrases are often obtuse and unhelpful (eg, “The meds will help organize your thinking”; “The meds will make you less paranoid”; “The meds will return you to baseline”). These abstractions may not speak to what matters to the person. Instead, I recommend 2 approaches.

The first approach is to directly ask, “How will we know this medicine is working for you?” Examples might be: I’ll know the meds are working for me when I: “can concentrate on my biology homework”; “am more patient with my toddler”; “can follow a football game”; or “win at online gaming again.”

When first asked, people may say, “I don’t know. You’re the doctor. You tell me how the meds are supposed to help.” Redirect the person by prompting, “I am happy to share my ideas, but I need to understand what matters to you. If this medicine works for you, what will change for the better?” The answers will provide a wealth of information. For instance, it is not unusual to hear that a person has unrealistic expectations for medications: “I’ll know the medicine is working for me if my marriage improves.” Of course, medication cannot improve a marriage. Having such an expectation can be a set-up for rejecting medications that are not working. Helping people shape expectations is important. For instance, “The meds can’t improve your marriage per se, but if they work, they can help you focus more on your partner and less on your fears. How does that sound?”

Even during acute episodes of psychosis, demonstrating concern and understanding for what matters to the person can be extremely reassuring and help build an alliance. We can use our intuition to infer what matters. For instance, a person who has been hearing distressing voices may be exhausted and would welcome some rest: “This medicine will help you rest and feel safe. How does that sound to you?”

A second approach to helping people establish their goals for medication treatment is the use of Power Statements.

 Power Statements help people express how they want medicine to help. A 2-part stem can be used to help people create their power statement: “I want medicine to help ____, so that I can ____.” Examples include: “I want medicine to help make the voices go away so that I can focus on my job at the pizza shop”; “I want medicine to help me relax, so I can get together with my boyfriend again”; and “I want medicine to help me concentrate again so I can graduate from high school.”

Power Statements act like a compass, keeping treatment focused on outcomes that matter to the person. Typically, we assess treatment outcomes by more generic measures such as the Positive and Negative Syndrome Scale (PANSS) score, lower recidivism, and longer community tenure. But at the level of the individual, those metrics can disguise treatment failure. For instance, people may have fewer hospitalizations and be stabilized and maintained on high-dose antipsychotics in the community, but they may also be living an isolated life in smoke-filled, single room-occupancy lodgings, staring at a television, and sleeping their lives away. This is not recovery and, at the level of the individual, it is a treatment failure.

Power Statements provide psychiatric care providers with an understanding of what successful treatment outcomes are, as defined by the individual. They are a study of N=1, focusing psychiatric care providers on symptom reduction in the service of personally meaningful goals. Complete symptom suppression is not a prerequisite for recovery. Many of us learn how to manage symptoms while living the life we want for ourselves.

Power Statements are easy to scale and can be created as a pen-and-paper task. In some settings, certified peer supporters, therapists, and rehabilitation staff help people prepare their statements before the med check visit.

 Psychiatric care providers begin the visit by reviewing the statement and asking, “Is this still your goal for our work together?” or “Are we making progress toward your goal?”

The journey to use medication optimally to support recovery involves many challenges.

 It is more than learning to swallow pills on schedule. Psychiatric care providers can support us on that journey through recovery-oriented strategies that convey hope and engage us as partners in the creation of a life beyond the diagnosis.

Dr Deegan is Principal and owns 50% of the company Pat Deegan, PhD & Associates, LLC in Byfield, Massachu- setts. The company created the CommonGround Program, which includes software, training, and an online Recovery Library. Personal Medicine and Power Statements, mentioned in the article, are two elements of the CommonGround Program.

 Deegan PE. The importance of personal medicine: a qualitative study of resilience in people with psychiatric disabilities. 

 MacDonald-Willson KL, Deegan PE, Hutchison SL, et al. Integrating personal medicine into service delivery: empowering people in recovery. 

 Deegan PE, Carpenter-Song E, Drake REet al. Enhancing clients’ communication regarding goals for using psychiatric medications. 

 Deegan PE. A web application to support recovery and shared decision making in psychiatric medication clinics. 

Deegan PE. The journey to use medication optimally to support recovery. 

Those of us who have a diagnosis of a psychotic disorder are, above all, human beings. We are more than the disorder. 

Prescribing Hope for Recovery

SPECIAL REPORT: SCHIZOPHRENIA & PSYCHOSIS

Psychotic disorders are potentially serious and enduring, frequently leading to substantial disability and premature death from suicide or comorbid medical illness. These disorders have been seriously 

in health systems worldwide, even in high-income countries, despite the availability of a range of effective therapeutic interventions and models of care.

 The good news is that better medium-term outcomes are now achievable through early diagnosis and comprehensive early-intervention models of care. Moreover, these outcomes can be sustained, if backed up with high-quality ongoing care to maintain and build on a platform of 

 The challenge is to make this evidence-based and cost-effective approach the new standard of care in the US and globally.

Psychosis is best considered as a range of experiences or symptoms that can develop through the intensification of normal beliefs and perceptions to form delusions or hallucinations, or the acquisition of new and abnormal perceptual experiences or delusional ideas. These constitute what are termed the 

 of psychosis; however, there are other dimensions or syndromes associated with psychotic disorders, notably negative symptoms and mood disturbance.

Psychosis may begin with “orphan” or isolated experiences, but more commonly emerges in the context of fluctuating anxiety and depression, subtle subjective and behavioral changes, and subthreshold warning signs. This pattern, which has been carefully operationalized, represents an earlier, less specific stage—even a pluripotential stage––of illness that already justifies a need for care and attracts additional comorbid syndromes and functional impairment (stage 1).

Once positive psychotic symptoms reach full threshold and are sustained, we can say that the stage of first-episode psychosis (FEP) is now present (stage 2), even if this typically occurs more gradually and dimensionally than is implied by the term, which is to a large extent an artefact of treatment systems. People are allowed to deteriorate to such an extent that a crisis is needed before entry to treatment can be achieved. 

is a heterogeneous umbrella term comprising a range of DSM/International Classification of Diseases diagnoses, including schizophrenia, schizoaffective disorder, brief psychotic disorder, and psychotic mood disorders. It can be seen as a gateway to more traditional diagnostic pathways as well as to remission and recovery.

Staging developed in clinical medicine as a strategy to add precision to diagnosis and treatment selection, and also to prognosis and prediction of outcome.

 Initially a purely clinical approach, it evolved––augmented by biopsy, imaging, and biomarkers––to a more sophisticated clinicopathological approach. Staging is a potentially useful strategy in conditions that have a propensity to persist or recur and lead to worsening impairment and/or premature death. Additionally, it is intimately linked to benefit-risk considerations, embedding the principle “first do no harm.”

Staging is valid when treatments offered in early stages of an illness can be shown to result in better outcomes, but they must be safer than treatments offered in late stages, as the benefit-to-risk ratio changes with illness progression. Remission or stabilization as well as progression are possible at each stage, but remission is usually less likely with each advancing stage, reflecting the interplay with prognosis.

Staging provides the optimal framework for early intervention and a preemptive approach to treatment; the goal is to reduce the risks of progression to later stages. This contrasts with the currently popular notion of stepped care, which is reactive, and only escalates treatment after rather than before a deterioration in clinical status. As such, stepped care represents more of a demand-management strategy than a preventive or preemptive clinical approach.

Biomarkers have the potential to sharpen the precision of staging in psychiatry; however, they are likely to span the traditional syndromal boundaries, which conversely contain heterogeneous biological subgroups. This means a transdiagnostic approach is essential for research and future refinement in staging because current categories are flawed. Transdiagnostic approaches acknowledge the fluid and dynamic nature of the onset and early stages of mental ill health, during which micro phenotypes ebb and flow; they either fade or evolve into a more stable syndrome or macro phenotype or, more commonly, syndromes, because comorbidity is very common (

). Staging has to accommodate this comorbidity and, as such, a transdiagnostic approach that transcends current diagnostic silos is required.

The idea of staging had been proposed earlier in common mental disorders.

 With the early intervention paradigm in psychosis, the ideal conditions existed for clinical staging to be formulated. Psychotic and severe mood disorders were utilized as prototypical disorders for which staging might have the greatest utility.

FEP was the fulcrum around which this began, and an evidence-based case was steadily made that the content of treatment for such cases was very different from what was appropriate for later stages of illness. An earlier clinical stage, the at-risk mental state or ultra/clinical high-risk state, was defined as covering the period prior to the threshold for a first episode of psychosis being reached. This period has become an intense focus for research and intervention.

The validity of these stages was supported by their manifestly different treatment needs and ultimately overwhelming 

that at least progression could be delayed, and early trajectories of illness significantly improved.

 Although some critics remained unconvinced, the mindset of the psychosis field moved from deterministic “doomed from the womb” thinking to a more preventive, recovery-oriented approach, strongly endorsed by patients and families.

A key strength of clinical staging is its ability to guide clinical practice, which is informed by several key principles (

of psychosis there is an earlier stage of illness during which positive psychotic symptoms (eg, distress, mood disturbance, functional impairment), are not dominant.

 During this prodromal stage, treatment consists of needs-based psychosocial interventions, influenced by cognitive behavior therapy (CBT), and a focus on treatable comorbid syndromes such as anxiety and depression, alleviating stress, strengthening coping, and minimizing illicit drug use. Because safer options are effective at this stage, antipsychotic medications are not indicated as first- or second-line treatment, and the benefit-to-risk ratio does not support their use.

Patients with FEP respond much better to all treatments if the duration of untreated psychosis (DUP) is reduced to a minimum. There is varying evidence on the exact window of time for optimal response, but delays of even a few weeks may make a significant difference to treatment response.

 This suggests that FEP might be better considered as a stage with substages within it. In fact, with a much shorter DUP now possible with early intervention, it may be possible for a small subgroup of patients to remit without antipsychotic medication if they are provided with intensive psychosocial interventions alone.

 This might be termed stage 2a. The RAISE (Recovery After Initial Schizophrenia Episode) study shows that specialized early psychosis care may only be more effective than standard care if DUP is not prolonged beyond a certain duration.

 This responsive substage could be designated stage 2b.

Within the first episode of psychosis, the staging approach and research evidence indicate that low doses of antipsychotic medications are effective but must be rigorously adhered to if adverse experiences are to be minimized and engagement maximized.

 Shared decision making has a crucial place here. The imperative to prevent weight gain and metabolic consequences means that medications least likely to produce these effects must be first line.

A subgroup of patients who do not respond to treatment with dopamine antagonists and reveal early treatment failure can be reclassified as a further substage of stage 2, or stage 2c. Alternatively, they can be regarded as having rapidly progressed to stage 4, even within the first 6 months post diagnosis. In this case, the benefit-to-harm ratio changes dramatically, and although clozapine has a number of risks, which means that it should not be used as first-line treatment, the evidence mandates its use early in the course of illness with treatment resistance or as illness rapidly progresses to stage 

Psychosocial treatments, notably vocational interventions such as Individual Placement and Support (IPS) and family interventions, must also be adapted to the stage of illness. Used early and throughout treatment, psychosocial interventions are especially effective at stage 2 in line with what is expected in a staging model and early intervention.

Following the first episode (stage 2), patients may enter stages 3 or 4. Stage 3 interventions involve the prevention of relapse with efforts to prevent and treat comorbidity and persistent subthreshold or residual symptoms of psychosis and other associated syndromes. Long-acting injectables can be seen as a preventive strategy. However, a personalized approach with substages and subgroups reflects a heterogeneity within stage 3. Thus, dose reduction and possible discontinuation are possible for a subgroup of patients.

Long-term follow-up studies reveal that late remission occurs in about 16% of cases.

 Current guidelines for the use of medications are understandably conservative, but patient heterogeneity and response to medications need to be further explored. Later-stage patients who appear to have stabilized, but with continuing symptoms and functional impairment, can be offered a different suite of psychosocial interventions. Interventions specifically linked to this stage can greatly improve patients’ quality of life. These may involve meaningful activity including part-time work, strength-based strategies, social engagement within the community to combat loneliness, family support, financial support, and expert medical care to respond to the greatly increased risk of medical illnesses.

A contributing life is possible for most people and a holistic blend of expert psychiatric, medical, and social care is essential for this to occur. The “soft bigotry of low expectations” is a consequence of poorly resourced systems of care and antiquated diagnostic thinking that is blind to the opportunities that new models of care and high-fidelity implementation can deliver. Such approaches depend on congruent mindsets and conceptual frameworks, and a much more educated and supportive wider community.

Dr McGorry is a professor of youth mental health at The University of Melbourne and executive director of Orygen in Melbourne, Australia. He has received past unrestricted grant funding from Janssen-Cilag, AstraZeneca, Eli Lilly, Novartis, and Pfizer, and honoraria for consultancy and teaching from Janssen-Cilag, Eli Lilly, Pfizer, AstraZeneca, Roche, Bristol-Myers Squibb, and Lundbeck. He has received grant funding from the Colonial Foundation, the National Health and Medical Research Council of Australia, NARSAD, the Stanley Foundation, the National Institutes of Health, and the Australian and Victorian governments.

The Lancet Commission on global mental health and sustainable development

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Malla A, Joober R, Iyer S, et al. Comparing three-year extension of early intervention service to regular care following two years of early intervention service in first-episode psychosis: a randomized single blind clinical trial. 

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Fusar-Poli P, Salazar de Pablo G, Correll CU, et al. Prevention of psychosis: advances in detection, prognosis, and intervention. 

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Psychotic disorders are potentially serious and enduring and have been seriously neglected in health systems worldwide. The good news is that better medium-term outcomes are now achievable.

Stage-Specific Treatment  of Psychotic Disorders

Fears about the overprescription of opioid analgesics and the opioid epidemic have resulted in initiatives for physicians to prescribe these medications more judiciously. However, new concerns about patients needlessly suffering untreated or undertreated pain have been raised.

Unfortunately, many lay people and even many health care providers still believe that opioids are the optimal treatment for all forms of pain and that there are no good alternatives. Studies, however, have shown that nonopioid pharmacologic therapies and nonpharmacologic therapies can be as effective and, in many cases, even more effective than opioids.

and meta-analysis of mind-body therapies (MBTs) for patients whose pain is being treated with opioids highlights how useful these modalities can be and the importance of considering them when caring for patients suffering with pain.

The review included 60 studies with 6404 participants. A variety of MBTs were employed, including meditation, hypnosis, relaxation, guide imagery, therapeutic suggestion, and cognitive-behavioral therapy (CBT) depending on the individual studies. The types of pain varied from procedural pain to burn pain to cancer-related pain to chronic pain. The impact of various MBTs on the pain and on the use of opioids were examined.

The findings indicated that meditation, hypnosis, therapeutic suggestion, and CBT were most likely among the MBTs to provide the greatest pain relief with moderate to large improvements. Meditation, hypnosis, and CBT appeared to have the greatest impact on opioid use. The researchers noted that the lack of evidence for the impact of the other MBTs may reflect that there were fewer studies rather than evidence that those MBTs are less likely to have an effect on either the pain or opioid use.

For the millions of patients whose pain is being treated with opioids, mind-body interventions are proving to be important considerations to ease suffering.

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Meeting Patients Where They Are: A Public Health Imperative

Prescribing Hope for Recovery

Stage-Specific Treatment of Psychotic Disorders

Mind-Body Therapies for the Management of Pain: How Effective Are They?

The Case Against Antidepressants for Bipolar Depression: Findings from STEP-BD

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