While the country’s headlines shone a light on the troublesome opioid epidemic, another drug epidemic was slowly emerging. Methamphetamine is now among the most abused illicit drugs in the United States. According to the Centers for Disease Control (CDC), methamphetamine use 

 in the United States from 2015 to 2018, rising to an annual use rate of 59.7 per 1000 adults, or 14,686,900 individuals per year.

The continued escalation of methamphetamine use, alone or with opioids, presents providers with complex medical challenges and difficult consequences for patients, families, and the legal and health care systems. Separately, each drug represents an epidemic and a crisis. Together, they magnify the medical complications facing our society.

Unlike opioids, methamphetamine lacks US Food and Drug Administration (FDA)-approved pharmacological treatment interventions. Nevertheless, amphetamine-type stimulants (ATS), including methamphetamine, have a unique history that began during World War II; they were then used in the 1950s and 1960s for depression and obesity.

 ATS use declined in the 1970s after its reclassification to a more restrictive schedule by the Comprehensive Drug Abuse Prevention and Control Act.

Figure 1. Percentage of Treatment Admissions Due to Methamphetamine Use

Figure 2. US Fatalities Associated With Narcotics

Table. Summary of Methamphetamine Pharmacokinetics by Administration Route

Legal restrictions led to new drug forms, and the number of individuals who used methamphetamine grew. Postamphetamine rescheduling led to manufacturing methamphetamine using phenyl-2-propane (P2P) and methylamine. When P2P became a schedule II controlled substance, ephedrine and pseudoephedrine became the predominant agents used for methamphetamine synthesis. The Combat Methamphetamine Epidemic Act of 2005 limited pseudoephedrine access and banned ephedrine, but these regulations resulted in only a temporary decline in use. In 2005, there were 192,000 new methamphetamine users per year, whereas by 2012, the number had markedly increased to 440,000 individuals per year.

, methamphetamine use was higher in men compared with women (8.7 vs 4.7 per 1000 adults, respectively).

 Adults aged 26 to 34 years had the highest rates of methamphetamine use (11.0 per 1000 adults), followed by those aged 18 to 25 years and 35 to 49 years (9.9 and 8.3 per 1000 adults, respectively). The prevalence of methamphetamine use was greater for those making either less than $20,000 per year or between $20,000 and $49,999 per year (15.6 and 7.6 per 1000 adults, respectively), compared with those at other income levels. For almost 45% of those who used the drug, duration of use was greater than 100 days per year; nearly 25% of all individuals who used methamphetamine reported administering the drug intravenously. About 53% met the DSM-5 criteria for methamphetamine use disorder and only 31.5% received substance abuse treatment.

The CDC also compared 2008 hospital admissions with 2017 admissions, finding 15,747,334 drug-related treatment admissions in individuals 12 years or older in 2017.

 The number of treatment admissions due to methamphetamine increased substantially (

These increases in use and treatment translate into a huge economic burden. Using 2005 

, the RAND Corporation estimated total economic costs of $23.4 billion, including indirect costs of about $12.6 billion.

 Based upon increasing usage in the past decade, undoubtedly the economic burden of the drug has substantially increased.

The opioid epidemic in the United States has been well documented for a decade. The CDC reported that 70,630 fatalities was associated with drug overdoses in 2019, including all drugs.

 That year, the second-highest number of fatalities were associated with stimulant drugs, largely methamphetamine (

Based upon the methamphetamine use and fatality data, it is apparent that it has become a 

 To complicate matters, an increasing number of individuals abuse both opioids and methamphetamine.

 The CDC reported that between 2015 and 2018, 57% of those who used methamphetamine also abused either heroin or prescription opioids.

 Similarly, hospital admissions among individuals who primarily used heroin (but also reported methamphetamine use) increased by 490% from 2008 to 2017. The most common administration routes were by (intravenous) IV injection (47.1%) and smoking (46.0%).

A survey in rural Oregon reported that 96% of participants (N = 112) who used opioids in the past 30 days also noted methamphetamine use, and 50% injected both opioids and methamphetamine.

 Participants indicated that methamphetamine was more widely available, less expensive, and less stigmatized compared with opioids. Individuals discharged from substance abuse programs perceived methamphetamine as a drug that prevented opioid overdose. Individuals who used both opioids and methamphetamine reported that the latter could serve as an opioid substitute, provide a synergistic high, and balance out the sedation from the opioids.6 On the other hand, individuals who used methamphetamine stated that opioids can be used to mitigate the former’s negative adverse effects. They believed that the addition of small amounts of methamphetamine could prolong opioid intoxication effects, and coinjection of both had a more desirable intoxication effect than using either substance alone.

Methamphetamine exists in 2 stereoisomer forms, the D- and L-forms; the D-form is 3 to 5 times more potent than the L-form (

 the dopamine, serotonin, and noradrenaline transporters, as well as the vesicular monoamine transporter-2.

 Heroin and other opioids are opioid receptor agonists.

 The opioid receptors are widely distributed in the central nervous system, including the nucleus accumbens (NAcc) and ventral tegmental area (VTA).

 Both methamphetamine and opioids promote the release of dopamine in the NAcc and VTA, indicating a common pharmacological pathway for both drugs regarding reward and reinforcement properties.

 When these agents are taken together, a pharmacodynamic synergy can occur in which dopamine release may be greater than with either agent taken alone. Further, stimulant actions may attenuate an opioid’s sedative actions, whereas opioids can prevent overstimulation by methamphetamine.

The route of methamphetamine administration affects its pharmacokinetics (

 For instance, the IV route produces the most rapid onset of effects, whereas smoking promotes a slightly slower onset (about 20 minutes). The elimination half-life of methamphetamine is between 9 and 12 hours. Its metabolism, shown in 

, is converted to 2 main metabolites: amphetamine (AMP) and the 4-hydroxy (OH) methamphetamine by the cytochrome P450 (CYP) 2D6 enzyme.

 The CYP2D6 system is prone to many possible drug-drug interactions and genetic polymorphisms (eg, extensive and poor metabolizers). Although CYP2D6 genotyping has not been conducted in methamphetamine pharmacokinetic studies, in one study, a single participant was reported to have an extremely low formation of AMP and 4-OH methamphetamine compared with the other 11 participants; it was suggested that this individual could be a poor metabolizer of CYP2D6.

A wide range of adverse effects (eg, psychological issues, withdrawal, overdose, cardiac and other medical problems) is associated with methamphetamine use.

 The most common psychological effects are agitation, psychosis, and suicidal ideation. Acute methamphetamine-induced psychosis is indistinguishable from acute paranoid schizophrenia with hallucinations and delusions. Hallucinations can be auditory, visual, and tactile, with delusions of persecution and reference. Psychosis can occur with doses greater than 50 mg, with an onset ranging from 7 minutes to 34 hours post drug administration. Fatalities from severe psychological effects include those related to accidents, suicides, and homicides. Withdrawal symptoms include insomnia, depressed mood/anxiety, cravings, reduced energy, and cognitive impairment. Agitation, dilated pupils, hypertension, tachycardia, and rapid respiration occur in overdose situations. The cardiac effects can include arrhythmias, hypertension, and sudden death. Other medical problems include pulmonary damage from smoking, pulmonary hypertension, rhabdomyolysis, cerebrovascular strokes, and seizures.

 Unlike other drugs of abuse, methamphetamine has been shown to cause significant neurotoxicity and possible brain injury by modulating at least 3 molecular cascades that involve oxidative stress, neurotoxic and excitotoxic effects, and neuroinflammation.

 Briefly, it alters sigma-1 receptors that increase reactive oxygen and peroxide formation, which leads to oxidative stress. Methamphetamine promotes glutamate transmission, increasing Ca+2 intracellular concentration, resulting in neurotoxic and excitotoxic effects. The third mechanism involves the drug binding to toll-like receptor 4 and activating proinflammatory cytokines (eg, interleukin-6) leading to neuroinflammation. It has been suggested that chronic methamphetamine exposure prior to a 

 (TBI) can magnify the injury and worsens outcomes. Conversely, individuals with a TBI seem to be more vulnerable to the neurotoxic effects of methamphetamine use.

Part of the recent increase in methamphetamine use may be associated with sex. Drug use before and during sex is known as chemsex, and methamphetamine is the most commonly abused drug for 

among men who have sex with men (MSM). It is frequently used along with gamma-hydroxybutyric acid to enhance the sexual experience.

 In one study, it was reported that of MSM aged 36 to 44 years, 36% had had chemsex with multiple partners. Some reported having chemsex with more than 10 partners during 1 session. The same study reported that methamphetamine use is typically associated with unprotected sex. MSM who participated in chemsex reported use more than 2 times per month with experiences taking place over the course of years. HIV, other sexually transmitted infections, and other medical complications become major concerns for individuals who engage in chemsex.

Individuals with substance use problems have been especially affected by COVID-19, and those who use methamphetamine are no exception. The drug can cause pulmonary damage, pulmonary hypertension, and cardiomyopathy, and it compromises pulmonary function, which may make patients more prone to chronic respiratory disease and may put them at risk for more severe illness from COVID-19. Methamphetamine can also impact the immune system by decreasing the efficiency of B cells, macrophages, and other defense mechanisms, further increasing the risk of fatality from COVID-19.

 Risks for and from COVID-19 are even higher for individuals who have HIV and use methamphetamine, because individuals with HIV already have a compromised immune system.

Besides the pulmonary and cardiac damage it causes, methamphetamine use can cause vulnerability to COVID-19 in an additional way: It can further impair an individual’s judgment when used in chemsex by affecting their decisions regarding pre-exposure prophylaxis or postexposure prophylaxis HIV treatment. This, in turn, enhances vulnerability to contracting COVID-19 and may lead to faster COVID-19 progression.

Treatment for drug addictions requires behavioral and, when appropriate, pharmacological interventions. The various 

 used in individuals with addictions include cognitive behavioral therapy, matrix model, contingency management, motivational enhancement therapy, acceptance and commitment therapy, and 12-step facilitation therapy.

 Each of these behavioral interventions can be effective in reducing methamphetamine use, but the patient must remain in a given treatment program for the best chance of success.

Although the FDA has made recommendations for medications to counteract opioid abuse, it has not yet done so for methamphetamine abuse. Although many different medications have been tested in randomized clinical trials, only 4 agents—methylphenidate, bupropion, modafinil, and naltrexone—displayed any benefits, and those were limited. None demonstrated adequate and consistent evidence for efficacy.

 Preliminary pilot studies with small numbers of participants looked at oral naltrexone 50 mg/day, bupropion 300 mg/day, and buprenorphine 8 mg/day; modest reductions were reported in all participants’ methamphetamine withdrawal cravings.

 Ultimately, some of these agents may have specific uses for addiction interventions.

 in individuals who were methamphetamine-dependent but were low-severity users (ie, less than daily).

 Topiramate 200 mg/day was unable to promote abstinence in those who used methamphetamine but did reduce the amount taken as well as relapse rates in those who were already abstinent.

 Mirtazapine 30 mg/day, when used in conjunction with substance use counseling, was associated with decreases in risky sexual activity.

 A comprehensive pharmacologic therapeutic review article on methamphetamine and amphetamine dependence yielded an absence of proven efficacy, although the studies were underpowered with low treatment completion rates.

Combination therapy may be more effective than individual agents. A large multicenter, double-blind, placebo-controlled, randomized clinical trial in individuals with methamphetamine use disorder (N = 403) evaluated the combination treatment of bupropion 450 mg/day and long-acting injection naltrexone 380 mg every 3 weeks.

 The study was powered at 90% (N = 370 needed) to detect a 24% difference between the combination treatment and the placebo. Two study stages were designed, each 6 weeks long. Stage 1 assigned participants to the bupropion and naltrexone group (n = 109) or placebo (n = 294) for the first 6 weeks. Participants who did not have a placebo response were randomly assigned the bupropion and naltrexone and placebo (1:1 ratio) for a second 6-week time period. Urine samples were obtained and tested twice weekly, and the primary outcome was defined as at least 3 methamphetamine-negative samples out of 4 samples at the end of stage 1 or 2. The primary outcome response rate averaged for the 2 stages was 13.6% for the bupropion and naltrexone group and 2.5% for the placebo group, indicating an overall treatment effect of 11.1% (P < .0001). This clinical trial, unlike previous studies, did not lack statistical power and had adequate treatment completions. However, the bupropion and naltrexone response rate was rather low, albeit greater than with the placebo, and illustrates the enormous challenge in finding an effective treatment approach for methamphetamine use disorder.

Methamphetamine use has been underrecognized compared with the opioid use epidemic, but it is a major health care concern, due to rapidly increasing usage of this drug and its highly addictive pharmacologic properties. Methamphetamine use poses many psychological and physiological challenges to users. Although behavioral interventions can be effective, there are no FDA-approved drugs for treating methamphetamine addiction.

is a professor in the Department of Pharmacotherapy at the University of North Texas (UNT) System College of Pharmacy, UNT Health Science Center, Fort Worth, Texas

Patterns and characteristics of methamphetamine use among adults – United States, 2015-2018

2. Courtney KE, Ray LA. Methamphetamine: an update on epidemiology, pharmacology, clinical phenomenology, and treatment literature. 

3. Jones CM, Olsen EO, O’Donnell J, Mustaquim D. Resurgent methamphetamine use at treatment admission in the United States, 2008-2017. 

4. Mattson CL, Tanz LJ, Quinn K, Kariisa M, Patel P, Davis NL. Trends and geographic patterns in drug and synthetic opioid overdose deaths – United States, 2013-2019. 

5. The Lancet. Opioids and methamphetamine: a tale of two crises [editorial]. 

Twin epidemics: the surging rise of methamphetamine use in chronic opioid users

7. Jones CM, Underwood N, Compton WM. Increases in methamphetamine use among heroin treatment admissions in the United States, 2008-17. 

8. Baker R, Leichtling G, Hildebran C, et al. “Like Yin and Yang”: perceptions of methamphetamine benefits and consequences among people who use opioids in rural communities. 

9. Palmer A, Scott N, Dietze P, Higgs P. Motivations for crystal methamphetamine–opioid co-injection/co-use amongst community-recruited people who inject drugs: a qualitative study. 

10. Li L, Everhart T, Jacob P III, Jones R, Mendelson J. Stereoselectivity in the human metabolism of methamphetamine. 

A review of the clinical pharmacology of methamphetamine

12. Di Chiara G, Imperato A. Drugs abused by humans preferentially increase synaptic dopamine concentrations in the mesolimbic system of freely moving rats. 

13. Trescot AM, Datta S, Lee M, Hansen H. Opioid pharmacology. 

14. Paulus MP, Stewart JL. Neurobiology, clinical presentation, and treatment of methamphetamine use disorder: a review. 

15. El Hayek S, Allouch F, Razafsha M, et al. Traumatic brain injury and methamphetamine: a double-hit neurological insult. 

16. Giorgetti R, Tagliabracci A, Schifano F, Zaami S, Marinelli E, Busardò FP. When “chems” meet sex: a rising phenomenon called “chemsex.” 

17. Sexualized drug use (chemsex and methamphetamine) and men who have sex with men. Ontario HIV Treatment Network. May 2019. Accessed April 23, 2021. http://www.ohtn.on.ca/wp-content/uploads/2019/06/RR138_MSMSDU_June17.pdf

18. Evers YJ, Hoebe CJPA, Dukers-Muijrers NHTM, et al. Sexual, addiction and mental health care needs among men who have sex with men practicing chemsex – a cross-sectional study in the Netherlands. 

19. Hossain MK, Hassanzadeganroudsari M, Apostolopoulos V. Why METH users are at high risk of fatality due to COVID-19 infection? 

20. Carrico AW, Horvath KJ, Grov C, et al. Double jeopardy: methamphetamine use and HIV as risk factors for COVID-19. 

21. Starks TJ, Jones SS, Sauermilch D, et al. Evaluating the impact of COVID-19: a cohort comparison study of drug use and risky sexual behavior among sexual minority men in the 

22. National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). June 1, 2020. Accessed March 26, 2021. 

https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/evidence-based-approaches-to-drug-addiction-treatment/behavioral-therapies

23. Santos G-M, Coffin P, Santos D, et al. Feasibility, acceptability, and tolerability of targeted naltrexone for nondependent methamphetamine-using and binge-drinking men who have sex with men. 

24. Ahmadi J, Sahraian A, Biuseh M. A randomized clinical trial on the effects of bupropion and buprenorphine on the reduction of methamphetamine craving. 

25. Heinzerling KG, Swanson A-N, Hall TM, Yi Y, Wu Y, Shoptaw SJ. 

Randomized, placebo-controlled trial of bupropion in methamphetamine-dependent participants with less than daily methamphetamine use

26. Elkashef A, Kahn R, Yu E, et al. Topiramate for the treatment of methamphetamine addiction: a multi-center placebo-controlled trial. 

27. Colfax GN, Santos G-M, Das M, et al. Mirtazapine to reduce methamphetamine use: a randomized controlled trial. 

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29. Trivedi MH, Walker R, Ling W, et al. Bupropion and naltrexone in methamphetamine use disorder. 

Articles

As all eyes were on the pandemic, another surge simmered below the surface.

Confronting the Methamphetamine Epidemic

H. Steven Moffic, MD, discusses the significance of topics surrounding birthdays, such as signature birthdays and their increased rate of suicide for men. 

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 being a Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He has recently been leading Tikkun Olam advocacy movements on climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of 

Videos

Take a closer look into the meanings of birthdays...

A Psychiatric Association to a Birthday

is head of the OECD New Approaches to Economic Challenges Unit.

The impact of the COVID-19 pandemic on women around the world has been both troubling and illuminating. Record numbers of women have had to drop out of the workforce, and 

 There has been a 25 to 300%increase in reported cases of domestic violence against women

 Although death and hospitalization rates related to the pandemic have been higher for men than women, the COVID-19 brain health crisis (everything from depression and anxiety to neurological disorders like Alzheimer disease) has disproportionately affected women. What are the reasons underlying this inequity, known as the “The Brain Gap”? What are the impacts on children, families, communities, and future generations?

Closing the gap will require a comprehensive and systematic approach to the addressing gender equality. Getting more women in research and health care is a good first step, but it is not nearly enough. To improve women’s mental health, we must incorporate new data: namely, the perspective and experience of women. Solutions that consider the experience of women are more likely to create structural change across sectors, from neuroscience and health care to racial equality, public policy, and workplace norms.

Biological, sociocultural, and economic factors are relevant to understanding and promoting gender health, and to elucidating and reducing gender disparities. At the most fundamental level, neuroscience and clinical research have not sufficiently incorporated sex and gender-based differences into their understandings the disease development, or the subsequent treatment considerations. Accounting for sex and gender differences is a must if we want to move from a one-size-fits-all medical model towards precision medicine, where big data and artificial intelligence may enable personalized solutions.

For example, as of 2019, Alzheimer disease and other forms of dementia are the 7th leading cause of death globally, with women accounting for 

 Unfolding research demonstrates that current strategies to address the ever-growing care burden and cost of dementias have not adequately considered sex and gender differences in the molecular presentations of the illness.

 Nor have they considered the gender-specific biological and socio-cultural risk factors, rates of disease progression, or considerations for community management to ensure equity in care.

The interactions with the reproductive system are crucial for brain health and aging in women. Menopause, surgical menopause, preeclampsia, higher rates of depression, primary caregiving, and lower education levels are risk factors for developing dementia.

 These findings, however, have not changed the way we contextualize and treat these conditions. Decreasing levels of estrogen in perimenopause can contribute to issues with cognitive performance that sometimes resolve post-menopause, but have also been found to increase rates of dementia-related cognitive decline.

 Such insights can influence the way we tailor and prescribe treatments to women with Alzheimer disease.

The conversation about women’s equality must not be limited to cisgender white females. Because brain health disparities are exacerbated in racial-ethnic minorities and other underserved and marginalized groups, accounting for the impacts of interpersonal violence, racism, casteism, poverty, trans and homophobia is the only way to truly achieve gender equality and, ultimately, economic and social prosperity. For example, posttraumatic stress disorder (PTSD) was originally considered to be an illness of combat veterans, but it is much more likely to develop in women as a result of sexual assault and intimate partner violence.

 The latter is unfortunately highly prevalent in minoritized communities, and studies have shown that women of color and of lower socioeconomic status have very high rates of PTSD.

 These discrepancies exist for other mental illnesses and syndromes, including depression, anxiety, attention-deficit/hyperactivity disorder, substance use disorders, migraine, and trauma-related disorders.

 Such insights must be taken into account in next generation health care solutions for women.

Research institutions are calling for the inclusion of a more diverse array of women in preclinical development and in clinical trials, and the expansion of research design to focus on culturally relevant experiences in order to collect more 

 Furthermore, in order to translate this data into action, we must promote female leadership in health care and public health efforts. Although the majority of the long-term care workforce is female and the majority of residents in nursing homes are women, women remain underrepresented in health care leadership, underlining the lack of gendered consideration in 

Unfortunately, while the number of women employed and promoted in the workplace had been slowly trending up prior to the pandemic, COVID-19 may have halted that 

 In the United States, more than 2.2 million women have dropped out of the labor force in the 

 Women of color have been disproportionately laid off or furloughed, while others have had to tend to caregiving and primary provider responsibilities at home.

Unfortunately, these trends will have lasting consequences. For example, markers of scientific productivity decreased by 30% for women during the pandemic, whereas productivity for men 

 This could significantly set women back from professional growth for the next decade. Moreover, in the business sector, 

 found that “This is not just a ‘she-cession,’ but a devastating loss of contributions.”

 Women who voluntarily left their work reported burnout and difficulty balancing work and personal responsibilities. In the study, 70% disclosed they do most of the cooking, household shopping, and cleaning, and 80% of women who plan to reenter the workforce are concerned about limited economic opportunities and obtaining jobs that do not take full advantage of their training and skillsets. These concerns have led to a push for expanded childcare options, paid time off or medical leave; government-approved stimulus packages for childcare providers. In addition, there should be support for flexibility for employees who have multiple roles and responsibility in and out of the office. These benefits, however, are not often inclusive of the most marginalized groups, who are overrepresented in sectors that require face-to-face interactions, forcing them to choose between work and domestic care as we continue our work/study-from-home pandemic lifestyle. 

Roles for women at home range from primary caregiver for children, elderly parents and relatives, to chef, housecleaner, therapist, and educator. According to some studies, the wellbeing of women has directly correlated to the wellbeing of their families, from children, to spouses, to parents and extended community.

 A recent study showed that the state of Texas lost $2.2 billion due to untreated maternal mental health issues, not only due to effects on the mother’s productivity and health, but also due to downstream effects on the health and development of the 

 Not surprisingly, untreated mental health conditions occurred in 18.2% of Black women, and 11.4% of non-Hispanic white women, again demonstrating the importance of breaking down the data to accurately reflect the relative impact on marginalized communities.

Despite women’s central role in family wellbeing, domestic violence against women has risen during the pandemic. Prior to the crisis, 1 in 3 women around the globe experienced physical or sexual violence at least once in their 

 Since the onset of the COVID-19 pandemic, there has been a reported surge in the number of calls to violence-against-women-and-girls 

 The United Nations projected that an additional 15 million women could be affected by violence every 3 months of 

 This type of trauma decreases women’s sense of empowerment and self-worth, further burdening women with symptoms of depression, anxiety, and keeping them locked in cycles of oppression.

It is clear that women carry the major weight during times of crises, a point that is becoming even more apparent during the current brain health crises. Solutions that include women are more likely to have success and create structural change across sectors, from neuroscience and health care to racial equality, public policy, and workplace norms.

To that point, evidence indicates that women are more proactive in taking advantage of opportunities to improve, rebound, and strengthen their brain health and resilience, and translate this charge to their families, communities, and the workplace. In a recent telehealth study, women across the lifespan enrolled in the BrainHealth Project (a landmark scientific study to define, measure, and enhance brain health and performance) at 3 times the rate of men.

 The results showed comparable gains between men and women in 3 factors contributing to global brain health: 1) clarity (innovation, reasoning, optimism, compassion), 2) fortitude (emotional balance), and 3) resilience (social support, purpose). These gains were achieved at a time when so many were experiencing heightened depression, anxiety, social isolation, and brain fog. These results suggest that, while women carry the weight during times of crises, they also are ready to build brain health for themselves, their families, and their communities. Giving major attention to the pivotal role of women in boosting economic and societal resilience may help shore up the weakening foundation of our families, communities, and workforces.

To close the brain gap, we must work to identify and quantify the mental health issues facing women, with the goal of identifying data-driven levers for change. These levers can include clinical research and care, policy and process changes, as well as investing in female-identifying entrepreneurs and companies focusing on menopause, fertility, trans health, and postpartum depression. Closing the brain gap will prepare our socioeconomic systems for future shocks and will also make for stronger communities in times of peace. Doing so will require a transdisciplinary effort that is committed to building the infrastructure required to support the diversity of women in society. In order to develop successful solutions, we must work toward better understanding the underlying problems. We cannot afford to do otherwise.

is a psychiatrist with the Massachusetts General Hospital at Harvard Medical School, and co-founder and chief clinical officer of the Brainstorm Lab for Mental Health Innovation at Stanford University.

is advisor to the chief of staff and gender advisor, Office of the Secretary-General, Organisation for Economic Co-operation and Development (OECD)

is special advisor to the OECD secretary general and head of the OECD New Approaches to Economic Challenges Unit.

is an associate with the PRODEO Institute and a Thiel Fellow at Stanford University. 

is director of the Monash Alfred Psychiatry research centre and head of the Central Clinical School Department of Psychiatry at Monash University

is professor and chief director of the Center for BrainHealth at the University of Texas at Dallas and co-lead of The BrainHealth Project.

CEO of the Women’s Brain Project and head of stakeholder liaison (Alzheimer disease) for Biogen.

is a fourth-year psychiatry resident at Yale Department of Psychiatry. She is the chief resident of digital psychiatry and the chief resident of quality improvement, and she is also the co-founder of the Women’s Mental Health Conference, the first academic and trainee-led conference on women’s wellbeing in the country.

is co-founder of the PRODEO Institute, co-lead of the OECD Neuroscience-Inspired Policy Initiative, president of PRODEO, adjunct associate professor with the Institute for Mental Health and Physical Health and Clinical Translation at Deakin University, instructor in brain health diplomacy and entrepreneurship at the Global Brain Health Institute (University of California, San Francisco and Trinity College Dublin).

Disclosures: Dr Chadha is currently an employee of Biogen International; her involvement in the Women’s Brain Project that she cofounded is pro-bono. Dr Aragam is a scientific advisor at BetterUp and has consulted for HealthyGamer, Tik Tok, and TASF. The opinions expressed in this manuscript are that of the authors and may not reflect the views of the organizations with which they are affiliated.

Women are leaving the labor force in record numbers

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6. Sourial N, Arsenault-Lapierre G, Margo-Dermer E, et al. Sex differences in the management of persons with dementia following a subnational primary care policy intervention. 

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8. Fields JA, Garovic VD, Mielke MM, et al. Preeclampsia and cognitive impairment later in life. 

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Long-term care workforce: caring for the ageing population with dignity

. Organisation for Economic Co-operation and Development. Accessed April 27, 2021. 

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Nearly 2.2 million women have left the labor force since February

. National Women’s Law Center. November 2020. Accessed April 27, 2021. 

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Verizon announces women’s co-lab as continued commitment to supporting women through current ‘she-cession.’

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Texas losing $2.2 billion by not treating mothers’ mental health, report says

. Austin American Statesman. March 21, 2021. Updated March 22, 2021. Accessed April 27, 2021. 

Addressing the impact of COVID-19 pandemic on violence against women and girls

. November 27, 2020. Accessed April 27, 2021. 

Domestic violence is a pandemic within the COVID-19 pandemic

. February 3, 2021. Accessed May 5, 2021. 

Gender-based violence: we must flatten the curve of this shadow pandemic

 November-December 2020. Online November 25, 2020. Accessed April 27, 2021. 

25. Chapman SB, Fratantoni JM, Robertson IH, D'Esposito M, Ling GSF, Zientz J, Vernon S, Venza E, Cook LG, Tate A, Spence JS. A novel BrainHealth index prototype improved by telehealth-delivered training during COVID-19. 

The COVID-19 pandemic has exacerbated mental health and gender inequalities around the world. Understanding the causes is the first step toward finding solutions. 

Highlighting Brain-Based Inequalities for Women: From Bedside and Boardroom to Policy

“You’re not simply a queer person; you are a multitude of selves, all trying to find a home that would you feel safe, secure, and that you will learn in and become the best psychiatrist that you can be,” said Marshall Forstein, MD, at the 2021 American Psychiatric Association Virtual Annual Meeting.

Forstein, who is an associate professor of psychiatry at Harvard Medical School, and Vice Chair for Education and Program Director of Adult Psychiatry Residency at Cambridge Health Alliance, led the session, “LGBTQ+ Medical Students and Applying to Psychiatry Residency.” He was joined by 4 students: Terrance W. Embry, MS; Allison Rhodes; Teddy G. Goetz, MS; and Matthew Abrams, all of whom discussed how to select and vet psychiatry residency programs as members of the LGBTQ+ community.

Their top tip? Finding a supportive environment that not just tolerated their identity, but celebrated it.

“It’s important that, across the US, no matter where you are, even if it’s a conservative area, that residency programs are actively thinking about how to support their students,” said Abrams.

“I thought that I needed to hide my identity in order to have professional advancement,” admitted Embry, in reference to applying to medical school. His policy has changed: He sought residencies that went beyond tolerating him.

Other tips and questions to keep in mind when applying for residency include:

-Find a program that openly shares their LGBTQ+ support. Do they ask for pronouns? Do they have an LGBTQ+ curriculum? Do they share their support on social media? Are there LGBTQ+ staff that serve as mentors?
-Make sure the program supports diversity of all kinds. If a program seems discriminatory to one group, what prevents them from discriminating against others?

-Find a location in which you feel safe. Is the community at large welcoming? Would you feel comfortable in that location of the United States?

-After interviews, film a 1-minute reaction clip. This will help remind you of your own excitement, neutrality, or disappointment about the experience.

-Coordinate health insurance. If a program’s health insurance does not cover LGBTQ+ needs, it might not be a good fit.

-Talk to previous or current residents, specifically LGBTQ+ residents. Have they experienced microaggressions in the program? Were they outed by staff, or called by the incorrect name?

Forstein also shared that he did not believe coming out is a necessary step in advancing a career in psychiatry.

“It’s about your authenticity with wherever you are on that continuum of coming out,” Forstein said, “which is a lifelong process.”

The panel expressed their hope that their own experiences and tips can help other members of the LGBTQ+ community find their homes in psychiatry.

Finding a program that is a good fit while LGBTQ+ may be more difficult than it seems…

Multitude of Selves: Applying to Residencies as an LGBTQ+ Medical Student

“The issues discussed today are really just the tip of the iceberg for women in academic psychiatry. There are a multitude of them: salary differences, harassment, parental leave policies, microaggressions, lack of mentorship, and these are just some of the challenges that young, female faculty face,” Marcia Unger, MD, MPH, a child psychiatrist at the University of California, Davis, said during a presentation at the 2021 Virtual American Psychiatric Association Annual Meeting.

In the presentation, “Triple Threat: Young, Female, Professional—the Experiences of Young Female Psychiatrists and Psychologists in Academic Medicine,” Unger and her colleagues shared some startling data: According to 2018-2019 data report, 17% of female faculty in academic psychiatry have experienced an instance of disrespect based on their gender, compared to only 1% of men.

Furthermore, according to their research, women were more likely to experience: diminished responsibility, decreased patient and provider trust, inappropriate verbal exchanges, and be asked to perform nonmedical tasks.

The panel covered 2 additional challenges based in gender discrimination against women in academic psychiatry: Impostor syndrome and motherhood. 

Imposter syndrome, a psychological phenomenon wherein people doubt their abilities and fear being exposed as a “fraud,” has a higher severity in female faculty. A 2016 report recorded 50% of female students were affected by impostor syndrome, compared to only 25% of their male counterparts.

“Men tend to own success, while women will state they were lucky,” said Anu Gupta, MD, a child psychiatrist at University of California, Davis.

Young, professional women in academic psychiatry are facing down the iceberg: gender discrimination. 

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