Nonsuicidal self-injury to the genitalia, or genital self-mutilation (GSM), is an uncommon form of self-harming behavior seen primarily, but not exclusively, in male patients with psychosis or schizophrenia spectrum disorders. As with any nonsuicidal self-injurious behavior, the severity of GSM 

 Since GSM was first described in the medical literature in 1901, infrequent case reports have been published in both psychiatric and urologic literature. The majority of these cases have been examples of patients exhibiting a single episode of GSM often involving amputation of all or part of the penis and testicles.

In this report, we present a complex and unusual case of repetitive GSM and explore the differential diagnoses and psychodynamic and psychosocial underpinnings, describing the patient’s unfolding presentation while exploring and expanding upon the limited existing literature on the subject.

A 26-year-old man presented to an outpatient mental health clinic with complaints of persistent depressed mood and emotional outbursts. During the interview, “Mr Carr” incidentally disclosed a 13-year history of repetitive, superficial cutting of the ventral aspect of his penis. Adding to the intrigue of this case, he initially denied any history of overt psychotic symptoms.

Mr Carr reported persistent depressed mood, anxiety, outbursts of anger, and increasing social isolation. He recently began taking courses to be trained as an information technology technician and soon after had a physical altercation with a classmate whom he believed was talking about him behind his back. This altercation led him to seek help at the clinic.

Mr Carr described a lifelong history of untreated depression with an aborted suicide attempt at the age of 12 (in which he held a knife to his wrist) and 1 hospitalization at the age of 24 due to suicidal ideation. As an inpatient, he was given an unknown medication, which he discontinued shortly after discharge. Around the time of this hospitalization, he began to feel self-conscious around his friends and family.

Mr Carr used to enjoy traveling and meeting new people but is now a loner without lasting friendships. He wanted to work as an information technology technician so that he could work in an isolated environment away from others. His interactions with family, classmates, and strangers on the internet have become more negative, which he attributes to his increasingly pessimistic world view. He endorsed low self-esteem and troublesome interpersonal sensitivity and felt that others are critical of him but admitted that he may be projecting his own feelings about himself onto those around him. He expressed a desire to improve his life and his social skills so that his interactions with others are more positive.

During the interview, Mr Carr was thoughtful, articulate, and had partial insight into his problems. He was attentive and polite to clinicians, and his thought processes were linear, logical, and goal directed. He was fully oriented with depressed affect. He scored 15 on the Patient Health Questionnaire-9 (PHQ-9), which indicated moderately severe depression. He denied current suicidal ideation.

When asked about nonsuicidal self-injury, he reported that since age 13, he has been cutting layers of skin from the ventral side of his penis about 2 to 3 times a year. He did not endorse erotic sensations or emotional relief as motivating these acts. Mr Carr stated all his sexual partners were female and that the cutting of his genitalia did not interfere with his sex life. He has not had any long-term romantic relationships.

Upon questioning, he denied any history of physical or 

. However, he later stated, “My whole life has felt like emotional abuse.” Mr Carr said his family makes him feel inadequate, and they wanted him to be circumcised. He said he was raised Catholic and was of Hispanic and Northern European ancestry. He did not know why he was not circumcised as an infant. An aunt recently asked him, “Why don’t you just have it done and be over with it?” He believes circumcision is not natural; he became visibly upset talking about the subject and declined to answer further questions regarding the cutting of his penis.

Mr Carr did not have a history of mania, 

, or visual hallucinations, and as far as he knows, there was no family history of psychiatric illness. He reported infrequent alcohol and cigarette use and daily marijuana use as self-treatment for his depression and anxiety. He used cocaine and psilocybin each on 1 occasion several years ago; he denied use of other drugs.

Mr Carr was agreeable to medication treatment and was started on 25-mg hydroxyzine and 30-mg duloxetine with instructions to increase the duloxetine dose to 60 mg after 7 days. He was also assigned to meet with a licensed clinical social worker for counseling.

Four days later, Mr Carr called a crisis hotline and reported that he was hearing voices. His psychiatrist was made aware of this call and phoned him to follow up. Mr Carr said he was unsure whether the voices were his neighbors “talking about him” or if the voices were internal. Two weeks later, he called his psychiatrist requesting a higher dose of hydroxyzine to treat his anxiety. When discussing what he was anxious about, he described an earlier event during which he was running errands when he became concerned that the strangers around him did not like him and were calling him names. He also stated that his hotel room was burglarized the night before, and he believed someone was “trying to intimidate [him].” Shortly after these incidents of increasing paranoia, Mr Carr accused his psychiatrist of not caring about him, moved out of state, and was lost to follow-up.

Although it is clear GSM behaviors occur within a spectrum of severity, a limitation of most literature reviews is that few have differentiated between low-intensity and more life-threatening GSM behaviors. The most recent systematic review of the available literature explored this issue directly but also called into question previous reports of the percentage of patients who are psychotic at the time of self-harm.

 sought to compare the psychiatric diagnoses behind 173 cases of GSM and to differentiate between mutilation-only and more extreme cases such as amputation of the penis, castration, or combined amputation and castration. Their review of the literature classified just 12.1% of GSM incidents as mutilation-only cases, whereas 35.8% involved penile amputation, 32.4% were cases of self-castration, and 19.7% were combined amputation/castration cases (

Psychiatric diagnoses were identified in 157 of the 173 cases examined (

). Common psychiatric disorders included schizophrenia spectrum as the most common (49%), followed by substance use (18.5%), personality (15.9%), and gender dysphoric (15.3%). These figures are in stark contrast to other reviews that placed the percentage of schizophrenia spectrum disorders higher, from 77% to 87%.

Veeder and Leo’s analysis found that patients who had a diagnosis of schizophrenia spectrum disorders were more likely to amputate their penises (with or without accompanying castration) than patients with other diagnoses and that castration only was more likely in patients with gender dysphoria. In the cases of mutilation only, 23.8% of patients had a diagnosis of schizophrenia spectrum disorders, 19% had a diagnosis of substance use disorder, 19% had a diagnosis of personality disorder, 9.5% had a diagnosis of depression, 9.5% had a diagnosis of gender dysphoria, and for 14.3%, a diagnosis was unknown or not reported.

Because he was lost to follow-up, many questions regarding Mr Carr’s GSM cannot be answered, and so a wide diagnostic net must be cast to explore the underlying diagnoses that may explain his behavior.

Given Mr Carr’s unfolding psychotic symptoms with auditory hallucinations and persecutory delusions after his visit, and considering the previously mentioned data, it seems most likely that he was experiencing the onset of a schizophrenia spectrum disorder.

 If (conservatively) 49% of patients exhibiting any form of GSM and 23.8% with mutilation-only GSM end up with a diagnosis of a schizophrenia spectrum disorder, then the cutting of his penis may have been Mr Carr’s first presenting sign, preceding the major criteria for any schizophrenia spectrum disorder by many years. Moreover, Mr Carr described himself as a loner, consistent with personality characteristics often noted in patients before the onset of psychosis.

There is at least 1 case in the literature in which a man castrated himself years before the onset of overt psychosis. At the time of the autocastration, this man received a diagnosis of schizotypal personality disorder due to odd beliefs or magical thinking and social withdrawal. Three years later, the patient presented with overt paranoia, disorganized thought, and the diagnosis was schizophrenia.

In addition to schizophreniform disorder, schizophrenia, and schizoaffective disorder, medication-induced psychotic disorder should also be 

in the differential diagnosis because Mr Carr’s psychotic symptoms appeared days after the initiating duloxetine.

 found that mood disorders were not a common diagnosis in the setting of GSM: only 8.9% of cases of any form of GSM and 9.5% of mutilation-only GSM involved patients meeting criteria for major depressive disorder (MDD).

 Mr Carr reported a long history of depression and met MDD criteria at the time of his presentation to the clinic. Therefore, MDD with psychotic features should be included in the differential diagnosis.

There is also the possibility that Mr Carr has been suffering with bipolar disorder for many years. He described a time before his hospitalization in which he hitchhiked, traveled through many states, slept on the couches of strangers, and pursued sexual relationships with women he had only just met. Without more information, it is difficult to determine whether this was simply age-appropriate youthful adventurous behavior or hypomanic episodes. The fact that Mr Carr experienced psychosis after starting duloxetine further supports the inclusion of bipolar disorder with psychotic features in the differential diagnosis.

In light of his almost-daily marijuana use, substance use disorder should be considered. Substance use disorders were reported in 19% of individuals with mutilation-only GSM.

 Mr Carr denied any cognitive or other impairment from his marijuana use, but one cannot rule out that marijuana or other possible additives may have exacerbated his paranoia or triggered the auditory hallucinations. Dual diagnosis is not uncommon in patients with psychotic disorders. No urine drug screen was performed to confirm that marijuana was the only substance in his system. Mr Carr stated that he began cutting himself before he began using marijuana, suggesting that marijuana use did not explain his GSM.

When considering a personality disorder (diagnosed in 19% of mutilation-only cases) as an underlying diagnosis, Mr Carr did exhibit some cluster A personality traits such as suspicion of others as found in paranoid or schizotypal personality disorders and a preference for solitary activities as seen in schizoid personality disorder.

 He also had some symptoms of borderline personality disorder with self-mutilating behavior (although not suicidal) and described intense anger and paranoid ideation, which may have been stress related and evolved into psychosis. However, he did not meet DSM-5) criteria for any one disorder. Moreover, these personality traits merge with Mr Carr’s psychotic and mood symptoms.

Of the 4 diagnoses, Veeder and Leo found most commonly in mutilation-only cases, gender dysphoria is the least likely to explain Mr Carr’s case, as he did not describe any dissatisfaction with his gender.

It is very difficult to find examples of patients who have practiced GSM 

. A report from 2002 found only 13 cases of repetitive GSM in the literature. The authors reported that 8 of the 13 cases (61.5%) involved male patients with gender dysphoria and in only 5 of the cases (38.5%) was the patient psychotic at the time. Of these 13 total cases, 46.2% began with low-intensity, nonpermanent forms of mutilation and progressed to more severe acts.

 Although it is a small sample size, this report highlights the importance of asking these patients about gender dysphoria and determining whether their self-harming behavior has evolved in severity over time.

DSM-5 cites nonsuicidal self-injury as a condition warranting further research. While Mr Carr’s behavior does not entirely fit within the proposed criteria for this disorder, it is worth noting here. DSM-5 characterizes 

 as repetitive, shallow but painful injuries to the body surface that commonly produce feelings of relief. Many individuals who practice this behavior report feelings of tension and craving for the mutilation followed by reduced tension and anxiety after the act. Whether Mr Carr felt this pattern of craving followed by relief, we do not know, but it is clear he did not intend to kill himself by GSM.

Case reports on GSM are not only scarce, they are also inconsistent in their documentation of the psychosocial factors underlying these acts. In the case of Mr Carr, one wonders what role the pressure from his family to undergo circumcision played in his GSM or whether his feelings of having been emotionally abused contributed to self-punishing behavior.

Several psychodynamic theories have been proposed regarding GSM. Some have posited that it could be related to Freudian castration anxiety. Thompson and colleagues

 described 2 cases of GSM by 2 young men who had recently lost their fathers, suggesting that an unresolved oedipal complex may have contributed to the GSM. The authors proposed that guilt about an attachment to their mother, ambivalence toward the father, and intense grief might have led to self-punishment by carrying out castration fears.

Findings from another case study of 3 patients suggest that GSM could be related to castration anxiety and unresolved oedipal situations.

 A case study of 2 patients with schizophrenia who carried out a different and extreme form of self-mutilation, self-enucleation, suggested that castration fears and failure to resolve oedipal conflicts, severe guilt, and self-punishment all contributed to these desperate acts.

 Mr Carr did not share specific details about his relationship with his parents other than general feelings of emotional abuse to support unresolved oedipal issues as influencing him.

Other risk factors identified in the literature include feelings of guilt surrounding a sexual conflict, as well as experiences of separation, a recent failure, and a history of self-mutilation (genital and nongenital).

 Unfortunately, the case of Mr Carr, like cases before it, lacks many important details that could contribute to our understanding of this unusual behavior. Questions such as whether he felt guilty about a past sexual encounter or if he was punishing himself for disappointing his family may never be answered. Consistent with the diagnostic complexity of Mr Carr, for 14.3% of mutilation-only GSM cases, a diagnosis was unknown or not reported.

GSM is an infrequent form of nonsuicidal self-injury that occurs within a spectrum of severity. It is very likely that less severe forms of GSM may be both underreported and unpublished. These factors combined with the immense shift in scientific understanding of human sexuality since the first cases were reported has contributed to the clinical mystery of GSM. When facing a case of GSM, clinicians should explore the motivations underlying the self-injury and consider a wide variety of psychiatric diagnoses. Medical treatment should be tailored to the patient’s presentation and underlying diagnosis, and the patient should be closely monitored for recurrence and escalation.

 is a medical student, University of Oklahoma Health Sciences Center, Oklahoma City, OK. 

is Vice Chair of Education, Ungerman Endowed Chair of Psychiatry, Department of Psychiatry and Behavioral Sciences, University of Oklahoma Health Sciences Center. The authors report no conflicts of interest concerning the subject matter of this article.

Male genital self-mutilation: a systematic review of psychiatric disorders and psychosocial factors

2. Catalano G, Catalano MC, Carroll KM. Repetitive male genital self-mutilation: a case report and discussion of possible risk factors. 

3. Greilsheimer H. Male genital self-mutilation. 

On background factors of male genital self-mutilation

5. Myers WC, Nguyen M. Autocastration as a presenting sign of incipient schizophrenia. 

6. Preda A, Maclean RW, Mazure CM, Bowers MB. 

Antidepressant-associated mania and psychosis resulting in psychiatric admissions

7. Tomita T, Yasui-Furukori N, Kaneko S. Visual hallucinations during duloxetine treatment in a patient with major depressive disorder. 

8. Thompson JN, Abraham TK. Male genital self mutilation after paternal death. 

9. Money J, DePriest M. Three cases of genital self-surgery and their relationship to transsexualism. 

10. Maclean G, Robertson BM. Self-enucleation and psychosis: report of two cases and discussion. 

Articles

This form of nonsuicidal self-injury occurs within a spectrum of severity, and it is very likely that cases are both underreported and unpublished.

Genital Self-Mutilation: A Cutting Conundrum

Racism is defined as a belief that one’s race is the primary determinant of the differences that produce an inherent superiority of one group over another. It is one of the ugliest aspects of human nature. It is still present today in all walks of life. This typical pattern of racism in America more commonly disadvantages African Americans.

The first memory I have of police brutality was at the age of eight years old in 1972. This happened to my next-door neighbor, the most prominent individual of the community, Mr 

, a radio personality and cousin of singer James Brown.

 One night he accidently bumped into and broke an officer’s flashlight. He was then slammed against the police vehicle. Instantly breaking his neck. He was arrested and dragged to jail because he was unable to walk. Was left unattended for 6 hours until finally a cellmate noticed him motionless and called for help. Only then the ambulance was called. He was now quadriplegic and suffered this way for 4 years until his untimely death. Despite the family pursuing legal recourse, the court ruled that no one was at fault. It left a deep feeling of powerlessness in the community.

Years later another seminal incident occurred close to where I grew up, in Jasper, Texas. A person named James Byrd had gone to the store. Three white men, possibly drunk, snuck up behind him, tied a rope around his neck, and drove off in a car at high speeds leaving him decapitated. This received international attention, again this created the circumstance where the entire black community felt powerless due to this racist act.

Many had hoped that progress would have occurred after events such as the burnings of Tulsa in 1921 or the brutal murder of Emmett Till in 1955. Unfortunately, this is not the case as recently witnessed by Mr Floyd’s murder. This reinforces the powerlessness mindset in African Americans.

Racism also manifests itself in more pernicious ways, such as 

 This type of racism is experienced by many African Americans, with the subsequent deleterious effects being immeasurable. I had this experience of being blamed for stealing by my pathology professor in medical school for something I did not do. I was involved with a medical student organization which was sponsoring a health fair where we displayed organ models on a Saturday. The following Monday, before I could return them, the professor walked in, without talking to me first, humiliated me for “stealing” them in front of the whole class. This was perhaps the most embarrassing incident in my life, where I perceived that I was being treated unfairly because of my race.

Regrettably, my daughter went through a similar experience in medical school. During testing, a professor, who had a track record for mistreatment of his ethnic students, asked questions that were unbefitting for a third-year medical student. As a result, he humiliated her by calling her names like “below-average” openly in front of her peers with great animosity and antipathy. Two of her Caucasian classmates documented to the dean that the professor had mistreated her. For me, as an African American father, this is particularly challenging. This is another example of how racist actions undermine the ability to feel competent in my capacity to protect my family. Another aspect of how contemporary racism is detrimental to society.

 described these individuals having a psychopathological defect/narcissistic personality disorder which allows for dehumanization of others. Other psychiatrists have opined that racism may meet the criteria for a full psychotic disorder. 

 explains that “extreme racism” is a type of delusional disorder. I think, racism is a multifaceted construct. In my experience as a Forensic Psychiatrist, Psychiatric disorders cause functional impairment. This is not the case in most racist individuals. I believe racism is intentional. For example, an African American athlete/celebrity is cherished, only because of their achievements. Whereas a typical person of color may not be given the same treatment. One thing we can agree on is the psychological effects racism has on its victims.

These effects are numerous and include depression, anxiety, psychological stress, and various other outcomes.

 Higher rates of substance abuse and affective moods disorders are also seen.

 Prejudice against African American populations lead to many socioeconomic factors which contribute to a negative psychological impact, such as reduced access to employment, housing, education, and health care, even psychiatric care.

Here it is most egregious. African Americans are often overdiagnosed and/or misdiagnosed due to 

 The clinician can have pre-formed expectations or assumptions of ethnic patients. African Americans are often diagnosed more with psychotic disorders that deem them more violent.

 Therefore, leading to more intrusive, aggressive, and severe interventions for these patients. For 30 years I have worked in prisons and state hospitals witnessing this mistreatment. Psychiatrists should be mindful of sociocultural factors that may influence behavior. Awareness may prevent this bias.

This time tangible changes must be implemented. One example is the removal of racist remnants. Things like the Confederate Flag and Monuments to Confederate Heroes. We must not embellish the deeds of white supremacy by encouraging their adverse racist principles. The Confederate Flag has always represented racism. For example, after the shooting by Dylann roof in 2015 at the AME church in South Carolina, Governor Nikki Haley removed the confederate flag immediately.

Racism is a problem of the majority; we can no longer expect just the minority to fix it. It requires an active process by White Americans to bring about change for the whole. All people need to unite because racism is an issue that affects all of us. It brings down our society. Sowing hatred and bigotry.

 is Assistant Dean, Clinical Education, Charles Drew University School of Medicine; Chief Medical Officer, Kedren Community Health Systems, Los Angeles, CA. He reports no conflicts of interest concerning the subject matter of this article.

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10. Metzl JM. 

Racism is one of the ugliest aspects of human nature. It is still present today in all walks of life.

A Psychiatrist’s Perspective on Racism: 2020

ADHD Quiz

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Do you know the indications for an EEG in a child with ADHD? Or which psychotherapy approaches for ADHD demonstrate evidence-based effectiveness? Answer these questions and more.

A 5-Question Quiz on ADHD

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."

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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

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.

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