 covered a wide variety of psychiatric issues and industry updates, from evidence-based novel therapies for bipolar depression to potential indicators of early-stage Alzheimer disease. Here are some highlights from the week.

Thinking Beyond the Guidelines: Evidence-Based Novel Therapies for Bipolar Depression

Bipolar depression (BD) can be difficult to treat due to several factors, and choosing the most appropriate treatment approaches should be based upon patient-specific factors (eg, comorbidities, preferences). Based on treatment response and these patient-specific issues, there are a variety of nonpharmacologic therapies and novel pharmacologic options that can be considered as part of the treatment plan.

Although many clinicians tend to focus on pharmacologic treatments for BD, nonpharmacologic interventions have been shown to be effective in bipolar depression, many of which contribute to an overall healthy lifestyle and can be recommended in addition to medications. Additionally, some of these interventions pose only a low risk, and they may be preferable to the use of medications for select patients. Barriers associated with implementation include cost and accessibility. Clinicians should familiarize themselves with the following interventions and recommend them to patients whenever possible. 

Formic Acid as a Urinary Biomarker for Early-Stage Alzheimer Disease

A new study is the first to identify formic acid as a sensitive urinary biomarker that can reveal early-stage Alzheimer disease.Investigators found that urinary formic acid is a sensitive marker of subjective cognitive decline that may indicate the very early stages of Alzheimer disease. A noninvasive, inexpensive urine test for formic acid could help improve the rate of diagnosis, which often comes too late for effective treatment.

“Alzheimer disease is a continuous and concealed chronic disease, meaning that it can develop and last for many years before obvious cognitive impairment emerges,” said the authors. “The early stages of the disease occur before the irreversible dementia stage, and this is the golden window for intervention and treatment. Therefore, large-scale screening for early-stage Alzheimer disease is necessary for the elderly.” 

As I have been writing this daily blog this morning, the sun has been coming up, dispelling the darkness. “Gaslighting” had been brought to my attention by a colleague. On this past Tuesday, it was revealed as Merriam-Webster’s Word of the Year, based solely on the data on most-searched words, excluding the timeless ones. Two definitions were provided, a long and a short one:

“Psychological manipulation of a person usually over an extended period of time that causes the victim to question the validity of their own thoughts, perception of reality, or memories and typically leads to confusion, loss of confidence and self-esteem, uncertainty of one’s emotional or mental stability, and a dependency on the perpetrator.”

Or more succinctly, “the act or practice of grossly misleading someone especially for one’s own advantage.” 

Being well versed in correct terminology is fundamental to building affirming clinical environments and psychosocial rapport with patients. Physicians are not expected to get everything right, but to take responsibility for their education and apologize in the event a mistake is made.

 a key distinction to make is between sex and gender. Sex is assigned at birth by a medical professional most often based on biological criteria, such as external genitalia. Gender refers to a person’s internal sense of self, which can be expressed through a diverse range of social, cultural, physical, and behavioral cues, such as clothing, pronouns, and physical embodiment.

 neither sex nor gender are binary, as evidenced by the existence of intersex and TGD individuals. And neither sex nor gender are categorical. Someone’s gender identity can change through their life, and someone’s sex can, too (eg, a person can change their gender expression, sex hormone levels, and the appearance of their genitalia). 

. And be sure to stay up-to-date by subscribing to the 

Do you have a comment on any of these or other articles? Have a good idea for an article and want to write? Interested in sharing your perspectives? Write to us at 

Articles

From evidence-based novel therapies for bipolar depression to potential indicators of early-stage Alzheimer disease, here are highlights from the week in Psychiatric Times.

The Week in Review: November 28-December 2

Reef Madness: Digging up the Dirt on an Australian Myth 

Reviewed by Robert M. Kaplan, MBChB, FRANZCP, MA, MPhil

The Australian continent is much beholden to the power of myth, and psychiatrists are likewise drawn to these tales. Going back at least 60,000 years, the Dreamtime arose from the theophany of the First Peoples. European settlement requires its own myths to explain the savage attempts to subdue a stubborn and unyielding continent. 

 is that of the bushman—that intrepid soul only really at home in the remote wild, as much at ease finding a desert waterhole as navigating near-impassable terrain. The belief in discovering a gleaming gold reef reflects a preoccupation that goes as far back as Jason and the Argonauts, with the mesmerizing power of the auriferous element escalating drastically during times of financial depression.

These elements notably came together in the story of Australian über-fantasist Harold Lasseter. Wheeling a large barrow of lies, Lasseter claimed that he had discovered a large gold-laced reef in the desert center during a trip when he was 18 years old—a trip, incidentally, that would have made him the first person to have traversed the continent from east to west. 

After years of searching for a believer, he found his man in John Bailey, head of the Australian Workers’ Union in Sydney. Although Lasseter’s vague, if not fantastical, story raised few doubts, such was the power of the vision of the fabulous reef that would not only relieve the poverty of the depression, but make Australia the richest country in the world.

In March 1930, the height of the depression, the most lavishly funded and equipped expedition to date set off with a team including Lasseter from Alice Springs to find the reef. The trip was a disaster from the start, with numerous breakdowns in the difficult conditions. The truck kept breaking down, the plane crashed, and the radio never worked. The team lost all confidence in Lasseter—whose behavior became increasingly withdrawn and strange as they progressed—and decided that there was no reef and to return home. 

Aware of the humiliation (if not fraud charges) that awaited him if he returned, Lasseter attached himself to a dubious character Paul Johns, who had 5 camels, and continued the search for an illusion that now only existed in his mind. He was never seen again.

Lasseter’s end took some time to unscramble. A second expedition, equally lavishly equipped, came back with no gold reef but plenty of rumors about Lasseter. The accepted version is that bushman Bob Buck found the remains in a cave and brought back his diary. Lasseter appears to have died a wretched and painful death, frantically scribbling his last notes to his wife, “What good [is] a reef worth millions? I would give it all for a loaf of bread.”

As an epitaph, it mimes the last words of the frozen Captain Scott: “For God’s sake, look after our people!” Both men, dying in the most remote places on Earth, were as much victims of their own hubris (to say nothing of incompetence) as extreme climate. While Scott was on a scientific expedition, Lasseter had a fantastic dream to find a solid reef of the most desirable substance on Earth: gold.

Thus died Harold Lasseter, the man who became a powerful myth. There is simply no convincing evidence that the reef exists, let alone that Lasseter was the first European to traverse Australia from east to west.

A legend of sufficient size has the dimensions of an octopus with a central body and limbs extending in various directions. For every big lie that is taken up, those who do become liars themselves, either by overcoming their reservations to make themselves believe the lie or by using the to further their own agendas. And almost everyone involved in seeking Lasseter’s reef had something to gain.

Bailey was one of the roughest players in Australian politics, always one step ahead of trouble. Federal Minister Arthur Blakeley appointed his brother, George, as the leader of the expedition. Errol Hampton Coote, the appointed pilot, had no pilot’s license and questionable flying skills. Furthermore, in his determination to be part of the action when the reef was discovered, he continually undermined Blakeley’s leadership.

This is what is actually known; the myth is entirely another matter. Australia is a strange country. It elevates loss, defeat, and demise far above victory and vindication. Burke and Wills, Ned Kelly, and Gallipoli—all utter failures in their own way—dominate the national myth. Lasseter was a compulsive liar, but the big one devoured him. His great failure has become part of the defining mythology of Australia. And now he is commemorated by a cave, a highway, a hobbit-like tombstone in Alice Springs, a casino, an ever-replenishing coterie of believers, and a story that never seems to end. At least 13 expeditions have set out to find the treasure, but all have failed.

This may not have been the fate Lasseter desired—but, for a fabulist, there are worse ways to go down in history.

After it was learned that Lasseter had disappeared and was presumed dead, the story was picked up by writer Ion Idriess, resulting in his book 

, a work with more than a little poetic license. It was a huge success that was sold in multiple editions and languages, as well as a prelude to the author’s astonishing output in producing 60 books and developing some of the great Australian legends, notably that of the Light Horse (in which Idriess served) and the Kidman cattle station story. It is fair to say that without Idriess, Lasseter’s myth would have disappeared decades ago.

At this point, psychiatrist Ernest Hunter, MD, enters the story. Hunter has a distinguished record of working with Indigenous patients in rural, often remote, areas. It comes thus as no surprise that Hunter is interested in myths—something intrinsic to understanding the Aboriginal experience in the vast continent. He has published widely on a range of related topics, especially human rights.

 Reef Madness: Digging up the Dirt on an Australian Myth

 is not as much another attempt to untangle the Lasseter story (numerous articles and books—including a chapter in this writer’s latest book—try this), but to understand how Idriess lit the flame that sparked the billowing Lasseter myth. Hunter conducted a meticulous investigation into archives, records, and 

, as well as interviews with relevant parties. He has form with Idriess, having previously written about “solitary men” in the book 

Vicarious Dreaming: With Jack Idriess on Madman's Island

Readers will note Hunter’s meeting with Bob Lasseter, who was 5 years old when his father left on the fateful trip. Bob devoted his life to restoring his father’s reputation and was featured prominently in the Luke Walker documentary 

. Hunter’s empathic handling of an old man who has been the subject of much derision is masterly. The explanation that the repeated trips into the desert were really to connect with the father who had vanished, rather than to find the reef itself, is convincing.

Long past the formal and often mind-numbing style of writing doctors, Hunter has produced a fine work of historiography and a thoughtful examination of how Idriess, traumatized by his military experiences in Palestine, not only played an important role in reifying the Lasseter myth, but commemorated those peripatetic characters who now have a place in the Australian identity.

is excellently written and highly recommended for readers who want to understand the enormous power of myth in the Australian identity and how biography can truly sparkle when done properly. Ernest Hunter is to be congratulated on his book, and we can only wait to see what he will come up with next.

is a forensic psychiatrist, writer, and historian. His latest book 

The King Who Strangled his Psychiatrist and Other Dark Tales

“Hunter’s book is excellently written and highly recommended for readers who want to understand the enormous power of myth in the Australian identity.”

is in the Department of pharmacology at the Institute of Neuroscience and Physiology, Sahlgrenska Academy, at the University of Gothenburg, Sweden.

Regular reports are published in the lay media regarding the alleged lack of efficacy of antidepressants. This time, it was 

 highlighting, amongst other reports, a new analysis by Stone et al,

 in which it was found that antidepressants work better than placebo only 15% of the time.

As usual in this type of reporting, “critical” voices are heard mostly unopposed, and little room is made for actual evidence-based interpretation of the data presented. In this article, I will review some of the claims made, provide evidence that the statistic 15% is most likely an underestimation of real-world antidepressant effects, and cast doubt on some other claims made about the (lack of) efficacy of 

In their analysis, Stone et al included all antidepressants and possible age groups. Thus, their estimate represents the average effects across all antidepressant trials submitted to the US Food and Drug Administration (FDA), but not necessarily one of the average antidepressants used. The 5 worst drugs, according to their analysis, are very rarely used for 

. Thus, the much more commonly used SSRIs outscore the least efficacious antidepressant, dothiepine, by a considerable margin. Further, antidepressants are probably less effective in treating depression in children and adolescents than in adults.

 However, they are also much less prescribed in the younger population, but the researchers did not account for that.

The main outcome measure in the Stone et al analysis is the sum score of the 17 items of the Hamilton Depression Rating Scale (HDRS-17-sum). The use of this measure has been widely criticized for many reasons: it lacks one-dimensionality,

 it might reflect factors other than depressive symptoms,

 and the majority of the measured symptoms are not present in many individuals with depression.

 Drug-placebo differences were found to be substantially larger when the sum score of 6 core depressive symptoms included in the unidimensional HDRS-6 scale were used.

 It was also found that drug-placebo differences for this subscale are similar in those with severe and nonsevere depression,

 article made a contrary claim against antidepressants.

HDRS items not included in the HDRS-6 are prone to pick up 

 from treatment, thus further diminishing apparent drug-placebo differences as measured using HDRS-17 sum score.

 Although adverse effects are certainly important to consider, including them in an efficacy measure is unreliable; for example, this measure is unable to distinguish between a treatment with low efficacy but no adverse effects and a highly effective treatment with more adverse effects.

Dosing is also an important issue. Drug-placebo differences are about twice as large at doses above the common starting one for the most frequently prescribed SSRIs compared.

 Yet, in the Stone et al analysis, all possible doses were included, including those shown to not be significantly more effective than placebo. In a recent publication,

 for example, a 22.3% drug-placebo difference was found for optimal SSRI doses in adults when using response (50% score reduction from baseline) on the HDRS-6 sum score as outcome measure; however, this number is more likely an underestimation than an overestimation.

Other issues in clinical trials include difficulties in finding drug-placebo separation, noncompliance to randomized drugs,

 Further difficulties are presented by the diagnosis itself, 

 being a multi-faceted, highly heterogenous disorder with low diagnostic reliability.

 Thus, it is unreasonable to expect substantial response and remission rates for any treatment for depression. Additionally, using strictly regulated trial protocols disallowing many concurrent treatments also impacts response and remission rates.

Although only company-sponsored trials were analyzed in most papers cited here, as well as in the Stone et al paper, unsponsored trials were found to show about 50% higher drug-placebo differences.

 It is possible that the studied populations in the latter more accurately reflect patients receiving treatment in clinical practice. This is another issue not reflected in most critical opinions about antidepressants, where it is instead stressed that trials are funded by pharmaceutical companies, with the results thus being inflated and untrustworthy.

, which is heralded as safer and more effective than antidepressants. Since safety data are very rarely collected in psychotherapy trials, comparisons in this regard are thus impossible. Also, neither the assumption of better efficacy holds true. In those few trials in which psychotherapy is compared to pill placebo, there is a difference of about 0.25 standardized mean differences (SMD),

 effects similar to the average antidepressant. However, every one of those trials was unblinded, as the patient was certainly able to distinguish psychotherapy from pills. This fact is entirely overlooked by Irving Kirsch, PhD, associate director of the Program in Placebo Studies and lecturer in medicine at the Harvard Medical School and Beth Israel Deaconess Medical Center, and others when interviewed by 

. (This is ironic, considering that he used the possibility of unblinding in antidepressant trials, which evidence shows is a nonissue,

 as an argument to dismiss the similar differences between antidepressants and placebo.

Understandably, the first author of the Stone et al paper—Marc B. Stone, MD, of the Center for Drug Evaluation and Research, US Food and Drug Administration—declined to comment in the 

 article, perhaps because media discussion lies beyond the obligations of FDA employees. My personal primary take-away point from this analysis is not the 15% number itself, but the finding of a subgroup of patients with 

 responding uniquely to antidepressants but not to placebo. Previously, other authors including Kirsch attempted to dismiss the average drug-placebo difference as being smaller than a “minimum clinically important difference,” assuming that the average difference is what is being experienced by all patients who are treated with antidepressants. It was, however, pointed out that their suggested “minimal difference” instead corresponds to the maximum achievable effect in this type of trial, and that the average difference does not reflect a general effect, but a higher likelihood of lower depression scores in the drug-treatment group.

In all, it might be that only 15% of those with depression experience significantly positive effects from antidepressant treatment compared to placebo, if the material studied was indeed representative of the average treatment, setting, and patient group. In real-world practice, the actual number might instead substantially differ depending on the drug used, the drug dose, the patient group treated, and the efficacy measure used. Effect estimates in clinical trials are more likely to underestimate than overestimate treatment effects.

The 15% number is then contrasted with 56%—the percentage of patients who apparently experience withdrawal effects. The author leaves us with a take-away that more people have withdrawal effects than antidepressant effects. Unfortunately, the 56% estimate was taken from a flawed

 that were uncontrolled and thus disregarded potential nocebo effects. Tapering was often abrupt—which is against guidelines—and again no difference was made between different drugs, even though drugs with short half-life (eg, paroxetine, venlafaxine) were driving the results. Ignoring these issues and contrasting estimates from uncontrolled surveys to drug-placebo differences from randomized controlled trials is nothing short of a woeful misuse of statistics. A more honest view could have been obtained by contrasting the withdrawal estimate to an efficacy estimate from the largest survey study, which showed that 83% of those taking antidepressants believed the drugs had reduced their depression.

Unfortunately, even more factual inaccuracies were presented in the 

 article. It was stated that antidepressants do not aid loss of energy, loss of interest, nor motivation, all being common symptoms in depression. In item-based analyses of SSRIs and the SNRI duloxetine, the opposite was revealed to be true, with small but replicable effects on all these symptoms.

 To the best of my knowledge, no better evidence exists on the contrary, thus rendering these statements by Joanna Moncrieff, MD, in the 

Another statement by the same author claims that the superiority of antidepressants can be attributed not to actual antidepressant effects, but to emotional numbing. A recent article in 

™ by Dawson and Pies rebutted this claim,

 and even more evidence was found in a recent analysis of SSRI trials using the Montgomery-Åsberg Depression Rating Scale (MADRS) as outcome measure.

 Here, an opposite effect to what was stated by the 

 interviewees was found, with a significant and positive drug effect against 

, as measured on the corresponding MADRS item. Thus, although emotional numbing may also be an adverse effect of SSRI treatment, the average effect instead corresponds to the individual with depression experiencing an improved ability to feel emotions.

 article is just another unfortunate example of one-sided media reporting, ignoring evidence contradicting claims of those critical to drug treatment, and casting unnecessary doubt on drugs that, while not perfect, are more than useful in alleviating symptoms of major depression, as well as many other disorders (eg, anxiety syndromes, obsessive compulsive disorder, and premenstrual dysphoric disorder). Unfortunately, I expect this tradition of antidepressant bashing will continue. Lay media seem disinterested in correcting their claims (neither the journalist in question nor 

 themselves responded when I shared my concerns) and instead will likely continue to seek sensationalist headlines and short-term profit.

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of 

1. Piore A. Antidepressants work better than sugar pills only 15 percent of the time. 

 September 9, 2022. Accessed November 29, 2022. 

https://www.newsweek.com/2022/09/30/antidepressants-work-better-sugar-pills-only-15-percent-time-1744656.html

2. Stone MB, Yaseen ZS, Miller BJ, et al. 

Response to acute monotherapy for major depressive disorder in randomized, placebo controlled trials submitted to the US Food and Drug Administration: individual participant data analysis.

Comparative efficacy and acceptability of antidepressants, psychotherapies, and their combination for acute treatment of children and adolescents with depressive disorder: a systematic review and network meta-analysis.

4. Fried EI, van Borkulo CD, Epskamp S, et al. 

Measuring depression over time . . . Or not? Lack of unidimensionality and longitudinal measurement invariance in four common rating scales of depression.

Quantitative rating of depressive states.

6. Lisinski A, Hieronymus F, Nilsson S, Eriksson E. 

Impact of chosen cutoff on response rate differences between selective serotonin reuptake inhibitors and placebo.

7. Hieronymus F, Lisinski A, Nilsson S, Eriksson E. 

Influence of baseline severity on the effects of SSRIs in depression: an item-based, patient-level post-hoc analysis.

8. Hieronymus F, Lisinski A, Eriksson E, Ostergaard SD. 

Do side effects of antidepressants impact efficacy estimates based on the Hamilton Depression Rating Scale? A pooled patient-level analysis.

A mega-analysis of fixed-dose trials reveals dose-dependency and a rapid onset of action for the antidepressant effect of three selective serotonin reuptake inhibitors.

10. Reis M, Aberg-Wistedt A, Agren H, et al. 

Compliance with SSRI medication during 6 months of treatment for major depression: an evaluation by determination of repeated serum drug concentrations.

11. Cipriani A, Furukawa TA, Salanti G, et al.

 Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis.

Antidepressant clinical trials and subject recruitment: just who are symptomatic volunteers?

13. Hieronymus F, Lisinski A, Hieronymus M, et al. 

Determining maximal achievable effect sizes of antidepressant therapies in placebo-controlled trials.

Depression is not a consistent syndrome: an investigation of unique symptom patterns in the STAR*D study.

15. Munkholm K, Paludan-Muller AS, Boesen K. 

Considering the methodological limitations in the evidence base of antidepressants for depression: a reanalysis of a network meta-analysis.

16. Cuijpers P, Turner EH, Mohr DC, et al. 

Comparison of psychotherapies for adult depression to pill placebo control groups: a meta-analysis.

17. Hieronymus F, Lisinski A, Nilsson S, Eriksson E. 

Efficacy of selective serotonin reuptake inhibitors in the absence of side effects: a mega-analysis of citalopram and paroxetine in adult depression.

The emperor's new drugs: medication and placebo in the treatment of depression.

The war on antidepressants: what we can, and can't conclude, from the systematic review of antidepressant withdrawal effects by Davies and Read.

A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: are guidelines evidence-based?

Adverse emotional and interpersonal effects reported by 1829 New Zealanders while taking antidepressants.

22. Lisinski A, Hieronymus F, Naslund J, et al. 

Item-based analysis of the effects of duloxetine in depression: a patient-level post hoc study.

23. Hieronymus F, Emilsson JF, Nilsson S, Eriksson E. 

Consistent superiority of selective serotonin reuptake inhibitors over placebo in reducing depressed mood in patients with major depression.

24. Dawson G, Pies RW. Antidepressants do not work by numbing emotions. 

https://www.psychiatrictimes.com/view/antidepressants-do-not-work-by-numbing-emotions

25. Hieronymus F, Lisinski A, Ostergaard SD, Eriksson E. 

The response pattern to SSRIs as assessed by the Montgomery-Asberg Depression Rating Scale: a patient-level meta-analysis.

Here’s why most of the claims recently made about antidepressants in Newsweek are wrong. 

Hooked on Hype? A Critical Examination of Recent Anti-Antidepressant Reporting

The first patient has been enrolled in a phase 2/3 clinical study to evaluate ulotaront (SEP-363856), a trace amine-associated receptor 1 (TAAR1) agonist with 5HT1A agonist activity, as an adjunctive therapy in the treatment of adults living with 

 (MDD). Ulotaront is also being evaluated in phase 3 clinical development for the treatment of schizophrenia, and it is the first TAAR1 agonist to be studied as an adjunctive therapy for MDD.

“The initiation of the phase 2/3 study evaluating the use of ulotaront as an adjunctive treatment of [MDD] is an important step towards exploring the full medical potential of this novel TAAR1 agonist,” said Armin Szegedi, MD, PhD, senior vice president and chief medical officer at Sunovion. “We have been encouraged by the pre-clinical data showing that ulotaront could have benefits for those living with mood disorder and look forward to enhancing the understanding of this innovative compound.”

The global, multicenter, randomized, double-blind, placebo-controlled study is designed to examine the efficacy, safety, and tolerability of ulotaront as an adjunctive therapy in the treatment of adults with MDD. Participants who do not respond to current 

 will be randomized to receive ulotaront or placebo along with their antidepressant therapy.

The primary endpoint for the study is the reduction of depressive symptoms, as measured by the change from baseline in Montgomery-Åsberg Depression Rating Scale (MADRS) total score, compared to placebo at the end of the study.

“MDD is a disabling mental health condition that often requires a combination of first-line antidepressant medication and adjunctive treatments to alleviate symptoms,” said John Kraus, MD, PhD, executive vice president and chief medical officer at Otsuka. “Even with available approaches, many patients do not achieve optimal responses to treatment, in part due to the heterogeneous nature of the condition, highlighting the need for new and different treatment modalities.”

1. OTSUKA and Sunovion initiate clinical development of ulotaront for the adjunctive treatment of major depressive disorder. Sunovion. News release. December 1, 2022. 

https://news.sunovion.com/press-releases/press-releases-details/2022/Otsuka-and-Sunovion-Initiate-Clinical-Development-of-Ulotaront-for--the-Adjunctive-Treatment-of-Major-Depressive-Disorder/default.aspx

The first patient in a phase 2/3 study evaluating ulotaront for MDD has been enrolled. 

First TAAR1 Agonist Studied as Adjunctive Therapy for MDD

Richard Berlin, MD, shares Jack Gilbert's poem, "

," a meditation on the great fire of love. 

has been writing a poem about his experience of being a doctor every month for the past 24 years in the

“Poetry of the Times” column. He is instructor in psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts. His latest book is

Videos

"Love is apart from all things. Desire and excitement are nothing beside it."


The Great Fires

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

“This little light of mine, I’m gonna let it shine . . . Everywhere I go, I’m gonna let it shine . . .” - traditional Gospel song

As I have been writing this daily blog this morning, the sun has been coming up, dispelling the darkness.

The Health Care Professional Ethical Choice: Ukraine, Iran, and Whether or When to Risk and Resist

“Gaslighting” had been brought to my attention by a colleague. On this past Tuesday, it was revealed as Merriam-Webster’s Word of the Year, based solely on the data on most-searched words, excluding the timeless ones.

 Two definitions were provided, a long and a short one:

“Psychological manipulation of a person usually over an expended period of time that causes the victim to question the validity of their own thoughts, perception of reality, or memories and typically leads to confusion, loss of confidence and self-esteem, uncertainty of one’s emotional or mental stability, and a dependency on the perpetrator.”

Or more succinctly, “the act or practice of grossly misleading someone especially for one’s own advantage.”

The term is derived from the 1938 play and 1944 film “Gaslight.” In the story, a husband tries to trick his new wife into believing she is going crazy, in part by telling her that their gaslights are working fine, while all the while he is intentionally and secretly dimming them while in the attic. In this case, the perpetrator was consciously doing the gaslighting, but it could be done unconsciously, too.

Why the rise in gaslighting usage? Does it have to do with the power struggles that are increasing normalization of divisiveness and scapegoating in this country? Personally, I have experienced it in an online psychiatric list serve where political correctness seemed to preclude the previously respectful interactions.

Almost by definition, there is commonly mental health harm from gaslighting that can include trauma, anxiety, and depression from the abuse and confusion. Paradoxically, it can also be a symptom of some psychiatric disorders, including the borderline, anti-social, and narcissistic personality disorders. However, the term has not appeared or been discussed much in the formal psychiatric literature.

It may be self-evident that someone being gaslighted may not realize it is happening to them. A clue is a sense of confusion over what is happening. Beneficial strategies include:

-Getting feedback about the situation from others that you trust

-Keeping evidence about what is happening to you

Probably, thanks to Merriam-Webster, the publicity from this award will help public recognition of the problem. When I left my gaslit situation, I felt immediately better and have not encountered another where I felt that way again.

Interestingly, the prior 2 words of the year were “pandemic” in 2020 and “vaccine” in 2021, both also relating to mental health. I suppose one could put these 3 years and 3 words together and sum up the pandemic times by concluding that we have all been gaslighted to some extent at some time as we continue to disagree about what is the best for the health and mental health of all. We need our lights of truth, insight, and caring to shine more strongly.

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

1. Gaslighting. Word of the Year 2022. Merriam-Webster. November 28, 2022. Accessed December 2, 2022. 

https://www.merriam-webster.com/words-at-play/word-of-the-year

Merriam-Webster’s Word of 2022: gaslighting. 

Shining Light on Gaslighting

In prior communications, we have discussed some of November’s recommended mental health awareness campaigns, including for Hindu Heritage and Native Americans. Learning about these dedicated months can not only convey their important health needs, but can help us appreciate the potential importance of their cultural contributions to all.

To Address Climate Change, This Psychiatrist Goes Where No One Has Gone Before

There are also awareness months for animals. Probably Floridians and the “snowbirds” who come there in the winter are most aware that, annually, November is Manatee Awareness Month. The massive, but gentle mammals migrate from the colder ocean waters for refuge in the warmer inland waterways from mid-November to late March. There are festivals that celebrate their peaceful and playful interaction with humans. Manatees are favorites of my wife and I; we once bought a stuffed manatee doll to provide some positive triggers to our lived experience with them.

However, manatees are on the Endangered Species list, and the reason has much to do with us humans. Although there are many factors that contribute to manatee deaths, the spike seems to be due to starvation, and it is human activity that is changing their necessary diet. The warmer water due to human-caused climate change also leads to freshwater becoming salinized, allowing algae to invade their preferred waters and disrupt the ecosystem.

Once again in these months, awareness is a necessary start, but not sufficient end. As we turn into December, action to alter human behavior for the good, such as the peacefulness and playfulness of the manatees, is a social psychiatric prescription.

Perhaps we should try to act more like manatees…

Manatees and Mental Health Months

Sitting on the park bench was an old couple holding hands and leaning on one other. Those trembling hands tried hard to stay on the cane but had a trusting hold on each other. On a bench 5 steps away sits another couple; the husband is scrolling through his phone while the wife looks a bit lost in her thoughts. During my run, I often see such couples. There are couples that discuss their errands like coworkers in a meeting and then there are those who cannot stop smiling and steal glances at each other during their walk. There are couples who laugh together and appreciate the flowers, and then there are those who argue about a certain habit of the other. What is 1 similarity they all have? They are together. The thread that holds them might be at the verge of emotional/physical snapping, but they still are together. Hard truth is that every quality relationship—no matter with whom—needs work, effort, and fostering.

How does one create/foster/reboot a relationship with our other half? Why does monotony seep in? Why don’t we feel attracted to them anymore? Where is that adrenaline rush we felt in the beginning? In relationships, there are 6 major needs that one wishes to be fulfilled: certainty, growth, love & connection, contribution, significance, and variety.

Certainty refers to stability. Human emotions are volatile forces of nature. To feel secure in the relationship, one needs stability. Knowing your partner is going to be there through thick and thin provides that security. Disagreements are common in a relationship, and you should find healthy ways of coping with them.

Be it intellectual, emotional, or spiritual, it is crucial to support your partner in the areas they feel most passionately about. Understanding and nurturing your partner’s passion helps with growth and emotional intimacy.

A couple communicates both verbally and nonverbally. We should not take our partner for granted and assume that they know that we love them. Besides telling them those 3 magic words and giving compliments, it is always better to show it in little ways like bringing flowers, leaving love notes, helping them finish an errand, switching roles and giving them breaks from usual household chores, and replacing their damaged belongings if any, because actions do speak louder than words.

Contributing and giving is something that solidifies our existence on the planet. How do we make a difference in a person’s life, especially the one who shares a life with us? Besides giving gifts and material things, what matters more is giving undivided attention, time, forgiveness, second chances, the benefit of doubt, and respect and privacy.

We all need to feel significant in life. Appreciating your partner and their qualities is an everyday process and gratitude never hurts. Being thankful and letting your partner know their worth in your life should be a priority.

We all have an inner child that gets shushed in the hustles of being an adult. Eventually, we do start craving the thrill of novelty. Rather than creating new romantic relationships every year/month/week seeking that thrill, rekindling the current relationship can be worth it. Keeping the inner child alive not only makes a relationship fun, but it is an excellent stress reliever. Dancing, working out, running, singing, painting, gardening, cooking, reading, and traveling together results in incredible growth both as a couple and as an individual.

Going this way, you can explore new dimensions of your relationship with your partner and with yourself, each day… every day. The bottom line is… life is too short to stay in monotony.

 is a consultant psychiatrist in Punjab, India.

Don’t grow old in your relationship, grow bold. 

Don’t Grow Old, Grow Bold Together

A new study is the first to identify formic acid as a sensitive urinary biomarker that can reveal early-stage Alzheimer disease.

Investigators found that urinary formic acid is a sensitive marker of subjective cognitive decline that may indicate the very early stages of Alzheimer disease. A noninvasive, inexpensive urine test for formic acid could help improve the rate of diagnosis, which often comes too late for effective treatment.

“Alzheimer disease is a continuous and concealed chronic disease, meaning that it can develop and last for many years before obvious cognitive impairment emerges,” said the authors. “The early stages of the disease occur before the irreversible dementia stage, and this is the golden window for intervention and treatment. Therefore, large-scale screening for early-stage Alzheimer disease is necessary for the elderly.”

New research finds that a urine test for formic acid could detect early-stage Alzheimer disease. 

The Week in Review: November 28-December 2

Reef Madness: Digging up the Dirt on an Australian Myth

Hooked on Hype? A Critical Examination of Recent Anti-Antidepressant Reporting

First TAAR1 Agonist Studied as Adjunctive Therapy for MDD

The Great Fires

Shining Light on Gaslighting

Manatees and Mental Health Months

Don’t Grow Old, Grow Bold Together

Formic Acid as a Urinary Biomarker for Early-Stage Alzheimer Disease

A Thanksgiving for Psychiatry