 (APA) Annual Meeting will enter its second year in a row as a virtual session, starting from May 1 and ending May 3, 2021. The core message, "Finding Equity Through Advances in Mind and Brain in Unsettled Times,"  mirrors the overarching themes that emerged this and last year both in the news and in medicine.

With over 130 educational presentations to choose from, topics will range from social issues such as equality, racism, and health equity, to trauma and PTSD resulting from mass shootings and the pandemic. 

, considered key leaders in psychiatry, will be presenting, chairing, or moderating throughout the weekend. Among them: 

•	In the session titled "Race, Religion, and Equity: Implications for Psychiatry," editorial board member H. Steven Moffic, MD, and advisory board member Ahmed Hankir, MD, will present on structural racism, conscious and unconscious bias, and other issues as they relate to psychiatric practice. Diversity & Inclusion Editor, Frank Clark, MD, will moderate in this important session.

•	John Torous, MD, MBI, digital psychiatry editor, will be involved in 2 presentations: "Harnessing Digital Technology to Bring About Long-Term Recovery from {FEP]" and "Three New Tools to Augment Care for People With Serious Mental Illness."

•	"Scope of Practice: The Evolution of Physician-Only Paradigm in Psychiatry" will be chaired by Michelle Riba, MD, deputy editor in chief. Dr Riba will be a speaker in a presentation titled "The #MeToo Movement: Implications for Psychiatrists."

•	"Caring for Older Adults With Mental Health Disorders and Dementia: American Association for Geriatric Psychiatry’s Response to ]the Pandemic]," with Rajesh R. Tampi, MS, MD, DFAPA, Geriatric Psychiatry Section Editor of 

Jack Weinberg Memorial Award in Geriatric Psychiatry

. The award, instituted in 1983, recognizes a psychiatrist who has devoted their career to psychiatry, 

, and goes above and beyond in the areas of clinical practice, educational training and mentorship, and important research.

•	Editorial Board member Philip R. Muskin, MA, MD's sessions include "Here’s Your Hat, What’s Your Hurry: Career Transitions in Academic Psychiatry"; "Educating and Supporting the Mental Health Workforce"; and "Treatment of Severe Obsessive-Compulsive and Related Disorders: What Do You Do If First-Line Treatments Don’t Work?" The latter session is chaired by Katharine A. Phillips, MD, also on the editorial board.

In addition to Q&As, lectures, 3 plenary sessions, and a virtual poster hall, noteworthy speakers include:

: The William C. Menninger Memorial Lecture. Dr Fauci is director of the National Institute of Allergy and Infectious Diseases and trailblazed efforts to fight the pandemic and the HIV/AIDs crisis. The Convocation and William C. Menninger Memorial Lecture takes place on May 2 at 10 AM., 

•	Opening session speaker Isabel Wilkerson will discuss Our Racial Moment of Truth. Wilkerson is the first African American woman to receive the Pulitzer-Prize in journalism and author of 

The Warmth of Other Suns: The Epic Story of America's Great Migration

•	The Rev James Lawson, who taught both Dr Martin Luther King Jr and Rep. John Lewis, talk about “Psychology of Racism and Nonviolence." 

•	The closing session takes place on May 3 at 10 AM. The keynote speaker is 

, John A. and Cynthia Fry Gunn Professor and Professor of Neurology and of Neurosurgery at Stanford University.

Additional speakers of note are Avrim Fishkind, MD, and Gonzalo J. Perez-Garcia, MD, who will talk about equity and ethics, as well as the future of telepsychiatry; Edmond Hsin T. Pi, MD, is covering mental health and racism in the Asian American population; and several other sessions will discuss structural racism, reparations and health equity, as well as the climate crisis and substance abuse. 

https://www.psychiatry.org/psychiatrists/meetings/annual-meeting

 for minute-by-minute scheduling and announcements. Daily updates will be shared on the 

Articles

New and noteworthy sessions fill the program at the American Psychiatric Association Annual Meeting, which enters its second year as a virtual session.

All Things Being Equal: A Challenge to the Status Quo

Attention-deficit/hyperactivity disorder (ADHD) is frequently 

 other psychiatric conditions, including psychotic disorders. There is 

 for shared genetic susceptibility to both conditions,

 and first-degree relatives of people with ADHD have twice the risk of having schizophrenia compared with healthy controls.

There is also an added risk of psychosis in patients with comorbid cannabis use. There are overlapping environmental 

 for both disorders, including obstetric complications, preterm birth, and low birth weight.

 There are also abnormalities in overlapping dopaminergic brain circuits in schizophrenia and ADHD.4 However, epidemiologic evidence for the association between psychotic disorders and ADHD remains inconsistent.

 performed a systematic review and meta-analysis of the association between ADHD during childhood and the subsequent risk of developing a psychotic disorder. The authors searched MEDLINE, Scopus, PsycInfo, and Web of Science from inception through November 2015. They included peer-reviewed case-control and cohort studies of children younger than 18 with ADHD (using any recognized diagnostic criteria) with a comparison group.

Table. Overlap between ADHD and Psychotic Disorders

The primary outcome was occurrence of any psychotic disorder (also using any recognized diagnostic criteria; including schizophrenia, schizophreniform disorder, brief psychotic disorder, schizoaffective disorder, delusional disorder, psychotic disorder not otherwise specified, or schizotypal personality disorder) at or after aged 18 years following a diagnosis of ADHD. They excluded studies with attention deficits or impulsivity without any ADHD diagnosis or adult ADHD diagnosis, or psychotic disorders that were diagnosed before or concurrently with ADHD. 

Relevant data—including relative risks (RR), odds ratios (OR), hazard ratios (HR), and 95% confidence intervals—were extracted for each study. An assessment of risk of bias and study quality was performed for each included study. Pooled measures of relative effects (eg, RR, OR, HR) were calculated using random-effects meta-analysis. Egger’s test and funnel plots were used to assess for potential publication bias. Subgroup and meta-regression analyses were performed for study design, sex, treatment, relevant psychiatric comorbidities, and type of outcome, but data were not available regarding substance use comorbidity.

The authors screened 3782 records and assessed 45 full-text articles for eligibility. After review, 15 studies (1 case-control and 14 cohorts) were included in the systematic review and 12 studies (1.85 million unique participants) were included in the meta-analysis. The median prevalence of 

 in the cohort studies was 0.5% for controls and 2.7% for the ADHD population, corresponding to an approximately 5-fold increased risk of subsequent psychotic disorder in children with ADHD (relative effect = 4.74, 95% CI 4.11-5.46).

Findings were similar in subgroup analyses (including schizophrenia versus other psychotic disorders, as well as the presence or absence of follow-up after aged 18 years). In meta-regression analyses, sex, and study quality did not moderate the association. There was no evidence of publication bias.

The authors performed the first meta-analysis of observational studies on the association between ADHD and psychotic disorders. They note that substance use disorder comorbidity is common to both conditions, and that the effects of 

 are also an important consideration, as there is inconsistent evidence on the possible association between chronic psychostimulant treatment and subsequent risk of psychotic disorder. 

There was inadequate data to consider effects of either substance use or psychostimulants in the present meta-analysis, and thus this information is relevant to future studies. They also note that psychotic symptoms and ADHD symptoms may overlap and can be confused and misdiagnosed (

). Strengths of the study included the large sample size and absence of publication bias. Limitations include clinical heterogeneity in the study populations, diagnostic criteria, and outcomes.

“Mr D” is a 21-year-old African American male outpatient at the community mental health center. He has a diagnosis of ADHD, combined type, and as a child, he received remote treatment with an unknown stimulant medication. His sister has depression, but his family history is otherwise unremarkable. At age 19, he was admitted for 1 week to the state psychiatric hospital because he had command auditory hallucinations for self-harm and began banging his head against the wall. He subsequently received a diagnosis of schizophrenia and cannabis use disorder. For the past year, he has been clinically stable on antipsychotic medication without additional psychiatric hospitalizations.

A childhood diagnosis of ADHD increased the risk of subsequent psychotic disorder almost 5-fold, independent of sex and diagnostic outcome (schizophrenia versus other psychotic disorder). Early detection (and management) of psychotic disorders in children with an ADHD diagnosis is essential.

1. Hamshere ML, Stergiakouli E, Langley K, et al. 

Shared polygenic contribution between childhood attention-deficit hyperactivity disorder and adult schizophrenia

Risk of bipolar disorder and schizophrenia in relatives of people with attention-deficit hyperactivity disorder

3. Linnet KM, Dalsgaard S, Obel C, et al. 

Maternal lifestyle factors in pregnancy risk of attention deficit hyperactivity disorder and associated behaviors: review of the current evidence

4. Howes OD, Kambeitz J, Kim E, et al. The nature of dopamine dysfunction in schizophrenia and what this means for treatment. 

5. Nourredine M, Gering A, Fourneret P, et al. 

Association of attention-deficit/hyperactivity disorder in childhood and adolescence with the risk of subsequent psychotic disorder: a systematic review and meta-analysis

There is evidence for overlapping risk factors and symptomatology between ADHD and psychotic disorders. New research investigates the association between ADHD during childhood and the subsequent risk of developing a psychotic disorder.









Examining the Relationship Between ADHD and Psychotic Disorders

In the 1930s and 1940s, researchers identified childhood autism as a unique condition. At the same time, many believed that children became autistic because they had cold, intellectual, emotionally withholding mothers.

But Clara Park, a woman whose daughter had autism, set out to understand autism differently and, along with other families and dedicated researchers, she upended the medical establishment’s view of her daughter’s condition.

In this Mental Health Minute, Marga Vicedo, PhD, discusses her recent book, 

Intelligent Love: The Story of Clara Park, Her Autistic Daughter, and the Myth of the Refrigerator Mother

. Along with telling Park’s story, the book shows how medical research can both reflect social attitudes and change them.

is professor of the history of science and medicine in the Institute for the History of Philosophy of Science and Technology at the University of Toronto. She is the author of 

Has the history of psychiatry informed your practice? 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

Videos

A mother’s quest to understand her child revolutionized our understanding of autism. 

What Causes Autism?

BrainsWay’s theta burst 3-minute protocol for the treatment of major depressive disorder (MDD) received 501(k) clearance from the US Food and Drug Administration (FDA). The theta burst protocol utilizes BrainsWay’s Deep Transcranial Magnetic Stimulation (Deep TMS) system, previously FDA-approved for 20-minute treatments of patients with MDD who did not respond to medical therapy.

“Adding our 3-minute treatment protocol to the list of growing solutions available to our provider partners expands the platform nature of this lifechanging technology,” Hadar Levy, Senior Vice President and General Manager of BrainsWay, said to the press. “Many patients and providers can benefit from significantly shorter treatment sessions, and our theta burst protocol can provide these patients with another option to manage their treatment resistant depression.”

In their application to the FDA, BrainsWay submitted safety and efficacy data from a study that enrolled 146 participants with MDD who received either standard deep TMS protocol or 3-minute theta burst protocol. Of the 146 patients, 80 received the 20-minute protocol and 66 received the theta burst 3-minute protocol. Both groups demonstrated statistically significant reductions in depression scores. The results met the equivalence criteria needed for the shorter treatment’s clearance.

The therapy uses BrainsWay’s H-1 coil helmet to excite or inhibit neurons in the prefront cortex using direct magnetic pulses. It is typically delivered 5 days a week for 4 weeks, and then adjusted based on patient response. Both treatments call for the same frequency and number of treatments, but the frequency of the pulses and inter-pulse breaks differ.

“The addition of theta burst to the available protocols further demonstrates BrainsWay’s commitment to expanding the utility of the BrainsWay Deep TMS system,” said Moria Ankri, Vice President of Research & Development. “This protocol shows that innovation need not be revolutionary or radical to have a positive effect on peoples’ lives. Having a 3-minute option for patients has the potential to expand access to care by providing patients with added flexibility in selecting courses of treatment that may fit better with their lifestyle.”

The BrainsWay theta burst protocol will be available on all BrainsWay systems already installed.

1. BrainsWay. BrainsWay receives FDA clearance for three-minute theta burst treatment protocol for major depressive disorder. News release. April 26, 2021. 

https://www.brainsway.com/news_events/brainsway-receives-fda-clearance-for-three-minute-theta-burst-treatment-protocol-for-major-depressive-disorder/

2. Boyle A. FDA clears three-minute depression treatment with Brainsway’s theta burst. BioWorld. April 26, 2021. 

https://www.bioworld.com/articles/506363-fda-clears-three-minute-depression-treatment-with-brainsways-theta-burst

The FDA cleared the way to use this deep transcranial magnetic stimulation system, which may be able to help treat depression in less than 5 minutes. 

Treating Depression in 3 Minutes

Susan J. Noonan, MD, MPH, talks about the need for both patients and family to understand symptoms of mood disorders. 

is a physician consultant and Certified Peer Specialist in the Department of Psychiatry at McLean Hospital and the Massachusetts General Hospital. She is the author of four books and a blog on managing depression, most recently 

Helping Others With Depression: Words to Say, Things to Do (December 2020)

. Dr Noonan offers peer counseling to fellow patients, including physicians and other professionals, and can be confidentially reached through her website at 

Teach both the patient and the patient's family are important steps to treating a mood disorder.

Family Matters: Challenges with Mood Disorders

John J. Miller, MD, discusses meditation and how to use the breath as a tool. 

is medical director, Brain Health, Exeter, NH; editor in chief,

; staff psychiatrist, Seacoast Mental Health Center, Exeter, NH; consulting psychiatrist, Exeter Hospital, Exeter, NH; consulting psychiatrist, Insight Meditation Society, Barre, MA.

Meditation is a process and practice available to all. 

The Tool Within

The poem “No Sympathy for Other” is inscribed on the face of the United Nations Building. The words were written by the Persian poet Saadi more than 800 years ago:

The sons of Adam are limbs of each other,

Having been created of one essence.
When the calamity of time affects one limb

The other limbs cannot remain at rest.
If thou hast no sympathy for the troubles of others
Thou art unworthy to be called by the name of a human.

We are interconnected. The worldwide COVID-19 pandemic has made that crystal clear.

The same is true for the worldwide crisis posed by climate change. Each crisis dramatically reveals the preexisting fractures in our society. Communities of color are first and most profoundly impacted by both COVID-19 and climate change and are least able to 

 The roots that link climate change and COVID-19 are neither inherent to the virus, nor to the dynamics of global warming. The profound disparities are driven by social determinants and the socioeconomic and political structures embedded in our society.

As early as the mid-1970s, scientists began warning the world community about threats of climate change. Most of their predictions fell on deaf ears. Yet their predictions have been remarkably accurate. What the scientists did not accurately predict was just how quickly we would be facing the consequences. The impacts are not in faraway places, nor in the distant future. No longer can we turn a blind eye as the fury and frequency of climate-driven disasters intrude on our lives.

We are forced to face multiple crises simultaneously: the pandemic, climate change, and the effects of racism. The worldwide COVID-19 pandemic has triggered a massive international health crisis and fueled economic decline, in which escalating poverty and disparities of wealth are inescapable. Rightful rage about centuries of simmering structural racism has ignited a movement demanding urgent racial justice.

Nightly news broadcasts reporting on the daily death toll of COVID-19 keep us attuned to the presence of the pandemic. Since the climate disasters occur more episodically and are spread across different locales, it is all too easy to let concerns recede into the background. How much can we face at one time? Nonetheless, we cannot afford to ignore the climate crisis; physics and Mother Nature will not wait. We ignore this at our own peril.

Structural racism refers to the laws and regulations, the resulting systems, and the cultural practices and norms that result in differential access to 

resources, opportunities, power, and wealth

 These are core sociopolitical issues that are embedded in American history and current society. The legacy of inadequately addressed racism has created the current intolerable disparities in our society, including marked disparities in health outcomes for communities of color. These structural components combine with the climate crisis to exacerbate the differential impacts that climate-driven events and disasters have on poor individuals and communities of color. Climate events act as threat multipliers, adding to and exacerbating current dangers.

Although we Americans are not unique in our capacity for racism, our history is built on genocide, slavery, colonialism, and the annihilation of what, in psychoanalytic language, is often called “the other.” Founded on principles of the Doctrine of Discovery and Manifest Destiny, European settlers saw the New World through 

 They hardly questioned the belief that what was here was for their taking. Progress was to exploit the land, expropriate the homeland from native occupants, and to extract the most out of African slave labor. Marching through time also meant the annexation and colonization of Brown communities. Later in 20th century, our foreign policy was dictated by securing alliances and controlling puppet governments for access to greater wealth and power. Examples abound in our efforts to control emerging countries in Central America and Southeast Asia.

Although the accumulation of wealth has been the preeminent economic driver of American imperialism, there are profound connections between psychic mechanisms and industrial capitalist growth. Enabling this quest for wealth, deeply embedded unconscious intra-psychic processes have allowed us to hold at arms’ length the historical suffering inflicted by genocide, slavery, and colonialism. These are the very same mechanisms in play when it comes to ignoring the destruction and aggression inflicted today on the communities that are most dramatically impacted by climate disruption.

Additionally, these same unconscious processes underpin our attitudes and our relationship with the natural world; destruction and aggressive plundering of our environment are all too common. We are left with damaged, scared, soiled places all the while feeling nostalgically perplexed about what has happened. What has gone wrong? How did the natural world, which previously brought solace and psychic restoration, begin to bring pain and mourning for the past? Note the new concept of 

, describing that deep melancholic grief when experiencing the change to our natural environment, 

Psychoanalyst Melanie Klein describes primitive paranoid-schizoid states that shed light the intra-psychic mechanisms operative in this realm.

 Only the “I” exists, and “the Other,” the mother, only exists as an extension of the desires and needs of the voracious infantilized self. Since there is no “other,” we are unable to experience other humans as brothers and sisters.

This infantile state also allows us to view the earth as nothing other than an inexhaustible source of supplies that exist for our pleasures. This has allowed us to take from Mother Earth endlessly and deny any limits on consumption.

Just as we have plundered the earth with willful disregard for the consequences, we have discounted the suffering of those who are most affected by climate ravages. Primarily, psychic defenses must minimize the suffering of people of color and keep our minds in a detached, distorted, intellectualized sphere. The false belief that African Americans do not experience pain in the same way that Whites do is an example of 

 To retain our emotional comfort requires us to unconsciously experience “the other” in 2 dimensional and dehumanized ways, or worse, as nonexistent in our minds.

We are also faced with a modern psychological epidemic within 

 Just as hysteria was the dominant psychic disorder during Freud’s time, we are now facing a modern epidemic of narcissism: a preoccupation with the individual or the self.

Narcissistic qualities are efforts to manage underlying, often unconscious feelings of inadequacy, inferiority, and insecurity. Such fragile states are managed through an inflated sense of superiority, self-aggrandizement, and a sense of entitled attitudes and behaviors. This requires undervaluing others to sustain the delicately inflated sense of self, often resulting in disregard for others and 

Such narcissistic qualities in individuals can be extended to broader manifestations seen in our socioeconomic-political groups. Isabella Wilkenson, the first woman of African-American heritage to win the Pulitzer Prize in journalism, builds on ideas of narcissism as she reframes the issues of racism through the lens of a 

 As on the fixed rungs of a ladder, each knows his specified place in the caste hierarchy. For example, the decades of socioeconomic losses of the white underclass and working classes have threatened their previously more stable place in the caste hierarchy. Struggling with the greater economic disparities and insecurity have threatened whole communities. Reacting against mounting pressure for justice from communities of color, some white communities collectively manage these threats with the compensatory sense of superiority and entitlement. In the effort to keep out the pain that would come with loss of status, the downtrodden find solace in collective grandiose fantasy. Desperate attempts to restore the threatened equilibrium have unleashed the current white supremacy movement, along with its violence.

Psychoanalyst Donna Orange, PhD, PsyD, has linked racism and climate change with unconscious 

 She describes these processes as states of “exaggerated entitlement,” reflecting attitudes of cultural superiority. The psychic states of denial and disavowal (knowing facts about climate change but experiencing the self as buffered from impacts) are dependent on this irrational sense of specialness and superiority which, she argues, is rooted in centuries of colonialism and slavery. Orange elaborates that we have been “morally numbed,” which contributes to our failure to deal with the climate crisis in general, and specifically the impacts of climate on communities of color.

The retreat to regressive psychic states in face of fears is not only ineffective in creating needed social solutions, but it also comes at great costs. Relying on fragile, unstable psychic structures cuts us off from the full range of feelings. Emerging from paranoid-schizoid position and narcissistic states allows for greater, more nuanced capacities to tolerate real limits, experience our common-ness, and recognize our dependency and interconnections with others and the natural world.

I suggest that we are all too vulnerable to regressive states when confronted by the magnitude and repeated assaults of climate disasters, and we must use our more mature selves to face the dual impacts of structural racism and climate chaos. It is tough to see, feel, and hold sympathy for the troubles of others. But as Saadi’s poem reminds us, we are “created as one essence,” and our “limbs cannot remain at rest” when others are in pain.

I reside in the traditional territory of the Ramaytush-Ohlone-Muwekma Nations and honor the ancestral community that inhabited and cared for this land. It is this dedication and awareness that inspired me to lead this series.

This collection of articles will highlight the specific ways various communities of color have been uniquely impacted by climate disruption. While the specific stories may be idiosyncratic, the shared interconnections cannot be lost. The final article will address some shared solutions.

We must rise to the challenge Saadi issued in his poem centuries ago, when he challenged us to be worthy “to be called by the name of a human.”

is clinical associate professor in the Department of Psychiatry at the University of California, San Francisco.

The impacts of climate change on human health in the United States: a scientific assessment

. US Global Change Research Program. April 4, 2016. Accessed April 15, 2021. 

2. Bailey ZD, Feldman JM, Bassett MT. How structural racism works - racist policies as a root cause of US racial health inequities. 

An Indigenous Peoples’ History of the United States for Young People

4. Albrecht G, Sartore GM, Connor L, et al. Solastalgia: the distress caused by environmental change. 

Introduction to the Work of Melanie Klein

6. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites

Narcissism: the science behind the rise of a modern ‘epidemic.’

. March 11, 2016. Accessed April 15, 2021. 

New insights into narcissistic personality disorder

. February 29, 2016. Accessed April 15, 2021. 

10. Orange DM. Climate and Justice. Lecture presented at the San Francisco Center for Psychoanalysis. April 1, 2019.

Climate Crisis, Psychoanalysis, and Radical Ethics

. Routledge, Taylor & Francis Group; 2017.

Powerful psychic defenses are keeping humanity from facing a number of interconnected crises. How can these psychic defenses be overcome? 

Introducing a New Series: Racism and Climate Change 

 shares insights, commentaries, practice tips, and research reviews from leaders in psychiatry and clinicians like yourself.

Tony Thrasher, DO, DFAPA
President, American Association for Emergency Psychiatry (AAEP)
Medical Director, Crisis Services, Milwaukee County, Wisconsin

There are 4 crucial misunderstandings about mass shootings. What are they and how can they be included in discussions with patients?

The Verdict Is in: A Corrective Emotional Antiracism Experience

H. Steven Moffic, MD
Editorial Board Member
Author, Anti-Semitism and Psychiatry: Recognition, Prevention, and Interventions

Reflections on a landmark court case and its impact on racism, mental health, and healing in the United States.

Symphonic Beauty: NMDA Glutamate Receptors

John J. Miller, MD
Editor in Chief
Medical Director, Brain Health, Exeter, New Hampshire

What’s really happening at the neuronal and synaptic level? Take a guided tour of this beautiful symphony as we begin to better understand our extraordinary biological systems.

Professor of Clinical Psychiatry
Past Vice-Chair of Education and Director of Training, Department of Psychiatry & Behavioral Sciences, SUNY-Downstate Medical Center, Brooklyn, New York.

When help was needed the most during COVID-19, psychiatrists stepped up and provided support to frontline workers. Lessons learned can support future endeavors as we confront residual symptoms of the pandemic and a very changed world.

Have a suggestion for a video or interested in sharing thoughts with your colleagues in an upcoming Mental Health Minute video? Let us know at 

® network, a first-of-its-kind 24-hour online program for health care professionals, by health care professionals..

Over the last year, we have compiled numerous videos about all aspects of psychiatry, medicine, and society. Check out a sampling here.

Minute-by-Minute PsychBytes

Lundbeck announced positive results from the Real-World Effectiveness of Vortioxetine (RELIEVE) study evaluating vortioxetine for the treatment of major depressive disorder (MDD) and how it affected their everyday lives.

“The strong results from this trial show that patients treated with [vortioxetine] experience a significant improvement in overall functioning over a substantial period of 6 months. I think it is an interesting aspect that this study specifically shows an effect of [vortioxetine] on family, work, and social life functioning. At the end of the day, we want to be able to restore brain health, so people can be at their best,” said Johan Luthman, Executive Vice President for Research and Development at Lundbeck.

While the mechanism of vortioxetine is not fully understood, it is an inhibitor of serotonin (5-HT) reuptake. It is also an agonist at 5-HT1A receptors; a partial agonist at 5-HT1B receptors; and an antagonist at 5-HT3, 5-HT1D, and 5-HT7 receptors. Vortioxetine is perhaps the first of its kind with this combination of pharmacodynamic activity.

A total of 994 participants were evaluated for depressive symptoms as measured by the 

 (SDS), a tool that assesses impairment patients find in the following areas of their lives: family, social life, home responsibilities, and work/school. Eligible participants included patients with MDD initiating treatment with vortioxetine or switching from another antidepressant to treat a current major depressive episode.

Data were collected at routine clinic visits at baseline, 3 months, and 6 months. Analysis showed significant and meaningful improvements by 6.9 points and 8.6 points respectively after 3 and 6 months on the SDS when compared to prior antidepressant treatment.

The secondary and exploratory endpoints were also met, with a 0.13 improvement on the EQ-5D utility score measuring health-related quality of life for participants, and a 7.4 decrease in depressive symptoms from baseline as measured by the PHQ-9 (Patient Health Questionnaire-9) scale.

The RELIEVE study provides novel insights, as its focus was on patient self-assessment of daily functioning and their own experiences with improvement after treatment with vortioxetine.

Full results will be published in a peer-reviewed scientific journal later in 2021 and presented at future medical conferences. At this time, however, caution is needed, and further research is warranted.

1. Lundbeck. Vortioxetine significantly improves overall functioning in a global real-world study in Major Depressive Disorder. News release. April 22, 2021. 

https://news.cision.com/h--lundbeck-a-s/r/vortioxetine-significantly-improves-overall-functioning-in-a-global-real-world-study-in-major-depres,c3330732

A recent study evaluated the everyday efficacy of this novel treatment for major depressive disorder. 

Real-World Effectiveness: New MDD Treatment

Richard Berlin, MD, shares poetry from Jehanne Dubrow about marriage. The poem, "Pledge," can be found in full 

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

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

"My love, I am pledging to this republic, for however long we stand..."


Pledged to a Little Nation

H. Steven Moffic, MD, discusses heroism and how doing the right thing often takes risk. 

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

Bystanders who view traumatic events tend not to react. This woman did. 

Darnella Frazier and How to Become a Hero

Dr Hasnain recently retired as an associate professor of psychiatry at Memorial University of Newfoundland, Canada. He was the head of the divisions of Geriatric and Consultation & Liaison Psychiatry at Eastern Health St. John’s, Newfoundland and Labrador. Currently he is a freelance health care activist focusing on public health education and health care reform.

Obesity is a prevalent global problem that affects patients with major mental illness disproportionately.

 It is associated with cardiovascular risk factors, including hypertension, dyslipidemia, and impaired glucose tolerance. Not surprisingly, the prevalence of these conditions is also high in patients with major mental illness. In fact, patients with major mental illness have a lifespan 

 than the general population, with cardiovascular mortality largely accounts for this difference.

Several biological, psychological, behavioral, and social factors predispose patients with major mental illness to obesity. One well-established risk factor is the weight gain-inducing side effect of antipsychotic drugs.

 Two features of this risk factor make it stand out: It is modifiable, and it is under the control of the prescriber.

Weight Gain-Inducing Risk of Antipsychotic Drugs

Most early antipsychotic drugs caused acute and chronic motor side effects. Clozapine was different because it was not haloperidol-like or a high-potency dopamine-2 full antagonist, but its routine use was prevented by the risk of agranulocytosis. Several safer atypical antipsychotic drugs have become available, and they are now standard treatment for schizophrenia and other approved indications. Despite this progress, an important side effect of clozapine—weight gain—has remained an issue with later-generation antipsychotics.

Researchers use 2 measures to determine the weight gain-inducing side effects of psychotropic drugs3: how many patients exposed to a given drug gain weight and how much weight is gained by patients. The latter can be measured as a crude number, or it can be standardized as a proportion of weight gain from baseline. Generally, weight gain greater than 7% from baseline is considered significant.

We now have extensive research on the weight gain-inducing and metabolic risks of antipsychotic drugs, including meta-analyses of the data.

 If we leave subtle differences and academic discussions aside, the common antipsychotic drugs can be grouped into 3 categories of weight gain-inducing potential (

Table 1. Relative Weight Gain–Inducing Risk of Commonly Used Typical Antipsychotic Drugs

Table 2. APA and American Diabetes Association Guidelines on Baseline Assessment and Monitoring of Patients Receiving Antipsychotic Medication

Figure. Approaches to Switching Antipsychotic Drugs

There are a few important things to remember when contending with weight gain-inducing risk. First, weight gain is an individual-specific phenomenon; therefore, each patient must be monitored individually. Second, young patients who were not previously exposed to an antipsychotic drug (ie, drug-naive patients) are at a much higher risk of weight gain than older individuals who are not drug-naïve.

 Third, there is some evidence that metabolic complications (dyslipidemia and/or glucose intolerance) may result from these drugs independent of significant weight gain.

 Lastly, antipsychotic drug use is associated with weight gain irrespective of the diagnosis.

Limiting and Managing Drug-Induced Weight Gain

A preventive approach.Losing excess weight is tough for anyone and even tougher for individuals with major mental illness.

 Obesity might not receive much clinical attention because it is not acutely distressing or life-threatening. In the long term, however, it contributes to morbidity and mortality. In addition, young, nonobese, drug-naive patients can gain significant weight within a matter of months when exposed to antipsychotic drugs with a high risk of weight gain.8 Once they have gained that weight, many of them will never be able to lose it.

Introduction: Finding Solutions While Managing Problems

Addressing Obesity in Patients Taking Antipsychotics

Sedation: The Ups and Downs of a Side Effect

Antipsychotic-induced weight gain evolves over time, leads to chronic complications, and is very difficult to reverse. Pharmacologic interventions used to tackle weight gain are modestly effective and worth considering in certain cases.