“Kate” is a 15-year-old Caucasian female with a history of attention-deficit/hyperactivity disorder (ADHD), diagnosed at age 7. At age 9, she reported nightmares 2 to 3 times weekly. Although her primary symptom was inattention, Kate also reported racing thoughts and a nocturnal burst of energy associated with initial insomnia more than half of nights. These symptoms improved between ages 7 and 9 with stimulant medication, but were still present. Now in high school, Kate reports a mild worsening of inattention. As her psychiatrist, how would you educate the patient and her parents about the relationship between sleep problems and symptoms in ADHD?

Sleep disturbances are a common comorbidity in ADHD, affecting approximately one quarter to one half of patients, including those who are treatment-naïve.

 There is a potential bidirectional association between exacerbations of sleep disturbance and ADHD symptoms.

 Therefore, sleep disturbances appear relevant to the clinical management of ADHD. Previous studies of sleep and ADHD have focused on childhood/early adolescence,

 and have not included repeated measurement of symptoms. Given that these symptoms can persist into adulthood, there is a need to understand their longitudinal relationships.

 investigated associations between sleep problems and ADHD symptoms in a longitudinal population-based cohort study. Among 18 million phone numbers, 7912 were randomly selected for survey. These numbers yielded 4186 eligible families, of whom 1055 (25%) were successfully recruited. Families were assessed in 3 waves (each 4 to 5 years apart), over a 9-year follow-up period. Among the enrolled families with complete data at all waves, 256 were included in the main analysis. 

Parents were surveyed about ADHD symptoms using a structured interview based on the K-SADS at each wave. A structured interview based on the 2 main questionnaires for sleep disturbances in children were also used at wave 1 (28, 29). In waves 2 and 3, half of subjects had a repeat interview for sleep disturbances.

Study authors first investigated bivariate correlations between sleep disturbance and ADHD symptom scores. They then used a random-intercept cross-lagged panel model to explore longitudinal associations between sleep disturbance and ADHD symptoms, reported as regression coefficients (β) and 95% confidence intervals.

The mean subject age was 9.4 at wave 1, 13.4 at wave 2, and 18.2 at wave 3, and 52% of the sample was male. More than 80% of parents were married, and more than 50% had attended college or university. Both sleep disturbances (ρ>0.24 for each) and ADHD symptoms (ρ>0.29 for each) were significantly correlated across the 3 waves. At each wave, sleep disturbances and ADHD symptoms were significantly correlated with each other (ρ>0.14 for each). Furthermore, sleep disturbances at waves 1 and 2 were significantly correlated with ADHD symptoms at wave 3 (ρ>0.14 for each). 

In cross-lagged models, sleep disturbance at wave 2 was a significant indicator of ADHD symptoms at wave 3 (β=0.15), explaining 12% of the within-person variance in ADHD symptoms. By contrast, ADHD symptoms at wave 2 did not predict sleep disturbance at wave 3. In secondary analyses, findings were stronger for inattentive (versus hyperactive-impulsive) symptoms.

The authors concluded that there is a directional association between sleep disturbance in early adolescence and ADHD symptom severity in early adulthood after considering between- and within-person effects. Findings were stronger for inattentive than hyperactive-impulsive symptoms. The primary study strength was the use of a longitudinal design with repeated assessments with consideration of directionality. Study limitations included missing data, reliance on parental reports of ADHD symptoms, and the use of telephone survey (versus in-person assessment).

This study demonstrates that sleep disturbance in early adolescence is an indicator of ADHD symptom severity in early adulthood. Findings suggest that routine assessment of sleep disturbance is warranted in patients with ADHD, and ADHD symptoms in children with sleep disturbances.

is a professor in the Department of Psychiatry and Health Behavior at Augusta University in Augusta, Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for 

The author reports that he receives research support from Augusta University, the National Institute of Mental Health, and the Stanley Medical Research Institute.

1. Sung V, Hiscock H, Sciberras E, Efron D. 

Sleep problems in children with attention-deficit/hyperactivity disorder: prevalence and the effect on the child and family

2. Cortese S, Faraone SV, Konofal E, Lecendreux M. 

Sleep in children with attention-deficit/hyperactivity disorder: meta-analysis of subjective and objective studies

3. Quach JL, Nguyen CD, Williams KE, Sciberras E. 

Bidirectional associations between child sleep problems and internalizing and externalizing difficulties from preschool to early adolescence

4. Chervin RD, Ruzicka DL, Archbold KH, Dillon JE. 

Snoring predicts hyperactivity four years late

Severe sleep problems in infancy associated with subsequent development of attention-deficit/hyperactivity disorder at 5.5 years of age

6. Gosling CJ, Cortese S, Konofal E, et al. 

Association of parent-rated sleep disturbances with attention-deficit/hyperactivity disorder symptoms: 9-year follow-up of a population-based cohort study

Articles

Good night, sleep tight! Researchers performed a 9-year follow-up of sleep disturbance and ADHD symptoms in a population-based cohort study.

Longitudinal Study of Sleep and ADHD Symptoms

 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

A colleague recently wondered why we in psychiatry do not tell enough stories about ourselves and our work. He had just read—and forwarded to me—the book review by Jerome Groopman, MD, in the July 25, 2022 

, titled “Why Storytelling Is Part of Being a Good Doctor.”

 The review began with Dr Groopman discussing how he came to be a popular writer of moving medical stories about life, death, and uncertainty after being a writer of the usually drier academic articles. The review then focused on the Chief of Pediatric Neurosurgery, Jay Wellons, MD, MSPH, and his mid-career memoir of 

. Such emotionally laden stories are what we all tend to remember over facts and figures, as important as those facts and figures may be in their own right.

The Violinist Joshua Bell and the Goldwater Rule: The Psychological Power of Context

Buyers Beware in Alzheimer Disease Neuroscience

Dr Groopman, in passing, touched upon many other physician writers. As usual, I noted that none of them were psychiatrists. Isn’t that strange at first glance? Here we can be in our close interpersonal relationships with patients who often share the gory and glory of their lives. Certainly, this was not the case in the time of Freud and his colleagues. Irving Yalom, MD, in our time has been one of the notable rare exceptions. With a similar academic background as Dr Groopman, I eventually tried to use the story conceit of a mock company when I was asked to write a book about the emotionally laden challenge of ethics in managed care.

Is our current reluctance to tell our stories the result of ethical confidentiality concerns? That should not be the case since we can disguise identity. Is it in part the spin-off influence of our Goldwater Rule against commenting on public figures and their public stories? We do not even seem to appear on the major media medical discussions of psychiatric topics. Is it because we have become more of a 15-minute med check provider devoid of interesting stories?

Last year, I wrote the Forward to the beautiful book, 

, with text by William Cleveland and artwork by Barry Marcus. It conveys a primal story with primal images. I now wonder: What is the primal story of psychiatry? Maybe you would like to share what you think that is.

To paraphrase Dr Seuss: Oh, the mental places we’ve gone! I am sure many of you have all kinds of psychiatric stories, short or long, to tell, too.

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. Groopman J. Why storytelling is part of being a good doctor. 

. July 18, 2022. Accessed August 1, 2022. 

https://www.newyorker.com/magazine/2022/07/25/why-storytelling-is-part-of-being-a-good-doctor-all-that-moves-us-jay-wellons

The Ethical Way: Challenges & Solutions for Managed Behavioral Healthcare

Does being a good storyteller make you a better clinician? 

The Stories That We in Psychiatry Have to Tell

, we worked with experts from multiple psychiatric areas to bring you thoughtful articles about a wide variety of psychiatric issues, from the new 988 suicide hotline to the role of antipsychotic selection in reducing nonadherence in schizophrenia. Here are some highlights from the issue.

The National Suicide Prevention Lifeline is getting an upgrade. On July 16, 2022, the Lifeline will change from its previous number (800-273-8255) to just 3 digits: 988. Although the old number will remain available for calls, individuals may call, text, or chat 988, where they will be connected with trained counselors.

Additionally, if functioning as intended, operators will be able to counsel callers 24 hours a day and dispatch specially trained responders, hopefully reducing armed law enforcement interventions and emergency department (ED) visits. 

It's Time to Think of Women: Mental Health Services for First-Episode Psychosis

As the World Health Organization reminds us, gender is a critical determinant of health, including mental health. Psychosis affects 3 in 100 individuals worldwide and typically develops around age 21 years. It includes diagnoses such as those of the schizophrenia spectrum and affective disorders. Early intervention services hold the promise of changing the trajectory of psychosis by providing specialized, coordinated care to individuals experiencing their first episode of psychosis (FEP). Evidence shows that FEP services can improve short-term and long-term outcomes for the individual (eg, employment) and for their community (eg, reduced disruptive public behavior, legal charges). What remains unknown, and maybe overlooked, is that women experiencing FEP might encounter gender-based disparities in accessing and receiving specialized care. 

Antipsychotic Selection is Important for Reduced Nonadherence in Schizophrenia

“Mr Spear” is a white man, age 43 years, with a 20-year history of schizophrenia who presents for an initial outpatient appointment with a primary complaint of insomnia. Upon further questioning, he explains that he is afraid to sleep due to paranoia because there are individuals outside his home at night who want to kill him. He will not take any medication that makes him drowsy. His mental status is otherwise unremarkable. He denies any suicidal or homicidal ideations and does not appear to attend to internal stimuli. He reports several previous psychiatric hospitalizations, but none in the past 3 years. He works full-time in construction and denies any work-related problems. After a discussion of risks and benefits, he agrees to a trial of daily low-dose aripiprazole (morning) and to return to the clinic in 4 weeks. However, Mr Spear does not show up for his follow-up appointment, he does not return a phone call to reschedule, and he never returns to the clinic. 

Caregiving: Walking the Personal and Professional Tightrope

August 16, 2019, in New Haven, Connecticut, was a beautiful summer evening. A delicious dinner at the Study at Yale hotel, where we were staying for the night, wrapped up a packed day of activities. These included a presentation and conversations about evidence-based addictions treatment modalities. The day could not have been better. I remember thinking that this was addiction treatment done right. A colleague invited a group of us to walk over to the Arethusa Farm Dairy store for their famous “designer” ice cream. I asked for a minute to go to my room and slip on some comfortable shoes for the 5-minute walk. I never returned. Instead, I called my colleague to tell him and everyone else to go ahead—I had to handle an urgent matter. I had at least 10 missed calls and several text messages from 2 neighbors. 

. 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 

The experts weighed in on a wide variety of psychiatric issues for the July 2022 issue of Psychiatric Times.

From the Pages of Psychiatric Times: July 2022

Laughter Therapy: Good Medicine to Make Your Heart Glad

Psychiatry Comic: Gamblers Anonymous

 is the president of the American Association for Emergency Psychiatry (AAEP) and the medical director of crisis services in Milwaukee county.

It would be nearly impossible to peruse any media, engage in any conversation, or interact in any workplace without coming across the topic of the increased number of mass violence episodes (usually mass shootings) in the United States. With this in mind, I wanted to share evidence and thoughts surrounding myths about these episodes… as well as their corresponding truths. Although this is important in terms of accuracy, it is even more germane as it pertains to appropriate messaging by psychiatric professionals to our patients and our communities.

Myth #1: “We live in a more violent world than ever.”

Although the number of firearm deaths is increasing (please see Myth #7), we have seen decreases over time of other violent events. This is important to many of our patients suffering from anxiety or trauma-based illnesses. This myth and its messaging can lead to worries regarding lack of control, fatalistic projections, and learned helplessness. Additionally, it is important to note that most of the 

 in the United States is not categorized as mass shootings. For instance, approximately 70 women are killed with firearms every month in situations of domestic violence.

Myth #2: “All of these perpetrators are mentally ill.”

The truth is that the majority of the individuals acting as 

 do not possess diagnosable or treatable mental illnesses. In other words, mass shootings are not predominantly attributed to those with mental illness. In fact, it is much more common for those living with mental illness to be a victim of a crime, not the perpetrator.

 If you examine all violent events, only a very small percentage (3% to 4%) are committed by individuals with mental illness. Although that number rises a bit when looking solely at incidents of mass violence, it is still quite small when looking at the overall data set (15% to 20%).

Myth #3: “Patients with severe and persistent mental illness are routinely dangerous.”

Debunking this myth is massively important; we need to properly message this to decrease stigma, increase access, and provide a safe community for those with severe and persistent mental illness (SPMI). Longitudinal studies have demonstrated that the majority of those with mental illness are not violent,

 and even more so, there is little to no evidence that there are high rates of 

 directed to others. On the rare instances in which violence is seen in the SPMI population, it is not usually perpetrated with guns, and it is not directed toward strangers and the general public.

 The 3 main items that tend to correlate as predictive factors for homicidal violence (whether one has a mental illness or not) is anger, intoxication, and access to firearms.

Myth #4: “Mass shootings are the most prevalent violent issue facing society now.”

Although episodes of mass violence are low incidence events (compared to all violent events), they are very powerful in terms of emotion, victims, and media coverage. In fact, other violent acts occur much more frequently. For instance, there were approximately 500 deaths from mass shootings between 2000 and 2016. During that same time period, there were almost 320,000 suicide firearm deaths.

 Moreover, recent data has shown the suicide numbers to be at least twice that of all homicides.

 Thus, from a public health standpoint, the rise in 

 dwarf that of homicides and other violent deaths (not just mass shootings).

Myth #5: “Enacting legislation focused on the mentally ill will decrease mass shootings.”

Part and parcel to Myth #2, this makes mathematical sense as there would not be significant change by focusing on 15% of the cases. By falsely looking at mental health, we are missing characteristics that have been found to be markedly more common in assailants, including 

, misogyny, and feelings of isolation and alienation (with rumination on perceived slights, particularly in the workplace). Additionally, most individuals who commit these shootings exhibit planning/practicing and cognitive appraisal. These actions are not consistent with psychosis, which is associated with the inability for self-care, nor would these traits be detected by present civil commitment statutes.

Myth #6: “Mental health screening and risk factors are the best way to predict mass shooting events.”

Very similar in tone to Myth #5, Federal Bureau of Investigations data has shown perceived victimization, rumination, and premeditation amongst perpetrators is more indicative of intent than mental health status. Similarly, Secret Service data has noted personal grievances, past violence, and a history of felonious events as predictive.

 As such, the most common predictors are not symptom domains normally seen in psychiatric illness. That being said, we have a lot to offer the field given our skills in risk assessment, interviewing, and inter-agency collaboration.

Myth #7: “Access to firearms is not a risk factor for episodes of mass violence.”

Although this topic comes with a great deal of emotion and history, it is noted to be an important part of messaging any conversation around mass violence. The US firearm homicide rate (from all causes) is 25 times higher than our peer high-income countries.

 Not surprisingly, the US gun death rate per 100,000 citizens is 3.24 compared with an average of 0.19 from our peer countries. Combine this with the fact that the United States has 44% of the world’s firearms (while only having 4.4% of the world’s population).

 Thus, it can be noted that American crime, in general, is more lethal than peer countries.

Myth #8: “Laws and policies addressing firearm access will not mitigate the risk of mass violence.”

Extreme risk protection orders in several states have been noted to reduce population level firearm suicide rates.

 Another intervention strategy is banning large capacity magazines. Interestingly, states without such bans have seen increased incidence of mass shootings and higher fatality rates when shootings occurred.

 Lastly, state legislation focusing on firearm restraining orders resulted in a 10% decreased 

From a suicide risk mitigation perspective, this degree of effect is consistent with the Lethal Means Safety literature,

 which notes that individuals do not displace aggression (ie, they do not just find another way). Consequently, legislation pertaining to firearm access has the ability to reduce several categories of gun violence (eg, suicide, mass homicide, and intimate partner violence).

Myth #9: “Schools are markedly more violent/dangerous than ever before.”

This is another dangerous misconception that can lead to more harm than good. Although the media focuses on this extensively, the actual numbers of school shootings pale in comparison to other violent acts, like suicide or intimate partner violence. In fact, you are 10 times more likely to encounter violence at a restaurant compared to school, and 100 times more likely to encounter violence in your own home.

Myth #10: “Focusing solely (or primarily) on mental illness issues with regard to mass shootings does no harm, right?”

Wrong. Using mental illness as the primary focus in these scenarios is not only inaccurate (as described previously) but it is also quite stigmatizing. In addition, when media coverage focuses on mental health as the driver in these tragedies, there is also a delayed wait time to enter outpatient psychiatric services (the irony). For example, a data set from 1997 to 2012 revealed that news sources focused on “dangerous people with illness” more so than “dangerous weapons.”

Now that we better understand these myths as well as the proper messaging to combat them, what do we do next as a profession? In other words, just because the majority of these cases are not perpetrated by individuals with primary mental illness, it does not mean that the field of psychiatry does not have a part to play—or that we should not be active in the conversation.We need to be involved in assistance, assessment, and we need to be present on the rare cases in which these events do involve someone with mental illness.

The field of threat assessment is an excellent example of a collaboration involving law enforcement, mental health, and several other federal agencies. They have many excellent suggestions regarding notification (ie, “if you see something, say something”) as well as reminding anyone involved to “never worry alone.”

 Many of the individuals who commit these crimes do not snap, but instead plan and prepare for months preceding the incident. Hence, there are instances of direct sharing of plans, and other times, more indirect “leaking” of intent.

 Threat assessment teams allow for longitudinal analysis and observation of individuals with these risk factors. Our field has an excellent opportunity to work with such stakeholders to improve identification and follow-up in such cases.

We have an important role in educating others about these 10 common misconceptions pertaining to mass violence. We must leverage solid research and data to help paint a more accurate picture. The reason we need to discuss the truth behind these issues is not only for the purpose of clarity but also to make sure that we are messaging appropriately in our advocacy and support of our mission. In doing so, we are advocating for not only our profession, but also for our communities at large.

is the president of the American Association for Emergency Psychiatry (AAEP), the medical director of crisis services in Milwaukee County, Wisconsin, and president elect of the Wisconsin Psychiatric Association.

1. Everytown analysis of CDC, National Violent Death Reporting System (NVDRS), 2019. 

https://everytownresearch.org/maps/mass-shootings-in-america/#domestic-violence-was-a-part-of-most-mass-shootings

2. Brekke JS, Prindle C, Bae SW, Long JD. 

Risks for individuals with schizophrenia who are living in the community.

3. CDC Leading Cause of death reports. National and regional 1999-2010; February 2013.

Mental illness, mass shootings, and the politics of American firearms.

5. Steadman HJ, Mulvey EP, Monahan J, et al. 

Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods.

Gun violence and victimization of strangers by persons with a mental illness: data from Macarthur Studies.

7. Monahan J, Steadman HJ, Silver E, et al. 

Rethinking Risk Assessment: The MacArthur Study of Mental Disorders and Violence

8. Injury Prevention and Control: Data and Statistics (WISQARS); CDC, 2018. 

https://www.cdc.gov/injury/wisqars/index.html

Explaining rare acts of violence: the limits of evidence from population research.

10. “Mass Violence in America: Causes, Impacts and Solutions.”National Council for Behavioral Health, Medical Director Institute, August 2019.

11. Fox K. How US gun culture compares with the world in 5 charts. October 3, 2017. Accessed July 18, 2022. 

https://www.wral.com/how-us-gun-culture-compares-with-the-world-in-5-charts/16993476/

12. Fisher M, Keller J. Why does the U.S. have so many mass shootings? 

. November 7, 2017. Accessed July 18, 2022. 

https://www.nytimes.com/2017/11/07/world/americas/mass-shootings-us-international.html

Effects of risk-based firearm seizure laws in Connecticut and Indiana on suicide rates, 1981–2015.

The effect of large-capacity magazine bans on high-fatality mass shootings, 1990–2017.

Fatal and non-fatal repetition of self-harm: systematic review.

Prevalence and offense characteristics of multiple casualty homicides: are schools at higher risk than other locations?

18. McGinty EE, Webster DW, Jarlenski M, Barry CL. 

News media framing of serious mental illness and gun violence in the United States, 1997-2012.

19. Thrasher T. Debunking 4 myths around mass shootings. Psychiatric Times. April 12, 2021. 

https://www.psychiatrictimes.com/view/debunking-4-myths-around-mass-shootings

20. Averting Targeted School Violence: A U.S. Secret Service Analysis of Plots Against Schools. US Department of Homeland Security, United States Secret Service, National Threat Assessment Center. Accessed July 18, 2022. 

https://www.secretservice.gov/sites/default/files/reports/2021-03/USSS%20Averting%20Targeted%20School%20Violence.2021.03.pdf

With so much media surrounding mass violence in the US, we need to sort out fact from fiction.  

10 Myths (and Corresponding Truths) About Mass Violence: How Psychiatrists Can Help

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

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

Videos

"In the ordinary weather of summer with storms rumbling from west to east like so many freight trains hauling their cargo of heat and rain..."


The Ordinary Weather of Summer

The majority of health care professionals and individuals with migraine believe migraine and mental health have a significant impact on one another, according to a recent survey.

The survey prompted 302 health care professionals who treat neurological diseases and 1100 individuals with migraine who also identify as having a mental health condition to share their opinions on migraine and its relationship to mental health. Among the participants, 92% of health care professionals and 84% of individuals with migraine reported that they believe worsening migraine can lead to a decline in mental health. Similarly, 94% of health care professionals and 87% of individuals with migraine reported that they believe better migraine control could result in better mental health. Most (91%) health care professionals and two-thirds (67%) of individuals with migraine reported that they believe those who can manage their stress and mental health conditions successfully are also better able to manage migraine.

The survey touched on conversations surrounding migraine. Although two-thirds of individuals with migraine said they believe it is important to discuss mental health with the health care professionals who are treating their migraines, 77% of them said they are hesitant to discuss their migraines with health care professionals due to stigma surrounding migraines and mental health. Almost 60% said they raise the topic themselves but would prefer that their health care professional would initiate the conversation—however, 70% of health care professionals reported that they ask patients about their mental health always or often.

The survey also addressed current and preferred treatment approaches. The top 3 most recommended mental health treatments among health care professionals were medication (83%), cognitive behavioral therapy or psychotherapy (71%), and relaxation therapy (70%). However, fewer individuals with migraine report using these techniques: 58%, 28%, and 26%, respectively. Most (91%) health care professionals and more than half (54%) of individuals with migraine said they believe migraine management should be more flexible and tailored to individual patient needs. Finally, nearly all individuals with migraine said they think it is equally important to treat migraine and mental health and would like their treatment plan to factor in both priorities. The survey was conducted by the American Migraine Foundation and Biohaven Pharmaceuticals.

“Closing the gaps in communication between health care professionals and their patients can help improve migraine and mental health management,” said Larry Newman, MD, professor of neurology at NYU Grossman School of Medicine and chair of the American Migraine Foundation, in a press release. “I hope that the findings of this survey encourage people with migraine to feel empowered to speak out about their pain and have deeper, meaningful conversations about migraine and mental health without worrying about stigma. These are important conversations that both people with migraine and health care professionals should initiate at every visit.”

Do you treat patients with comorbid migraine and psychiatric illness? We want to hear about your experiences and clinical pearls. Write to us at 

1. American Migraine Foundation survey shows nearly all people with migraine and healthcare professionals believe migraine and mental health significantly impact each other. Biohaven Pharmaceuticals. News release. July 28, 2022. Accessed July 28, 2022. 

https://www.biohavenpharma.com/investors/news-events/press-releases/07-28-2022

Survey results addressed connections between migraine and mental health, stigma, and treatment preferences.

Migraine and Mental Health: Patients, Health Care Professionals Share Their Perspectives

 is causing quite the stir in psychiatric circles, as it suggests that depression is not likely caused by a chemical imbalance, and thus calls the function of antidepressants like selective serotonin reuptake inhibitors (SSRIs) into question.

“It is always difficult to prove a negative, but I think we can safely say that after a vast amount of research conducted over several decades, there is no convincing evidence that depression is caused by serotonin abnormalities, particularly by lower levels or reduced activity of serotonin,” said lead author Joanna Moncrieff, MD, a professor of psychiatry at University College London (UCL) and a consultant psychiatrist at North East London National Health Service Foundation Trust. “Many people take antidepressants because they have been led to believe their depression has a biochemical cause, but this new research suggests this belief is not grounded in evidence.”

Investigators synthesized and evaluated evidence on whether depression is associated with lowered serotonin concentration or activity, aiming to include all relevant studies that have been published in the most important fields of research on serotonin and depression.

“This review suggests that the huge research effort based on the serotonin hypothesis has not produced convincing evidence of a biochemical basis to depression…” read the review. “We suggest it is time to acknowledge that the serotonin theory of depression is not empirically substantiated.”

As news of the review’s conclusions hit the popular press, critics of psychiatry have praised the findings while the psychiatric community emerged with concerns of their own.

More on this subject will be forthcoming in 

™. In the meantime, if you have thoughts on this new research, write to us at 

1. Moncrieff J, Cooper RE, Stockmann T, et al. 

The serotonin theory of depression: a systematic umbrella review of the evidence.

2. No evidence that depression is caused by low serotonin levels, finds comprehensive review. 

https://www.ucl.ac.uk/news/2022/jul/no-evidence-depression-caused-low-serotonin-levels-finds-comprehensive-review

A new review shows that there is no convincing evidence that depression is caused low levels of serotonin. 

New Review Calls Antidepressants Into Question—But Does the Review Have Merit?

In this episode of The Big Q, Richard M. Berlin, MD, shares the discussions he has with patients when he introduces them to new medications.

is an instructor in psychiatry at the University of Massachusetts Medical School in Worcester, Massachusetts. He has also been writing a poem about his experience of being a doctor every month for the past 24 years in 

 in a column called “Poetry of the Times.”

What is the first thing you share with your patient when you are about to prescribe a new medication?

Reviewing History and Options

Though difficult to define, synchronicity often refers to the simultaneous occurrence of events which seem significantly related but have no obvious casual connection. It can seem like the symbolic trail that leads to a new destination. Spiritually speaking, it can refer to being guided toward something beyond yourself. Carl Jung took synchronicity into the psychological realm of meaningful coincidences, though sometimes the meaning can seem elusive. Sometimes, it seems, you just know it when you experience it.

Personally, synchronicity has been of increasing fascination and importance to me in recent years. Ever since the Jewish High Holy Days during October 2019, it seems that synchronicity has happened to me more or less daily, even guiding what I write about.

Now synchronicity has come to the intermittent eulogies I write. Whether sacred or secular, it seems to me that these 2 eulogies are of divine psychiatric careers.

Dr Fawcett died on May 9, 2022, the day after Mother’s Day, at the age of 88.

He received his MD at Yale Medical School in 1960, as I did in 1971, both of us still during the period when there were no tests during medical school there. Besides that connection in our informal relationship, we ended up with some overlapping research interests. During medical school, my required research project was about depression in medical inpatients and later published; later, Dr Fawcett found that severe combined depression and anxiety was a significant risk factor for suicide in psychiatric inpatients.

Dr Fawcett became well-known as a leader and innovator in the area of mood disorders. That expanded into the realm of expert court testimony about depression and suicide. One notable example was testifying against Jack Kevorkian, MD, and his medical assistance in dying, concluding that many of those patients had untreated, but treatable depression.

Dr Fawcett received many awards for his work on mood disorders, but also established an award for residents when he was Chair of Psychiatry at Rush Medical School in Chicago. The “Dr Fawcett Was Wrong Award” was given to those who found research contradicting something he had taught them.

What I liked best in his career was his position as the editor of 

. I sometimes read the articles in a given issue, but always read his 1-page editorials. And this is where scholarly synchronicity comes in. Searching for an example to share in this eulogy, I quickly ran across the May 2009 special issue on, yes, synchronicity—a rarely covered topic in psychiatry, then and now. It was guest edited by Bernard Beitman. Articles included “Synchronicity, Weird Coincidences, and Psychotherapy,” “Synchronicity and Psychotherapy: Jung’s Concept and Its Use in Clinical Work,” and “Clinical Implications of Synchronicity and Related Phenomena.”

Dr Fawcett’s Editorial was, as usual, innovative and titled “Creative Synchronicity in Treatment and in Other Human Relationships.”

 He extended the usual definition to include a creative intent to consciously act to reinforce a positive state in another individual, especially as a psychotherapeutic addition to the prescribing of medication.

When he was told one day that his malignant melanoma was free of metastases, he had an epiphany, left Rush and moved to Santa Fe “to watch sunsets” and write a science fiction novel titled 

, based on his own illness and life changes. For sure, he at least lives on in the expert knowledge he conveyed, the charismatic inspiration he gave, and the grateful people he helped.

Robert Daly, MD: Synchronicity in a Mentor and Mentee

July 4th, our country’s Independence Day, always has special meaning, but seemingly more so this year in regard to psychiatrists. On that day, the mass shooting during a parade in Highland Park received national attention. I added a few reflective daily columns on it for 

A few days later, I found out from our Editor-in-Chief Emeritus, Ronald Pies, MD, that the psychiatrist Robert Daly, MD, also died on that day at the age of 89. As I reviewed his career in his obituary, it seemed full of humanism as well as a broad range of psychiatry. He became a Professor of Psychiatry and Bioethics and Humanities at SUNY Upstate Department of Psychiatry in Syracuse, where he worked for 40 years. While there, he helped establish the Consortium for the Cultural Foundation of Medicine and the Institute for Ethics in Health Care, speaking on these subjects around the world. In his work-life balance, he spent time with his family, friends, sports, and Holy Cross Church.

Dr Pies communicated this to me about him:

“Bob Daly was one of my mentors during residency, and—along with Gene Kaplan—one of the foremost influences on my career. One comment from Bob that deeply affected me and confirmed my choice of psychiatry as a specialty: ‘With psychiatry, you can do biology in the morning and theology in the afternoon!’ I will sorely miss him.”

He felt a bit like Socrates to Dr Pies in his wisdom, principles, and brilliance, but likely friendlier. I can see why. I would just add to the quote that at dinner you can then discuss the spirituality in psychiatry and the psychiatry in spirituality.

The important relationship of Drs Daly and Pies continued over the years. Perhaps it reached it reached one of its zeniths in a joint article for 

™ on March 4, 2010, titled “Should Psychiatry and Neurology Merge as a Single Disciplines?”

 It was based on a Grand Rounds at Syracuse from August 27, 2009. In support of the resolution was Dr Pies; in opposition was Dr Daly. I would conclude that the real winner of this debate was their relationship and us readers. Certainly, Dr Daly’s legacy lives on in Dr Pies and so many others that he influenced and helped.

Whether you believe in the importance of synchronicity or not, the lives of both Drs Fawcett and Daly had significant meaning professionally and personally. And whether there was any divine intervention in their passing away at similar ages and similar times, they both remind us of the humanity and ethics necessary to supplement the benefits of hard science and to counter the inhumanity of mass shootings. For me, they exemplify the range of what psychiatry can—and should—cover, from neurology to cultures, and from the needs of the individual patient to the needs of society.

Synchronicity, weird coincidences, and psychotherapy.

Synchronicity and psychotherapy: Jung’s concept and its use in clinical work.

Clinical implications of synchronicity and related phenomena.

4. Fawcett J. Creating synchronicity in treatment and in other human relationships. 2009;39(5).

Should psychiatry and neurology merge as a single disciplines?

The loss of these 2 psychiatrists resonates. 