Psychiatric and medical comorbidities can complicate the differential diagnosis and hamper treatment success. Thus, investigators around the globe continue to examine how these comorbidities interact with each other. In this Research Roundup, 

 looks at clinical issues and implications of comorbidities associated with depression, eating disorders, COVID-19, and more.

Depression, Bipolar Disorder, and Sleep in Children and Adolescents

Recently, investigators conducted a narrative literature review of affective disorders and sleep difficulties in children and young people, seeking to understand the relationship between sleep and both depression and bipolar disorder.

Monica Comsa, FRACP, of the Child and Adolescent Mental Health Service at Cumbria Northumberland, Tyne and Wear NHS Foundation Trust in the United Kingdom, and colleagues found that parasomnias, narcolepsy, and sleep-related movement disorders are associated with depression in children and adolescents. Additionally, children and adolescents with depression can present with a number of sleep difficulties, which are also associated with several other issues such as more severe depression, greater fatigue, suicidal ideation, physical complaints, pain, and decreased concentration.

, obstructive sleep apnea, and circadian rhythm disorders are associated with both depression and bipolar disorder in children and adolescents. Sleep difficulties can occur before, during, and after an episode of depression or bipolar disorder.

“Sleep disturbances among adolescents with 

 can affect the severity of depressive and manic symptoms, are a poor prognostic indicator, and have been associated with social and academic impairment,” said Comsa and colleagues.

These sleep difficulties may be the result of medication. According to the investigators, antidepressants and antipsychotics can directly affect sleep architecture, and clinicians should be cognizant of this problem when prescribing and might instead consider nonpharmacological interventions. These interventions for sleep problems might minimize the risk of relapse in affective disorders.

Investigators suggested that a multimodal approach to target both the affective and specific sleep disorders is the ideal treatment plan. “Psychoeducation, consistent sleep-wake schedules, and tailored interventions for addressing sleep problems should play an important role in the prevention and treatment of mental health difficulties, at any age,” they wrote. “Concomitantly addressing sleep problems can lead to an increased remission rate of depression.”

More research is required to understand the impact of combined interventions on clinical outcomes, concluded investigators.

“Of most importance is the impact of specific treatment for sleep disorders on the long-term outcome of affective disorders. Clinicians need to know if better nights reliably lead to better days.”

1. Comsa M, Anderson KN, Sharma A, et al. 

The relationship between sleep and depression and bipolar disorder in children and young people.

Impulse Control Disorders and Behavioral Addictions in Patients With Eating Disorders

There is a moderate prevalence of impulse control disorder (ICD) and behavioral addiction (BA) comorbidities in individuals with 

 (EDs), investigators have found in a first-of-its-kind meta- analysis.

Because the prevalence has never been systematically examined, Daniel J. Devoe, PhD, MSc, and colleagues performed a series of random effects meta-analyses of peer-reviewed literature reporting prevalence of ICDs or BAs in individuals with EDs. The investigators included 35 studies with a total of 9646 individuals who had an ED and analyzed the prevalence of different behavioral addictions among these individuals. The mean age of participants was 25.5 years (range, 16.7-43.9), and 97.7% were female.

Results showed that stealing/shoplifting behaviors were the most common form of behavioral addictions in individuals with EDs, with a prevalence of 30%. Devoe et al also noted prevalence of pathological/compulsive buying at 19%, kleptomania at 18%, and pathological internet use at 12%. Intermittent explosive disorder, trichotillomania, and gambling had prevalence rates of 5%, 3%, and 2%, respectively.

ICDs are more closely associated with bulimia nervosa and binge-purge subtype than other ED diagnoses and behaviors, the investigators noted. This finding supports previous research indicating that individuals with binge-purge subtypes are more likely to have ICDs, partly due to impulse control difficulties and greater emotion regulation. The investigators also noted that certain personality traits (eg, perfectionism, impulsivity), psychiatric comorbidity, age of onset (eg, early age of onset may worsen prognoses), and concurrent substance use disorders may also play a role in deteriorating ED prognoses. They suggested that future research explore common underlying pathomechanisms.

“Although causal inferences cannot be drawn, the numbers strongly suggest that clinical screening/monitoring of ICDs/BAs should be part of the clinical routine in cohorts with EDs,” Devoe et al concluded.

1. Devoe DJ, Anderson A, Bahji A, et al. 

The prevalence of impulse control disorders and behavioral addictions in eating disorders: a systematic review and meta-analysis.

First-of-Its-Kind Study of Antidepressant Use in Patients With Depression and Type 2 Diabetes

Although treatment guidelines do not provide specific prescribing recommendations for antidepressants in individuals with 

, effective treatment of depression in patients with comorbid depression and type 2 diabetes is important for both conditions.

In a first-of-its-kind study looking at the prevalence of antidepressant prescribing and associated patient characteristics, Jeffrey et al

 searched 7 databases using terms related to depression, type 2 diabetes, and antidepressant medication. From the 9 utilized reports, the investigators determined that the prevalence of antidepressant prescribing varied considerably between studies—from 18% to 87%.

“This review has highlighted the gap in our knowledge about which antidepressant agents are being used in adults with comorbid depression and [type 2 diabetes], and alongside which concurrent medications and comorbidities. Thus, we are unaware of the extent to which such individuals are at risk from the risks associated with polypharmacy and other 

Investigators also found that women with type 2 diabetes are more likely to be prescribed antidepressants versus men; however, the difference is less than in the general population. Additionally, individuals with more advanced type 2 diabetes mellitus who use insulin were as likely to be prescribed antidepressants as those who did not use insulin.

“This is the first systematic review to our knowledge that investigates the prevalence and characteristics of 

 prescribing in adults with comorbid depression and [type 2 diabetes],” the study authors wrote. They added that, “There is an urgent need for longitudinal studies to inform guidelines on the long-term safety and effectiveness of antidepressant prescription in persons with comorbid depression and [type 2 diabetes].”

With a lack of evidence to support the long-term use of antidepressants in individuals with type 2 diabetes, special care should be taken when prescribing antidepressants—especially in more complex patients who have higher risks of potential adverse events.

1. Jeffrey A, Maconick L, Francis E, et al. 

Prevalence and characteristics of antidepressant prescribing in adults with comorbid depression and type 2 diabetes mellitus: a systematic review and meta-analysis.


COVID-19 Mortality Risk in Patients With Psychiatric Disorders

Patients with psychiatric disorders who were hospitalized for 

experienced higher mortality rates, but not due to their underlying psychiatric disorders, study results show.

The study, led by Nicolas Hoertel, MD, PhD, MPH, of Paris University and Corentin-Celton Hospital in Issy-les-Moulineaux, France, explored previous research indicating a connection between psychiatric disorders and increased mortality in patients with COVID-19. Hoertel et al conducted an observational multicenter respective cohort study of patients who had received a laboratory-confirmed diagnosis of COVID-19. The study included 15,168 patients who were hospitalized with COVID-19, of whom 857 also had received a diagnosis of a psychiatric disorder. Of this population, 59.6% had a substance- or illness-induced psychiatric disorder; 46.4% had a primary psychiatric disorder; and 6.1% had both types of disorders.

The investigators found that across a mean follow-up period of 14.6 days (SD = 17.9 days) 38% of patients with a psychiatric disorder died, compared with 8.9% of patients without a psychiatric disorder (odds ratio [OR] = 6.27; 95% CI; 5.40-7.28; P < 0.01). Individuals with a psychiatric disorder had a 6-fold higher risk of mortality than those without a psychiatric disorder, and this risk remained higher when adjusting for factors such as sex, age, and current smoking status in individual psychiatric diagnoses (adjusted OR [AOR] = 3.27; 95% CI; 2.78-3.85; P < 0.01). However, when adjusting for obesity and other medical comorbidities, the investigators found no statistically significant association with increased mortality in individuals with psychiatric disorders compared with individuals without psychiatric disorders (AOR = 1.02; 95% CI; 0.84-1.23; P = 0.86). Notably, diagnosis of a mood disorder was associated with reduced mortality, which the investigators suggested could be related to use of certain antidepressants such as fluvoxamine and fluoxetine, which may have anti-inflammatory or antiviral effects.

The investigators concluded that the risk of COVID-19–related mortality may be higher in individuals with psychiatric disorders due to the overall higher prevalence of obesity and medical conditions in this population—which also increases the risk of developing severe cases of COVID-19—rather than factors related to the psychiatric disorders themselves.

“Future studies including data on outpatients and inpatients with and without 

 and taking into account main medical risk factors of severe COVID-19 (ie, age, medical comorbidities, and obesity) will be important to determine whether the risk of hospitalization and mortality due to SARS-CoV-2 infection is similar or different across psychiatric diagnoses and psychotropic medications prescribed,” Hoertel et al concluded.

1. Hoertel N, Sánchez-Rico M, Muela P, et al. 

Risk of death in individuals hospitalized for COVID-19 with and without psychiatric disorders: an observational multicenter study in France


Psychiatric Comorbidities Affect Psychotic Depression Outcomes

Results of a recent study on gender and psychiatric comorbidities in individuals with psychotic depression (PD) found that comorbidities have significant implications for PD age of onset and outcomes.

Using the Northern Finland Birth Cohort 1966 and other national registers, Miika Nietola of the Department of Psychiatry at the University of Turku and colleagues analyzed 12,058 individuals who had been followed since they were in utero for lifetime psychiatric diagnoses, age of illness onset, hospitalizations, disability pension rate, and mortality. Fifty-eight individuals in the sample had received a lifetime diagnosis of PD (male, n = 23; female, n = 35); the lifetime prevalence of PD in the participants was 0.5%; and the median age of PD onset for participants was 40.2 years.

In comparing outcome variables in subgroups for gender and comorbid PD or 

(AUD), the investigators identified the prevalence of comorbid personality disorders at 38% and comorbid AUDs at 41%. Results showed that psychiatric hospitalization was more strongly associated with male gender (P = .03), personality disorder (P < .01), and comorbid AUD (P < .01). Comorbid PD also was associated with earlier onset (P < .01) and higher mortality (P = .03) and was more common in men than women at 61% and 29% (P = .03), respectively. However, Nietola et al found no statistical difference related to gender in the disability pension rate for individuals with PD.

Since little is known about the effects of gender and comorbid psychopathologies on PD prognoses, the investigators stated that this study’s findings highlight a need for further research on these effects in individuals with PD and on PD in general—especially since comorbid personality disorders have been associated with poorer outcomes in individuals with nonpsychotic depression. They also suggested that clinicians control the effects of gender and comorbidity as confounding factors in PD trajectories.

“Clinical implications of high alcohol use and personality disorder comorbidity in PD include rigorous assessment of these disorders in everyday practice and active implementation of effective treatments,” Nietola et al wrote. “There are potential possibilities to improve outcomes of PD by focusing more on those detrimental comorbidities that appear to associate with a malign course of illness.”

1. Nietola M, Nordström T, Miettunen J, et al. 

Effects of gender and psychiatric comorbidity on the age of illness onset and the outcome of psychotic depression—a birth cohort study

Articles

Catch up on all the latest in psychiatric comorbidities. 

Research Roundup: Psychiatric Comorbidities in the News

 is common for US adults and even more pervasive for patients presenting in psychiatric settings. Estimates of previous experience of traumatic events is 51% to 84% in the general adult population and 76% to 91% in those seen in psychiatric settings.

 The most prevalent comorbid disorders among adults with 

 (SMI) are substance use disorders (SUDs).

 Despite trauma symptoms often being underreported, 30% to 60% of individuals seeking treatment for SUD also meet criteria for 

 Acknowledgment of “dual diagnosis dates back decades, into the early 1980s; however, the classification of PTSD and SUD as 

 is inadequate to capture the range of symptoms and impairments of this diverse patient population.

 Greater understanding of approaches to SUD and related support services may help psychiatric providers provide multifaceted, comprehensive support to patients with SMI, PTSD, and SUD.

Evidence-based treatments exist for both PTSD and SUD; however, the approaches are rarely integrated, despite recognition of frequent cooccurrence. There are trends to further integrate 

 (TIC) in both SUD and psychiatric settings,

 but these services are seldom cohesive. To combat the SUD epidemic, availability of medication-assisted treatment/recovery has focused on primary care and the treatment of SUD as a chronic health condition. There is also greater opportunity for psychiatric providers to strengthen their care of patients with comorbid SMI, PTSD, and SUD by continually linking emergent evidence with clinical care. As the SUD epidemic has further intensified during the 

 the need for trauma-informed psychiatric care addressing SMI and SUD is even greater.

Treatment of SMI-related distress or symptomatology in isolation from SUD fails to address the whole person and is likely to result in suboptimal outcomes.

 Without integration of SUD and SMI care, providers risk inappropriately generalizing diagnoses without recognizing the context and lens of SMI symptoms. Addressing an epidemic requires the responsiveness of all providers.

 As SUD services, treatment, and research have advanced, we highlight 5 practices that are useful in supporting psychiatric clinicians as they effectively integrate trauma-informed SUD and SMI treatment.

There is substantial evidence that clinicians do not routinely ask patients about trauma history in clinical settings.

 Despite growing recognition of the impact of adverse childhood experiences on individuals and awareness of trauma prevalence, both institutional and intrinsic barriers interfere with provider inquiries about 

 Although a psychiatric history often includes inquiries about traumatic experiences, TIC requires routine attention to symptomatology and reactions to trauma. Documentation of a single question within an initial evaluation is inconsistent with TIC, but consistently attending to previous experiences with and responses to trauma throughout care is imperative.

 Trauma assessments at initial visits may underreport traumatic experiences, as patients may not feel comfortable disclosing these at a first-time appointment.

Similarly, inquiring about substance use and recurrence of substance use must be an ongoing practice. Patients may not disclose substance use right away for a multitude of reasons. As the provider learns this information, the trajectory of care may change, much like when we are asking about trauma. Assessment around SUD also requires being trauma-informed, as increased 

 Patient omission of disclosing a substance use recurrence is common in psychiatric care, often related to fears of losing care or prescription medication. To mitigate this risk and develop space for honest disclosure, clinicians can share their policies or practices related to substance use and foster open discussions—discussions that acknowledge cravings and recurrence are likely to increase with stress and trauma.

Recognize Trauma as a Primary Pathway to Substance Use

For decades, the pervasive narrative around 

 was the “gateway hypothesis,” which has now been widely refuted. The gateway hypothesis—that consumption of a particular substance will lead to or increase the likelihood of progressive substance use—came to prominence after publication by Kandel in 1975. The 4-stage sequence of drug consumption—from beer and wine, to tobacco and hard liquor, to cannabis, to other illicit drugs—indicates that only individuals who use 1 drug have a chance of progressing through the sequence.

 Although substance use is associated with use of other substances, a causal relationship where alcohol and/or cannabis are gateway drugs has been disproven.

 Conversely, marijuana use has been associated with reductions in 

Drug use sequences and initiation vary based on cultural context and on unmeasured common causes that are understood to be more impactful on subsequent drug use than initial use of a particular substance.

 There is clearly an association between experiences of trauma and 

, as patients meeting criteria for PTSD are 14 times more likely to have a comorbid SUD when compared with patients without PTSD.

 Both initiation of opioid use and transition to injection opioid use from other routes may be related to experiences of trauma.

One notable evidence-based approach is integrated treatment for cooccurring disorders (ITCOD). Integrating treatment approaches for mental illness and SUDs requires looking at combining efficacious existing treatments while modifying interventions that may be outdated or lack reliable benefit.

 ITCOD is a multifaceted approach to treatment and care that captures the importance of individual therapy, assertive outreach, social support interventions, and long-range perspective via a patient-centered framework.

As we unlearn the non–evidence-based “gateway hypothesis,” a deeper dive into traumatic experiences and their relation to substance use is likely to serve both provider and patient. Often, substance use initiation is related to seeking relief from pain as well as traumatic events and symptoms.

 Providers can more fully explore events preceding substance use initiation or transition to nonprescribed medication with compassionate understanding, recognizing that 

 may have been the only accessible and available coping tool at that time.

When we sit in the office with a 40-year-old patient, for example, imagine, as they are sharing memories of their traumatic upbringing with you, that they are 12 years old and not in your office, but in their home—terrified of the trauma there. They have no resources or outlets. A substance is introduced, and it temporarily provides some relief of the awful feelings that they are experiencing. That is not a moral weakness or deficiency. One can imagine what one would do in that situation, but the context and the patient’s experience are of utmost importance, and we need to remove our own opinions from the equation. Intergenerational trauma is another prevalent reality, and the cycle perpetuates. When someone comes to see us for help, it is our job to use our expertise and understanding to facilitate their healing and 

Partner With Patients Across Multiple Pathways to Recovery

Substance-specific 12-step programs like Alcoholics Anonymous (AA) and Narcotics Anonymous are often considered synonymous with peer-led recovery. These programs have benefited millions of people over the course of decades. However, these models are based on an abstinence-only philosophy with religious/spiritual elements, wherein sobriety is the explicit goal for group members. These programs have provided effective support for countless individuals and families, but they do not fit all people seeking or maintaining recovery.

Abstinence-only models are not a panacea. Many individuals suffering from SUD are not able or ready to totally discontinue use or are turned off by the religious basis of these groups, resulting in disengagement from these services.

 Alternatives to spiritually based and abstinence-only peer-led mutual support groups exist and should be considered viable recovery pathways for patients. They include SMART Recovery, Secular Organizations for Sobriety, Moderation Management, LifeRing, Women for Sobriety, and Celebrate Recovery, among others.

 In addition to these peer-led groups, harm reduction services—including peer-led groups and/or syringe services programs—can be a critical low-barrier access point to engage patients with SUD who are not interested in abstinence. Abstinence and 

 are often conceptualized as diametrically opposed; in reality, they serve as different engagement points on a continuum. Appropriate service or program recommendations are dynamic, contingent upon individual differences in needs and desires surrounding treatment and recovery.

Instead of referring patients to treatments that are not well suited to the individual, acknowledging the multiple pathways to treatment and recovery is imperative. We have heard of the challenging routes patients have faced on their journey to treatment and recovery, such as a provider telling them they could not be seen “until they go to AA and stop drinking.” This advice is as good as telling your patient to leave your office and never come back again. Supporting multiple pathways helps meet patients where they are, learn where patients are in their willingness to engage in treatment, and determine which modalities may be the best fit for them. It is important to engage in a shared decision-making process and provide options, rather than providing a paternalistic recommendation that does not take patient preference or prior experiences into consideration.

Approach With Unconditional Positive Regard

When assessing patients, the longstanding OLDCARTS (onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, severity) acronym utilized in general medicine can be adapted for psychiatric evaluation and assessment. Information gathering in a psychiatric evaluation is not a rigid, linear, “checking off the boxes” process—there is, of course, an 

art to facilitating an informative interview

. Asking our patients when the symptom or trauma started or occurred and ascertaining what was going on in their life around the time that they started using substances are crucial to assembling the pieces of the puzzle each of our patients presents. Often, a silent “Aha!” moment occurs when these connections are made, relating the timing of trauma to the onset of substance use or to an increase in one’s patterns of use. This is important to recognize upon evaluation, and it is important to keep that context for ongoing treatment, especially as individuals who have experienced trauma are likely to experience trauma again in their lives. This can make individuals in recovery more susceptible to recurrence of substance use.

Approaching our patients from a place of unconditional positive regard, a concept expanded upon by Carl Rogers, is central to facilitating a safe space for our patients to share with us what is going on without judgment, and without fear of disappointing us as providers. Our interactions with patients are timebound, limited, and within a physical space most often that is “our” home turf: our office space.

Ongoing self-reflection and assessing areas of one’s own implicit biases are imperative. A systematic review looking at health care professionals’ attitudes toward patients with SUDs found negative attitudes toward this patient population, which impacted patient outcomes unfavorably.

 There are often inciting events for these views, and the outward expression is likely most often unintentional. As lifelong learners, we are well served to recognize when inaccurate conceptualizations (eg, the gateway hypothesis) have led us astray in oversimplifying substance use within our visits.

Engage in Ongoing Knowledge and Skill Development

A systematic review of negative provider views impacting patient outcomes identifies needs for education, training, and improved structure to better support complex patients.

 Formal educational opportunities including fellowships in 

, addiction certification, and Suboxone waiver training are increasing in availability and accessibility.

 All health care providers practicing clinically are required to participate in continuing education. Due to the 

, many states have specifically added requirements for continuing education related to opioid prescribing and opioid use disorders. It is quite beneficial to seek out and take advantage of learning opportunities in areas that are not necessarily our daily focus or in those we studied quite a while ago.

There are peer-facilitated learning opportunities, as well as the PACT-MAT ECHO model,

 which is an all-teach, all-learn approach. These sessions have many benefits, especially since comorbidity of a psychiatric disorder along with a SUD is often an area where clinicians appreciate feedback and recommendations for ongoing care. It is also an excellent opportunity to network and for clinicians to become familiar with other area resources and referral locations.

As psychiatric care providers amid a challenging health care landscape and a global pandemic, we are tasked with providing optimal care to our patients and meeting their needs. The evidence, as we have noted, continues to evolve, and this provides all of us with the opportunity to self-reflect and continue adapting in our own practice and methods. Opportunities for collaboration and growing our knowledge base abound, and within the field we are lucky to have colleagues and mentors to support us along this journey.

is a psychiatric-mental health nurse practitioner in the Seacoast, New Hampshire, area, and a clinical assistant professor and program director of the Post-Masters Psychiatric-Mental Health Nurse Practitioner Certificate Program, Department of Nursing, University of New Hampshire, Durham.

serves as the project manager for the Harm Reduction Education and Technical Assistance project, a multiorganization collaboration dedicated to reducing drug-related harms, based at the Department of Nursing, University of New Hampshire. She is also an adjunct professor in the university’s Department of Social Work.

is a family nurse practitioner in community health and an assistant professor of nursing at the University of New Hampshire. Dr Nolte’s research focus is reducing drug-related harms.

Does trauma-related training have a relationship with, or impact on, mental health professionals’ frequency of asking about, or detection of, trauma history? A systematic literature review.

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https://store.samhsa.gov/sites/default/files/d7/priv/ebp-kit-building-your-program-10112019.pdf

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Trauma-informed care for individuals with serious mental illness: an avenue for community psychology’s involvement in community mental health.

5. Beckett P, Holmes D, Phipps M, et al. 

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Untreated posttraumatic stress among persons with severe mental illness despite marked trauma and symptomatology.

8. Brunette MF, Oslin DW, Dixon LB, et al. 

The opioid epidemic and psychiatry: the time for action is now.

9. McCauley JL, Killeen T, Gros DF, et al. 

Posttraumatic stress disorder and co-occurring substance use disorders: advances in assessment and treatment.

10. Nöel W, Wang J. Is cannabis a gateway drug? Key findings and literature review. National Institute of Justice. 2018. Accessed January 7, 2022. 

https://www.ojp.gov/pdffiles1/nij/252950.pdf

11. Bradford AC, Bradford WD, Abraham A, Bagwell Adams G. 

Association between US state medical cannabis laws and opioid prescribing in the Medicare part D population.

12. Degenhardt L, Dierker L, Chiu WT, et al. 

Evaluating the drug use “gateway” theory using cross-national data: consistency and associations of the order of initiation of drug use among participants in the WHO World Mental Health Surveys.

13. Nolte K, Drew AL, Friedmann PD, et al. 

Opioid initiation and injection transition in rural northern New England: a mixed-methods approach.

14. Lederhos Smith C, Severtsen B, Vandermause R, et al. 

Seeking chronic pain relief: a hermeneutic exploration.

15. Henwood BF, Padgett DK, Tiderington E. 

Provider views of harm reduction versus abstinence policies within homeless services for dually diagnosed adults.

Broadening the base of addiction mutual-help organizations.

17. Carver H, Ring N, Miler J, Parkes T. 

What constitutes effective problematic substance use treatment from the perspective of people who are homeless? A systematic review and meta-ethnography.

18. van Boekel LC, Brouwers EPM, van Weeghel J, Garretsen HFL. 

Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review.

The development of fellowship training in addiction psychiatry.

20. Salvador J, Bhatt S, Fowler R, et al. 

Engagement with Project ECHO to increase medication-assisted treatment in rural primary care.

30% to 60% of individuals seeking treatment for SUD also meet criteria for PTSD.

Supporting Patients With Serious Mental Illness and Comorbid Substance Use Disorder and Posttraumatic Stress Disorder

Language used to describe patients in electronic health records (EHRs) may be perpetuating racial bias and other negative stereotypes in health care, according to results of a new study.

Using machine learning techniques, investigators analyzed potentially stigmatizing language in more than 40,000 history and physical notes in EHRs from 18,459 adult patients at an academic medical center in Chicago, Illinois. Sun et al found the odds of 

 having 1 or more negative descriptors such as “refused,” “(not) adherent,” “(not) compliant,” or “agitated” noted in their EHRs were more than twice (2.54; 95% CI; 1.99-3.24) the odds of white patients, even after adjusting for sociodemographic and health characteristics.

The differences were not solely based on 

. Medicare and Medicaid beneficiaries, for example, were more likely to have negative descriptors applied to them than were patients with commercial or employer-based insurance, as were unmarried patients compared with patients who were married, the study results showed.

The findings are especially troubling, Sun and colleagues wrote, given that other studies have found that less than 20% of text in inpatient progress notes is original, with much of the information imported from prior documentation. As a result, “subsequent providers may read, be affected by, and perpetuate the negative descriptors, reinforcing stigma to other health care teams,” Sun et al wrote.

The investigators found that notes written for outpatient visits were less likely to have negative descriptors in the patient’s EHR than inpatient encounters. They theorized this resulted from inpatient settings being inherently more stressful, thereby increasing the risk of doctors using stereotypes as cognitive shortcuts.

Sun et al also found that race-based differences in the use of negative descriptors narrowed after March 1, 2020. They theorized this was due to the stark racial differences in care and outcomes highlighted by the COVID-19 pandemic and the pandemic’s overlap with “a historically defining moment of national response to racialized state violence” created by the 

killings of George Floyd and other Black Americans

“These social pressures may have sensitized providers to racism and increased empathy for the experiences of racially minoritized communities,” Sun et al wrote.

The authors further noted it is imperative that medical institutions better address the issue of implicit racial bias and institute provider training. For example, they noted a physician’s use of the term aggressive may reflect the physician’s personal bias regarding Black men, adding that once a negative label becomes part of the patient’s record, “it potentially affects the perceptions and decisions of future providers regardless of whether future providers hold a bias about Black men being aggressive.” Similarly, they recommended “people first” language (eg, saying a patient has an alcohol use disorder instead of labeling them an alcoholic) be used in interprofessional communication.

Similarly, Sun et al also suggested that regulatory bodies such as the Accreditation Council for Graduate Medical Education develop specific recommendations for the use of nonstigmatizing, patient-centered language to prevent the transmission of bias.

The need is especially important, they wrote, in light of the OpenNotes policies adopted by medical institutions. These policies allow patients full access to their EHRs, including chart notes. Sun et al added that inappropriate and negative language used to describe patients may risk “harming the patient-provider relationship with downstream effects on patient satisfaction, trust, and even potential litigation.”

1. Sun M, Oliwa T, Peek ME, Tung EL. Negative patient descriptors: documenting racial bias In the electronic health record. 

 January 19, 2022. Accessed January 26, 2022. 

https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2021.01423

EHRs May Enhance, Prolong Racial Bias in Clinical Settings, Study Results Show

Recent years have seen a remarkable increase in public discourse about mental health issues, with representations of mental illness in popular culture becoming increasingly varied, nuanced, and abundant. Each artist brings their own mental health experiences to their work; however, depictions of mental illness and the mental health care system are often demonizing, sensationalized, or grossly inaccurate. Such misfires can further stigmatize patients with psychiatric disorders. As such, it is important to celebrate accurate representations of psychiatric issues and treatment. As members of the Group for the Advancement of Psychiatry Committee on Arts and Humanities, we wanted to share some excellent representations of mental health issues in film and television over the past year.

When perception diverges from reality, terror ensues. In 

, the viewer experiences the disorienting decline of Anthony (played by Anthony Hopkins) as he grapples with dementia. Anthony struggles to understand where he is, who he is, and who is around him. Director Florian Zeller deftly places the viewer into Anthony’s frame of mind as he experiences the horror of mistrusting his memories and perceptions. There is no overdramatization or embellishment. Zeller trusts that the stakes of this proud man—a well-off retired engineer—losing his faculties are high enough. As a result, the viewer is left feeling profound empathy. When a nurse hugs a crying and confused Anthony in the final scene, it feels genuinely cathartic to know he is comforted by human touch. The end of the film comes as a relief, as it does for many families with someone suffering with dementia. 

, an honest portrayal of the fragility of the mind, is well worth experiencing.

, an Israeli drama about a Haredi (ultraorthodox) family in Jerusalem, began streaming its third season in March 2021, with Hebrew and Yiddish dialogue subtitled in English. This thoughtful series centers on Akiva Shtisel (portrayed by Michael Aloni), an endearing but hapless son, brother, and father. Akiva is an oddity in his family and his insular religious community because of his artistic pursuits—he is a painter—and for his serial failures in love. In this season, we meet Racheli, a new love interest for Akiva, recently widowed and now a single father. Racheli, we learn, quietly suffers from what appears to be bipolar disorder. The touchingly human telling of their love story weaves Racheli’s psychiatric illness into the story seamlessly, neither glamorizing nor minimizing it, neither stigmatizing it nor ignoring its inherent cultural stigma.

Other subplots touch upon mental health themes. Akiva’s sister and brother-in-law navigate their fragile marriage while watching their children strive to build families of their own. Akiva’s niece silently and courageously endures a complicated pregnancy. Through it all, Akiva’s father, widower Shulem, tries desperately to keep his family under his thumb while searching for companionship.

 gives viewers a fascinating glimpse into a world foreign to most, yet somehow simultaneously familiar. Although our day-to-day culture often either silences mental illness or sensationalizes it, Shtisel’s fictional portrayal seems to bring us closer to reality than real life. That’s good TV.

 is an Australian documentary series that streamed its second season on Netflix in 2021. It is about young men and women with autism spectrum disorder who are looking for romance. The episodes are without commentary and with minimal intervention from the filmmakers and crew who chaperone dates. The otherwise high-functioning participants are behind the developmental curve in the worlds of sex and love, although they have touchingly supportive, loving, and nonjudgmental families (a series highlight).

There is little suggestion of mental health treatment, except for light coaching from a specialist—a mature, patient, and direct woman. She gives concrete advice on icebreaking, social conversation, and showing interest in the other, and she literally diagrams uncomfortable moments. The participants have structured dates and even speed-dating with a matching matrix. Sometimes they decide to be friends, and at other times, they get sidetracked by their single-minded focus on specific topics, as is common in individuals with autism spectrum disorder.

The series is remarkable for what is absent: insincere and staged competition, pathologizing, disability emphasis, and creepy voyeurism. While the characters are mostly straight, there are also gay and bisexual individuals integrated seamlessly by the filmmakers. The episodes are compelling, and we cheer on the participants. However, we return to reality with an understanding that these individuals face the same obstacles as everyone else. They suffer disappointment but show resilience. At least one couple married. For the viewer, 

 is uplifting and affirming in showing how intimacy and love are not out of reach for those on the spectrum.

An American football coach, Ted Lasso (Jason Sudeikis), is hired to run an English Premier League soccer team without any knowledge of how to play the game. He has tremendous confidence and an optimistic attitude toward the human condition. He evokes a positive response in others—undaunted by their negative responses to him—bringing them along to elevate their own personal experiences. Happily, a new star player, Danny, appears, whose credo is “football is life.” When Danny accidentally kills the team’s mascot dog with a penalty kick, he is traumatized and becomes quite depressed. His new motto becomes “football is death.”

When the coach is not able to help pull Danny out of his depression, the team brings in a therapist who helps him move forward. After seeing the therapist’s success with Danny, many other, often macho, members of the team engage her services. They realize that by simply talking about what is on their minds, they are able to feel better and move on in their lives. Ted also reluctantly seeks her services when he has to leave the sidelines because of a panic attack during a critical match. When knowledge of Ted’s panic disorder becomes public, he challenges the media to look at the treatment of mental health in sports.

Although the show later depicts unrealistic boundary violations after the therapist suffers from a biking accident, the two agents of change, Ted Lasso and the therapist, are complementary in advancing the inner lives of the team members. Much of the success of the series is due to the viewer also being exposed to the possibility that positive change can occur with optimism, self-confidence, and good therapy.

 stars Nicholas Cage as Rob Feldman, a former chef who makes a solitary living by truffle foraging with his beloved and talented pig. From the beginning, it is hinted that Rob is coping with tragedy, and as a result, he is no longer interested in engaging in society. From time to time, Rob receives visits from Amir, who supplies truffles to high-end restaurants. One day, Rob’s pig is stolen by unidentified assailants. Rob, blaming Amir because he had spread word in town about the pig’s abilities, asks Amir to accompany him to Portland and find his pig. The duo goes through an odyssey with the hope of rescuing Rob’s lost love. 

The portrayal of Rob, who shows traits of autism spectrum disorder, such as impaired social skills and a restrictive pattern of interests, is laudable. His fixation on cooking and food makes him the best chef and truffle forager in town. Rob copes with his loss with support from an unlikely friend. Despite being very different, like Rob, Amir is also coping with the loss of an important figure in his life. As such, a peculiar bond and attachment is formed between the two, and this human connection across differences has a healing power.

The movie version of this Broadway musical, 

, is populated with mental health issues. In this story, both teenagers and adult parents present their guarded, inauthentic selves to the world. As often happens in worthwhile musicals and operas, when characters sing, their true selves blast out of mental shackles. “Why should I play this game of pretend?” asks Evan, the protagonist, played by young actor Ben Platt, who originated the Broadway role. He painfully stutters incoherent phrases, retracting and contradicting every word, avoiding eye contact with his world. He is on a trio of psychiatric medications. His single-parent mother unconsciously imprisons him by considering him “sick.”

A schoolmate’s mother embraces the pathologically shy Evan, mistakenly believing he was close friends with her son, Connor, who recently died by suicide. In fact, the only moment of contact between the boys was when Connor bullied Evan. However, Evan not only perpetuates the lie, but develops a fantasy of his and Connor’s friendship, using Connor as an idealized transitional object, a teddy-bear of warmth. As long as Evan is immersed in the lie, Connor’s family welcomes Evan into an accepting family he never had, and his awkwardness fades. Eventually, his lie thrusts him onto the world stage as an icon for adolescent mental health. Evan appears a star, but inevitably, the lie is revealed and Evan’s world crashes. Will traumatized Evan fall from grace or transform into maturity? Can real-world actions and emotions match truths that once were only sung in songs? Sometimes in therapy and the outside clinical world, disillusionment leads to growth.

 is a coming-of-age comedy whose second season launched this past July. Never’s central protagonist, Devi Vishwakumar (played by Maitreyi Ramakrishnan), is a 15-year-old Indian-American girl. Less than 5 minutes into the first episode, narrator John McEnroe (yes, that John McEnroe) tells us that Devi’s parents immigrated to the United States in September 2001 (“Not a super-chill time to be a brown person in America”); her father died of a sudden heart attack during her freshman year; she developed functional paralysis in her legs shortly thereafter; and the paralysis resolved suddenly 3 months later while she was straining to get a look at her crush. Devi is an overachieving nerd struggling with the unprocessed grief of her father’s death, her complicated relationship with her mother, and her cultural identity. The conflict of the show hinges on Devi’s vows to improve her social status and experience “normal” American teenage life.

The show’s pacing and occasionally over-the-top performances set the tone for its comedic content, but they also mirror aspects of the adolescent experience that can be confusing, chaotic, clumsy, and replete with drama. While not all the psychiatric themes feel authentic (eg, the paralysis resolution), the underlying struggles of the teens generally do, and the show tackles issues including grief, coming out, family dynamics, and, briefly, anorexia. Similarly, Devi’s exchanges with her therapist (played by Niecy Nash) are often too compressed and laden with wit to serve as a how-to for supportive therapy, but, far more important, they do provide a positive, destigmatizing depiction of a helpful therapeutic relationship. On its surface, 

 is a typical teen rom-com, but at its core, it has a lot of heart.

is a fellow of the Group for the Advancement of Psychiatry Committee on Arts and Humanities. 

 is chair of the Group for the Advancement of Psychiatry Committee on Arts and Humanities. Other committee members include Anish Ranjan Dube, MD, MPH; Fernando Espí Forcén, MD, PhD; Donald C. Fidler, MD; Andrew Lustbader, MD; Christopher Snowdy, MD; Kenneth J. Weiss, MD; and Helena Winston, MD, MPhil, MS. 

Celebrating accurate representations of psychiatric issues and treatment in film and television from the past year.

Best Recent Screen Portrayals of Mental Health Issues

Nephrotoxicity is a well-known adverse effect of lithium. Monitoring for nephrotoxicity and using 

 with great caution in patients with renal impairment are standards of care.

The estimated glomerular filtration rate (eGFR) has become an easily available routine measure for baseline and periodic monitoring of kidney function in patients on lithium.

 Laboratories report eGFRs of less than 60 mL/minute/1.73 m

 as abnormal and indicating risk of chronic kidney disease (CKD). Stage 3 CKD, associated with an eGFR of 45 plus or minus 14 mL/minute/1.73 m

Vol 39, Issue 3

Research Roundup: Psychiatric Comorbidities in the News

Supporting Patients With Serious Mental Illness and Comorbid Substance Use Disorder and Posttraumatic Stress Disorder

EHRs May Enhance, Prolong Racial Bias in Clinical Settings, Study Results Show

Best Recent Screen Portrayals of Mental Health Issues

Chronic Kidney Disease and Lithium—A New Perspective

While Listening to Annie Lamott Give Tim Ferriss Her Advice for Writers

Optogenetics and Piercing the Professional Armor

“Inappropriate” Consults: Taxonomy and Strategy

Exploring Antipsychotic Dose-Response

The Assessment of Depression Among Older Adults

DSM-5-TR…Already?

Refining the Wheel

I Revealed That I Take Medication for My Mental Health to Millions Online. Here’s What Happened.

Perspectives on Excited Delirium and Ketamine