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Susan J. Noonan, MD, MPH talks about the importance of dispelling false beliefs about mental illness. 

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 

"Talking about it will only make it worse..."

Myths About Mental Illness

VistaGen Therapeutics presented data that highlighted the proposed mechanism of action (MOA) of its phase 3 investigational drug candidate PH94B in a poster session at the Anxiety and Depression Association of America’s 2021 Virtual Annual Conference. PH94B is a nasal spray designed for the treatment social anxiety disorder (SAD) without directly activating gamma-amino butyric acid (GABA

This sets Ph94B’s MOA apart from that of benzodiazepines such as alprazolam, diazepam, and lorazepam, all direct GABA

 receptor positive modulators. VistaGen hopes to offer an alternative to displace these drugs, along with other highly-addictive benzodiazepines used for treating SAD and other anxiety disorders.

“The results are in agreement with PH94B’s lack of benzodiazepine-like side effects and safety concerns reported in PH94B clinical studies—for example, lack of sedation, cognitive impairment or abuse liability potential,” Louis Monti, MD, PhD, Vice President, Translational Medicine of VistaGen said to the press. “This study demonstrated that PH94B’s mechanism of action is through neural regulation of forward inhibitory GABAergic neurons in the limbic amygdala and is differentiated from benzodiazepines’ mechanism of action, which is through a direct local potentiating effect on GABA receptors. These data are key in understanding PH94B’s overall potential effectiveness and safety for individuals suffering from SAD and many other anxiety disorders.”

PH94B, an investigational odorless pherine nasal spray, also has therapeutic potential in a wide range of additional anxiety disorders and phobias. In phase 2 clinical trials, PH94B was self-administered in microgram-level doses and produced rapid-onset anti-anxiety effects within approximately 15 minutes.

To help differentiate PH94B’s MOA from that of benzodiazepines, VistaGen studied whether PH94B had positive modulatory effects on GABA receptors. For example, one of the key results reported in the poster presentation included no significant effect on GABA potentiation at doses up to 10 micromolar when compared to the 300% potentiation induced by diazepam, a commonly benzodiazepine.

“Given the FDA’s recent Drug Safety Communication that outlined and highlighted the safety risks associated with benzodiazepine use, the implications resulting from this study are significant,” said Mark Smith, MD, PhD, Chief Medical Officer of VistaGen. “PH94B may have the potential to displace benzodiazepines altogether and become the safer alternative to help the millions of Americans suffering from anxiety with limited options for safe, effective treatment options. These existing treatments can actually hurt instead of help. We look forward to launching our Phase 3 clinical development program for PH94B next quarter and continuing to push forward in our mission to get it into the hands of those in need as soon as possible.”

Further publications on PH94B can be found 

1. Globe Newswire staff. VistaGen’s poster presentation at the Anxiety and Depression Association of America’s 2021 Annual Conference differentiates PH94B’s mechanism of action from highly-addictive benzodiazepines. VistaGen. March 22, 2021. 

https://ir.vistagen.com/press-releases/detail/166

This social anxiety disorder treatment does not directly activate gamma-amino butyric acid (GABA-A) receptors, setting it apart from benzodiazepines. 

A Potential Benzodiazepine Replacement

What is addiction, and how can psychiatrists best respond to the opioid (and other drug) epidemic? What have we done wrong about it in the medication and other effective treatments for addiction? What does addiction do to the brain?

Lloyd I Sederer, MD, a psychiatrist, public health expert, and writer provides key insights on what we can do to save more lives from overdose deaths.

Dr Sederer is adjunct professor at the Columbia University School of Public Health; director of Columbia Psychiatry Media; Chief Medical Officer of 

. He has been chief medical officer of McLean Hospital; affiliated with Harvard; Mental Health Commissioner of New York City; and Chief Medical Officer of the New York State Office of Mental Health, the nation’s largest state mental health agency. The mission of 

 is to find the causes of and cures for mental illness.

Ink Stained for Life: Coming of Age in the 1950s. A Bronx Tale

is a board-certified psychiatrist and assistant professor in Clinical Psychiatry at Columbia University Medical Center and the New York State Psychiatric Institute. She serves as the medical director and team psychiatrist at ONTrackNY Washington Heights Community Service clinic. She completed her public psychiatry fellowship and adult psychiatry residency at Columbia University where she was a chief resident and co-organized the curriculum on racial/ethnic mental health disparities. In addition to her clinical work in the public sector, she also works in Columbia's psychiatric emergency room and has a private practice in Upper Manhattan. 

 is a fellow in consultation-liaison psychiatry at Columbia University Irving Medical Center with a part time private practice. She was formerly a chief resident at Columbia’s psychiatry residency program. Before medical training, she received an MS in Narrative Medicine, an interdisciplinary field that studies illness through a humanities lens. She is co-author of 

Conquering Lyme Disease: Science Bridges the Great Divide

 and has interests in medical education, psychotherapy, and medical humanities.



Thanks to Columbia University Department of Psychiatry for allowing us to present the Breakthrough Session podcast with experts in the field of psychiatry.

How can we save more lives and prevent overdose deaths? Lloyd I Sederer, MD, a psychiatrist, expert in public health, and author provides insights.

Lloyd Sederer, MD: A Conversation About Addiction and the Opioid Epidemic

“The problem of treatment-resistant depression in later life [TRD-LL] is increasingly recognized but remains poorly characterized,” Randall Espinoza, MD, MPH, told the audience at the American Association of Geriatric Psychiatry Annual Meeting. According to Espinoza, estimates of its prevalence run from 6% up to 40% in geriatric patients with depression, depending on how treatment-resistant depression (TRD) is defined.

At a session titled “Beyond ECT – Neuromodulation and Interventional Psychiatry for Treatment Resistant Depression in Later Life,” Espinoza and his colleagues Aaron Kaufman, MD, and Ali Ashghar-Ali, MD, discussed the challenges of identifying and treating TRD in older patients, including the latest results from clinical research.

TRD is associated with increases in morbidity and mortality, including greater levels of pain and suicide. It leads to higher health care costs, lower quality of life, and reduced workplace productivity. TRD can be chronic and recurrent: 20% to 35% of patients have continuous depression for more than 1 year, and 25% to 40% of patients experience a recurrence within 2 years, and 60% have a recurrence after 

Despite the prevalence of TRD, simply identifying it may be a challenge, Espinoza noted. He broke it down into 3 possible categories: 1) nonresponse to treatment and a high degree of functional impairment, 2) treatment resistant depression, which shows minimal to partial response to treatment, and 3) treatment refractory depression, which shows no response to treatment and 

 He noted that TRD may have a different epidemiology in older adult populations and may arise due to trauma, social adversity, and losses. Furthermore, treatment is complicated by brain aging and the fact that most clinical trials deliberately exclude older adults, which makes pharmacological options uncertain.

Espinoza also warned that TRD in older patients may be accompanied by significant comorbidities, including anxiety disorders, substance abuse, and cognitive and personality disorders.

In terms of treatment, Espinoza suggested that clinicians consider moving from the framing of “treatment-resistant” to a “difficult to treat” depression (DTD) model.

 The TRD model treats depression as a chronic rather than acute illness. To the biological emphasis of the TRD model, it would add a neurobiopsychosocial focus. Rather than judging progress according to cure or remission alone, it also emphasizes capability, recovery, and symptom management.

As Espinoza explained, “DTD captures not only acute phase treatment but also encourages a shift of focus to long-term treatment with the goals of improving overall function, quality of life, and optimization of treatment when full remission is no longer viable.”

Turning to more specific treatment options, Ashghar-Ali noted that “ECT remains [the] gold standard for neuromodulation intervention in older adults,” and noted clinicians have other options as well. He reviewed 2 studies of repetitive transcranial magnetic stimulation (RTMS)/DEEP TMS, which 

Ashghar-Ali also discussed ketamine. Although it is not approved by the US Federal Drug Administration (FDA) for treating TRD, ketamine has shown 

 Esketamine, however, is FDA approved for treating depression. Ashghar-Ali noted that esketamine plus an antidepressant demonstrated a statistically significant treatment effects in patients aged 65 to 74 years (although not for patients aged more than 75 years).

 He concluded that esketamine might play a helpful role in treating TRD in patients during the 64 to 75 age band.

Kaufman considered the possible role of lithium augmentation. He discussed 1 study in which lithium augmentation had a high remission rate (63.6%) among elderly patients with treatment resistant depression, and another in which geriatric patients responded significantly better to lithium augmentation than 

 He noted that some evidence also existed for augmenting with atypical antipsychotics and stimulants.

Psychotherapy is also an option. Kaufman presented from a meta-analysis of psychotherapy in later-life depression that found large effects, when compared with 

 The evidence is strongest for problem-solving therapy, interpersonal psychotherapy, and cognitive behavioral therapy. Exercise, meditation, acupuncture, and Tai Chi had also been shown to help in a number of cases.

During the Question and Answer period, both Kaufman and Ashghar-Ali spoke to why treatments beyond ETC may be necessary.

“These are of course really challenging cases,” Kaufman said. Some patients may have trouble recalling the details of her medication and adherence history, and many do not trust ECT. “We’ve all had patients decline ETC and want to pursue alternatives,” Kaufman said further.

Alternately, said Ashghar-Ali, “a lot of people come to ECT with the assumption that it’s the only option left.”

But, Ashghar-Ali and Kaufman concluded, ECT is in fact only 1 option, and there are many others for clinicians and patients.

1. Benson C, Szukis H, Sheehan JJ, et al. An evaluation of the clinical and economic burden among older adult Medicare-covered beneficiaries with treatment-resistant depression. 

2. Pilon D, Joshi K, Sheehan JJ, et al. Burden of treatment-resistant depression in Medicare: a retrospective claims database analysis. 

3. Rush AJ, Aaronson ST, Demyttenaere K. Difficult-to-treat depression: a clinical and research roadmap for when remission is elusive. 

4. Lisanby SH, Husain MM, Rosenquist PB, et al. Daily left prefrontal repetitive transcranial magnetic stimulation in the acute treatment of major depression: clinical predictors of outcome in a multisite, randomized controlled clinical trial. 

5. Conelea CA, Philip NS, Yip AG, et al. Transcranial magnetic stimulation for treatment-resistant depression: naturalistic treatment outcomes for younger versus older patients. 

6. Murrough JW, Perez AM, Pillemer S, et al. Rapid and longer-term antidepressant effects of repeated ketamine infusions in treatment-resistant major depression. 

7. Ochs-Ross R, Daly EJ, Zhang Y, et al. Efficacy and safety of esketamine nasal spray plus an oral antidepressant in elderly patients with treatment-resistant depression-TRANSFORM-3. 

8. Kok RM, Nolen WA, Heeren TJ. Outcome of late-life depression after 3 years of sequential treatment. 

9. Buspavanich P, Behr J, Stamm T, et al. Treatment response of lithium augmentation in geriatric compared to non-geriatric patients with treatment-resistant depression. 

10. Huang AX, Delucchi K, Dunn LB, Nelson JC. A systematic review and meta-analysis of psychotherapy for late-life depression. 

If patients decline electroconvulsive therapy, psychiatrists still have many good options. 

How to Identify and Tackle Treatment-Resistant Depression in Geriatric Patients

Sage Therapeutics announced 2 data sets from the ongoing phase 3 open-label SHORELINE study evaluating zuranolone: complete 12-month data from the 30 mg cohort and interim data from the 50 mg cohort. 

, a once-daily, 2-week therapy for the treatment of 

 (PPD), is an investigational oral neuroactive steroid (NAS) GABAA receptor positive allosteric modulator.

“Sage embarked on the LANDSCAPE clinical program to evaluate the safety and efficacy of zuranolone with the ambition of reimagining the treatment for depression with the goal of a rapid-acting, durable, treat-as-needed option in a disease where innovation is lacking and the incidence rate has unfortunately increased exponentially in the last 20 years,” Barry Greene, Chief Executive Officer at Sage Therapeutics, said to the press. “Today we are announcing additional positive data from the SHORELINE Study that demonstrate continued strong results from the 30 mg dose and strengthens our confidence in the potential of the 50 mg dose. Designed as a naturalistic study, these data approximate real-world evidence of use of zuranolone at 30 mg and 50 mg doses. We look forward to the results of the WATERFALL and CORAL Phase 3 pivotal data readouts in MDD this year.”

This clinical study was designed to evaluate the safety and tolerability of zuranolone 30 mg and 50 mg in adults for up to 1 year, and the currently analyzed data show that zuranolone was generally well-tolerated in both the 30 mg and 50 mg dose cohorts. Reported adverse events were generally consistent with results seen in previous zuranolone clinical trials; they included somnolence, headache, and dizziness.

In the 30 mg zuranolone cohort, 725 participants with MDD were treated with a first dose of zuranolone 30 mg once nightly for 14 days. Researchers evaluated participant response using the 17-item Hamilton Rating Scale for Depression (HAMD-17). The mean baseline HAM-D score (± SD) at entry was 25.3 ± 4.1 (n=725). Of the 725, 173 participants did not achieve response to the first course and left the study; however, 505 (73.5%) patients achieved response and 276 (40.2%) achieved remission (HAM-D ≤7).

From the initial group, 489 continued beyond the first treatment course. Of the 489, 210 used only the single initial course, 125 used 2 total courses, 58 used 3 total courses, 53 used 4 total courses, and 43 used 5 total courses. It was noted that adverse events decreased in frequency through the first 3 courses and remained stable over the next 2 courses.

From May 2020 onwards, all newly enrolled participants received 50 mg of zuranolone. The achieved response rate for these participants is 149/185 (80.5%), while the achieved remission rate is 80/185 (43.2%). This 50 mg cohort has completed the first course and the 12-month follow-up is expected to be completed in late 2021.

The SHORELINE study, as the first naturalistic, clinical development trial for MDD, is providing realistic insight into the potential use for zuranolone, if it is successfully developed and approved. Sage Therapeutics plans to report additional data from patients in the 50 mg dose cohort in late 2021, and present additional data from the study at conferences and in peer-reviewed journal articles.

1. Sage Therapeutics announces continued positive zuranolone data for both 30 mg and 50 mg doses in open-label SHORELINE study in patients with MDD. 

https://www.businesswire.com/news/home/20210317005285/en/Sage-Therapeutics-Announces-Continued-Positive-Zuranolone-Data-for-Both-30-mg-and-50-mg-Doses-in-Open-Label-SHORELINE-Study-in-Patients-with-MDD

New data from the ongoing SHORELINE study may bring good news for treating MDD. 

Incoming Data: News from Naturalistic MDD Clinical Trial 

Patients with cancer are at increased risk for both suicidal ideation and completed suicide due to a combination of biological and psychological factors that must be addressed to increase quality of life. More research is needed to determine the best methods of screening, evaluation, and treatment for suicidal thoughts and actions in this population.

- Cancers with the highest suicide risk include head and neck, lung, and pancreas.

- Health care providers do not feel adequately prepared to assess patients for suicidality.

- Increased risk is associated with older age, male gender, increased paid, lack of social supports, preexisting mood disorders, hopelessness; iatrogenic and biological factors must be assessed and addressed.

Cancer has plagued humanity since the beginning of recorded history. The first mention of cancer in the literature appeared in the Edwin Smith papyrus, dated ~3000BC. Surviving documents from ancient Greek and Roman physicians detail attempts at diagnosing and curing and give us the language we use today (oncos and cancer, respectively).

Although the overall prevalence of mortality due to cancer has been decreasing, it is still the second leading cause of death in the United States, responsible for 599,108 (21.3% of total) deaths in 2017.

 In comparison, suicide ranks 10th in this list, with 47,173 (1.7% of total) deaths. The most common cancers worldwide are lung, breast, 

, prostate, skin, and stomach; lung, colorectal, stomach, liver, and breast cancers account for the most deaths.

Changing attitudes toward suicide has altered the recorded prevalence over time, but it has always been a factor in human death. The desire to control, to some extent, the timing and manner of one’s death has always been a human temptation, and this draw increases when physical or emotional distress are present. Although estimates vary, patients with cancer are, at minimum, twice as likely to die by suicide. Moreover, having psychiatric care pre-diagnosis may not mitigate this increased risk.

Suicide risk is not the same for all types of cancer, nor is it consistent over the disease course (

).Several studies have found that suicide risk is at least twice that of the general population and is highest immediately after diagnosis.

Among cancers with the highest suicide risk are those affecting the head and neck, lung, pancreas, and larynx/pharynx. Prostate cancer has a higher suicide rate in the first year after diagnosis, but lower overall unless metastatic disease is found, with additional increased risk when treatment is defined but not received. Unique to cancer is that the risk of suicide persists more than 15 years past diagnosis.

In addition to increased suicide risk, patients with head and neck cancers have higher depression scores than the general population even before a cancer diagnosis, leading to the question whether this subset of patients are struggling with a biological cause in addition to diagnosis-related symptoms.

 Complicating these cases is the well-known association of many head and neck cancers with tobacco, alcohol, and other substance use, leading to the question of whether the pre-existing mood disorders lead to substance use that increases the risk of cancer. The relative increase in number of cases linked to human papillomavirus instead of substance use may alter this picture.

Regarding lung cancer, although the risk of suicide has been decreasing, Rahouma and colleagues6 found that these patients are at a higher risk than those with the more prevalent breast, prostate, or colorectal cancer. Furthermore, a large proportion of suicides may occur in patients with possibly non-fatal disease.

The risk in patients with breast cancer has been relatively stable over the last 4 decades and may be linked to whether the patient has undergone surgery. Findings from Simpson and colleagues

 indicate that penile cancer patients have one of the lowest suicide rates and, in their study, all patients who died by suicide had undergone surgical intervention. The link between surgical intervention and suicide risk may be linked to cosmetic effects, particularly as they affect sexual organs and can potentially alter patients’ view of their desirability and sexual roles.

In colorectal cancer, risk differs depending on the site of the lesion. Distally located disease is linked to a higher rate of suicide. This effect may be due to the more severe effects of distal disease on quality of life. Suicide risk in patients with stomach cancer was 

 with diarrhea, which can have a significant impact on lifestyle.

 It is not surprising that patients with terminal cancers report significantly more suicidal ideation.

One of the challenges in suicide prevention is determining the most effective ways to assess risk and screen for suicidal thoughts and intentions. Very little information has been collected regarding formal suicide risk assessment in cancer patients 

 found that health care providers did not feel adequately prepared to ask about suicidality or provide support and resources to patients.

The Columbia Suicide Severity Rating Scale (C-SSRS) is widely used for assessing suicidal intent, acts of furtherance, and suicide attempts. It has been studied and validated, and it is available in a variety of languages. It is free and designed to be used by anyone, including people without prior mental health care experience; there are versions specifically for people with cognitive impairments and children. However, it does not provide guidance as to full assessments or further steps once the screening is positive.

The Beck Hopelessness Scale asks true/false questions about future orientation, motivation, and expectations in order to assess negative feelings about the future. It can be used as an indirect evaluation of suicidal thoughts but does not address it directly. The detailed interpretation report can be very useful in assessing changes over time, but although the questions can be asked by anyone, the interpretation requires a trained professional.

The Hamilton Depression Scale (HAM-D) is a relatively brief questionnaire that asks about a variety of symptoms of depression; suicide is mentioned in 1 of the 17 questions, which are on a graded scale. It does not ask about atypical symptoms and, while it has relatively high sensitivity, specificity is low.

The Patient Health Questionnaire-9 (PHQ-9) is a brief set of questions designed to be asked and reviewed by any health care professional, with recommendations of when to advise further assessment by a mental health professional. It has shown to be reliable and valid in multiple studies. Like the HAM-D, it has relatively high sensitivity and low specificity.

Multiple studies have shown cancer as an independent risk factor for completed and attempted suicide. Spoletini and colleagues

 contrasted suicide in the general population, which they attributed to “genetic and psychological vulnerability to stress,” to suicide in cancer patients, which involved the “intrinsic bio-psychological vulnerability to distress” linked to changes in the immune system associated with cancer. Thus far, research has not identified consistent risk factors that enable the jump from suicidal ideation to suicide attempts. Underlying factors such as mood disorders may increase risk but require “additional precipitating events or conditions.”

Hopelessness and rumination are primary cognitive predictors; and hopelessness may be associated with recurrent self-harm. Depression is a major risk factor, as it is in the general population, but the cancer population is at higher baseline risk for depression, which has been linked to immunological changes.

 Identification and treatment of depression in cancer patients has been shown to decrease morbidity and mortality.

An important component of identifying at-risk patients is to determine the characteristics of those who historically have higher rates of suicide. As in the general population, the overall suicide rate in patients with cancer is linked to male gender, white race, lack of a partner and/or other social supports, and preexisting emotional or anxiety disorders as significant risk factors.

 In addition, older age, pain, advanced, disease, and poor prognosis are variables specific to this population that increase the risk of both suicidal ideations and suicide. Physical illnesses in general, particularly those associated with physical pain with consequent lifestyle limitations, are consistent risk factors that play a role in at least 25% of suicides, and the correlation increases with age.

 Patients with significant uncontrolled pain are at higher risk—thus a key component of cancer treatment must be adequate pain control. Minimal information has been collected on how substance use as reaction to a cancer diagnosis contributes to the risk of suicide. This may prove to be an important factor (

Although few thorough examinations of the methods typically used for suicide have been conducted, the National Cancer Institute 

 that overdose with painkillers and sedatives is the most common method of suicide used by cancer patients, and most of these occur at home.

 Despite this, screening for other methods of suicide (particularly firearms) should not be neglected.

A general understanding of suicidal ideation and behaviors involves alterations in the serotonin and HPA systems. The effects of a disease like cancer that alters immune system function can also alter these axes, which may result in increased risk of suicide. Independently of co-occurring cancer, the immune system is altered in depression (changes in cytokine and cell mediated immunity, changes in HPA axis) and may contribute to the development of depression in a reciprocal manner.

Depression secondary to medical causes should be ruled out in cancer patients. This typically includes an evaluation of B12 and folate levels, anemia, thyroid hormone imbalance, and adrenal hormone imbalance. The utility of assessing electrolyte abnormalities, including sodium, potassium, and magnesium remains unclear, although there is considerable interest in the effect of imbalances on mental health.

To further complicate this picture, several medications used to treat cancer have been linked to depression, such as corticosteroids, L-asparaginase, interferon-alpha, and amphotericin B.

Careful review of medication regimens and treatment alternatives may offer options for minimizing the effect of cancer therapy on mental health.

The “escape model” of suicidal drive may come into play, particularly in patients with a terminal diagnosis. This model postulates that the desire to escape from intolerable distress, combined with increased awareness of the factors contributing to that distress, leads to suicide.

 Accordingly, cancers with less than 5-year survival rates correlated to higher suicide risk, leading some to wonder whether the type of cancer is more important than the cancer diagnosis.

There are confusing data regarding the complicated mix of desire to speed up death, depression, hopelessness, and suicide risk. It appears that patients with baseline depression are more likely to want hastened death, expressing this desire up to 4 times as often, but Porta-Sales and colleagues

 found that simply discussing the wish for more rapid death did not cause distress, and that nearly 80% of patients felt it was an important topic for the care team to discuss.

Studies of suicidal ideation and completed suicide in adult cancer patients and survivors make up the bulk of the research in this area. As treatments and survival rates for childhood cancers improve, long-term studies of this population must include this information to more fully understand the lifelong effects of cancer treatment in children and adolescents, particularly since suicide is the top cause of death in the young adult populations of many developed countries. Gunnes and colleagues

 showed an increased risk of suicide in Norwegian patients aged 23 to 48 years who had a diagnosis of cancer before the age of 25. At exceptional risk were survivors of brain and testicular tumors, as well as leukemia. An American study did not replicate this finding but reported an increased risk of suicidal ideation compared with sibling controls.

 The average age of those who reported a first incident of suicidal ideation was 34 years, and they were, on average, 26 years past diagnosis. This is a serious example of how the sequelae of childhood cancer treatment can persist far into adulthood.

Is Refusal of Treatment a Form of Suicide?

Complicating the discussion of suicide in cancer patients is the subject of refusal of treatment. Is this considered suicide? Frenkel

 noted that “the unique patients who refuse conventional treatment are at times self-directed, confident, and active, and have thought deeply about the meaning of life and cancer and about their cancer treatment options.” What does it mean to have the ability to choose, to some extent, when we will die? This controversy has been taken all the way to the Supreme Court, with Justice Brandeis writing in Olmstead vs US that “the right to be left alone . . . the most comprehensive of rights and the right most valued by civilized men,” and Justice Burger clarifying that “nothing in this utterance suggests that Justice Brandeis thought an individual possessed their rights only as to sensible beliefs, valid thoughts, reasonable emotions.”

 Physicians are trained that the ultimate goal is to save or at least prolong life, but often neglected is the consideration of quality of life and patients’ desire to live, and die, in a manner they can, to some extent, control. Isenberg-Grzeda and colleagues

 reported on 3 patients who attempted suicide after being deemed ineligible for medical assistance in dying, further exemplifying the desire to have some say over the end of their lives.

Treatments can be quite similar to the treatment of depression in the general population, with psychotherapy and pharmacotherapy (selective serotonin reuptake inhibitors, selective serotonin-norepinephrine reuptake inhibitors, mirtazapine, trazodone) forming the basis. The most recent review of antidepressant therapy for depression in cancer patients did not show a significant improvement from placebo, but 

 noted that there were few studies from which to draw this information and noted that much more research is needed in this area.

Psychotherapy, no matter how brief, can help patients adjust to their new health circumstances and reassess their view of their life up until their diagnosis and goals going forward. In addition, special considerations such as the influence of altered immune activity and the effects of chemotherapy must also weigh into treatment decisions. Moreover, prescribers must be judicious in choosing medications that can be expected to show some positive effect within the patient’s expected lifetime, which may be significantly shortened. Stimulants may be useful in treating symptoms of fatigue and inattention that are common during cancer treatment. Close collaboration with the oncologic team can help to optimize mental health during cancer treatment.

Suicide and cancer are the top 10 causes of death in the adult population of the United States, and the world. Patients with cancer are at increased risk for both 

 and completed suicide. Factors contributing to this increase are both biological and psychological and components must be addressed in a timely fashion to increase quality of life. A refusal of treatment must not automatically be considered an instrument of suicide but viewed as a complex decision factoring in goals of care, particularly quality of life. More research is needed to determine how best to evaluate and treat oncology patients for suicidal thoughts and behaviors.

is faculty member, Department of Psychiatry, Albert Einstein Medical Center, Philadelphia, PA. The authors have nothing to disclose regarding this article.

1. Centers for Disease Control and Prevention. National Health Report Highlights. Accessed July 14, 2020. https://www.cdc.gov/healthreport/publications/compendium.pdf

. Accessed July 14, 2020. https://www.who.int/news-room/fact-sheets/detail/cancer

14. McFarland DC, Walsh L, Napolitano S, et al. Suicide in patients with cancer: identifying the risk factors. 

3. Kumar V, Chaudhary N, Soni P, Jha P. Suicide rates in cancer patients in the current era in United States. 

4. Klaassen Z, Arora K, Wilson SN, et al. Decreasing suicide risk among patients with prostate cancer: implications for depression, erectile dysfunction, and suicidal ideation screening. 

5. Davies AD, Davies C, Delpo MC. Depression and anxiety in patients undergoing diagnostic investigations for head and neck cancers. 

6. Rahouma M, Kamel M, Abouarab A, et al. Lung cancer patients have the highest malignancy-associated suicide rate in USA: a population-based analysis. 

7. Urban D, Rao A, Bressel M, et al. Suicide in lung cancer: who is at risk? 

8. Simpson WG, Klaassen Z, Jen RP, et al. Analysis of suicide risk in patients with penile cancer and review of the literature. 

Suicide ideation in stomach cancer survivors and possible risk factors

10. Granek L, Nakash O, Ben-David M, et al. Oncologists,’ nurses,’ and social workers’ strategies and barriers to identifying suicide risk in cancer patients. 

11. Spoletini I, Gianni W, Caltagirone C, et al. Suicide and cancer: where do we go from here? 

12. Li C, Li C, Forsythe L, et al. Mental health services utilization and expenditures associated with cancer survivorship in the United States. 

13. Sherrill C, Smith M, Mascoe C, et al. Effect of treating depressive disorders on mortality of cancer patients. 

15. Abourmrad M, Shiner B, Riblet N, et al. Factors contributing to cancer-related suicide: a study of root-cause analysis. P

16. National Cancer Institute. Depression (PDQ®). . Accessed July 14, 2020. https://www.cancer.gov/about-cancer/coping/feelings/depression-pdq

17. Kenna HA, Poon AW, de los Angeles CP, et al. Psychiatric complications of treatment with corticosteroids: review with case report. 

18. Celano CM, Freudenreich O, Fernandez-Robles C, et al. Depressogenic effects of medications: a review. 

19. Pinto EF, Andrade C. Interferon-related depression: a primer on mechanisms, treatment, and prevention of a common clinical problem. 

20. Weddington WW. Delirium and depression associated with amphotericin B. 

21. Baumeister RF. Suicide as escape from self. 

22. Porta-Sales J, Crespo I, Monforte-Royo C, et al. The clinical evaluation of the wish to hasten death is not upsetting for advanced cancer patients: a cross sectional study. 

23. Gunnes MW, Lie RT, Bjorge T, et al. Suicide and violent deaths in survivors of cancer in childhood, adolescence, and young adulthood: a national cohort study. 

24. Brinkmann TM, Zhang N, Recklitis CJ, et al. Suicide ideation and associated mortality in adult survivors of childhood cancer. 

27. Isenberg-Grzeda E, Bean S, Cohen C, et al. Suicide attempt after determination of ineligibility for assisted death: a case series. 

28. Ostuzzi G, Matcham F, Daughy S, et al. 

Antidepressants for the treatment of depression in people with cancer

29. Zaorsky NG, Zhang Y, Tuanquin L, et al. Suicide among cancer patients. 

30. Al-Ghazal SK, Fallowfield L, Blamey RW. Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction. 

31. Pham TT, Talukder AM, Walsh NJ, et al. 

Clinical and epidemiological factors associated with suicide in colorectal cancer

32. Dalela D, Krishna N, Okwara J et al. Suicide and accidental deaths among patients with non-metastatic prostate cancer. 

33. Janes T. How can a suicide screening and prevention procedure be implemented in a cancer center? 

34. Anguiano L, Mayer DK, Piven ML et al. 

A literature review of suicide in cancer patients

Patients with cancer are at increased risk for both suicidal ideation and completed suicide. The authors discuss factors contributing to this increase in both biological and psychological realms.

Suicidal Ideation and Behaviors in Oncology Patients

Jaya Jaya Myra talks about foods that can assuage inflammation in the body. 

 is a best-selling author, TEDx & motivational speaker, and mind-body wellness expert teaching the definitive connections between purpose and health. Her debut book, 

Vibrational Healing: Attain Balance & Wholeness. Understand Your Energetic Type

 is published in 10 languages and available worldwide. Her 2nd book, 

Which foods could be contributing to symptoms of depression, and which foods can help combat them?

What Food Causes Inflammation?

Susan J. Noonan, MD, MPH, talks about the lead up to, and the process of inpatient care. 

What happens if a patient is too ill to manage at home?

The Ins and Outs of Inpatient Admission

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

 is the Theodore J. Castele Professor of the History of Medicine and Associate Director of the Program in Medicine, Society, and Culture at Case Western Reserve University, Cleveland, Ohio. He holds secondary appointments in the Departments of Bioethics and Psychiatry. He earned degrees in history from Wesleyan (BA), Stanford (MA), and Johns Hopkins University (PhD); he also studied psychiatric epidemiology at Columbia University. He is the author of 

Imperial Bedlam: Institutions of Madness and Colonialism in Southwest Nigeria

 (University of California Press; 1999); 

Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy

 (Polity Books; 2020). His articles have appeared in journals including the

 Journal of the History of Medicine and Allied Sciences, Harvard Review of Psychiatry, Bulletin of the History of Medicine

Dr Sadowsky is a leading historian of psychiatry, and one I am proud to call him my teacher. As a psychiatry resident, I attended his lectures on history of psychiatry as part of our residency didactics and benefitted greatly from them. Sadowsky was 

 in 2017 by Greg Eghigian, PhD, about his book, 

, an interview that is well worth revisiting. The present interview is about his new book 

. I admire Sadowsky for his ability to tackle complex and controversial issues with scholarly rigor and fair-minded appraisal, and I am delighted to have him participate in this series.

 Before I jump into my questions, I want to give you an opportunity to introduce your book to the readers on your own terms. What are the issues that occupy you? I suppose some folks on hearing about 

 may reflexively think, “What… another book about depression? Don’t we have enough of those already?” Perhaps in your response you can also touch on why a new history of depression was needed in your opinion.

 First, not many of the books about depression are histories. Take 

The story of depression, through time and around the world. 

Depression