Hero

Videos

Slideshows

Articles

Podcasts

Poll

The data is clear: We should expect an increasing number of 

 and gender diverse (TGD) youth presenting to our practices over the coming years.

 We must ask ourselves: Are we prepared to treat these patients and their families with the most affirming, evidence-based treatment available?

For discussion purposes, consider a prototypical case of “Bar,” an 11-year-old child who presents to your office accompanied by his parents. Bar was assigned female at birth but recently began identifying with “he/him” pronouns; he is scared to face impending puberty. Bar’s father informs you that he is afraid Bar will be “bullied for being gay.”

Recent qualitative studies suggest that the caregivers’ response and adjustment to their TGD child’s identity development is critical to the child’s mental health.

 An integrative family therapy approach should affirm and support the TGD child in an equal partnership between the caregivers and the child.

 Addressing attunement and attachment is important for the family system, as there is likely longstanding 

 from adoption of rigid, binary gender norms.

 Families should prioritize building psychosocial support for, and affirming the gender identity of, the TGD child, rather than focus on worries like “Is this my fault?” “What went wrong?” or “Is this just a phase?” The family may express grief due to the loss of an expected future they associated with the assigned sex of a transitioning child.

Distress tolerance and interpersonal relationship dynamics can be tested during a gender transition

 may be misdiagnosed with personality disorders.

 Dialectical behavioral therapy is a good therapeutic option for these patients.

 It is important that group therapy options provide affirming environments for transgender group members. This includes the facilitator’s role modeling of appropriate usage of pronouns and chosen names during therapy sessions.

Disclosing a shared identity with a patient can aid the therapeutic alliance by displaying understanding and empathy for the patient’s experience, which can facilitate trust and reciprocity.

 It is vital that providers reflect on whether self-disclosure is being done with the intent of improving patient care, and peer supervision around this can be of value.

Psychiatrists should model inclusive environments to their TGD patients within their offices and clinical spaces.

 Patients and their families should feel safe to give feedback to the psychiatrist when they fail to produce an affirming patient experience.

 In these situations, the administrative response should be transparent and timely, and it should address the root cause of the issue. Psychiatrists should collaborate and advocate with the family and other community and mental health professionals, such as school psychologists and counselors, to create affirming environments within the child’s home and school life.

 It is imperative that work with TGD patients involves ongoing feedback and participation from affected community members throughout the learning and healing process.

To create a more affirming environment for a TGD child, psychiatrists should collaborate with the family, school, and community. For example, using noninvasive and empowering language can be a great first step in establishing not only a good environment, but also a therapeutic alliance. See 

Psychiatric Terminology: Is the Field Doing Enough?

Gender Dysphoria and Its Significance in the TGD Community

Gender dysphoria is a term that originated within psychiatry. The DSM-5-TR defines gender dysphoria as “the psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity.” Gender euphoria is an accepted term used in the TGD community that recently entered the peer-reviewed literature.

 It is defined as a “joyful feeling of rightness” and the “powerfully positive emotions” that comes from one’s gender. See 

 for more details on gender dysphoria and euphoria.

Gender dysphoria is caused by repeated exposure to gender-nonaffirming environments, which can result in higher rates of 

, anxiety, trauma and stress disorders, rumination, somatization, and suicidality in TGD individuals.

 The mismatch between a person’s self-identified gender and invalidating environments can occur within multiple domains, including online, home, school, athletic, employment, carceral, and health care settings.

 Access to affirming environments and health care improves mental health outcomes

; on the other hand, nonaffirming environments and barriers to health care increase disparities for TGD individuals.

 Due to recent attempts to criminalize evidence-based affirming health care for TGD individuals, psychiatrists should expect to see an increase in patients presenting with gender dysphoria in the near future.

The Gender Minority Stress and Resilience Theory

The Gender Minority Stress and Resilience Theory describes the disparate impact of risk and protective factors on the experience of internalized (proximal) and external (distal) oppression in TGD communities.

 factors combine with other forms of social identity–based discrimination, such as racism and socioeconomic disadvantage. Taken together, this intersectionality is responsible for the structural pathways leading to systemic health care inequities experienced by TGD community members (ie, social determinants of health).

 provides more details on minority stress and resilience.

Minority stress models have been used to explain the increased risk for biological, psychological, and social health disparities observed in TGD communities. These biological factors include increased rates of cardiovascular disease and cancer-related outcomes, whereas psychological outcomes of minority stress include depression and suicidality.

 Among the TGD community, social disparities and structural disadvantages have been noted in increased rates of incarceration, housing instability, underinsurance, and risk behaviors, such as 

 expands on this topic and gives examples of resilience, or protective factors, that moderate the effect of minority stress.

 Resilience factors include methods to create systemic and structural changes that increase the psychosocial support and affirming environments available to TGD individuals.

 Additionally, TGD individuals can learn skills such as community building, advocacy, role modeling, and other expressions of pride, self-worth, and self-acceptance.

You diagnose Barr with gender dysphoria and provide supportive psychotherapy throughout the social transition process. You present Barr with information regarding his local community center, where Barr becomes active in peer support and social activities. You provide educational resources to Barr’s parents, who join their local PFLAG (Parents, Families, and Friends of Lesbians and Gays) chapter to speak with other parents of TGD children. You discuss the changes in pronouns with Barr’s school psychologist and work with school administration to help develop strategies for Barr to express his gender authentically within the school’s policies.

After a year of treatment, although Barr feels more confident in his masculine gender expression, he reports ongoing depression due to expected changes with puberty. As a result, you refer Barr and his parents to a gender-affirming endocrinologist to discuss options regarding potential puberty suppression and timing.

Psychiatrists are in a unique position to empower their patients by recognizing and addressing key issues surrounding gender and sexuality. This includes the use of sensitive and inclusive language and assisting the field in adapting to ongoing evolution of community standards of care. Similarly, it is important to integrate transition and resocialization efforts with the patient’s family, community centers, and school professionals. 

 provides a list of potential resources to help in this endeavor. Together, we can work to provide affirmative and evidence-based care for all youth, whether or not they identify within the gender binary.

is a sixth-year medical student at Universidad Peruana Cayetano Heredia in Lima, Peru. She aspires to become a neurologist and to continue advocating through research and policymaking for the transgender community. 

 is a board-certified neurologist and graduate student of social service at Fordham University, where they perform activism and research for the transgender community.

1. Jones JM. LGBT identification in U.S. ticks up to 7.1%. Gallup. February 17, 2022. Accessed October 3, 2022. 

https://news.gallup.com/poll/389792/lgbt-identification-ticks-up.aspx

2. Turban J, Ferraiolo T, Martin A, Olezeski C. 

Ten things transgender and gender nonconforming youth want their doctors to know.

3. Bhattacharya N, Budge SL, Pantalone DW, Katz-Wise SL. 

Conceptualizing relationships among transgender and gender diverse youth and their caregivers.

Integrative family therapy with transgender, gender diverse, and non-binary (TGDNB) young people.

Working toward family attunement: family therapy with transgender and gender-nonconforming children and adolescents.

Treating family members of transgender and gender-nonconforming people: an interview with Eric Yarbrough, M.D.

7. Austin A, Craig SL, D’Souza S, McInroy LB. 

Suicidality among transgender youth: elucidating the role of interpersonal risk factors.

8. Goldhammer H, Crall C, Keuroghlian AS. 

Distinguishing and addressing gender minority stress and borderline personality symptoms.

9. Sloan CA, Berke DS. Dialectical behavior therapy as a treatment option for complex cases of gender dysphoria. In: Kauth MR, Shipherd JC, eds. 

Adult Transgender Care: An Interdisciplinary Approach for Training Mental Health Professionals.

 Routledge/Taylor & Francis Group; 2018:123-139.

Therapist self-disclosure of sexual orientation revisited: considerations with a case example.

11. Banerjee SC, Staley JM, Alexander K, et al. 

Encouraging patients to disclose their lesbian, gay, bisexual, or transgender (LGBT) status: oncology health care providers’ perspectives.

12. Acosta W, Qayyum Z, Turban JL, van Schalkwyk GI. 

Identify, engage, understand: supporting transgender youth in an inpatient psychiatric hospital.

13. Brown JM, Naser SC, Brown Griffin C, et al. 

A multicultural, gender, and sexually diverse affirming school-based consultation framework.

14. Katz-Wise SL, Sansfaçon AP, Bogart LM, et al. 

Lessons from a community-based participatory research study with transgender and gender nonconforming youth and their families.

15. Beischel WJ, Gauvin SEM, van Anders SM. 

“A little shiny gender breakthrough”: community understandings of gender euphoria.

16. Dhejne C, Van Vlerken R, Heylens G, Arcelus J. 

Mental health and gender dysphoria: a review of the literature.

17. Chumakov EM, Ashenbrenner YV, Petrova NN, et al. 

Anxiety and depression among transgender people: findings from a cross-sectional online survey in Russia.

18. Wanta JW, Niforatos JD, Durbak E, et al. 

Mental health diagnoses among transgender patients in the clinical setting: an all-payer electronic health record study.

19. Cardoso Silva D, Salati LR, Villas-Bôas AP, et al. 

Factors associated with ruminative thinking in individuals with gender dysphoria.

Increased prevalence of depression, anxiety, and adjustment and somatoform disorders in transsexual individuals.

Cyberbullying and LGBTQ youth: a systematic literature review and recommendations for prevention and intervention.

23. Brown C, Porta CM, Eisenberg ME, et al. 

Family relationships and the health and well-being of transgender and gender-diverse youth: a critical review.

24. Kosciw JG, Clark CM, Truong NL, Zongrone AD. The 2019 National School Climate Survey: the experiences of lesbian, gay, bisexual, transgender, and queer youth in our nation’s schools. GLSEN. 2020. Accessed October 3, 2022. 

https://www.glsen.org/sites/default/files/2021-04/NSCS19-FullReport-032421-Web_0.pdf

25. Kulick A, Wernick LJ, Espinoza MAV, et al. 

Three strikes and you’re out: culture, facilities, and participation among LGBTQ youth in sports.

Should I stay or should I go? Employment discrimination and workplace harassment against transgender and other minority employees in Canada’s Federal Public Service.

 Racial/ethnic disparities in history of incarceration, experiences of victimization, and associated health indicators among transgender women in the U.S.

28. Kattari SK, Bakko M, Hecht HK, Kattari L. 

Correlations between healthcare provider interactions and mental health among transgender and nonbinary adults.

29. Russell ST, Pollitt AM, Li G, Grossman AH. 

Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth.

Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults.

31. James SE, Herman JL, Rankin S, et al. The report of the 2015 U.S. transgender survey. National Center for Transgender Equality. 2016. Accessed October 3, 2022. 

https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf

32. Puckett JA, Cleary P, Rossman K, et al. 

Barriers to gender-affirming care for transgender and gender nonconforming individuals.

Legislation to criminalize gender-affirming medical care for transgender youth.

Resilience in the study of minority stress and health of sexual and gender minorities.

35. Heise L, Greene MH, Opper N, et al; Gender Equality, Norms, and Health Steering Committee. 

Gender inequality and restrictive gender norms: framing the challenges to health.

36. Streed CG Jr, Beach LB, Caceres BA, et al; American Heart Association Council on Peripheral Vascular Disease; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Radiology and Intervention; Council on Hypertension; and Stroke Council.

 Assessing and addressing cardiovascular health in people who are transgender and gender diverse: a scientific statement from the American Heart Association.

37. Flentje A, Heck NC, Brennan JM, Meyer IH. 

The relationship between minority stress and biological outcomes: a systematic review.

Associations between minority stress, depression, and suicidal ideation and attempts in transgender and gender diverse (TGD) individuals: systematic review and meta-analysis.

39. Glick JL, Lopez A, Pollock M, Theall KP. 

Housing insecurity and intersecting social determinants of health among transgender people in the USA: a targeted ethnography.

Differential access to transgender inclusive insurance and healthcare in the United States: challenges to health across the life course.

Prevalence and correlates of substance use among transgender adults: a systematic review.

Psychological interventions promoting resilience among transgender individuals: Transgender Resilience Intervention Model (TRIM).

43. Reisner SL, Bradford J, Hopwood R, et al. 

Comprehensive transgender healthcare: the gender affirming clinical and public health model of Fenway Health.

Psychiatrists are in a unique position to empower their patients by recognizing and addressing key issues surrounding gender and sexuality. 

Affirming Evidence-Based Care for Young Patients Who Are Transgender or Gender Diverse

“So many adult patients—women—come in and are being newly diagnosed with ADHD [attention-deficit/hyperactivity disorder] for the first time,” Pamela Wall, PhD, PMHNP, FAANP, told attendees of the

 American Psychiatric Nurse Association 36th Annual Conference

. The goals for the session were to explain the reason for this phenomenon and to share some of the unique issues associated with ADHD in adult women.

Implicit bias was a top reason for missing the diagnosis earlier in women, Wall explained, as she conducted a mini-experiment with attendees. After asking attendees to visualize a child who is hyperactive, Wall surveyed the group to see what gender they saw; most of the audience pictured a boy.

In addition, she said what is known about 

 now versus what was known 20 or 30 years ago has changed, which allows for new adult cases to be diagnoses. Similarly, children often have mechanisms in place during their childhood that may hide the functional issues associated with ADHD—parents who set schedules and monitor them, schools with regimens, etc. These “safety nets” disappear as patients age and become adults, move out of their family home, go off to college, enter the workforce, etc.

To help illustrate this point, Wall shared a case example of a 30-year-old woman who initially presented with depressed mood, anxiety, panic, racing thoughts, and sleep onset insomnia. The patient was very successful in school growing up and credits that partially to strict schedules and expectations by her parents as well as her swimming regimen. In later sessions, she admitted to a history of struggling with concentration and organization and said she was often forgetful. After seeing success at a community college, she decided to move way to finish her education. Unfortunately, she struggled and received failing grades, so she moved back home. The current concentration issues are causing problems at her work as well as with her marriage, and thus she sought help.

Wall said patients like this often respond well to pharmacological treatment, even to the point of addressing other comorbidities like anxiety and depression. It is not uncommon, she added, for patients to tell her, “I feel calm for the first time in my life,” after initiating ADHD treatment.

There are differences between men and women with adult ADHD, Wall added. For instance, females may have higher hyperactivity and impulsivity than males, but it might register instead as restlessness. In some cases, the “restlessness” in women gets confused with anxiety, Wall noted. In terms of

, males usually have externalizing varieties like conduct disorder and oppositional defiant disorder. On the other hand, females tend to present with complaints of pain, anxiety, and somatoform disorder, she said. Girls with ADHD are also more likely to have disruptions in their relationships than boys, which results in lower self-esteem. Also important are the hormonal effects on ADHD in girls and women, she said. Finally, not all rating scales are normed for gender, Wall added. She said she uses the Conners rating scale for ADHD, as it has been normed for gender.

psychopharmacological and nonpharmacological treatments

 are successful for female patients, Wall noted. Stimulants are not recommended for women who are pregnant or breastfeeding, she added. Interestingly, she said girls respond better than boys with combined pharmacological and nonpharmacological treatment.

The APNA 36th Annual Conference was held October 19 - 22, 2022, in Long Beach, California. 

Why are more and more adult women being diagnosed with ADHD? A presentation at the APNA Annual Conference shed light on the issue.   

Examining the Increasing Number of Adult Women With ADHD

The attempt to politicize and legalize medical care continues. Following the Supreme Court strike down of 

, the federal law allowing abortion for the last 50 years, a bill was introduced this past Friday in Congress that would bar gender-affirming care for transgender minors across the country.

Already, the state of Florida has banned Medicaid coverage of gender transition care for those of any age, using the controversial managed care business criteria of “non-medically necessary.”

 Today is Florida’s primary election day, perhaps with national implications, as abortion and LGBTQ+ rights having been hot topics of debate.

Yesterday, USA Today concluded that there was a false claim about Boston Children’s Hospital’s transgender care program.

 After sharing an informational video, the hospital and its involved physicians were threatened with violence. I am sure many connected to such care anywhere remember that doctors providing abortion were murdered and Salmon Rushdie was recently stabbed with the intent to kill.

Before I retired from clinical care in 2012, I had provided evaluation and care both of women seeking abortion in 1972 and anyone requesting gender transition care starting in the 1990s. Research supported my clinical sense that such care significantly improved the mental health of patients in both groups, including eliminating suicide risk. I also reported on both for 

These recent legal developments regarding abortion and gender are posing major ethical dilemmas for psychiatrists and other physicians. The Preamble of our ethical principles states that our first priority is to patients, but secondarily to society, colleagues, and ourselves. So, if society bans certain medical procedures and care, does that eliminate our responsibility to people desiring them? Section 3 would suggest that it does not, as it states

“A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.”

Now, how far should a physician and the representative professional associations ethically go to protest, redress, and educate the public about these legal changes if they are known to harm patients or would-be patients, when it is personally and organizationally risky to do so?

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

The Ethical Way: Challenges & Solutions for Managed Behavioral Healthcare.

2. Hudnall H. Fact check: false claim about Boston Children’s Hospitals transgender care program. USA Today. August 22, 2022. Accessed August 23, 2022. 

https://www.usatoday.com/story/news/factcheck/2022/08/22/fact-check-false-claim-boston-hospitals-transgender-care/10340507002/

 American Psychiatric Association Press; 2013.

Gender-affirming care: medically necessary for mental health. 

Will Transgender Care Follow the Path of Abortion?

“We always want to make sure we weigh the risks of the untreated psychiatric disorder when we are considering treatments, especially medication exposures, for women of reproductive age,” said Marlene Freeman, MD, professor of psychiatry at Harvard Medical School.

In her presentation, “Pregnancy and Postpartum Management of Psychiatric Disorders,” at the 

2022 Annual Psychiatric Times™ World CME Conference

 in San Diego, Freeman discussed how it is important to focus on antidepressant treatment in women with depression during pregnancy and the postpartum period. Approximately 45% of pregnancies in developed countries are unplanned, shared Freeman, and 75% of teen pregnancies are unplanned.

 Furthermore, 82% of US women have had a child by age 40.

 This is why it is important to tend to psychiatric disorders, which carry risks for both mother and baby if left untreated.

“The risks of the untreated psychiatric disorders impact efficacy and outcomes as well as child development overall,” Freeman said.

Freeman also stated that the absolute risk of selective serotonin reuptake inhibitors (SSRIs) exposure in pregnancy is small, and reproductive safety data on SSRIs exceed what is known about many other medications used in pregnancy. Prevalence of SSRI use during pregnancy is 3% to 7%.

According to recent research, there is no evidence of increased risk for major malformations or cardiovascular malformations in the offspring of women who took SSRIs while pregnant.

Another concern raised about SSRIs there is the potential increased risk of autism. Freeman shared that, through studies and meta-analyses, results have determined that SSRIs are associated with increased risk of autism, but not by cause and effect because you must factor in maternal psychiatric illness, which appears to be the driving factor.

Treatment Recommendations for Postpartum Depression

Approximately 10% to 15% of women experience major depressive episodes post-delivery, and that number increases to 25% to 40% if the woman has a history of major depressive disorder.

“Postpartum depression has been called the most common obstetrical complication,” Freeman said.

Freeman had a number of tips for treating mothers with postpartum depression, including using the lowest effective doses of SSRIs, consulting with perinatal/reproductive psychiatry specialists as needed, and maximizing nonmedication treatments. These nonpharmacologic strategies are (1) maximized social supports, (2) psychoeducation of patient and family, (3) group therapy or support groups, (4) interpersonal therapy, and (5) cognitive behavioral therapy.

“There are a lot of unknowns involved with pregnancy,” Freeman concluded. “We want to make sure that the treatment decisions we make are really collaborative with patients.”

To further support patients and their clinicians, Freeman referred to 

First-trimester use of selective serotonin-reuptake inhibitors and the risk of birth defects.

Newer antidepressants in pregnancy and rates of major malformations: a meta-analysis of prospective comparative studies.

3. Einarson A, Pistelli A, DeSantis M, et al. 

Evaluation of the risk of congenital cardiovascular defects associated with use of paroxetine during pregnancy.

4. Alwan S, Reefhuis J, Rasmussen SA, et al. 

Use of selective serotonin-reuptake inhibitors in pregnancy and the risk of birth defects.

Teratogenicity of SSRIs--serious concern or much ado about little?

The use of selective serotonin reuptake inhibitors during pregnancy and breast-feeding: a review and clinical aspects.

7. Wogelius P, Nørgaard M, Gislum M, et al. 

Maternal use of selective serotonin reuptake inhibitors and risk of congenital malformations.

8. Huybrechts KF, Palmsten K, Avorn J, et al. 

Antidepressant use in pregnancy and the risk of cardiac defects.

Antidepressant exposure during pregnancy and risk of autism in the offspring, 1: meta-review of meta-analyses.

Treatment of mood disorders during pregnancy and postpartum.

11. Pearlstein T, Howard M, Salisbury A, Zlotnick C. 

12. Branquinho M, de la Fe Rodriguez-Muñoz M, Maia BR, et al. 

Effectiveness of psychological interventions in the treatment of perinatal depression: a systematic review of systematic reviews and meta-analyses.

Treating women of reproductive age who have depression can be difficult. Here’s an overview on the subject from the 2022 Annual Psychiatric Times™ World CME Conference. 

The Importance of Managing Psychiatric Disorders During Pregnancy and Postpartum

Hormonal changes are among a host of issues that can influence psychiatry and medical conditions in women, and being aware of the total picture can deeply impact these patient’s treatment, C. Neill Epperson, MD told attendees at the 2022 

 World CME Conference being held in San Diego this week.

Epperson, who is a professor and chair of the department of psychiatry at the University of Colorado in Aurora, Colorado, discussed the interaction between the endocrine system, early childhood influences, the brain, and the nervous system at the meeting.

Epperson noted that it is important for psychiatrists to consider the

when treating patients, particularly as it relates to women, since there are pronounced differences between genders in how hormones impact their mental health. The differences in how hormone treatments affect women begin in adolescence she said, with young girls twice as likely than male counterparts to be prescribed a steroid, often related to addressing unprotected sexual intercourse at sexual debut.

“Always think about what kind of steroid/contraception they are on, as they can profoundly affect the endocrine system,” Epperson explained. This is also true for women who are menopausal, as hormones have been shown to influence executive function, sexuality, cardiovascular disease, and mental health issues including major depressive disorder in women undergoing life transition. Postpartum, oxytocin has been shown to play a key role in milk letdown and uterine contraction, and it has a profound impact on maternal nurturing. 

“I’m not saying it’s all about the hormones, but I am saying if you don’t think about it you’re missing a big piece of the puzzle,” Epperson said.

Shifting gears to another “piece of the puzzle,” Epperson addressed how early life experience can impact hormones, which in turn can have an influence on a patient’s mental health. She discussed the work ofIda Haahr-Pedersen, PhD, from Trinity Center for Global Health in Dublin, Ireland, and colleagues in a study that looked at 1839 US household survey participants and assessed self-reported rates of 

The investigators found that women were twice as likely as their male counterparts to report ACE as well as social and emotional difficulties in childhood. 

In perimenopausal women, Epperson said, the most common ACEs associated with 4+ status for women included emotional abuse, domestic violence, emotional neglect, and physical neglect, and 15% of women in this age range are in the 4+ ACE group. There is also wide variability of ACE impact on women depending upon where they live, so taking that into account when considering how to interact with patients, and female patients in particular, is important as well, she said.

The endocrine system is an important puzzle piece when addressing psychiatric disorders. 

Gender Issues

Affirming Evidence-Based Care for Young Patients Who Are Transgender or Gender Diverse

Examining the Increasing Number of Adult Women With ADHD

Will Transgender Care Follow the Path of Abortion?

The Importance of Managing Psychiatric Disorders During Pregnancy and Postpartum

Consider the Endocrine System When Addressing Mental Health

The Model Minority Myth and Medicine: Racism, Sexism, and Mental Health

Our Women Deserve Better

Gender and Sex Issues in Bipolar Disorder

Insomnia and Cognition in Males vs Females With Schizophrenia

From the Pages of Psychiatric Times: April 2022