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“In a disaster, we naturally tend to pay attention toward the most immediate victims, so people who are impacted physically and with physical injuries and damages,” Gaëlle Rached, MD, MSc, said in a new research presentation at the 2022 American Psychiatric Association Annual Meeting. But what about the family members who live thousands of miles away?

Rached, Research Postdoctoral Fellow at Northwestern University, shared details about the events of August 4, 2020, when the residents of Beirut experienced a massive explosion as a result of improperly stored ammonium nitrate at the port. More than 200 individuals were killed, and many more were injured and left homeless. Although Rached was in the city and saw firsthand the devastation and trauma, she found herself taken aback by the reports from expat friends and colleagues. 

“They heard about the blast from social media, and they tried reaching out to their families, but they weren't able to reach them,” she said. “The lines weren't connecting. They spent hours trying to reach them and thinking and imagining the worst… Can you imagine sitting at home looking at these headlines and wondering what your family is going through? Can you imagine seeing these videos shared over on social media and being stuck abroad due to COVID, not being able to help?”

As she talked with her colleagues about these experiences, she realized that the traumatic experiences were similar, “but somehow a little bit different.”

In general, expatriates are exposed to stressful living conditions, which makes them more susceptible to developing mental health problems, Rached noted. Yet their general mental health is not well studied, and even less is known about such in the context of traumatic events. Thus, Rached and colleagues conducted a 7-month study to examine the impact of the Beirut explosion on expats.

The study consisted of 670 Lebanese citizens or first generation from Lebanese descent who were residing abroad (not in Lebanon) and at least 18 years old. Of that population, 268 experienced the explosion and/or had close family members physically impacted by it. The median age was 31, and the majority (62.2%) were female. Participants came from all over the world, with the highest percentages coming from the United States and France. Study co-authors included Muriel Slim; Dimitri Fiani, MD; Margarita Abi Zeid Daou, MD; and Souraya Torbey, MD.

Participants were screened using the Hopkins Symptoms Checklist and the PTSD Checklist for DSM-5. Preliminary analysis found almost 60% of the 268 who had more personal experience had scores on the PTSD Checklist indicative of PTSD. Furthermore, about 41% of participants screened higher than the threshold for anxiety and depression on the Hopkins Symptom Checklist. Both younger age and female sex were associated with higher scores, even months after the event occurred.

Rached explained their results show expatriates’ mental health are negatively affected by traumatic events in their home countries:

- Regardless of how long the expat has been away from their home country

- Regardless of if they experienced the event or witnessed it firsthand

“My simple message would be that there are 200 million expats around the world right now. Look out for expats in your life—your friends, your coworkers, your colleagues—especially when the country is going through traumatic events,” Rached concluded.

Are you attending the 2022 American Psychiatric Association Annual Meeting? We want to hear your thoughts! Share recaps, reflections, and experiences with us at PTEditor@mmhgroup.com. Be sure to visit us at booth 1852.

Research explored how a traumatic explosion affected individuals around the world. 

New Data Shows Trauma’s Ripple Effects

“I think until we really understand the underlying neurobiology of PTSD, we’re stuck with a situation where the patient gets better, but they don’t get well.”

Charles B. Nemeroff, MD, PhD, Matthew P. Nemeroff Endowed Chair and professor in the University of Texas at Austin (UT Austin) Dell Medical School Department of Psychiatry & Behavioral Sciences, discussed the neurobiology of posttraumatic stress disorder (PTSD) at the 2022 American Psychiatric AssociationAnnual Meeting. In the session—moderated by Edmond Hsin T. Pi, MD—Nemeroff described the diagnosis, epidemiology, and pathophysiology of PTSD, along with notable risk factors and some current and emerging treatments for PTSD.

According to Nemeroff—who is also director of the Institute for Early Life Adversity Research and co-director of the Center for Psychedelic Research & Therapy at UT Austin Dell Medical School—PTSD is the only diagnosis in DSM-5 that is dependent on an external event, and the traditional view is that most individuals who develop PTSD eventually recover from it. However, there are several preexisting conditions and risk/vulnerability factors for PTSD that play a role in its development and course, including female sex; childhood or adolescent trauma exposure; family or personal history of anxiety or mood disorder; stressful life events in the prior and following year; and either panicked reactions (eg, shaking, sweating) or dissociative reactions (eg, tunnel vision, slow motion) at the time of the trauma.

Nemeroff also cited several pathophysiology studies using PTSD as the prototype gene X environment interaction disease, with a special focus on candidate genes such as FKBP5 and CRHR1, which have been shown to be predictive of PTSD development. These, along with preexisting conditions and risk/vulnerability factors for PTSD, are important because “psychiatry needs to focus on identifying people who are at risk for psychiatric disorders and intervening before the breaking point (the first psychotic episode, etc),” he stated.

Nemeroff discussed multiple options for psychosocial and pharmacological PTSD treatments, all with the general goals of reducing core symptoms, improving function and quality of life, strengthening resilience, relieving comorbid disorders, preventing relapse, and providing rehabilitation. For psychosocial treatments, he discussed exposure therapy, anxiety management, desensitization, hypnotherapy, and cognitive behavioral therapy (CBT). He added that CBT is a particularly notable psychosocial treatment, stating that “There’s no doubt that either a cognitive processing therapy or trauma-focused CBT should be a component of the treatment.”

In terms of pharmacological PTSD treatments, Nemeroff cautioned that “PTSD takes much longer to respond to medication than depression. You have to stick with it.” He did, however, discuss the efficacy of selective serotonin reuptake inhibitors (SSRIs) sertraline (Zoloft) and paroxetine (Paxil)—the only 2 drugs approved by the US Food and Drug Administration (FDA) for the treatment of PTSD—as well as 3,4-methyledioxymethamphetamine (MDMA)-assisted therapy. Recent research has highlighted the potential of MDMA-assisted therapy as a potential breakthrough treatment for PTSD. “This is the most exciting finding in the PTSD world,” Nemeroff stated. “I believe there will be a role for MDMA in the treatment of PTSD.”

How can we more effectively help patients with PTSD? Charles B. Nemeroff discusses the diagnosis, epidemiology, and pathophysiology of PTSD, along with current and emerging treatments, at the 2022 APA Annual Meeting.

Understanding the Neurobiology of PTSD

, we worked with experts from multiple areas in psychiatry to bring you thoughtful articles about a wide variety of psychiatric issues, from managing depression in older adults and differences in trauma response to the effects of the COVID-19 pandemic on youth and the growing US mental health crisis. Here are some highlights.

Psychiatric Care in the US: Are We Facing a Crisis?

By the end of 2021, many American adults found themselves inthe worst mental state in years. According to the US Census Bureau’s Household Pulse Survey, 47% of adults reported symptoms of anxiety,

 and 1 in 5 adults disclosed suffering from a mental illness.

 Despite this, it is estimated that less than half of Americans with a mental disorder get adequate treatment.

“It has been just over a year now since the COVID-19 pandemic struck the United States full force. A year of hunkering down and Zooming in, teleworking and telepsychiatry, economic and social upheaval, and steady scientific progress. Looking back to last March, we knew this would be difficult. But we didn’t know how difficult. And we certainly didn’t know that the challenge of COVID-19 would last this long,” said Joshua A. Gordon, MD, PhD, director of the National Institute of Mental Health, in a 2021 director’s message.

Why Men and Women May Respond Differently to Psychological Trauma

Posttraumatic stress disorder (PTSD) is a mental health disorder that arises after experiencing a traumatic event in about 10% of exposed individuals. A hallmark symptom is the reexperiencing of the traumatic event in the form of nightmares or flashbacks or reliving the event upon certain triggers. 

These unwanted memories cannot be controlled, and the event may feel like it is happening again. Individuals with PTSD will try to avoid these memories by not talking about them or by staying away from situations where potential triggers might be present (eg, the store where the robbery took place or watching the news about current combat events or natural disasters).

Several cognitive and mood alterations—such as memory problems, negative thoughts or feelings, and high arousal levels—may manifest themselves in several ways. These include being easily startled and having angry outbursts, sleeping problems, or difficulty concentrating on everyday tasks. 

The Management of Depression Among Older Adults

Depression is not an uncommon condition among older adults, and it is often underdiagnosed in this population. Depression also results in greater rates of morbidity and mortality among older adults. 

The neurobiology of depression includes a complex interaction among various biological, psychological, and social factors. The identification of depression among older adults requires a thorough history, a focused physical examination, appropriate laboratory studies, and the use of neuropsychological testing when necessary.

Current available treatments for older adults with depression include psychotherapy, pharmacotherapy, electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and collaborative care approaches.

 In addition, some evidence indicates that aerobic and supervised group exercise regimens may improve depressive symptoms among older adults.

 In this review, we assess the evidence for using psychotherapy, pharmacotherapy, ECT, TMS, and collaborative care approaches for the treatment of depression among older adults. 

Here’s How the COVID-19 Pandemic is Shaping the Next Generation

The full picture of teenagers’ experience of COVID-19 is just beginning to emerge. The school closures, canceled proms, and separation from friends seemed a small price to pay to save the lives of thousands—but in exchange, the adolescents who represent the younger side of Generation Z were robbed of the capstone of their formative years. It created an atmosphere of uncertainty and anxiety among some teens, about both the future and their place in it.

As if the pandemic was not enough, teens watched as police violence and racial tensions reached breaking points. They saw angry mobs take over cities and storm the Capitol. Then Mother Nature swept in with deadly wildfires and other natural disasters that underscored the threat of climate change. 

. And be sure to stay up-to-date by subscribing to the 

Do you have a comment on any of these or other articles? Have a good idea for an article and want to write? Interested in sharing your perspectives? Write to us at 

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

From the Pages of Psychiatric Times: April 2022

) is a mental health disorder that arises after experiencing a traumatic event in about 10% of exposed individuals. A hallmark symptom is the reexperiencing of the traumatic event in the form of nightmares or flashbacks or reliving the event upon certain triggers. These unwanted memories cannot be controlled, and the event may feel like it is happening again. Individuals with PTSD will try to avoid these memories by not talking about them or by staying away from situations where potential triggers might be present (eg, the store where the robbery took place or watching the news about current combat events or natural disasters). Several cognitive and mood alterations—such as memory problems, negative thoughts or feelings, and high arousal levels—may manifest themselves in several ways. These include being easily startled and having angry outbursts, sleeping problems, or difficulty concentrating on everyday tasks.

Although men experience traumatic events more often than women overall, studies have shown that women are 2 to 3 times more likely to develop PTSD after experiencing a traumatic event than men: about 10% to 12% in women compared with 5% to 6% in men.

 It is not just the prevalence of PTSD that differs between women and men, but also their PTSD subcluster scores. For instance, women report reexperiencing the event and anxious arousal more often than men,

 although a study looking at PTSD trajectory symptom courses over 1 year after admission to emergency departments found that a recovering trajectory is more prevalent in women, while men more often showed a delayed onset of their symptoms.

Gender differences in PTSD symptoms that are due to stressors associated with the COVID-19 pandemic have also been reported, with women scoring significantly higher than men. Women have higher rates of reexperiencing events and of negative alterations in cognition or mood,

 dissociative responses, and a range of other posttraumatic reactions.

 With regard to the expression of PTSD symptoms, men might be more likely to feel anger and to have trouble controlling their anger, whereas women might feel more often anxious and depressed, as well as easily startled.

Which factors may help us understand why men and women respond differently to trauma? We describe how gender differences in the characteristics and timing of the traumatic event, as well as in the immediate and later biological and psychological reactions to the event, can impact how people respond to trauma.

 We would like to emphasize that there are no standard male or female response types to traumatic stress, but some features are more common in women and others in men. We use the term sex in this text to refer to a biological construct rooted in genetics, anatomy, and physiology. “Gender” is defined as a psychosocial construct that is an internal sense of self—whether individuals see themselves as women, men, or other gender identities—including the psychological, behavioral, and social consequences of one’s perceived gender.

In general, high-impact events, such as sexual abuse or interpersonal violence, are associated with a higher probability of developing PTSD than are lower-impact events, such as car accidents or disasters. Men and women differ in how often they experience specific types of traumatic events. Although men experience high-impact events, 

women have a much higher chance of being exposed to these types of events than men

. This difference in exposure is partly responsible for the increased risk of PTSD in women.

Timing of the event is another important aspect for understanding gender differences in PTSD. Women experience traumatic events more often at a younger age. In children, these experiences may disrupt their neurobiological development, especially when repeated, such as in domestic violence or sexual abuse by a caregiver. Repeated childhood trauma, especially in combination with emotional neglect, is also a risk for personality disorders, dissociative disorders, or so-called complex PTSD.

 Biologically, there is accumulating evidence that in addition to more girls being exposed to this type of trauma, there are also differences in how different areas of the brain are being affected between boys and girls.

 Socially, traditional socialization encouraging gender-conforming behavior (eg, girls and women should be emotional and passive) seems to be less advantageous for women in terms of mental health.

Culturally, the increased risk of PTSD symptoms in women is magnified in more traditional cultures. However, this increased risk may not be evident among women in professions traditionally regarded as masculine, such as first responders, police officers, and veterans.

 summarizes results from a US Department of Veterans Affairs survey comparing differences in the prevalence of mental health conditions, including PTSD, among male and female veterans who had experienced military sexual trauma.

In order to understand the psychological strengths and problems of trauma survivors in the general population, it is important to consider gender stereotypes and roles across cultures, cultural responses to traumatic events, and cultural impact on symptom expression. Norms, beliefs, and rituals may shape the subjective meaning of trauma—for example, beliefs about the spiritual importance of nightmares and their significance for physical security in Native American communities or a local concept of a trauma-related syndrome such as baksbat (broken courage) among the Khmer in Cambodia.

 Furthermore, several non-Western cultures may use somatic symptoms to express distress. Our treatments are also still mostly Western-based and need both gender- and culture-sensitive approaches.

Acute Responses and Stress-Coping Pathways

High acute psychological responses to an event comprise a well-established risk factor for the development of PTSD. After an event, women report higher levels of perceived threat and acute distress than men. In addition, the risk factor of peritraumatic dissociation (ie, experiencing dissociative states such as depersonalization, derealization, amnesia, and/or detachment during the traumatic event, which is more prevalent in women than in men) has been found to be related to higher autonomic arousal, which can predict the subsequent formation of distressing intrusions.

Coping styles that may be more or less effective in reducing acute stress levels also differ between genders. In line with a masculine gender role, men often cope with traumatic stress in a more problem-focused manner, which may decrease the risk of PTSD symptoms developing and of them becoming more chronic and severe, if they do develop.

 In contrast, women use more avoidant and emotion-focused coping styles, including relaxation, but they are also more likely to take psychoactive substances in the attempt to reduce the high arousal levels that are associated with a heightened risk of PTSD. The most pronounced gender difference is seen in seeking social support as a coping style, which is much more frequent among women. Because women are more likely to show a “tend-and-befriend” response to stress, which is clearly related to the availability of support from their social network, it is no surprise that unavailability of social support is one of the strongest predictors of PTSD.

Neurobiologically, numerous studies show dysregulation in several systems in individuals with PTSD. Acutely after trauma, the amygdala—the alarm center of the brain—activates the sympathetic nervous system and sets a chain of neurobiological stress responses in motion.

 PTSD has consistently been associated with amygdala hyperactivity and lower ventromedial prefrontal cortex control over the amygdala, which may explain the vivid fear-laden memories in PTSD. Within the neuroendocrine response, a dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis is typically found in PTSD (eg, with lower basal cortisol levels and enhanced glucocorticoid receptor [GR] function). And the most consistently found reaction to PTSD relating to the immune system is a proinflammatory state.

Sex-specific epigenetic and neuroendocrine influences (eg, gonadal hormones or oxytocin) and immune responses contribute to differential responses to trauma.

 For example, women have often been reported to have lower basal cortisol concentrations compared with men, while showing a larger cortisol response to stress and lower proinflammatory cytokines. These impact the stress response chain and are associated with a higher PTSD risk. However, our knowledge of sex differences is based on limited data from women; until recently, only 2% of neurobiological research had been conducted in females (and these were mainly rats, not humans).

Treatment of PTSD and Clinical Implications

The treatments of choice for PTSD are psychological interventions, such as trauma-focused cognitive behavioral therapy and eye movement desensitization and reprocessing.

 The results for military personnel and veterans, overall, are less than impressive.

 Some studies show that men may drop out of trauma treatment more often than women, and that recovery rates are higher in women than men,

 but evidence for these gender differences is limited and inconsistent, according to recent systematic reviews.

Several pharmacological approaches (fluoxetine, paroxetine, sertraline, and venlafaxine) reduce PTSD symptoms, but with a lower effect size than psychological treatments.

 Little research has been conducted on sex and gender differences in response to pharmacotherapy for PTSD; most still involve single-sex studies in men.

 A literature review of pharmacologically assisted psychotherapy for adults with PTSD showed approaches that combine medication and psychological treatment, including 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy, may be promising interventions,

 but sex and gender differences are yet to be determined.

In sum, there are both sex and gender differences in biological, psychosocial, and cultural factors that may explain why PTSD is more prevalent in women than in men. In clinical practice, however, diagnostics should not be affected by gender stereotypes that could result in underdiagnosis of sexual trauma and PTSD in men.

Women are more likely to experience high-impact events during a developmentally sensitive period of life. However, if this happens to boys, the impact is not smaller than in girls. Neurobiological dysregulations (eg, in the HPA axis) and coping styles are important factors in explaining differential responses of men and women to psychological trauma. We need more research on sex- and gender-sensitive personalizing of both psychological and pharmacological treatments to optimize efficacy.

Still too much research is done in men only. Sex- and gender-sensitive research and reporting has certainly been growing in recent years, but more diversity in research populations is needed. Sex/gender-disaggregated data analyses will provide more valid information on the roles that sex and gender play in traumatic experiences.

As diverse populations of traumatized individuals from Western and non-Western world regions seek mental health care, it is also critical to understand the role of culture in how men and women conceptualize trauma and express traumatic symptoms. This knowledge will help us better understand how to optimize gender-sensitive treatment cross-culturally.

Future research on PTSD should also focus on the interaction between sex and gender in response to traumatic events. As researchers gather more data on the roles of sex and gender as biological, psychosocial, and cultural variables in posttrauma responses, the picture will become clearer.

is professor of psychotraumatology at Amsterdam University Medical Centers, Department of Psychiatry, University of Amsterdam, the Netherlands, and is director of research at ARQ National Psychotrauma Center, Diemen, the Netherlands. She is editor-in-chief of the European Journal of Psychotraumatology, and she is chair of the Global Collaboration on Traumatic Stress. 

 is a researcher and lecturer at the Department of Medical and Clinical Psychology at Tilburg University, Tilburg, the Netherlands. She is the guest editor of the special “Sex & Gender” issue of the European Journal of Psychotraumatology.

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Cultural scripts of traumatic stress: outline, illustrations, and research opportunities

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PTSD is more prevalent in women than in men. What are the biological, psychosocial, and cultural factors that may explain why?

According to a study conducted before the COVID-19 pandemic, a virtual connection to a psychiatrist office may be enough to help individuals with posttraumatic stress disorder (PTSD) and bipolar disorder who live in more rural communities get effective care.

The randomized study examined approximately 1000 participants with PTSD, bipolar disorder, or both conditions. Results showed that most participants engaged well with 2 types of telehealth: (1) telepsychiatry collaborative care, in which a psychiatrist makes the initial diagnosis via video and the local clinic team provides psychotherapy while the local primary care physician handles prescriptions with consultation from the telepsychiatrist, and (2) telepsychiatry/telepsychology enhanced referral, in which a psychiatrist makes the initial diagnosis and handles medication prescriptions, and a psychologist provides psychotherapy by telehealth. The data came from the Study to Promote Innovation in Rural Integrated Telepsychiatry (SPIRIT) trial, which involved participants from 24 clinics in Michigan, Washington, and Arkansas.

Leading this secondary analysis of the SPIRIT data was Jennifer Severe, MD, of the Department of Psychiatry at Michigan Medicine, along with Paul Pfeiffer, MD, MS, codirector of the Mental Health Innovation, Services and Outcomes Program within the U-M Department of Psychiatry, and John Fortney, PhD, from the Department of Psychiatry and Behavioral Sciences at the University of Washington.

“The study started at a time where clinicians had reservations about treating psychiatrically complex patients with telehealth or integrated care models. Understandably, engagement in care was one of the many concerns,” said Severe. “This study showed that patients with multiple psychiatric conditions and who also struggle with several chronic physical health problems can engage well in mental health treatment with their primary care doctors or remote mental health specialists.”

While participants responded well to both types of therapy, participants who were assigned to get a form of psychotherapy from a specially trained nurse or social worker on staff at their local clinic ended up completing 60% more such sessions than those who were assigned to connect with a clinician via videocall. The ongoing in-person contact with their nurses or social workers checking on their other health needs may have been a contributing factor.

Another such study using data from the SPIRIT trial demonstrated patients in both groups reported statistically significant improvements in perceived access to care, decreases in their mental health symptoms and medication side effects, and improvements in their quality of life.

This current study took more of a look at how patients’ own clinical characteristics affected their experience with telehealth, and how well they stuck with the treatment course. For example, results showed that participants who have issues with drugs, and those experiencing manic symptoms from their bipolar disorder, may need additional support to get started on psychotherapy or to stay with it. Additionally, those who have multiple physical health conditions may be most likely to maintain their mental health medications and talk therapy programs.

1. Severe J, Pfeiffer PN, Palm-Cruz K, et al. 

Clinical predictors of engagement in teleintegrated care and telereferral care for complex psychiatric disorders in primary care: a randomized trial.

2. Where mental health help is scarce, telehealth makes a big difference. News release. February 7, 2022. Accessed March 22, 2022. 

https://www.newswise.com/articles/where-mental-health-help-is-scarce-telehealth-makes-a-big-difference

Two forms of telehealth can improve quality of life and care for patients with PTSD and bipolar disorder who live in more rural communities. 

Building a Connection: Telehealth for PTSD and Bipolar Disorder Treatment

 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 

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

PTSD

New Data Shows Trauma’s Ripple Effects

Understanding the Neurobiology of PTSD

From the Pages of Psychiatric Times: April 2022

Why Men and Women May Respond Differently to Psychological Trauma

Building a Connection: Telehealth for PTSD and Bipolar Disorder Treatment

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

Psychedelics and the Future of Psychiatry

Weeds, Wildflowers, and Wordsworth

Exploring the Link Between Migraine and PTSD

PTSD in Late Life: An Update on Clinical Issues