Tag: medical students

Brexpiprazole + Sertraline: A New Hope for PTSD Treatment

We’ve all seen it: PTSD that won’t budge. Patients try sertraline or paroxetine—the so-called “gold standards”—and walk away with little more than side effects and a sense of failure.

Enter a new contender: brexpiprazole + sertraline.

A recent Phase 3 randomized controlled trial might finally offer something real for those stuck in the PTSD trenches.

🚨 The Results

In a study across 86 sites with over 550 adults, adding brexpiprazole (2–3 mg) to sertraline (150 mg) led to a 5.6-point greater reduction on the CAPS‑5 (the gold-standard PTSD measure) compared to sertraline + placebo. That’s not a marginal win—it’s a clinically significant shift, especially in a treatment-resistant population.

Responder rates tell the story even clearer:

  • 68.5% of patients on the combo had ≥30% reduction in symptoms
  • Compared to 48.2% on sertraline alone
  • That’s a +20% absolute response rate boost

And the improvements weren’t just short-lived. Benefits held through 12 weeks, even during a post-treatment observation period. No relapse, no rebound—just stability.

🧩 More Than Symptom Checklists

It wasn’t just about PTSD symptoms. This combo also:

  • Improved psychosocial functioning (B-IPF scores)
  • Reduced anxiety and depression (HADS)
  • Lowered global illness severity (CGI-S)
  • Helped with all symptom clusters, including reexperiencing, avoidance, and hyperarousal

That’s rare. Most meds in psychiatry hit one or two domains and leave the rest hanging. This one made a dent where it counts: function, resilience, and real-world relief.

⚠️ What About Side Effects?

Brexpiprazole is still an atypical antipsychotic, so there’s baggage. But the trial data suggest it’s relatively well-tolerated:

  • Fatigue: 6.8%
  • Weight gain: 5.9%
  • Somnolence: 5.4%
  • Discontinuation due to AEs? Just 3.9%, vs 10.2% in placebo.

No new safety signals. No psychosis worsening. Not perfect, but not the metabolic disaster zone we see with other agents.

🚀 What’s Next?

The FDA is reviewing this combo

For those of us treating chronic PTSD, this may be a real tool—not just a shiny new molecule with good marketing.

Until then, it’s worth paying attention. Because when sertraline alone doesn’t cut it—and we know it often doesn’t—this combo could offer a lifeline.

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Reject dogma—embrace nuance in Psychiatry

🔹 Psychoanalysis should not be treated as sacred doctrine. Freud was a clever and influential thinker, but not a prophet.


🔹 Biological psychiatry is equally vulnerable to dogma. Not every symptom signals a disease, and not every distress warrants medication.


🔹 That said, evidence-based pharmacology has its place—especially when medications show clear, replicable benefits in defined clinical conditions.

The future of psychiatry lies in balanced thinking, not blind allegiance—to Freud, to biology, or to any single model of mind.

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🌿 CBD for Psychosis? A Landmark Trial is Underway 🧠

A major new study—the Stratification and Treatment in Early Psychosis (STEP) trial—is set to investigate CBD as a potential treatment for psychosis on a larger scale than ever before. Led by Philip McGuire, MD, professor of psychiatry at Oxford University, STEP will involve 1,000 participants across 30 sites in 10 countries 🌍, making it one of the most ambitious trials of its kind.

🔬 Why it matters:
✅ CBD has shown promise in early studies for psychosis, but large-scale evidence is needed.
✅ STEP will combine three smaller trials to explore effectiveness, biomarkers, and precision treatment approaches.
✅ Nature Medicine named it one of 11 studies that will shape medicine in 2025.

🚀 Could CBD redefine psychosis treatment? The results could change the landscape of psychiatric care. Stay tuned!

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💊 Are Antidepressants Overprescribed in the U.S.? 🤔

The question of whether antidepressants are overprescribed in the United States is complex and depends on how “overprescription” is defined.

Arguments Suggesting Overprescription

  1. Broad Diagnostic Criteria:
    • The criteria for diagnosing conditions like major depressive disorder (MDD) can be broad, potentially leading to overdiagnosis and, consequently, overprescription.
  2. Prescribing Practices:
    • Primary care physicians write most antidepressant prescriptions, often without thorough psychiatric evaluation.
    • Some prescriptions are written for mild cases of depression or subclinical symptoms where psychotherapy or lifestyle changes might suffice.
  3. Off-Label Use:
    • Antidepressants are frequently prescribed off-label for conditions like insomnia, chronic pain, or anxiety, contributing to their high utilization.
  4. Pharmaceutical Influence:
    • Aggressive marketing by pharmaceutical companies has historically played a role in increasing antidepressant use.

Arguments Against Overprescription

  1. Underdiagnosis and Undertreatment:
    • Despite high prescription rates, many individuals with diagnosable depression or anxiety disorders go untreated, particularly in underserved populations.
    • Stigma and access barriers often prevent people from seeking care.
  2. Increasing Mental Health Awareness:
    • Growing awareness of mental health issues may explain rising prescription rates, as more people seek help for legitimate conditions.
  3. Non-Psychiatric Indications:
    • Antidepressants are also effective for non-depressive disorders, like obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and chronic pain, which justifies some of their broader use.

Data on Antidepressant Use

According to surveys, about 1 in 8 Americans aged 18 and older take antidepressants, and usage is particularly high among women, especially those aged 40–59. While this might seem like a high prevalence, it may also reflect greater recognition and treatment of mental health issues.

Key Considerations

  • Patient-Centered Care: The decision to prescribe antidepressants should be tailored to the individual, based on a comprehensive assessment of their symptoms and needs.
  • Access to Alternatives: Many individuals lack access to evidence-based non-pharmacological treatments like psychotherapy due to cost, availability, or stigma, making antidepressants a more feasible option.
  • Role of Education: Educating both prescribers and patients on appropriate use can reduce potential overprescription.
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Narcissistic Personality Disorder: Two Faces Explained

The key difference between vulnerable narcissistic personality disorder (NPD) and grandiose NPD lies in how the narcissistic traits are expressed and how the person copes with feelings of inadequacy and low self-esteem. Both fall under the umbrella of narcissistic personality disorder, but they represent different presentations:

Grandiose Narcissism

  • Core Traits:
    • Overt self-importance and entitlement.
    • A strong sense of superiority and belief in their own greatness.
    • Craving admiration and validation from others.
    • Often charismatic, confident, and socially dominant.
  • Defense Mechanisms:
    • Rely on denial and externalizing blame to avoid feeling vulnerable.
    • Tend to dismiss or belittle others’ opinions if they conflict with their own.
  • Interpersonal Behavior:
    • Exploitative in relationships, using others to bolster their self-esteem.
    • Seek out positions of power or visibility to maintain their inflated self-image.
  • Emotional Regulation:
    • Typically outwardly composed and unbothered, though they may become aggressive or vindictive if their self-image is challenged.

Vulnerable Narcissism

  • Core Traits:
    • Feelings of inadequacy, hypersensitivity to criticism, and low self-esteem.
    • A covert sense of entitlement—believing they deserve admiration but fearing they won’t get it.
    • A façade of humility or introversion, masking deep insecurities.
  • Defense Mechanisms:
    • Use avoidance and withdrawal to protect themselves from perceived rejection or failure.
    • Internalize blame and self-doubt, leading to cycles of shame and self-criticism.
  • Interpersonal Behavior:
    • Appear shy, reserved, or socially anxious, but they harbor fantasies of being special or recognized.
    • May oscillate between needing reassurance and distancing themselves from others out of fear of being hurt.
  • Emotional Regulation:
    • Prone to depression, anxiety, and mood swings.
    • Vulnerable to feelings of emptiness and envy of others’ success.

Clinical Distinction

  • While grandiose narcissists may seem outwardly self-assured and dominant, vulnerable narcissists are more likely to present with symptoms resembling mood or anxiety disorders, often masking their narcissistic traits.
  • Both types share a fragile self-esteem at their core but manifest it in opposite ways: grandiose types inflate their self-image, while vulnerable types retreat into themselves.

Grandiose Narcissism in a Clinical Setting

Case Example:

  • Presentation: A 45-year-old CEO attends therapy after his spouse threatens divorce, citing his arrogance and lack of empathy. He describes the problem as “Everyone just misunderstands how hard it is to be as driven and successful as me.”
  • Behavior in Session:
    • Dominates conversations, dismisses the therapist’s insights, and subtly challenges their expertise.
    • Boasts about his achievements, financial success, and social status but avoids discussing emotional issues or personal failures.
    • Minimizes his spouse’s complaints as “overreactions,” viewing them as jealous or ungrateful.
  • Underlying Issues:
    • Although he appears self-confident, his grandiosity masks deep fears of failure and inadequacy.
    • His need for admiration and his inability to tolerate criticism create interpersonal conflict.
  • Therapeutic Challenge:
    • Establishing rapport while gently confronting his defensiveness.
    • Helping him acknowledge and address the vulnerability underlying his grandiosity without triggering a withdrawal or rage response.

Vulnerable Narcissism in a Clinical Setting

Case Example:

  • Presentation: A 30-year-old graduate student seeks therapy for persistent depression and social anxiety. She describes herself as “a failure” and avoids academic conferences because she feels “everyone there is smarter and more talented.”
  • Behavior in Session:
    • Initially shy and reserved but gradually reveals fantasies of being recognized as brilliant and exceptional in her field.
    • Complains about colleagues receiving awards, feeling envious and deeply resentful, but also guilty for having those feelings.
    • Struggles to accept praise, dismissing it as insincere or undeserved, and reacts strongly to perceived slights or criticism.
  • Underlying Issues:
    • She feels torn between craving recognition and fearing rejection.
    • Her self-esteem depends heavily on external validation, but she avoids situations where she might fail or be criticized.
  • Therapeutic Challenge:
    • Helping her tolerate and process feelings of inadequacy without retreating into shame or avoidance.
    • Building her sense of self-worth independent of external achievements or comparisons.

Comparison:

  1. Interpersonal Dynamics:
    • Grandiose narcissists demand validation and admiration from others; vulnerable narcissists fear and avoid situations where their insecurities might be exposed.
    • The CEO pressures the therapist to affirm his greatness, while the student fears the therapist will see her as inadequate.
  2. Emotional Reactions:
    • The CEO might react to confrontation with anger or dismissal, while the student might respond with shame or withdrawal.
  3. Defense Mechanisms:
    • Grandiose types externalize blame (“They’re the problem”), whereas vulnerable types internalize it (“I’m the problem”).

Clinical Insights

Both types present challenges in therapy:

  • Grandiose narcissists may struggle with self-reflection, requiring careful, non-confrontational approaches to expose vulnerabilities.
  • Vulnerable narcissists are often more willing to explore their insecurities but may require help managing their intense shame and self-doubt.

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Breaking the Anxiety Barrier: LSD a Game-Changer for GAD?

Should LSD be considered a treatment for generalized anxiety disorder (GAD)? The results from MindMed’s Phase 2b study suggest it just might be. While this is only one study, and the FDA’s cautious stance on psychedelic-based treatments like MDMA raises questions about future approval, the findings are worth exploring. So, let’s dive in.

GAD is a fascinating and somewhat controversial diagnosis. Notably, the study excluded participants with major depressive disorder, a condition frequently comorbid with GAD, which raises interesting questions about the choice to isolate GAD. Some in the psychiatric field even challenge the validity of GAD as a distinct psychiatric disease, arguing it reflects broader distress rather than a discrete disorder.

Psychedelics like LSD are surging to the forefront of psychiatric research, largely because the field is starved for innovation. Decades of research and sophisticated drug development have yielded limited breakthroughs in understanding or treating psychiatric conditions. Meanwhile, society often clings to the hope that complex human behavior and mental health challenges can be reduced to something as simple as a pill you take every 12 weeks. The appeal of psychedelics lies in their potential to disrupt this paradigm—but can they deliver?

Key Findings:

  1. Dose-Dependent Response:
    • Patients receiving a higher dose (200 µg) of MM-120 showed rapid and sustained improvements in anxiety symptoms.
    • The reduction in anxiety symptoms was statistically significant compared to the placebo group.
  2. Speed of Onset:
    • Improvements were observed as early as two weeks post-dosing, suggesting a rapid therapeutic effect.
  3. Duration of Effect:
    • The anxiety-reducing effects lasted up to 12 weeks following a single administration, indicating long-lasting benefits.
  4. Safety Profile:
    • The treatment was generally well-tolerated, with mild to moderate adverse effects such as headache, nausea, and transient emotional changes. There were no reports of severe adverse events related to the study drug.
  5. Mechanistic Insights:
    • MM-120 appears to modulate serotonin 5-HT2A receptors, leading to enhanced neuroplasticity and emotional processing, which may underlie the observed clinical improvements.

I’m always interested in the study population and if the researchers selected a group of patients with prior psychedelic use. Here is what I found 

Participant Screening and Inclusion:

  1. Prior Psychedelic Use:
    • Some participants may have had previous experiences with psychedelics (e.g., LSD, psilocybin, MDMA), as long as such use did not interfere with the integrity of the study (e.g., recent or habitual use, which might influence tolerance or expectations).
    • Individuals with significant past psychedelic use might be excluded to minimize potential biases in response to the trial drug.
  2. Psychedelic-Naïve Participants:
    • The trial likely included a substantial proportion of participants who were psychedelic-naïve, meaning they had never used substances like LSD or psilocybin before.
    • This approach helps ensure that the observed therapeutic effects can be attributed to MM-120 rather than prior familiarity or psychological preparation for psychedelic experiences.

Why Prior Use Matters:

  • Expectation Bias:
    • Participants with past psychedelic experiences may anticipate certain effects, influencing subjective outcomes like anxiety reduction.
  • Safety and Tolerability:
    • Previous exposure to psychedelics might affect how participants tolerate or respond to the treatment.
  • Generalizability:
    • Including both psychedelic-naïve and experienced individuals helps make the findings applicable to a broader population.

Implications:

This study suggests that psychedelic-assisted therapy, especially with compounds like MM-120, has significant potential as a novel treatment for GAD, offering rapid and durable relief after just one dose. These findings pave the way for further research and larger-scale trials.

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Evidence-Based Diets for ADHD: Insights from Randomized Controlled Trials (RCTs)

Diet plays a significant role in brain health and behavior, making it a promising area for ADHD symptom management. While dietary changes are not a substitute for standard treatments, several dietary interventions have shown evidence-based benefits in improving ADHD symptoms.

1. Omega-3 Fatty Acid Supplementation

  • Why: Omega-3 fatty acids, particularly EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid), are crucial for brain development and function.
  • Evidence:
    • A 2018 meta-analysis of RCTs found that omega-3 supplementation improved attention and reduced hyperactivity in children with ADHD.
    • Higher EPA-to-DHA ratios (e.g., 3:1) were more effective.
  • How to Implement:
    • Include fatty fish (e.g., salmon, mackerel, sardines) 2–3 times per week.
    • Consider omega-3 supplements (1–2 grams daily with a high EPA content).

2. Elimination Diets

  • Why: Some children with ADHD may react adversely to specific foods or additives, exacerbating symptoms.
  • Evidence:
    • The Restricted Elimination Diet (RED), such as the oligoantigenic diet, has been tested in RCTs. A 2011 RCT published in The Lancet found significant symptom reductions in 64% of children who followed a restricted diet for 5 weeks.
    • Foods commonly eliminated include dairy, wheat, soy, eggs, and food additives.
  • How to Implement:
    • Work with a healthcare provider or dietitian to guide the process.
    • Reintroduce foods one at a time to identify triggers.

3. Additive-Free and Preservative-Free Diets

  • Why: Artificial food colorings, preservatives, and sweeteners may worsen hyperactivity in some children.
  • Evidence:
    • A meta-analysis published in Pediatrics (2012) found that artificial food coloring elimination reduced ADHD symptoms in a subset of children.
  • How to Implement:
    • Avoid processed foods with artificial dyes (e.g., Red 40, Yellow 5).
    • Read ingredient labels and choose whole, minimally processed foods.

4. Mediterranean Diet

  • Why: The Mediterranean diet is rich in nutrients critical for brain health, such as omega-3s, antioxidants, and vitamins.
  • Evidence:
    • A 2017 study in Pediatrics suggested that children who adhered to a Mediterranean diet had fewer ADHD symptoms compared to those with poor adherence.
  • How to Implement:
    • Focus on fruits, vegetables, whole grains, nuts, seeds, fish, and olive oil.
    • Limit red meat, processed foods, and added sugars.

5. Low-Glycemic Index (GI) Diet

  • Why: High-GI foods (e.g., sugary snacks) cause rapid blood sugar spikes and crashes, which may worsen hyperactivity and inattention.
  • Evidence:
    • A small RCT found that a low-GI diet improved behavior in children with ADHD by stabilizing energy levels and focus.
  • How to Implement:
    • Choose whole grains, legumes, and non-starchy vegetables.
    • Avoid sugary drinks, white bread, and refined snacks

6. High-Protein Diets

  • Why: Protein supports the production of neurotransmitters like dopamine, which is often dysregulated in ADHD.
  • Evidence:
    • Some studies suggest that protein-rich breakfasts improve attention and reduce impulsivity during the day.
  • How to Implement:
    • Include protein-rich foods (e.g., eggs, yogurt, lean meats, nuts) in each meal.
    • Avoid skipping breakfast to maintain consistent energy levels.

Micronutrient Supplementation

  • Why: Nutrient deficiencies (e.g., zinc, magnesium, iron) are linked to ADHD symptoms.
  • Evidence:
    • RCTs show that zinc and magnesium supplementation improves hyperactivity and impulsivity, particularly in children with low baseline levels.
    • Iron supplementation benefits those with low ferritin levels.
  • How to Implement:
    • Have nutrient levels tested by a healthcare provider.
    • Include nutrient-rich foods like spinach (iron), nuts (magnesium), and seafood (zinc).

Recommendations

  1. Prioritize Whole Foods: Focus on unprocessed, nutrient-dense foods.
  2. Limit Sugars and Additives: Avoid foods with high sugar content, artificial sweeteners, or additives.
  3. Monitor Responses: Keep a food and symptom journal to identify potential triggers or improvements.
  4. Consult Professionals: Work with a dietitian or healthcare provider to ensure nutritional adequacy and tailor dietary changes to individual needs.

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The Silent Crisis: Physician Suicide in the United States

I saw these magnets today on the refrigerator located in the physicians lounge and it seemed like a good reminder 

In the U.S., an estimated 300-400 physicians die by suicide each year, a staggering rate far higher than that of the general population. This crisis, largely unspoken in healthcare settings, underscores the immense pressures physicians face daily. The high expectations, long hours, emotional exhaustion, and the stigma around seeking mental health support create a dangerous environment where burnout can quickly spiral into severe mental health struggles.

Physicians are trained to endure, often putting others’ health before their own. But the costs of “pushing through” take a toll. Many feel they cannot safely reach out for help without risking their careers due to institutional stigma around mental health treatment. This cycle of isolation and suppressed emotion can lead to tragic outcomes.

Organizations are beginning to address this issue by implementing wellness programs, peer support systems, and confidential mental health resources, but more systemic changes are needed. Reducing the stigma around mental health support, reforming punitive policies, and fostering a culture of openness in medicine could be life-saving.

Physician suicide affects us all—it robs the healthcare system of dedicated professionals and leaves profound impacts on patients, families, and communities. It’s time to break the silence and actively support those who care for us.

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The Culture of Burnout in Modern Medicine

Modern medicine has given rise to a new culture of burnout. As physicians, we are already high achievers—it’s a prerequisite to make it through the intense training. However, this constant push for relentless productivity often leads to feelings of exhaustion and disconnection. In medicine, the focus is always on doing more—seeing more patients, finishing more tasks, and achieving more outcomes each day.

With digital technology, we’re constantly connected, always on call. Patients, colleagues, and administrators reach out through calls, texts, and emails at all hours. The pressure to respond immediately leads to guilt when we can’t meet these demands, even when they’re unreasonable. The result? We push ourselves beyond our limits, sacrificing our own well-being in the process.

This grind leaves little room to rest or tend to our mental health. The importance of downtime is overlooked, even though it’s essential for long-term sustainability in our profession. But it’s time we rethink the culture of busyness and productivity. We need to start focusing on slowing down, with an emphasis on not staying busy for the sake of being busy.

If you’re like me, you’ve probably tried this, only to find your mind immediately wandering to the next thing you need to do. The challenge is real. But to reclaim a deeper sense of meaning and purpose in both our personal and professional lives, we must commit to this change. By slowing down, we can begin to find more peace, love, and joy in our day-to-day activities.

Let’s reclaim our lives—it’s long overdue

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The parallels between the psychiatric asylums and modern inpatient psychiatric treatment 

The history of psychiatric asylums is a dark chapter in mental health care, yet the more I reflect on it, the more I see troubling parallels between the asylum era and our modern system of inpatient psychiatric treatment.

Asylums, in their earliest forms, were created with good intentions: to provide care for those with severe mental illnesses and intellectual disabilities who could not be safely or adequately treated in their communities. However, as these institutions became overcrowded, underfunded, and poorly staffed, they devolved into places of neglect, abuse, and suffering. The eventual closures of these institutions were a necessary response to the horrific conditions exposed, but the underlying issues didn’t disappear. They merely shifted.

Today, many of the same challenges persist in our modern inpatient psychiatric system. Patients with severe mental illnesses or disabilities still require long-term care, but instead of asylums, they are placed in short-term facilities. These hospitals are often understaffed and overburdened, operating under financial pressures to prioritize quick turnover rather than long-term recovery. It’s not uncommon for patients to be admitted, stabilized just enough for discharge, and then readmitted within weeks—sometimes even days—because the core issues remain unaddressed.

In both the asylums of the past and the short-term psychiatric hospitals of today, patients often receive the same types of medications and therapies. The difference is that today’s treatment settings operate under stricter legal frameworks aimed at preserving patient rights, but the lack of continuity and depth in treatment results in a revolving door of care. Rather than focusing on sustained recovery, the focus is often on crisis management and meeting insurance-imposed timelines.

This cycle is problematic for patients and clinicians alike. For patients, it results in frustration, instability, and a lack of meaningful progress. For healthcare workers, it leads to burnout, similar to what was seen in the asylum era. The system, despite its modern façade, hasn’t evolved enough to address the long-term needs of individuals with severe mental illnesses. Until we invest in creating a system that prioritizes long-term, comprehensive care, we risk repeating the mistakes of the past—only this time without the walls of the asylum to contain the issue.

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