The tragic loss of a 33-year-old ophthalmology resident by suicide is a heartbreaking reminder of the immense pressures faced by those in the medical field. Residency, known for its intense demands and long hours, often leaves little room for self-care, mental health support, and the emotional toll that comes with caring for others. This devastating event highlights the urgent need for systemic changes in medical training and work environments, ensuring that mental health resources are accessible, stigma is reduced, and medical professionals receive the support they need. Our hearts go out to the family, friends, and colleagues affected by this tragedy.
As a doctor myself, I ask you—who hasn’t felt like they’re running on empty at one point or another during their training or career? The #burnout in this profession is as real as it gets. It can destroy your life, ruin time with your family, and, in the worst cases, end your life. Are we really the ones who are sick, or are we just products of a sick society? We need to do better for each other.
This reminds me a lot of the depression question. Patients often tell me, “Dr. Rossi, you don’t know what it’s like to be anxious.”
I usually have a quiet chuckle to myself because anxiety is something everyone experiences. It’s a natural part of life. We all have areas where we feel competent, and others where we feel out of our depth. It’s in those areas, the places where we feel uncertain or inadequate, that anxiety can really interfere with our ability to function.
My most challenging personal experience with anxiety happened during the infamous 4th term of medical school at St. George’s University. By this point, you’ve survived the first year and are well into the second. However, this term is notorious, and it often feels like the school uses it to weed out students—which, in my opinion, is a bit unethical. The structure of my routine completely changed. More requirements, longer lab hours, and less time to study. The familiar rhythm I had relied on to keep up was suddenly turned on its head.
Throughout that term, I was constantly on edge, overwhelmed by the pressure that all my hard work could slip away at any moment. I still vividly remember the first time I experienced a panic attack. It was early morning; I woke up drenched in sweat, my heart racing, and I couldn’t catch my breath. I was scared enough to go to the university clinic, and that’s when I found out it was a panic attack.
That experience taught me firsthand what anxiety truly feels like. It’s not just a fleeting worry—it can become physical, paralyzing, and all-consuming. When I talk to patients about anxiety, it’s from a place of understanding. Anxiety doesn’t discriminate, and it certainly doesn’t mean we’re incapable—just human.
Rising Antidepressant Overdoses: A Growing Concern in the U.S.
Recent data reveals that antidepressant overdoses in the U.S. have been steadily increasing from 1999 through 2022. According to a CDC report released last month, there were 5,863 overdose deaths attributed to antidepressants in 2022—numbers comparable to heroin-related fatalities, which claimed 5,871 lives. While these figures represent a small fraction of the over 100,000 overdose deaths that year—most of which involved fentanyl—they signal a troubling trend that demands attention.
Potential Causes for the Rise in Antidepressant Overdoses
Understanding the root causes of this increase is challenging, given the complexity of overdose data and the lack of detail on the exact substances involved. However, there are several factors worth considering.
First, many individuals with opioid use disorder (OUD) also suffer from co-occurring mental health conditions like depression and bipolar disorder. These patients are often prescribed antidepressants, sometimes too liberally, in my experience working in community mental health. When opioids are mixed with antidepressants, opioids are often the primary cause of death in overdoses. Yet, I’ve also encountered numerous patients who have attempted suicide using antidepressants alone.
Newer antidepressants are generally safer in overdose compared to older drugs, such as monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs). While these older medications tend to be more effective, they come with significantly higher risks in overdose situations. This is something I frequently emphasize to residents: older drugs are more dangerous, but the newer ones, though safer, can still have serious consequences.
Chronic pain patients, who are often prescribed opioids, are another vulnerable group. Their risk of suicide is heightened by the constant pain they endure, and many of these individuals are also prescribed antidepressants like duloxetine, which is indicated for pain management, or more dangerous TCAs such as amitriptyline and nortriptyline. Additionally, gabapentin—another drug commonly prescribed to these patients—has been known to increase the risk of death when taken with opioids.
Overprescription of Antidepressants: A Contributing Factor?
There has also been a sharp rise in antidepressant prescriptions across the U.S., which I believe warrants scrutiny. Antidepressants are, at best, symptom management tools, with a modest effect size of 0.33 in many studies. Given these limited benefits, we should be more judicious about who we prescribe these medications to and for how long.
Withdrawal symptoms from long-term—and sometimes even short-term—use of antidepressants can be severe, increasing the risk of suicide. I’ve personally seen this with a family member who experienced debilitating headaches and vertigo after stopping sertraline. She was unable to work or function for nearly two weeks, highlighting how challenging withdrawal can be for some patients.
Balancing Risks and Benefits in Mental Health Treatment
Any population for whom antidepressants are considered a treatment option is inherently at high risk for suicide. That said, there are many confounding factors in the overdose data, and mainstream mental health reporting often glosses over the nuances of psychiatric research and treatment. When prescribing medications, it’s crucial to weigh not only the pros and cons of the drugs themselves but also to tailor treatment to each individual’s unique needs.
I continue to prescribe antidepressants to patients whom I’ve carefully evaluated and believe will benefit, even if only in the short term. However, I am transparent with them: antidepressants are unlikely to resolve deeper psychological conflicts or “problems of living.” Mental health is rarely black and white, and much of this uncertainty stems from our incomplete understanding of the brain.
In short, we need to acknowledge the complexity behind the rise in antidepressant overdoses and respond with a more nuanced, patient-centered approach to prescribing these medications.
Life is a journey full of ups and downs, and sometimes, we find ourselves at a low point, feeling defeated and uncertain. But remember, it’s not about how many times you fall; it’s about how many times you get back up.
A comeback isn’t just about bouncing back—it’s about bouncing forward. It’s about using your setbacks as a setup for a stronger, wiser, and more resilient version of yourself.
Believe in Yourself: Trust in your abilities and your potential. You have everything within you to overcome challenges and achieve greatness.
Set Clear Goals: Define what success looks like for you. Break down your goals into manageable steps and tackle them one by one.
Learn from the Past: Reflect on what led to the setback. Embrace the lessons learned and use them to fuel your growth.
Stay Positive: Surround yourself with positivity. Cultivate a mindset of gratitude and optimism, even in the face of adversity.
Take Action: Don’t just dream about your comeback—take concrete steps towards it every day. Consistency and perseverance are key.
Seek Support: Lean on friends, family, or mentors who believe in you. Their encouragement can be a powerful motivator.
Celebrate Small Wins: Acknowledge and celebrate every small victory along the way. Each step forward is progress.
Remember, the greatest comebacks are born from the greatest setbacks. Your story is far from over, and this is just the beginning of a new, exciting chapter. Keep pushing, keep striving, and watch as you rise stronger than ever.
As an inpatient psychiatrist, you encounter a wide array of stories and experiences. Many of my trainees find this to be the most fascinating and engaging part of the job. We have the unique opportunity to delve into the inner workings of the mind and understand the thought processes of patients with serious mental illnesses (SMI). One of the things that often emerges during our evaluations is the presence of various types of delusions. Some are more common than others, with persecutory and grandiose delusions being frequent examples. I often hear patients claim that unknown groups are conspiring to ruin their lives, or a manic patient might declare, “I’m Jesus Christ.”
Over the years, I’ve noticed that these delusions tend to remain consistent, with similar themes recurring during subsequent admissions. In case you’re wondering, I often see the same individuals with the same issues multiple times a year, giving me a wealth of data points to support this observation. This insight is supported by a recent article from JAMA Psychiatry, which found that delusional content remains consistent across episodes of psychosis. This consistency can help us recognize the early stages of decompensation and potentially intervene before hospitalization becomes necessary. For instance, if a patient claims, “I’m Jesus Christ” during one episode, it’s likely they will express the same delusion during future episodes.
Another significant finding from this study is the importance of maintaining the intensity of interventions throughout the follow-up period. Unfortunately, there are many reasons why this doesn’t always happen, but when it doesn’t, poor outcomes are often the result.
I’ve had tremendous success with Electroconvulsive Therapy (ECT) in treating resistant depression (TRD). I’ve witnessed remarkable turnarounds, where individuals on the brink of despair have found new joy in life. Such rapid improvements are often not seen with medication alone.
Until now, there have been various theories about how ECT works in treating depression. I’ve always viewed it as a combination of increased neuroplasticity, which allows new, more adaptive connections to form quickly, and a boost in all major monoamine neurotransmitters.
However, new research published in Translational Psychiatry suggests that aperiodic brain activity might be key to the improvements we see with ECT. There’s a significant increase in this type of brain activity after patients undergo ECT, which enhances inhibitory activity in the brain, effectively “pumping the brakes” and alleviating depressive symptoms.
Unfortunately, ECT remains one of the most stigmatized and underutilized treatments in psychiatry. It’s estimated that less than 1% of those with treatment-resistant depression (TRD) receive ECT—a disheartening statistic that contributes to depression’s status as a leading cause of disability.
For patients where medications have repeatedly failed, ECT can be a life-saving treatment. There are many compelling stories of lives transformed by ECT, but the public rarely hears them. We need to create more opportunities to share these powerful success stories.
The future of mental health care hinges on the education and training of the next generation of psychiatrists. As we face an ever-growing array of mental health challenges, it is imperative that we equip upcoming professionals with the knowledge, skills, and empathy necessary to make a profound impact on the lives of their patients.
The Evolving Landscape of Psychiatry
Psychiatry is a dynamic field, continually evolving as new research, treatments, and technologies emerge. From advancements in psychopharmacology to the integration of telepsychiatry, the landscape of mental health care is rapidly changing. To stay at the forefront of these developments, future psychiatrists must receive comprehensive and up-to-date education.
Comprehensive Training Programs
Effective training programs are essential to prepare future psychiatrists for the complexities of the field. These programs should encompass a wide range of topics, including neurobiology, psychopharmacology, psychotherapy, and cultural competence. By providing a well-rounded education, we can ensure that new psychiatrists are equipped to address diverse patient needs and offer holistic care.
Emphasis on Empathy and Communication
While technical knowledge is crucial, the human element of psychiatry cannot be overstated. Empathy, active listening, and effective communication are foundational skills that every psychiatrist must possess. Training programs must emphasize the importance of building strong therapeutic relationships, fostering trust, and understanding the unique experiences of each patient.
Encouraging Research and Innovation
The field of psychiatry thrives on innovation and research. Encouraging young psychiatrists to engage in research not only advances our understanding of mental health but also fosters a culture of curiosity and continuous learning. By supporting research initiatives and providing opportunities for scholarly exploration, we can inspire the next generation to push the boundaries of what is possible in mental health care.
Addressing Stigma and Promoting Mental Health Awareness
Education plays a critical role in combating the stigma associated with mental illness. By instilling a deep understanding of the social, cultural, and psychological factors that contribute to stigma, we can empower future psychiatrists to advocate for their patients and promote mental health awareness. This advocacy extends beyond the clinical setting, influencing public policy, community outreach, and broader societal attitudes.
Integrating Technology and Telepsychiatry
The COVID-19 pandemic has underscored the importance of telepsychiatry and digital health solutions. Training the next generation of psychiatrists to effectively utilize technology can expand access to care, especially in underserved areas. Familiarity with telepsychiatry platforms, digital diagnostic tools, and electronic health records will be essential for future practitioners.
Lifelong Learning and Professional Development
The journey of a psychiatrist does not end with formal education. Lifelong learning and professional development are essential to staying current with advancements in the field. Encouraging a culture of continuous education, through conferences, workshops, and peer collaboration, ensures that future psychiatrists remain well-informed and adaptable.
Conclusion
Educating the next generation of psychiatrists is not just about imparting knowledge; it is about shaping compassionate, innovative, and resilient professionals who will lead the charge in improving mental health care. By investing in their education, we are investing in the future well-being of individuals and communities worldwide. Let us commit to providing the highest quality training and support to those who will one day carry the torch of psychiatry forward.
In the first part of this series, we discussed anxiety and specifically generalized anxiety disorder (GAD) as a diagnosis. Now we are going to look at the research associated with the treatment of GAD and let the research inform our decision making about what works when a person presents with GAD. Some of these findings may surprise you.
SSRIs
Although the effect size of SSRIs in GAD is small, 0.33 they remain the recommended first line option for treatment. It’s also important to confirm that someone has had an adequate trial of SSRI treatment before assuming it’s not effective. The choice of which SSRI will depend on the side effect profile and other patient factors such as presence of insomnia, substance use, or pregnancy. Escitalopram is a good place to start, fluoxetine, or sertraline can be alternative options. Although paroxetine has the FDA approval for GAD it has more side effects like weight gain and sedation, along with several other factors that make this medication a poor first-line option. If the first medication trial is ineffective it’s reasonable to try a second SSRI or switch to the SNRI duloxetine.
When SSRIs Don’t Work
The next step in many cases is to try a medication from a different class. Two SNRIs have been well studied in GAD, venlafaxine, and duloxetine. Venlafaxine is not considered a first line choice due to the side effect profile and the small increase in efficacy. From the meta-analysis on anxiety treatments the effect size is 0.36 slightly better than the SSRIs but it would likely be undetectable clinically. Duloxetine is slightly better with respect to side effects and can be a good choice if you chose to use an SNRI for anxiety treatment. It has the added benefit of lower risk for sexual side effects compared to venlafaxine and possibly improved cognition.
Bupropion in Anxiety Disorders
There is some evidence for the use of bupropion in GAD. In one study small study of 25 participants bupropion beat the SSRI escitalopram head-to-head. Other lines of evidence include more improvement in GAD when bupropion was added as a combination treatment with SSRIs compared to adding buspirone. For clarification the effect size of buspirone in GAD is 0.17 which would be unlikely to produce any observable clinical improvement in anxiety symptoms. I largely stay away from buspirone unless it’s used to treat sexual side effects of SSRIs. Bupropion may be good option for patients who do not want the side effect profile of an SSRI. Although we lack the large RCTs for bupropion in GAD there is some evidence to support its use. The negative studies indicating bupropion worsened symptoms of anxiety come from studies in panic disorder where bupropion was found to worsen panic symptoms.
What About New Antidepressants?
Vortioxetine had a lot of hype when it first came out, and many believed it would work for GAD. Unfortunately, like many medications when we believe something should theoretically work based on the mechanism of action, we are sadly disappointed. This is one of those cases. The effect size was found to be 0.12 and it did not even cross into the small range. This medication performed worse than buspirone for GAD.
Vilazodone also had one positive study published for GAD. Again, based on the MOA it should work just fine, it has typical SSRI like effects in addition to 5-HT1A effects like buspirone, you should get the best of both worlds theoretically. This one positive study was followed by two distinctly negative studies and a calculated effect size of 0.26 which is considered small.
Both were not submitted for FDA approval for GAD based on the negative results.
The Hydroxyzine Argument
Hydroxyzine is an antihistamine that’s been out for a long time. As I stated earlier it has approval for tension associated with psychoneurosis which is the old psychanalytic way of describing anxiety. It’s often seen as ineffective, but the effect size was higher than SSRIs and SNRIs for the treatment of GAD. Hydroxyzine had an effect size of 0.45, and we may want to reconsider the use of this medication. Some limitations are the size of the studies and duration of the studies, but this still provides a fair amount of evidence that hydroxyzine may perform better than we think.
Quetiapine Surprised Me
Quetiapine is an antipsychotic medication usually not considered as a treatment option for anxiety disorders. However, the effect size was large with a range from 1.0 to 2.2. To put this in perspective this medication outperformed SSRIs, SNRIs, and benzodiazepines. Why did it not gain FDA approval? If you watched my other videos, you should know that the side effect profile is difficult to tolerate. Metabolic side effects and sedation are common, and the FDA does not view anxiety disorders as significant enough to warrant this degree of risk. One place where this medication may be very useful is in bipolar disorder with severe anxiety. We avoid antidepressants in this population at all costs, quetiapine offers a good option with strong evidence and strong antidepressant effects in bipolar depression.
Where this fits in clinical practice for me is as a 3rd or 4th line option after all other avenues have been explored except for bipolar disorder as stated above. The antipsychotic medications have been known to have a positive effect on anxiety, but the limitation remains side effects.
Anxiety as a less Severe Form of Psychiatric Illness
According to the FDA medications like aripiprazole and quetiapine are reasonable adjunctive therapies for patients with major depression that does not respond to first line treatment options. This is not their view for anxiety disorders that respond poorly to first line options. When we look at disability caused by depression and anxiety there isn’t much difference in the odds of being disabled for depression vs anxiety (3.5 Vs 3.1). For whatever reason we continue to view anxiety as less significant although DSM does not identify a clear diagnostic hierarchy.
Things like psychotherapy are often recommended as first line options. In the 1980’s when GAD was first conceived, it was thought to be a mild disorder where psychotherapy is the most effective treatment. In fact, psychotherapy did well it had an effect size of 0.5 which is nearly the same as benzodiazepines. Psychotherapy is a good place to start for anyone presenting with an anxiety disorder. I’m also a big believer of combining psychotherapy and medication for anxiety disorders.
What about Benzos?
Benzodiazepines can have all sorts of effects on the body. Largely we think of the benefits of benzodiazepines in anxiety disorders as having a major effect on the physical symptoms of anxiety and not so much on the chronic worry that characterizes the disorder. Many of the effects of benzodiazepines would not be measured by traditional anxiety rating scales based on the updated conception of GAD. Nevertheless, Benzodiazepines had an effect size of 0.4-0.5 which falls into the moderate range for GAD.
A final Option to Consider
Silexan the proprietary extract of Lavender oil has good evidence and a large effect size when used to treat GAD. In Germany there is a respect for the power of natural products, and they are regulated and prescribed in the same manner as pharmaceutical drugs. When silexan was studied in GAD the effect size can range from 0.5 to 0.9. This is a large effect size and I have another video that covers Silexan in detail if you are interested. This can be added to most medication regimens without significant drug interactions and has even been shown to decrease the use of benzodiazepines in those who are using them for GAD. It can be purchased under the brand Name Calm Aid for around $30 per month, and if you are wondering I get no financial compensation for saying this I’m just presenting the evidence.
Conclusion
We covered a lot here today and I think one of the most important points to stress is the importance of finding the underlying cause of anxiety symptoms. I believe anxiety is driven by other underlying factors as discussed at the beginning of the video. There are many reasons to be anxious and all require a different approach. Without this clarification the patient is likely to continue struggling. Another important point is theoretical mechanism of action that should work, do not always work as seen in the case of vilazodone. We also had some surprises, hydroxyzine, and silexan performed very well but traditional first line options such as SSRI and SNRIs were not so great. I hope this discussion was helpful and if you want more content on anxiety disorders, let me know below in the comments section.
Attention deficit hyperactivity disorder (ADHD) in the adult population is a topic of great debate. There are many psychiatrists who say ADHD symptoms do not suddenly disappear as a person continues into adulthood. On the other hand, there are some psychiatrists who do not think ADHD is a real diagnosis.
The term ADHD might be better thought of as attention deficit disorder (ADD). The concept of hyperactivity is more common in the child/adolescent patient population. It’s unclear if the hyperactivity is related to executive dysfunction which is the hallmark of ADHD. It may be that the hyperactivity is within the range of normal (agitation or activation) for a child, or signs of another mood disorder such as mania in bipolar illness (especially true in the adult population as bipolar diagnosis is commonly reserved for adult patients).
We can make an argument that placing children in a traditional school setting where they are asked to sit and pay attention to uninteresting material for 7 hours is unnatural and directly against the way humans evolved to function. The human body and mind evolved to move and be active not to sit in classrooms. As a result, agitation, hyperactivity, and acting out can be the result of this unnatural state.
The hallmark of ADHD is attentional impairment and executive dysfunction. Hyperactivity is not seen in adult populations with ADD.
Attention As a Trait
Attention can be thought of in the same manner as blood pressure. There is a mean blood pressure in the population but there will be individuals that fall outside the standard curve. Most people in the population will fall in the middle having a reasonable amount of attention and those with low attention levels do not necessarily have a disease although they may have consequences associated with reduced attentional activity. When someone is overly attentive it can be a symptom of disorders like obsessive compulsive disorder (OCD) or psychosis. Like blood pressure, having readings that are too high or too low can cause problems. It’s normal to have a certain amount of inattention, and we can think of attention as a spectrum with a range of normal levels.
What are the Causes of Inattention
-It could be a perfectly normal trait, as we explained some people have lower attention spans naturally as a personality trait
-Mood disorders like depression and bipolar disorder have in inattention as a possible consequence of the change in mood
-Psychotic disorders also have cognitive changes that may cause inattention (internal preoccupation)
-Anxiety disorders
-Neurocognitive disorders
-We should avoid diagnosing ADD in the setting of one of these other conditions.
Would you diagnosis ADD during a manic episode?
Prevalence of ADHD in the U.S.
-The prevalence of ADHD in the U.S. ranges from 5.6% to 15.9% and there is great variability depending on the geographic region
-For most biological diseases we should see similar prevalence rates across populations and geographic regions. For example, schizophrenia has a prevalence of about 1% worldwide. So why do we see significant differences across the U.S.?
-We do not know much about the role socioeconomic factors, diet, exercise, and other social factors play in the development of ADHD. It’s possible that these are significant contributing factors resulting in the symptoms associated with ADHD.
Is ADHD a neurodevelopmental issue?
-One way of thinking about ADHD is as a neurodevelopmental problem that eventually improves over time.
-In children with ADHD they seem to achieve peak cortical thickness later than children without ADHD, this has been confirmed on imaging studies.
-The important part is eventually these children catch up with the normal controls. It’s more a delay in brain development and not a permanent state.
-The ADHD children are about 2 years behind the normal controls and the area of greatest delay is the prefrontal cortex which is responsible for executive function.
How Common is ADHD and Does it Last into Adulthood?
Over the past decade ADHD in adult populations has gotten more attention. Some would say the prevalence in adults is 4% to 5% with equal rates being seen in men and women.
The national comorbidity survey estimated 46% of children with ADHD have symptoms that persist into adulthood. Many of these individuals had comorbid anxiety disorders and we know anxiety can be a major cause of inattention and executive dysfunction.
In other studies, similar findings were reported. What stands out to me in all these studies is the high rates of comorbid mood disorders including depression and bipolar disorder. It’s hard to make a diagnosis of adult ADHD in the presence of other conditions considering the significant overlap of symptoms and cognitive dysfunction associated with mood disorders.
It’s possible that mood and anxiety disorder can account for most adult ADHD cases and a variation of a normal trait could explain the rest (individuals with low attention)
Looking at medication response doesn’t help us much as amphetamines are helpful in everyone even those who do not have a psychiatric disorder (think college kids taking them for midterms)
When you correct for comorbidities in Adult ADHD, only about half of the young adults meeting criteria for ADHD had ADHD only. Estimates from this showed that most children diagnosed with ADHD were no longer meeting criteria in adulthood (83% no longer had symptoms). Many of the newly diagnosed cases of ADHD were in individuals who did not have ADHD as children (87% did not have ADHD as children).
This indicates that about 20% of children diagnosed with ADHD will have symptoms persist into adulthood, the other 80% will not
In animal models, amphetamines have been shown to have some dangerous effects
-Decrease response to reward stimuli
-increased anxiety
-decreased dopamine activity
-decreased long-term survival of neuronal cell in the hippocampus (excitotoxicity)
Risk of Substance Use With Stimulant Prescriptions
Most psychiatrists will tell you the risk of substance use disorder does not increase with stimulant medication treatment; in fact it’s reduced when ADHD is treated. However, a well-designed randomized controlled trial of delinquent behavior and emerging substance use in medication treated children found significantly higher rates of substance use in the stimulant treated individuals. The conclusion by Molina et al. was we need to re-evaluate the risk of substance use disorder as children age when they are prescribed stimulants. Now correlation does not equal causation, but this should give us some pause when blinding stating there is no risk for addiction with stimulant use (this claim is mostly based off observational data and not randomized controlled trial data).
