Shrinks In Sneakers

Tag: medication

  • The U.S. Withdrawal from the WHO: What It Means for Global Health 🌍

    The U.S. Withdrawal from the WHO: What It Means for Global Health 🌍

    The U.S. is officially withdrawing from the World Health Organization (WHO)—a move with far-reaching consequences for global health, research, and disease prevention. Here’s why this matters:

    🔹 Pandemic Preparedness 🦠: The WHO coordinates global responses to pandemics. Without U.S. support, funding gaps could slow future outbreak responses.

    🔹 Vaccine & Drug Research 💉: The U.S. plays a key role in funding and collaborating on medical breakthroughs. Withdrawing could disrupt research efforts in areas like HIV, TB, and malaria.

    🔹 Health Security Risks 🚨: Global health threats don’t respect borders. A weaker WHO means less surveillance and slower containment of emerging diseases.

    🔹 Loss of Influence 🇺🇸: The U.S. has historically shaped global health policies. Leaving the WHO could reduce its ability to set standards and priorities.

    The long-term impact of this decision remains uncertain, but one thing is clear: global health is interconnected, and a fractured response benefits no one.

    What do you think about this move? Drop your thoughts below. ⬇️ #GlobalHealth #WHO #PublicHealth

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

    💊 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.
  • Post-SSRI Sexual Dysfunction (PSSD): An Emerging Concern

    Post-SSRI Sexual Dysfunction (PSSD): An Emerging Concern

    Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), have been a cornerstone of treatment for mood and anxiety disorders for decades. However, as their use has become more widespread, concerns about their side effects—particularly those related to sexual health—have grown. A new wave of attention has focused on Post-SSRI Sexual Dysfunction (PSSD), a phenomenon in which sexual side effects persist even after the discontinuation of SSRI medications.

    What is PSSD?

    It is well-established that up to 50% of patients taking SSRIs experience some degree of sexual dysfunction while on the medication. These effects are usually thought to be transient, resolving within weeks or months after stopping the drug. However, PSSD represents a different and more troubling pattern: persistent sexual dysfunction lasting three months or longer after discontinuing the medication.

    Patients with PSSD frequently report symptoms such as:

    • Genital anesthesia (reduced or absent genital sensation).
    • Anorgasmia (inability to achieve orgasm).
    • Loss of libido (reduced or absent sexual desire).

    In men, erectile dysfunction and ejaculatory issues are common, while women often report reduced arousal and difficulty achieving orgasm. Unlike transient sexual dysfunction, the hallmark of PSSD is its persistence long after the drug has been stopped.

    The Challenge of Evidence

    The evidence supporting PSSD as a formal diagnosis remains limited and primarily consists of:

    • Case reports
    • Case series
    • Observational data, often derived from internet forums and patient advocacy groups

    While these sources highlight distressing patient experiences, they fall at the bottom of the evidence hierarchy. Without randomized controlled trials or large-scale cohort studies, it is impossible to definitively establish causation between SSRI use and PSSD. This lack of robust evidence complicates efforts to understand the true prevalence, biological mechanisms, and risk factors for PSSD.

    Potential Biological Basis

    The exact mechanism of PSSD remains unclear, but hypotheses include:

    1. Serotonin neurotoxicity: Excessive serotonin signaling may lead to long-lasting changes in the central or peripheral nervous systems.
    2. Dopamine suppression: Chronic serotonin elevation may inhibit dopamine pathways, which play a critical role in sexual function.
    3. Receptor desensitization or downregulation: Long-term SSRI use may alter serotonin and other neurotransmitter receptors in ways that persist after discontinuation.

    None of these theories have been definitively proven, and more research is needed to uncover the underlying pathophysiology.

    Prevalence and Diagnosis

    The true prevalence of PSSD is unknown due to the lack of large, high-quality studies. However, anecdotal reports suggest it may be rare but severely impactful for those affected.

    Currently, there are no standardized diagnostic criteria for PSSD. The most common approach involves:

    1. A history of SSRI use.
    2. Persistent sexual dysfunction lasting three months or more after discontinuing the medication.
    3. Symptoms such as genital anesthesia or nipple insensitivity, which are more specific to PSSD compared to general sexual dysfunction.

    What to Do if You Suspect PSSD

    For clinicians and patients encountering persistent sexual dysfunction, it’s essential to first explore modifiable and reversible causes of sexual dysfunction:

    • Lifestyle factors: Obesity, smoking, poor cardiovascular health, and sedentary behavior can contribute to sexual dysfunction.
    • Endocrine issues: Low testosterone or other hormonal imbalances should be evaluated.
    • Medications: Drugs such as finasteride (for hair loss) and isotretinoin (for acne) are also associated with persistent sexual dysfunction and may confound the diagnosis.

    If PSSD remains the primary suspected diagnosis, a timeline of symptoms is crucial. Note when the antidepressant was started, when sexual dysfunction began, and whether the symptoms improved or worsened after stopping the drug.

    The Bottom Line

    PSSD is an evolving area of concern in psychiatry and pharmacology. While current evidence does not definitively prove a causal relationship between SSRIs and persistent sexual dysfunction, the growing number of reports warrants further investigation. Until higher-quality studies emerge, clinicians should approach this condition with empathy and caution.

    Patients experiencing sexual dysfunction should work closely with their healthcare providers to rule out reversible causes and explore management options. For now, the best strategy is awareness, vigilance, and a patient-centered approach to treatment planning.

  • Can β-Blockers Really Delay the Onset and Progression of Huntington’s Disease?

    Can β-Blockers Really Delay the Onset and Progression of Huntington’s Disease?

    Huntington’s disease (HD) is a devastating neurodegenerative disorder that affects individuals and their families on multiple levels. Over the years, I’ve worked with many patients suffering from HD, and it’s difficult to overstate the physical, cognitive, and emotional toll this disease takes. Beyond the progressive motor dysfunctions that eventually rob patients of their independence, the neuropsychiatric symptoms, including severe depression, irritability, and even psychosis, can be equally debilitating. Tragically, suicide risk in this population is alarmingly high, particularly in the early stages when patients are still aware of their prognosis.

    One of the greatest challenges we face in treating Huntington’s disease is the lack of disease-modifying treatments. While therapies exist to help manage symptoms, such as tetrabenazine for chorea or antidepressants for mood disturbances, these interventions only address parts of the disease. To date, there has been little that offers hope for slowing its relentless progression.

    However, a recent article published in JAMA titled “β-Blocker Use and Delayed Onset and Progression of Huntington Disease” has introduced a glimmer of hope. The study explored the potential role of β-blockers in altering the course of HD. These medications, commonly prescribed for hypertension and cardiac conditions, may also have neuroprotective properties. According to the study, β-blocker use was associated with delayed onset and slowed progression of Huntington’s disease. The study analyzed data from a cohort of over 1,000 patients, utilizing longitudinal assessments to measure disease onset and progression. Statistical analysis revealed a significant reduction in the rate of disease progression among patients taking β-blockers compared to those who were not, with a hazard ratio of 0.78 (95% CI, 0.65–0.92; p < 0.01). This is a groundbreaking finding because it suggests a readily available and widely used class of medications could have a profound impact on a previously untreatable condition.

    The way β-blockers work to slow the progression of HD isn’t entirely clear, but it’s thought they might help by reducing brain inflammation and preventing damage caused by overstimulated nerve cells. Furthermore, they could potentially mitigate some of the psychiatric symptoms seen in HD, such as aggression and anxiety, by dampening the overactivity of the sympathetic nervous system.

    For those of us who work closely with this patient population, findings like these provide a much-needed sense of optimism. If future research confirms these results, we may see a shift in how HD is managed. Imagine being able to tell a patient, “We have a medication that might slow this disease’s progression.” That could be life-changing for so many individuals and their families.

    This study is an important reminder that even in diseases where hope seems scarce, progress is being made. For me, it reinforces why we never stop searching for answers—because even small steps forward can eventually change lives in ways we never imagined. It also underscores the importance of continued research and innovation in the field of neurodegenerative disorders. For patients with HD, their loved ones, and the clinicians who care for them, this kind of news is invaluable.

    What are your thoughts on the use of β-blockers for HD? Have you seen this approach applied in your practice or with your patients? Let’s continue the conversation and keep hope alive for those impacted by this challenging disease.

  • Narcissistic Personality Disorder: Two Faces Explained

    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.

  • Iclepertin Trial Results: Insights on Schizophrenia Treatment

    Iclepertin Trial Results: Insights on Schizophrenia Treatment

    📢 Update on Schizophrenia Research #MentalHealth #Schizophrenia

    🧠 Iclepertin (BI 425809), initially showing promise in Phase II trials, unfortunately did not meet the primary and key secondary endpoints in the Phase III CONNEX program. Despite this, it was well tolerated, and the safety profile remained consistent.

    🔬 Phase III Results:

    • No statistically significant improvements in cognition or functioning were observed compared to placebo over six months.

    Context: Iclepertin is a glycine transporter 1 (GlyT1) inhibitor, a class of drugs aimed at enhancing the function of the NMDA receptor by increasing glycine levels. This receptor plays a crucial role in cognitive processes, and improving its function was hypothesized to alleviate cognitive impairments in schizophrenia.

    📊 Visual Insights: Below are graphs illustrating the trial data, showing the comparison between Iclepertin and placebo groups across various cognitive assessments.

    🔍 Implications and Next Steps: Although these results are disappointing, they provide valuable insights for future research. The findings highlight the complexity of treating cognitive impairment in schizophrenia and underscore the need for continued exploration of new therapeutic targets and strategies.

    What’s next? Researchers will analyze the data further to identify any subgroups that may have benefited and explore other potential mechanisms to address this unmet medical need.

    💬 Join the Discussion: Have you or someone you know experienced cognitive challenges related to schizophrenia? What are your thoughts on current treatment options? Share your experiences or questions below—let’s foster a supportive community!

    🔔 Stay Updated: Follow us for more updates on ongoing research and join our forums for in-depth discussions on mental health innovations. Together, we can stay informed and connected. #ClinicalTrials #Neuroscience #Breakthrough

  • New ASAM and AAAP Guidelines for Stimulant Use Disorder: Key Updates

    New ASAM and AAAP Guidelines for Stimulant Use Disorder: Key Updates

    The American Society of Addiction Medicine (ASAM) and the American Academy of Addiction Psychiatry (AAAP) recently released updated guidelines for the treatment of stimulant use disorder (SUD).

    1. Comprehensive Assessment: The guidelines emphasize a thorough assessment of patients, including the use of validated screening tools to diagnose SUD, assess severity, and identify co-occurring mental health disorders.
    2. Evidence-Based Psychosocial Interventions: Behavioral therapies remain the cornerstone of treatment. Cognitive-behavioral therapy (CBT), contingency management (CM), and motivational interviewing (MI) are recommended due to strong evidence of their efficacy.
    3. Pharmacological Treatments: While no medications are currently FDA-approved specifically for stimulant use disorder, the guidelines discuss off-label use of medications like bupropion and naltrexone, which show promise in reducing stimulant use and cravings in some patients.
    4. Harm Reduction Strategies: Recognizing the importance of harm reduction, the guidelines support interventions like needle exchange programs and education on safer use to reduce the risk of infectious diseases and other health complications.
    5. Integrated Care Models: The guidelines highlight the importance of integrated care that combines medical, psychiatric, and social support services, aiming to provide holistic care tailored to individual patient needs.
    6. Special Populations: Specific recommendations are provided for treating special populations, including pregnant individuals, adolescents, and those with co-occurring mental health disorders, recognizing the unique challenges these groups face.
    7. Recovery Support: Emphasis is placed on long-term recovery support, including peer support groups, vocational training, and housing assistance, to help individuals maintain recovery and improve their quality of life.

    These guidelines represent a significant step forward in the standardization of care for individuals with stimulant use disorder, aiming to improve outcomes through evidence-based, patient-centered approaches. For clinicians, staying informed and implementing these recommendations can greatly enhance the quality of care provided to this population.

  • Evidence-Based Sleep Routine for ADHD

    Evidence-Based Sleep Routine for ADHD

    Sleep challenges are common among individuals with ADHD, as difficulty winding down, racing thoughts, and irregular schedules can interfere with restful sleep. Establishing a structured, evidence-based bedtime routine can significantly improve sleep quality, attention, and emotional regulation. 

    1. Stick to a Consistent Schedule

    • Why: Consistency trains your body’s internal clock (circadian rhythm).
    • How:
      • Go to bed and wake up at the same time every day, including weekends.
      • Avoid sleeping in more than 1 hour on weekends to prevent disrupting your schedule.

    2. Limit Screen Time Before Bed

    • Why: Blue light from devices suppresses melatonin production, delaying sleep onset.
    • How:
      • Stop using screens (phones, tablets, TVs) at least 60 minutes before bedtime.
      • Use blue light filters or glasses if screen use is unavoidable.

    3. Create a Calming Bedtime Routine

    • Why: A predictable sequence of activities signals to your brain that it’s time to wind down.
    • How:
      • Start 30–60 minutes before bed with calming activities, such as:
        • Reading a physical book (non-stimulating material).
        • Light stretching or yoga.
        • Journaling to offload thoughts or plan the next day.
        • Taking a warm bath or shower.

    4. Optimize Your Sleep Environment

    • Why: ADHD brains are more sensitive to stimuli, so a serene environment promotes deeper sleep.
    • How:
      • Darkness: Use blackout curtains or a sleep mask.
      • Quiet: Use white noise machines or fans to block out distractions.
      • Temperature: Keep the room cool (around 65–68°F).
      • Comfort: Invest in a supportive mattress and breathable bedding.

    5. Exercise Regularly, But Not Too Late

    • Why: Physical activity improves sleep quality but can be overstimulating if done too close to bedtime.
    • How:
      • Aim for 30–60 minutes of exercise daily, preferably in the morning or early afternoon.

    6. Avoid Stimulants in the Evening

    • Why: ADHD medications, caffeine, and nicotine can interfere with sleep onset.
    • How:
      • Avoid caffeine after 2 PM.
      • Discuss timing of ADHD medication with your doctor to minimize nighttime interference.

    7. Limit Naps

    • Why: Long or late naps can disrupt nighttime sleep.
    • How:
      • If you nap, limit it to 20–30 minutes earlier in the day.

    8. Avoid Heavy Meals and Alcohol Before Bed

    • Why: Digestion and alcohol can disrupt sleep cycles.
    • How:
      • Finish eating at least 2–3 hours before bed.
      • Limit alcohol consumption, especially in the evening.

    9. Address Racing Thoughts

    • Why: ADHD often causes a “busy brain” at bedtime.
    • How:
      • Use a “brain dump” journal to write down lingering thoughts, worries, or to-dos.
      • Pair journaling with a gratitude exercise to shift focus to positive thoughts.

    Example ADHD Sleep Routine

    7:30 PM: Start winding down with light activities (reading, stretching).
    8:00 PM: Turn off screens and dim the lights.
    8:15 PM: Take a warm shower or bath.
    8:30 PM: Journal to offload thoughts or plan the next day.
    8:45 PM: Practice 10 minutes of meditation or deep breathing.
    9:00 PM: Get into bed, listen to white noise, or practice gratitude.
    9:30 PM: Lights out.

  • Breaking Down Barriers: The Impact of Psychotherapy on Suicidal Ideation and Attempts

    Breaking Down Barriers: The Impact of Psychotherapy on Suicidal Ideation and Attempts

    New Insights from JAMA

    This systematic review and meta-analysis dives deep into the impact of both direct and indirect psychotherapy on suicidal ideation and suicide attempts.

    Key takeaways:

    1. Broad Scope: The study analyzed a vast array of data, ensuring a comprehensive overview of psychotherapy’s effectiveness in reducing suicidal thoughts and behaviors.
    2. Direct vs. Indirect Therapy: It highlights the distinct impacts of direct (face-to-face) and indirect (telehealth, self-help) psychotherapeutic approaches.
    3. Hope for Patients: The findings are a beacon of hope, showing significant reductions in suicidal ideation and attempts post-therapy.

    As healthcare providers, this data reinforces the crucial role of psychotherapy in our therapeutic arsenal. It’s a powerful reminder of how our interventions can save lives and offer patients a brighter, more hopeful future.

    For those in psychiatry and mental health care, this is a must-read article that could shape how we approach treatment for individuals at risk.

    Let’s continue to break down barriers and provide life-saving care. 💪✨

    Link to the article: https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2824096

  • 🚨 New Research Alert! 🚨

    🚨 New Research Alert! 🚨

    We’re diving deep into the latest JAMA Psychiatry article on Social Determinants of Health & Suicide-Related Outcomes 🧠💔. This groundbreaking study sheds light on how factors like income, education, and community support play a crucial role in mental health and suicide prevention. 📊🏡💬

    Key Takeaways: 🔍 Social & economic inequalities significantly impact mental well-being. 🛠️ Addressing these factors can save lives and improve outcomes.

    🤝 Community support is more vital than ever.

    💡 With regard to suicide attempt, experience of childhood abuse and maltreatment and sexual assault, gender and sexual minority status, and parental suicide mortality were the strongest risk factors. 

    💡 For suicide mortality, justice system–involved individuals in the community, exposure to others’ and parental suicide, firearm accessibility, divorce, experience in foster care, release from incarceration, and midlife (age 35-65 years) unemployment were the SDOH with consistently strong effects. 

    Join the conversation and let’s work towards a more equitable and supportive world! 🌍✨

    #MentalHealthMatters #JAMAPsychiatry #SocialDeterminants #community #psychiatry #psychiatrist #doctor#mentalhealth #mentalhealthmatters #mentalhealthishealth #SuicidePrevention #HealthEquity #Psychiatry#Research #Wellness 🌈❤️🧠

    🔗 https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2828935