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class="mx-1">,</span></span><span class="text-md mr-2"><a class="text-author text-gray-500 hover:text-primary underline hover:no-underline decoration-gray-400" href="/authors/melissa-fickey-md">Melissa Fickey, MD</a></span></div></div></div><div class="max-w-full"><div class="flex flex-wrap sm:flex-nowrap items-center w-fit my-2"></div><div class="w-full flex flex-col sm:flex-row justify-between mt-2"><div class="block md:hidden "><div class="mt-2 flex items-center max-w-fit"><button title="NeuroStar TMS for Adolescents With Major Depressive Disorder: A Look at the New Data" aria-label="facebook" class="react-share__ShareButton" style="background-color:transparent;border:none;padding:0;font:inherit;color:inherit;cursor:pointer"><svg viewBox="0 0 64 64" width="32" height="32"><circle cx="32" cy="32" r="31" fill="#3b5998"></circle><path d="M34.1,47V33.3h4.6l0.7-5.3h-5.3v-3.4c0-1.5,0.4-2.6,2.6-2.6l2.8,0v-4.8c-0.5-0.1-2.2-0.2-4.1-0.2 c-4.1,0-6.9,2.5-6.9,7V28H24v5.3h4.6V47H34.1z" 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background: #7F7F7F; color: white; padding: 2px; border-radius: 100%; } </style></div><style> video::cue { display: inline; background-color: #b8dcf6; padding: 2px 2px; } audio { height: 40px; } .rhap_container { width: 300px !important; border-radius: 100px !important; height: 40px !important; box-shadow: 0px 0px 2px 2px rgba(0,0,0,0.1); } .rhap_progress-section { width: 150px; margin-left: 35px; } .rhap_controls-section { position: relative; bottom: .75rem; } .rhap_time { font-size: 12px; color: rgb(0,55,103); } .rhap_progress-bar { color: rgb(0,55,103) !important; } .rhap_progress-filled { background-color: rgb(0,55,103) !important; } .rhap_progress-indicator { height: 15px; width: 5px; top: -5px; margin-left: 1px; background-color: rgb(0,55,103) !important; } .rhap_repeat-button { display: none; } .rhap_volume-bar, rhap_volume-button, .rhap_volume-indicator { background: rgb(0,55,103) !important; } .rhap_volume-bar { height: 2px; width: 35px; position: relative; left: 22px; bottom: 21px; } .rhap_volume-button { // width: 5px; // height: 5px; flex: 0 0 26px; position: relative; left: 22px; bottom: 21px; } .rhap_volume-button svg { height: 18px; width: 18px; } .rhap_volume-indicator { height: 8px; width: 8px; top: -2.75px } .rhap_button-clear { color: rgb(0,55,103) !important; } .rhap_play-pause-button { color: rgb(0,55,103) !important; font-size: 30px !important; width: 30px !important; height: 30px !important; position: relative; right: 90px; bottom: 22px; } .rhap_main-controls button { color: rgb(0,55,103) !important; } audio::-webkit-media-controls-play-button, video::-webkit-media-controls-play-button { -webkit-appearance: media-play-button; color: #b8dcf6; } audio::-webkit-media-controls-panel { background-color: white !important; color: #000; } audio::-webkit-media-controls-current-time-display, audio::-webkit-media-controls-time-remaining-display { font-size: 12px; } </style></div></div></div><div class=" lg:w-full flex flex-col lg:flex-row lg:items-center lg:justify-end"></div><div class="w-full flex flex-col px-4 py-4 border-t border-b border-solid border-gray-400 my-4 "><h3 class="text-primary text-xl font-semibold">Key Takeaways</h3><ul class="list-disc px-8"><li class="py-2 "> NeuroStar TMS therapy achieved remission in nearly 60% of adolescents with MDD, showing significant antidepressant effectiveness and dose-response effects. </li><li class="py-2 "> The study involved 1283 patients, making it the largest sample of adolescents and young adults with MDD treated with TMS. </li><li class="py-2 hidden"> NeuroStar is the only FDA-cleared TMS device for adolescents aged 15 and older, reinforcing its safety and effectiveness as a first-line adjunct treatment. </li><li class="py-2 hidden"> TMS offers a non-drug treatment pathway with minimal adverse effects, providing a valuable option for adolescents unresponsive to traditional antidepressants.</li></ul><span class="text-xs font-bold text-primary underline cursor-pointer mt-2 ml-4">SHOW MORE</span></div><p class="py-2 mb-2 text-sm italic text-gray-600">According to new data, NeuroStar Advanced TMS helped nearly 60% of adolescents with major depressive disorder. </p><div class="py-2"><div class="blockText_blockContent__TbCXh"><div class=""><div style="width:48%;float:left;max-width:525px;margin:0 1.5rem 1.5rem 0;clear:both;cursor:" class=" figure"><div class="flex-none relative text-center"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27320%27%20height=%27400%27/%3e"/></span><img alt="Melissa Fickey" title="Melissa Fickey" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain"/><noscript><img alt="Melissa Fickey" title="Melissa Fickey" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F60a8a242efef4dcca3c2e74f18eefed5676af69d-320x400.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F60a8a242efef4dcca3c2e74f18eefed5676af69d-320x400.png%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 2x" 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text-align: center; } </style></div><p class="pb-2"><strong>CLINCAL CONVERSATIONS</strong></p><p class="pb-2">According to data presented at the 2024 American Academy of Child and Adolescent Psychiatry (AACAP) annual conference, NeuroStar Advanced transcranial magnetic stimulation (TMS) therapy helped nearly 60% of adolescents with major depressive disorder (MDD) reach remission. Investigators sought to determine the outcomes of adolescents and young adults aged 12 to 21 years with MDD and anxiety who were treated with TMS in community settings.<sup class="text-inherit">1</sup></p><p class="pb-2"></p><p class="pb-2">Data were extracted from a treatment registry of 1283 patients with MDD; 682 patients were aged 12 to 19 years, and 601 were aged 20 to 21 years. This is the largest sample to date of adolescents and young adults with MDD. Primary outcome measures were the Patient Health Questionnaire-9 (PHQ–9) and Generalized Anxiety Disorder-7 (GAD–7).<sup class="text-inherit">2</sup> The analyses examined outcomes from patients who completed 20 or more sessions and an intent-to-treat sample. In the completer sample (N=1169), results show that 59.4% of patients aged 12 to 19 and 36.4% of patients aged 20 to 21 met the PHQ-9 response and remission criteria, respectively. Investigators observed marked dose-response effects and antidepressant effectiveness improved with longer treatment courses (<em>P</em> < .0001). The greatest symptom reduction was seen over the first 10 sessions, with no plateau before treatment termination. The adolescent and young adult subgroup data did not differ in treatment effects.</p><p class="pb-2"></p><p class="pb-2">To better understand this data, <em>Psychiatric Times</em> sat down with Melissa Fickey, MD, a board-certified psychiatrist who specializes in child, adolescent, and adult psychiatry.</p><p class="pb-2"></p><p class="pb-2"><strong><em>Psychiatric Times</em>: Tell us a little about that data shared at the AACAP annual meeting. What is the most important takeaway from this data for practicing mental health clinicians?</strong></p><p class="pb-2"><strong>Melissa Fickey, MD:</strong> The data presented at AACAP highlights a breakthrough for teens and young adults struggling with depression and, in some cases, anxiety. This study was the most extensive of its kind, examining over 1200 young people aged 12 to 21 years old who received treatment with NeuroStar Advanced Therapy’s TMS. The results were very encouraging and showed more than 70% of those treated experienced meaningful improvements (or a 6 point or more change in their PHQ-9 score).</p><p class="pb-2"></p><p class="pb-2">The positive results from this study reinforce the FDA clearance, as NeuroStar is the only FDA-cleared TMS device for treating adolescents with MDD aged 15 and older. Prior data also show a 78% response rate and 48% remission rates in teens and ultimately provide compelling evidence supporting TMS as a highly effective treatment for adolescents with MDD.</p><p class="pb-2"></p><p class="pb-2"><strong><em>PT</em>: Do you think this data will help patients and families considering TMS feel more comfortable?</strong></p><p class="pb-2"><strong>Fickey:</strong> This data can provide significant confidence to patients and their families who might be apprehensive about beginning treatment with TMS. As mentioned, these are the largest study results of its kind, and they reinforce the safety and effectiveness the FDA reviewed when deciding NeuroStar is a first-line add-on option for adolescents with MDD age 15 and up. Not only did most participants experience meaningful improvements in both depression and anxiety, but adverse effects were minimal. Additionally, the data show treatment made an impact after only a few sessions and results improved for those who completed a full treatment course.</p><p class="pb-2"></p><p class="pb-2"><strong><em>PT</em>: Treatment with TMS resulted in marked improvement in both depressive symptoms and anxiety in adolescents and young adults. There are limited approved treatment options in this age category. At what point do you determine it is time to try TMS?</strong></p><p class="pb-2"><strong>Fickey: </strong>NeuroStar is currently the only TMS therapy that is approved as a first-line adjunct treatment for adolescents—so it can be a first-line option for adolescents aged 15 and up in conjunction with other modalities, like antidepressant medications or talk therapy. It can also be used if a patient has tried other options but is not seeing a large impact on their mental health. MDD is a substantial public health challenge impacting at least 4.3 million adolescents annually in the United States, but despite current options, symptoms do not improve in approximately 30% of adolescents who opt for traditional antidepressants, according to independent NIH studies.<sup class="text-inherit">3</sup></p><p class="pb-2"></p><p class="pb-2">TMS offers a new pathway for relief without the systemic adverse effects typical of antidepressant medications, which can be a huge help to younger patients and their families. The data presented at AACAP show us that the earlier we introduce TMS in persistent cases, the better the outcomes can be.</p><p class="pb-2"></p><p class="pb-2"><strong><em>PT</em>: NeuroStar is the only FDA-cleared TMS device to treat adolescents aged 15 and older as a first-line adjunct treatment. You are a diamond provider for NeuroStar TMS. Do you have any recommendations for mental health clinicians who might be considering utilizing TMS in their own practices?</strong></p><p class="pb-2"><strong>Fickey: </strong>NeuroStar, as the only FDA-cleared device for patients aged 15 and up, stands out as a nondrug option, making a real difference for young people. I have been practicing with NeuroStar for 6 years, and the results we have seen in my practice, and from the data, show remarkable improvements in both depression and anxiety—it is an opportunity to offer a solution that can genuinely change lives.</p><p class="pb-2"></p><p class="pb-2">Beyond its clinical efficacy, integrating NeuroStar into practice offers several practical benefits that can further enhance patient care. One notable feature is the proprietary TrakStar Patient Data Management System, which streamlines patient data management. This system ensures a smooth experience for patients, from their initial consultation through treatment, fostering their engagement and commitment to the process. It also makes it easy on me and my staff to track a patient’s progress during the course of the treatment.</p><p class="pb-2"></p><p class="pb-2">Additionally, private and public insurance policies are increasingly covering it for adolescents and adult populations, reflecting a growing recognition of TMS as a valuable treatment option. This broader and rapidly increasing acceptance we have seen over the past few years—especially this year after the FDA clearance for adolescents—makes it that much easier to offer NeuroStar as an effective treatment for patients who are struggling.</p><p class="pb-2"></p><p class="pb-2"><strong><em>PT</em>: Is there anything else you would like to share?</strong></p><p class="pb-2"><strong>Fickey: </strong>This study marks a pivotal moment in the treatment of depression and anxiety for adolescents and young adults. It is not just about the data—it is about opening new doors for those often underserved by traditional treatments. With such a large, real-world sample, I hope both patients and providers can see the true value of TMS—particularly how NeuroStar is transforming our approach to mental health in this age group. This research represents a beacon of progress, and I believe NeuroStar will change the landscape of adolescent mental health treatment for years to come.</p><p class="pb-2"></p><p class="pb-2"><strong><em>PT</em>: Thank you!</strong></p><p class="pb-2"></p><p class="pb-2"><strong>Dr Fickey</strong><em> is a board-certified psychiatrist specializing in child, adolescent, and adult psychiatry and works as a forensic psychiatric consultant. She is also the founder of Embracing Life Wellness Center.</em></p><p class="pb-2"></p><p class="pb-2"><strong>References</strong></p><p class="pb-2">1. NeuroStar oral presentation at AACAP 2024 highlights largest study evaluating TMS efficacy in adolescents with depression. Neuronetics. News release. October 14, 2024. Accessed October 21, 2024. <a rel="nofollow noreferrer noopener" target="_blank" href="https://ir.neuronetics.com/news-releases/news-release-details/neurostarr-oral-presentation-aacap-2024-highlights-largest-study">https://ir.neuronetics.com/news-releases/news-release-details/neurostarr-oral-presentation-aacap-2024-highlights-largest-study</a></p><p class="pb-2">2. Croarkin PE, Aaronson ST, Carpenter LL, et al. <a rel="nofollow noreferrer noopener" target="_blank" href="https://www.jaacap.org/article/S0890-8567(24)01827-6/fulltext">A naturalistic study of transcranial magnetic stimulation treatment in adolescents and young adults with depression and anxiety.</a> <em>J Am Acad Child Adolesc Psychiatry. </em>2024;63(10):S306.</p><p class="pb-2">3. Ayvaci ER, Croarkin PE. <a rel="nofollow noreferrer noopener" target="_blank" href="https://pubmed.ncbi.nlm.nih.gov/37149350/">Special populations: treatment-resistant depression in children and adolescents.</a> <em>Psychiatr Clin North Am</em>. 2023;46(2):359-370.</p></div></div><div class="flex items-center lg:w-3/4 mb-4 pb-12"></div><div class="jsx-19ede9f0a5a45918 py-4 relative bg-primary md:px-8 -ml-6 xs:ml-0 w-screen xs:w-auto"><div class="jsx-19ede9f0a5a45918 px-4 sm:px-0"><div class="flex justify-between items-center py-1 space-x-4 border-0 select-none sm:border-b border-secondary"><div class="text-3xl text-white text-lg sm:text-3xl">Related Videos</div></div></div><div style="scroll-snap-type:none" class="jsx-19ede9f0a5a45918 flex items-start overflow-x-auto space-x-4 py-4 relative mx-auto w-full pl-4"><a id="" class="w-[200px] h-fit space-y-3 flex-none select-none no-underline" style="scroll-snap-align:center;text-decoration:none" 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Investigators sought to determine the outcomes of adolescents and young adults aged 12 to 21 years with MDD and anxiety who were treated with TMS in community settings.1\n\n\n\nData were extracted from a treatment registry of 1283 patients with MDD; 682 patients were aged 12 to 19 years, and 601 were aged 20 to 21 years. This is the largest sample to date of adolescents and young adults with MDD. Primary outcome measures were the Patient Health Questionnaire-9 (PHQ–9) and Generalized Anxiety Disorder-7 (GAD–7).2 The analyses examined outcomes from patients who completed 20 or more sessions and an intent-to-treat sample. In the completer sample (N=1169), results show that 59.4% of patients aged 12 to 19 and 36.4% of patients aged 20 to 21 met the PHQ-9 response and remission criteria, respectively. Investigators observed marked dose-response effects and antidepressant effectiveness improved with longer treatment courses (P < .0001). The greatest symptom reduction was seen over the first 10 sessions, with no plateau before treatment termination. The adolescent and young adult subgroup data did not differ in treatment effects.\n\n\n\nTo better understand this data, Psychiatric Times sat down with Melissa Fickey, MD, a board-certified psychiatrist who specializes in child, adolescent, and adult psychiatry.\n\n\n\nPsychiatric Times: Tell us a little about that data shared at the AACAP annual meeting. What is the most important takeaway from this data for practicing mental health clinicians?\n\nMelissa Fickey, MD: The data presented at AACAP highlights a breakthrough for teens and young adults struggling with depression and, in some cases, anxiety. This study was the most extensive of its kind, examining over 1200 young people aged 12 to 21 years old who received treatment with NeuroStar Advanced Therapy’s TMS. The results were very encouraging and showed more than 70% of those treated experienced meaningful improvements (or a 6 point or more change in their PHQ-9 score).\n\n\n\nThe positive results from this study reinforce the FDA clearance, as NeuroStar is the only FDA-cleared TMS device for treating adolescents with MDD aged 15 and older. Prior data also show a 78% response rate and 48% remission rates in teens and ultimately provide compelling evidence supporting TMS as a highly effective treatment for adolescents with MDD.\n\n\n\nPT: Do you think this data will help patients and families considering TMS feel more comfortable?\n\nFickey: This data can provide significant confidence to patients and their families who might be apprehensive about beginning treatment with TMS. As mentioned, these are the largest study results of its kind, and they reinforce the safety and effectiveness the FDA reviewed when deciding NeuroStar is a first-line add-on option for adolescents with MDD age 15 and up. Not only did most participants experience meaningful improvements in both depression and anxiety, but adverse effects were minimal. Additionally, the data show treatment made an impact after only a few sessions and results improved for those who completed a full treatment course.\n\n\n\nPT: Treatment with TMS resulted in marked improvement in both depressive symptoms and anxiety in adolescents and young adults. There are limited approved treatment options in this age category. At what point do you determine it is time to try TMS?\n\nFickey: NeuroStar is currently the only TMS therapy that is approved as a first-line adjunct treatment for adolescents—so it can be a first-line option for adolescents aged 15 and up in conjunction with other modalities, like antidepressant medications or talk therapy. It can also be used if a patient has tried other options but is not seeing a large impact on their mental health. MDD is a substantial public health challenge impacting at least 4.3 million adolescents annually in the United States, but despite current options, symptoms do not improve in approximately 30% of adolescents who opt for traditional antidepressants, according to independent NIH studies.3\n\n\n\nTMS offers a new pathway for relief without the systemic adverse effects typical of antidepressant medications, which can be a huge help to younger patients and their families. The data presented at AACAP show us that the earlier we introduce TMS in persistent cases, the better the outcomes can be.\n\n\n\nPT: NeuroStar is the only FDA-cleared TMS device to treat adolescents aged 15 and older as a first-line adjunct treatment. You are a diamond provider for NeuroStar TMS. Do you have any recommendations for mental health clinicians who might be considering utilizing TMS in their own practices?\n\nFickey: NeuroStar, as the only FDA-cleared device for patients aged 15 and up, stands out as a nondrug option, making a real difference for young people. I have been practicing with NeuroStar for 6 years, and the results we have seen in my practice, and from the data, show remarkable improvements in both depression and anxiety—it is an opportunity to offer a solution that can genuinely change lives.\n\n\n\nBeyond its clinical efficacy, integrating NeuroStar into practice offers several practical benefits that can further enhance patient care. One notable feature is the proprietary TrakStar Patient Data Management System, which streamlines patient data management. This system ensures a smooth experience for patients, from their initial consultation through treatment, fostering their engagement and commitment to the process. It also makes it easy on me and my staff to track a patient’s progress during the course of the treatment.\n\n\n\nAdditionally, private and public insurance policies are increasingly covering it for adolescents and adult populations, reflecting a growing recognition of TMS as a valuable treatment option. This broader and rapidly increasing acceptance we have seen over the past few years—especially this year after the FDA clearance for adolescents—makes it that much easier to offer NeuroStar as an effective treatment for patients who are struggling.\n\n\n\nPT: Is there anything else you would like to share?\n\nFickey: This study marks a pivotal moment in the treatment of depression and anxiety for adolescents and young adults. It is not just about the data—it is about opening new doors for those often underserved by traditional treatments. With such a large, real-world sample, I hope both patients and providers can see the true value of TMS—particularly how NeuroStar is transforming our approach to mental health in this age group. This research represents a beacon of progress, and I believe NeuroStar will change the landscape of adolescent mental health treatment for years to come.\n\n\n\nPT: Thank you!\n\n\n\nDr Fickey is a board-certified psychiatrist specializing in child, adolescent, and adult psychiatry and works as a forensic psychiatric consultant. She is also the founder of Embracing Life Wellness Center.\n\n\n\nReferences\n\n1. NeuroStar oral presentation at AACAP 2024 highlights largest study evaluating TMS efficacy in adolescents with depression. Neuronetics. News release. October 14, 2024. Accessed October 21, 2024. https://ir.neuronetics.com/news-releases/news-release-details/neurostarr-oral-presentation-aacap-2024-highlights-largest-study\n\n2. Croarkin PE, Aaronson ST, Carpenter LL, et al. A naturalistic study of transcranial magnetic stimulation treatment in adolescents and young adults with depression and anxiety. J Am Acad Child Adolesc Psychiatry. 2024;63(10):S306.\n\n3. Ayvaci ER, Croarkin PE. Special populations: treatment-resistant depression in children and adolescents. Psychiatr Clin North Am. 2023;46(2):359-370.","description":"According to new data, NeuroStar Advanced TMS helped nearly 60% of adolescents with major depressive disorder. 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At what point do you determine it is time to try TMS?","_key":"8b5514a4753b1"}],"_type":"block"},{"uploadAudio":null,"medias":null,"_type":"block","style":"normal","_key":"a978b5a1f0c0","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Fickey: ","_key":"8a176487dd8c0"},{"_type":"span","marks":[],"text":"NeuroStar is currently the only TMS therapy that is approved as a first-line adjunct treatment for adolescents—so it can be a first-line option for adolescents aged 15 and up in conjunction with other modalities, like antidepressant medications or talk therapy. It can also be used if a patient has tried other options but is not seeing a large impact on their mental health. 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Patients were included if they were 18 or older, understood the native language, and scored ≥ 4 on at least one of the following items from the Positive and Negative Syndrome Scale (PANSS): delusions, hallucinatory behavior, grandiosity, suspiciousness/persecution, or unusual thought content.","_key":"0ab872d231320","_type":"span"}],"_type":"block","style":"normal","_key":"0137f1457e7e","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"b6ce21aae70b0"}],"_type":"block","style":"normal","_key":"c6b7b8110466"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"The mean age of research participants was 30.9, more than half of the group were men, about one-third of the group had no lifetime exposure to APs, and a majority were diagnosed with schizophrenia via the International Classification of Diseases (ICD).","_key":"e4504c5c382d0"}],"_type":"block","style":"normal","_key":"bf16f6b75802"},{"style":"normal","_key":"2d056d862ee1","markDefs":[],"children":[{"marks":[],"text":"","_key":"d1d48b93e9880","_type":"span"}],"_type":"block"},{"_type":"block","style":"normal","_key":"b6c615a301e1","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/topics/addiction-suds-compulsive","_key":"d2dc6ea06f41"}],"children":[{"_type":"span","marks":[],"text":"Exclusions included organic psychosis or psychosis due to psychoactive ","_key":"4b2df0cf460f0"},{"_type":"span","marks":["d2dc6ea06f41"],"text":"substance abuse","_key":"7cf11d003178"},{"_type":"span","marks":[],"text":", hypersensitivity to the active substance or any of the excipients of the study drugs, prolactin-dependent tumors, phaeochromocytoma, and concomitant use of medications that could induce torsade de pointes, use of levodopa, and known risk of narrow-angle glaucoma.","_key":"53e5c7cc1c5c"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"da96dc220c8f0"}],"_type":"block","style":"normal","_key":"52c30776b567"},{"_key":"d7ed925223a2","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Researchers controlled for gender, age, onset age, DUP, education level, dosage of AP, previous exposure to APs, and substance use.","_key":"fb35c17eb2220"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"66364f8c861e","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Of the 98 patients, 56.1% reported any moderate to severe trauma. Within each subtype, 17.5% reported physical abuse, 31.6% reported emotional abuse, 16.3% reported sexual abuse, 31.6% reported emotional neglect and 28.6% reported physical neglect. Over half of the sample, 66%, reported previous exposure to APs.","_key":"373fb429b4840"}]},{"children":[{"text":"","_key":"ac568c1b3bed0","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"a4ddac08e2c9","markDefs":[]},{"_key":"e2375c1c2ddd","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Study Execution and Procedure","_key":"44188570e0320"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Researchers randomized patients to receive treatment with orally administered aripiprazole, amisulpride, or olanzapine, and dosages were decided by the patient and psychiatrist within the following ranges: aripiprazole at 5 to 30 mg/d, amisulpride at 50 to 200 mg/d and olanzapine at 2.5 to 20 mg/d. This model was based on data from the Bergen, Stavanger, Innsbruck, Trondheim (BeSt InTro) study which examined the effectiveness of the three medications.","_key":"51ce0354b3460"},{"_type":"span","marks":["superscript"],"text":"3","_key":"ebaba192bae5"}],"_type":"block","style":"normal","_key":"c22009dbb246"},{"_type":"block","style":"normal","_key":"ca14e4ec2914","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Drug allocation was open to the patient and clinical team but sealed from researchers. Patients could refuse the first drug in the sequence; they were asked the reason for refusing and offered the second drug in the sequence. 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The Child Trauma Questionnaire-Short Form was administered at the 6-week follow-up to avoid acute phases for increased validity. The SCID diagnostic interview was administered as soon as possible to determine inclusion according to diagnosis within the schizophrenic spectrum.","_key":"9424fcdc17b70"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":[],"text":"","_key":"f1c2b7b82d890"}],"_type":"block","style":"normal","_key":"09813df35e85","markDefs":[]},{"_type":"block","style":"normal","_key":"d0cf81a87b21","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Results","_key":"594cf39217e00"}]},{"_type":"block","style":"normal","_key":"5cc3ea9eee55","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Mørkved et al found abuse subtypes could predict psychosis symptom levels and AP effectiveness. Results showed that participants who experienced sexual abuse were more likely to display positive psychosis symptoms following AP treatment. 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Further, there was an effect of physical neglect and decreased treatment effectiveness shown by increased levels of general psychopathology symptoms.These findings are important, as it shows that type of childhood trauma reported by SSDs patients could have implications for the effectiveness of antipsychotic treatment.”","_key":"57556a1d9b650"},{"_type":"span","marks":["superscript"],"text":"1","_key":"78ba6c30f1e3"}],"_type":"block","style":"normal","_key":"5b42f93aa46a"},{"style":"normal","_key":"f9704d7284e4","markDefs":[],"children":[{"_type":"span","marks":["superscript"],"text":"","_key":"fbb331d9b811"}],"_type":"block"},{"style":"normal","_key":"a542587ba913","markDefs":[],"children":[{"_key":"2c9227d1ddfd0","_type":"span","marks":["strong"],"text":"References"}],"_type":"block"},{"_key":"d6b8e711c68e","markDefs":[{"href":"https://pubmed.ncbi.nlm.nih.gov/39241487/","_key":"cbaff671f6d2","nofollow":true,"blank":true,"_type":"link"}],"children":[{"_type":"span","marks":[],"text":"1. 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Today, we’ll teach you how to use blue light filters to stabilize the circadian rhythms that regulate mood and sleep, and how to use them in ","_key":"e45918effa9b0","_type":"span"},{"_type":"span","marks":["1198bbed81a5"],"text":"dark therapy","_key":"299805087023"},{"marks":[],"text":", a behavioral therapy for mania.","_key":"3575cf901bec","_type":"span"},{"_type":"span","marks":["superscript"],"text":"2","_key":"f2efb30b51eb"}],"_type":"block","style":"normal","_key":"74c64a3be23f"},{"_type":"block","style":"normal","_key":"baf9da45e634","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Blue Light and Lunar Cycles","_key":"468b1c6ce26c0"}]},{"style":"normal","_key":"069af0e50d8d","markDefs":[],"children":[{"marks":["strong"],"text":"CHRIS AIKEN","_key":"2dcff61dce8d0","_type":"span"},{"_type":"span","marks":[],"text":": There are 2 well-known photoreceptors in the eye. The rods see black and white, and the cones add color vision. But in the 1990s a new photoreceptor was discovered – melanopsin – which only responds to the blue wavelength of light. This photoreceptor doesn’t help us see, but it does regulate our circadian rhythm. In the past, this system worked well because we didn’t have much blue light in the evening. There were candles, starlight, fireplaces – all yellow light.","_key":"2dcff61dce8d1"}],"_type":"block"},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/32252567/","_key":"fe0f92d0923b"}],"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME","_key":"943378cefa1b0"},{"_type":"span","marks":[],"text":": Except once a month when the blue moon was full. And it’s no coincidence the word lunatic arose in the middle ages as a term for mental illness. It was believed that some people went into temporary bouts of insanity that followed the lunar cycle – the moon. Seven hundred years later, ","_key":"943378cefa1b1"},{"_type":"span","marks":["fe0f92d0923b"],"text":"reports","_key":"8c8c27f27800"},{"_type":"span","marks":[],"text":" linking the full moon to worsening of psychiatric disorders continue to roll in.","_key":"5c3799391272"},{"_type":"span","marks":["superscript"],"text":"3","_key":"e0312ad21686"}],"_type":"block","style":"normal","_key":"7641e7f4c6d3"},{"children":[{"text":"Blue Light Blockers","_key":"22afb4f3c5e90","_type":"span","marks":["strong"]}],"_type":"block","style":"normal","_key":"52e54edb5332","markDefs":[]},{"_key":"e2613fe8d544","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN","_key":"700b98cbf4f20"},{"_key":"700b98cbf4f21","_type":"span","marks":[],"text":": And in today’s world, every night is a full moon, because cell phones, plasma TVs, and energy efficient bulbs emit a lot of blue light. But technology has also come to the rescue in the form of blue light filtering glasses. These are amber colored glasses, and when you wear them they filter out close to 100% of blue light. They’ve gained popularity among sports figures and celebrities, because wearing them at night improves sleep – which then raises cognitive and athletic performance. But most models out there do not filter enough blue light to make a meaningful difference in psychiatric disorders. We recommend the glasses that were used in the clinical research – and there are 2 types. Some studies have used Uvex glasses, eg Uvex Skyper S1933X and Uvex Ultra-spec 2000, which are $10 to 15 dollars on Amazon."},{"_type":"span","marks":["strong"],"text":" ","_key":"285651f59c0a"},{"marks":[],"text":"Another option is lowbluelights.com.","_key":"46a5e7d06801","_type":"span"},{"_type":"span","marks":["strong"],"text":" ","_key":"11eb94fabb93"},{"text":"Any pair on that site will work, and these are much better quality for a higher price, around $50.","_key":"66ffc53ae5a8","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"_key":"78d6c8e5e7e9","markDefs":[],"children":[{"marks":["strong"],"text":"KELLIE NEWSOME","_key":"9c694a732b9b0","_type":"span"},{"marks":[],"text":": I keep a pair of these glasses at my desk for patients to try on. They’re usually surprised to see the world looks quite pleasant through them. They don’t make things dark, but give the world a relaxing, yellow hue. Some patients find them so soothing that I have to warn patients not to wear them during the day, because doing so will flip their circadian rhythm in the wrong direction. When you wear them, your brain will think it’s in pitch darkness, and we only want that effect at night.","_key":"9c694a732b9b1","_type":"span"}],"_type":"block","style":"normal"},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/15713707/","_key":"12575d5be836"}],"children":[{"_type":"span","marks":["strong"],"text":"CHRIS AIKEN","_key":"1a20ca278b3c0"},{"_type":"span","marks":[],"text":": Wearing them has real biological effects. When you put them on, your melatonin starts to rise, the same as it does in a ","_key":"1a20ca278b3c1"},{"_type":"span","marks":["12575d5be836"],"text":"pitch-dark room","_key":"390d3a981cbc"},{"marks":[],"text":".","_key":"91282980cf2d","_type":"span"},{"_type":"span","marks":["superscript"],"text":"4","_key":"697961003892"},{"_type":"span","marks":[],"text":" Sometimes patients ask if they can just take melatonin instead, but that doesn’t have the same effect. In a recent randomized controlled trial, taking artificial melatonin did nothing to stabilize mood in bipolar disorder.","_key":"c6dff41e430d"},{"text":"5","_key":"2599727d60a1","_type":"span","marks":["superscript"]},{"_type":"span","marks":[],"text":" So it’s not enough to have melatonin drizzled on the brain. There are other biological effects involved in pumping out the brain’s indigenous melatonin that are necessary here.","_key":"555373281736"}],"_type":"block","style":"normal","_key":"59a191d00673"},{"style":"normal","_key":"c7d38350dc8b","markDefs":[{"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/view/blue-light-depression-bipolar-disorder","_key":"c8e9043c10b4"}],"children":[{"_type":"span","marks":[],"text":"If you want to know more about the biological effects of light and darkness listen to our August 2nd podcast on ","_key":"c82b3a5ff5f60"},{"_type":"span","marks":["c8e9043c10b4"],"text":"Blue Light, Depression, and Bipolar Disorder","_key":"c82b3a5ff5f61"},{"_type":"span","marks":[],"text":". Now, let’s move on to the clinical research.","_key":"c82b3a5ff5f62"}],"_type":"block"},{"children":[{"_type":"span","marks":["strong"],"text":"Origins of Dark Therapy","_key":"d63f0e30dbe20"}],"_type":"block","style":"normal","_key":"79f7a0caf625","markDefs":[]},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/7512910/","_key":"b2f2bf6e15cb"}],"children":[{"_type":"span","marks":["strong"],"text":"KN","_key":"d47c38c77a240"},{"_type":"span","marks":[],"text":": In the 1980s Thomas Wehr, MD, and Norman Rosenthal, MD, made a surprise discovery while working at the National Institute of Mental Health (NIMH). Some patients had worsened depression in the wintertime that improved with light therapy. Their research suggested that circadian rhythms played a strong role in mood disorders, something that was already hinted at by the high rates of insomnia in major depression and the fact that a night without sleep often triggered an episode of mania. So, Wehr turned his attention from morning light to evening darkness. He began with normal subjects and placed them in a pitch-dark room for 14 hours overnight, imitating a dark winter night where the sun goes down at 6 PM and rises at 8 AM. The subjects were a little sleep deprived before the experiment, getting about 7 hours per night, something Wehr thought might be due to the artificial evening light of modern life. After a few weeks in the dark bedroom, their ","_key":"d47c38c77a241"},{"_type":"span","marks":["b2f2bf6e15cb"],"text":"sleep stabilized","_key":"5640001f0a8e"},{"_type":"span","marks":[],"text":" to 8 hours and 15 minutes per night, closer to the recommended amount an adult needs.","_key":"78be0d17874c"},{"_key":"456071b75d5a","_type":"span","marks":["superscript"],"text":"6,7"}],"_type":"block","style":"normal","_key":"d79872329c72"},{"style":"normal","_key":"4e8d605914a3","markDefs":[{"href":"https://pubmed.ncbi.nlm.nih.gov/9611672/","_key":"0ed721ba65fa","blank":true,"_type":"link"}],"children":[{"_key":"248c11caaf5c0","_type":"span","marks":["strong"],"text":"CA"},{"_type":"span","marks":[],"text":": Then in 1994 a man came to the NIMH seeking help for rapid cycling bipolar disorder. Most patients don’t call up the NIMH to get help, so we can imagine this man had a pretty bad case. He was a successful engineer with a hyperthymic temperament, but in his 40s he became depressed and started fluoxetine and nortriptyline. He got better on this combination, but then went into a 4-year bout of rapid cycling moods cycling in and out of depression and hypomania every 1 to 2 months. Mood stabilizers did not help, so he came to the NIMH. Wehr knew that sleep disruption could trigger rapid cycling, and he wondered if his super-dark room could stabilize it. He put the patient through the same protocol he used for sleep, placing him in a pitch dark room for 14 hours each night. With this dark therapy, he improved so rapidly that they eased the schedule from 14 hours of darkness to 10 hours each night (10:00 PM to 8:00 AM). He stayed well with that regimen, and that is how dark therapy was ","_key":"248c11caaf5c1"},{"_type":"span","marks":["0ed721ba65fa"],"text":"born","_key":"7b881f4d97bb"},{"_type":"span","marks":[],"text":".","_key":"acda32c28c17"},{"_key":"29d23936e285","_type":"span","marks":["superscript"],"text":"7"}],"_type":"block"},{"markDefs":[],"children":[{"text":"KN","_key":"28fdb6c254e70","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":": But the treatment didn’t really take off. First, it’s hard to get patients in a pitch-dark room overnight. We’re talking so dark that you can’t see your hands in front of your face. Second, we need more than an intriguing case report to put this into practice. The first problem was resolved in the early 2000s by James Phelps, MD.","_key":"28fdb6c254e71"}],"_type":"block","style":"normal","_key":"52ef0cf3e93f"},{"children":[{"marks":[],"text":"Phelps was working in private practice in Oregon when he chanced upon 3 discoveries that would open up new therapeutic doors in bipolar disorder. First, he learned about Wehr’s research on dark therapy. Then he learned about the new photoreceptor, melanopsin, that set the circadian rhythm by responding to blue light. He wondered if dark therapy could be accomplished by blocking only the blue wavelength of light, and that brought him to the third piece of the puzzle: blue light filtering glasses. Other fields of medicine had already raised alarms about the hazards of evening blue light (such as increased risk of cancer and heart disease) and a company was manufacturing these to improve sleep and health. Phelps called this ","_key":"9749394b1d240","_type":"span"},{"text":"virtual darkness","_key":"9749394b1d241","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":" and tried the glasses out on his patients. For some, the glasses did nothing, but about half of his patients reported their sleep was better when they wore the glasses 1 to 2 hours before bed.","_key":"9749394b1d242"},{"_type":"span","marks":["superscript"],"text":"8","_key":"065994221bfc"}],"_type":"block","style":"normal","_key":"78971994f42f","markDefs":[]},{"_type":"block","style":"normal","_key":"390955093fb9","markDefs":[],"children":[{"marks":[],"text":"He then discovered that welders used the same blue-light filters to protect their eyes at the local welding shop, and this opened the door to more treatments because these factory grade lenses were only $7. Phelps tested them and the fit the bill. ","_key":"03ea9e517e010","_type":"span"},{"_type":"span","marks":["em"],"text":"Consumer Reports ","_key":"572dbf06ea9e"},{"_type":"span","marks":[],"text":"later ran tests of blue light blockers and also concluded that the Uvex safety lenses he was using were among the strongest filters.","_key":"186d9f90286e"}]},{"_key":"71ea429c2694","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Phelps tested the waters, but the definitive study was a full-scale randomized trial in patients who were hospitalized for mania. In addition to treatment as usual, half wore amber lenses in the evening, and half wore (placebo) gray lenses, until sleeping in a pitch-dark room. The improvements were dramatic over the first week, with a large effect size of 1.9, while the control group barely changed.","_key":"fec10e0ca0740"},{"marks":["superscript"],"text":"2","_key":"8839f67a375e","_type":"span"}],"_type":"block","style":"normal"},{"_key":"cc6b6fdc0b3d","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"The Protocol","_key":"1394ceb614ae0"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"596761a4cde7","markDefs":[],"children":[{"_type":"span","marks":[],"text":"You don’t need to be in the hospital to do this therapy. Phelps has had success using it in an outpatient practice, and we have as well. Here’s how you do it.","_key":"30bfbe3945da0"}]},{"_type":"block","style":"normal","_key":"0c4add95764a","markDefs":[],"children":[{"marks":[],"text":"The original protocol required manic patients to be in either pitch darkness or virtual darkness (that is, with the amber glasses on) for 14 hours, from 6:00 PM to 8:00 AM. It took about a week for the mania to improve, and as it did the protocol was relaxed a bit, from 14 hours per night to 10 hours per night. So instead of putting the glasses on at 6 PM, they’d put them on at 7:00 PM, then 8:00 PM, and for prevention thy would move it to 9 or 10 PM. They don’t wear the glasses while asleep. That’s what the pitch-dark bedroom is for. But they do put them on if they are awake and the lights are on.","_key":"4cd04c50e02d0","_type":"span"}]},{"markDefs":[],"children":[{"_key":"da5c4ea963040","_type":"span","marks":[],"text":"And the pitch darkness really does matter. Even light as dim as a nightlight on can interfere with melatonin secretion. In a large epidemiologic study of older adults, sleeping with a night light on doubled the risk of depression over 2 years compared to a pitch-dark bedroom."},{"marks":["superscript"],"text":"9","_key":"352455f41630","_type":"span"}],"_type":"block","style":"normal","_key":"c3741b08e60d"},{"children":[{"_type":"span","marks":[],"text":"But how do they get their bedroom pitch dark in this electric light world? ","_key":"e1b57027dcc10"},{"text":"Black out curtains","_key":"e1b57027dcc11","_type":"span","marks":["1ce054c35f5b"]},{"text":", electrical tape over LEDs, towels or draft snakes under doors, or sleeping in the basement. If there is still stray light, patients can also sleep with a good eye mask.","_key":"e1b57027dcc12","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"97b2fbfacdec","markDefs":[{"blank":true,"_type":"link","href":"http://www.shiftshade.com/","_key":"1ce054c35f5b"}]},{"markDefs":[],"children":[{"text":"CA","_key":"d49119795ed50","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":": One problem we run into is patients who feel they can’t sleep without the TV on. Usually the reason is depressive rumination. These patients rely on the TV to distract them from their negative, ruminating thoughts. If that’s the case, we recommend ambient music or boring audiobooks instead. Another problem is patients who are afraid of the dark, such as those with PTSD. Here we have a technological solution. They can use amber colored nightlights that don’t emit any blue light. They are available for around $12.","_key":"d49119795ed51"}],"_type":"block","style":"normal","_key":"8273b2575cc1"},{"children":[{"_type":"span","marks":["strong"],"text":"KN","_key":"350baa9963580"},{"_key":"350baa9963581","_type":"span","marks":[],"text":": One modification we don’t recommend is to rely on blue-light filters on laptops and cell phones. Most devices have a setting that turns down the blue in the evening, and no doubt this is certainly a good thing and we’d recommend it in conjunction with dark therapy, but it doesn’t filter 100% and it isn’t going to take care of the background lights. You can find this feature in your smart phone’s settings, or if you’re using a laptop try downloading f.lux (spell it out) for windows or Candlelight by Oliver Denman for Mac."}],"_type":"block","style":"normal","_key":"be6037e19876","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"But what if your patient can’t put the glasses on at 6 PM? Remember the 14-hour protocol was used for hospitalized mania, and they loosened it up as the patient got better. In practice, you might use dark therapy for hypomania, mild mixed states or as an intervention for early signs of mania. In those cases, putting the glasses on 2 hours before bed might be enough.","_key":"4d197f0fc8a80"}],"_type":"block","style":"normal","_key":"4686c1580b2e"},{"_key":"e7257a6d8b9d","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"CA","_key":"08f2c9b1d95b0"},{"text":": It’s also important to set up expectations. Tell your patient that dark therapy is going to help stabilize their mood, but it may not help them fall asleep. Here’s an interesting pearl from that controlled trial. The patients who got better with the dark therapy didn’t actually sleep more. They slept a little less than the placebo group, but their sleep did get more regular. It went from sleeping and waking at random times to a more steady, stable circadian pattern.","_key":"08f2c9b1d95b1","_type":"span","marks":[]},{"text":"2","_key":"fdeda177bab5","_type":"span","marks":["superscript"]},{"_type":"span","marks":[],"text":" A lot of times patients will give up on dark therapy because they think it is supposed to help them sleep.","_key":"a32bdea71870"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":["strong"],"text":"Dark Therapy for Insomnia","_key":"48c1d1ea6fac0"}],"_type":"block","style":"normal","_key":"b5c98c8d3194","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"KN","_key":"c513a824ead30"},{"text":": Dark therapy improves mania, but what does it do to sleep? We found 3 randomized controlled trials that tested them out in insomnia, and they had a large effect, helping patients stay asleep longer, fall asleep earlier, and deepening sleep quality.","_key":"c513a824ead31","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"10-12","_key":"8e57359618ec"},{"text":" One of them used the blue light blockers as an adjunct to CBT-insomnia, where half the patients had the behavioral therapy with placebo glasses and half used the blue-light blockers. Not only did sleep improve with the blockers, but so did anxiety and depression.10 Another study looked at performance on cognitive tests after wearing the glasses, and that got better as well, probably because the patients were sleeping better.","_key":"cd9d39970f97","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"11","_key":"0f8658398107"},{"_type":"span","marks":[],"text":" In the sleep studies, patients put the glasses on 1.5 to 2 hours before bedtime.","_key":"98a0034680a3"}],"_type":"block","style":"normal","_key":"e5c617dea0f8"},{"children":[{"_type":"span","marks":[],"text":"Blue light blockers have been used successfully in jet lag, and they tend to help night owls fall asleep earlier.","_key":"fa05ef5e016d0"}],"_type":"block","style":"normal","_key":"c7b0aabbd537","markDefs":[]},{"style":"normal","_key":"5bbc20f2c723","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"CA","_key":"08b9b8d0af4d0"},{"marks":[],"text":": I wear them myself and I can attest to that. I’m more patient and have better attention, a little quicker on my feet, the next day if I wore them before bed.","_key":"08b9b8d0af4d1","_type":"span"}],"_type":"block"},{"style":"normal","_key":"8e7e003f8d09","markDefs":[],"children":[{"text":"Dark Therapy for Depression","_key":"e1c47995de9a0","_type":"span","marks":["strong"]}],"_type":"block"},{"_type":"block","style":"normal","_key":"d00277c9dd9f","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"KN","_key":"1a8bcf789c6c0"},{"_type":"span","marks":[],"text":": Blue light blockers have a big effect in mania and rapid cycling, and for sleep they deepen sleep quality and turn night owls into morning people. But can they help depression? We know from animal studies and epidemiologic studies that blue light causes depression, but when it comes to clinical studies using blue light blockers to treat depression the results are mixed. In that CBT-insomnia study, they did improve depressive symptoms, but those patients had clinical insomnia, not clinical depression.","_key":"1a8bcf789c6c1"},{"_type":"span","marks":["superscript"],"text":"10","_key":"a07fecd7c3f5"},{"_type":"span","marks":[],"text":" Beyond that, we have only 2 controlled trials, 1 positive, 1 negative. The positive one was small (n = 27) and centered on postpartum depression, where nocturnal awakening is the norm. Women who used blue-light blockers and low-blue light bulbs had greater improvements than those who used placebo glasses and bulbs.","_key":"6e47b195828e"},{"_type":"span","marks":["superscript"],"text":"13","_key":"b361669caef5"},{"_type":"span","marks":[],"text":" The negative study was also small (n = 20) and included depressed patients with insomnia. The investigators suspected that the glasses might not have worked because the patients found them uncomfortable and did not wear them as much as they should.","_key":"28351afde38b"},{"_type":"span","marks":["superscript"],"text":"14","_key":"489c274fec81"}]},{"children":[{"_key":"8ef4c38d11c10","_type":"span","marks":["strong"],"text":"Warnings"}],"_type":"block","style":"normal","_key":"95648ec7ee55","markDefs":[]},{"children":[{"marks":["strong"],"text":"CA","_key":"e8037cb641160","_type":"span"},{"_type":"span","marks":[],"text":": When worn at night, blue light filters have beneficial, biological effects, but can they have side effects? Nothing major showed up in the studies. Possibly headaches, and there are reports of depression in some patients. This usually improves by putting the glasses on later, say, 7 PM or 8 PM instead of 6 PM. Although you can see pretty clearly through the glasses, color vision is distorted so we don’t recommend them while driving.","_key":"e8037cb641161"}],"_type":"block","style":"normal","_key":"0a03b0a2d077","markDefs":[]},{"_type":"block","style":"normal","_key":"0699b5b917a3","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"KELLIE NEWSOME","_key":"8eabe01ecb250"},{"marks":[],"text":": We have links to recommended brands of blue-light blockers in the text to this podcast. 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If you do not already have an account with Physicians’ Education Resource, LLC, you will be prompted to create one. 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We present a multidisciplinary approach and clinical practice guideline (CPG) for providing evidence-based standardized treatment to this special population. The CPG was developed by an interdisciplinary workgroup at the University of Michigan, C.S. Mott Children’s Hospital, based on our own clinical experience and modeled on standard practices within the field of adolescent medicine, as outlined in a similar protocol by Sylvester and Forman at Boston Children’s Hospital.","_key":"9839bab2e0bc0"},{"_type":"span","marks":["superscript"],"text":"4","_key":"b6bbfd6a30aa"},{"_type":"span","marks":[],"text":" Additionally, we share access to internally developed psychoeducation materials for patients and families in hopes that these resources might aid in practice efforts at other institutions. Even with a formalized protocol, we highlight ongoing treatment challenges relating to acute behavior management, capacity concerns, ethics around compelling care, and common barriers to discharge planning.","_key":"87d34d64329c"}]},{"children":[{"_type":"span","marks":["strong"],"text":"A Multidisciplinary Approach","_key":"7b0ac63cd5690"}],"_type":"block","style":"normal","_key":"9b53583ed214","markDefs":[]},{"children":[{"_type":"span","marks":[],"text":"At our hospital, patients who are admitted for medically monitored nutrition restoration are cared for by a primary general pediatrics team, made up of an attending pediatric hospitalist, pediatric residents, and medical students. Our protocol requires consultation to adolescent medicine (AM), pediatric CL psychiatry, and a registered dietitian nutritionist (RDN). Additional team members have varied levels of involvement based on each patient’s needs, and might include psychiatry social workers, a behavioral support nurse, child life specialists, art and music therapists, spiritual care, learning specialists, and any other relevant medical subspecialty consultants (eg, pediatric endocrinology, pediatric cardiology). Bedside nurses play a crucial role in each patient’s care and are vital members of the multidisciplinary team. A patient care attendant (a 1:1 bedside observer) is assigned to each patient upon admission and is continued for at least the first 24 hours, at which point the team and family discuss the benefit of maintaining that resource for the duration of the stay. Indication for the patient care attendant include increased supervision and monitoring of eating disorder behaviors in the hospital setting to ensure integration of these concerns into the treatment plan.","_key":"71012045b6e40"}],"_type":"block","style":"normal","_key":"b18f8ef07e4a","markDefs":[]},{"_key":"49d48242bdac","markDefs":[],"children":[{"_type":"span","marks":[],"text":"In many cases, complexities in the clinical presentation or psychosocial situation are so impactful for treatment planning that it is beneficial for the primary and consultant teams to round jointly each day. We also regularly convene multidisciplinary care team meetings, generally once toward the beginning of the admission and again closer to discharge. These meetings typically include the family (and sometimes the patient) and, if needed, step-down treatment centers, to optimize treatment progress and to plan for next steps in care.","_key":"aafc703267200"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":[],"text":"Approaching the medical admission with this multidisciplinary team model from start to finish helps signal to patients and families that eating disorders are complex illnesses requiring not only medical stabilization and treatment but also comprehensive mental health, family, and social support interventions. Furthermore, we find that the multidisciplinary approach is vital for the well-being of our care teams, providing reinforcement and reassurance to individual team members as they navigate complex family dynamics and high expressed-emotion interactions.","_key":"7c7e51a172f80"}],"_type":"block","style":"normal","_key":"5fe64c3b474d","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Patient Characteristics","_key":"801ff04e13980"}],"_type":"block","style":"normal","_key":"d266949fddb2"},{"children":[{"_type":"span","marks":[],"text":"C.S. Mott Children’s Hospital admits patients through aged 24 years though most are younger than 21 years. Most patients who are admitted for malnutrition related to disordered eating are in their mid- to late teens, but we have seen increasingly younger patients over the last few years, especially in the 10- to 12-year-old range. Patients 25 years and older are admitted to our University Hospital, where they are treated under a similar protocol, modified for that age population.","_key":"7082161184120"}],"_type":"block","style":"normal","_key":"4cd7089aed59","markDefs":[]},{"_type":"block","style":"normal","_key":"03170a85ee66","markDefs":[{"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/topics/emergency-psychiatry","_key":"588605806bf8","nofollow":true}],"children":[{"_type":"span","marks":[],"text":"Some patients self-present to the ","_key":"58bf5dd9ca830"},{"marks":["588605806bf8"],"text":"emergency department","_key":"f127921226f4","_type":"span"},{"_type":"span","marks":[],"text":" (ED) due to significant weight loss or concerning symptoms, such as fainting or fatigue. Many patients are referred to the ED by primary care physicians or our own outpatient AM clinic upon detecting abnormal vitals, labs, physical exam signs, or failure to respond to outpatient management in the context of weight loss or reported food restriction. Often, patients carry an existing diagnosis of an eating disorder and are being followed longitudinally for that condition by AM or outside eating disorder specialists. Some patients, however, are presenting for first-time evaluation in the acute care setting and have never discussed the notion of an eating disorder diagnosis with a medical or mental health clinician. Unfortunately, there is a cohort of patients who have had multiple medical admissions to our hospital for malnutrition and are well known to the inpatient pediatric and consultation teams; this can be both helpful and challenging in treatment planning.","_key":"c5c0edccb54d"}]},{"_key":"3f5fb6fccdf4","markDefs":[{"href":"https://www.psychiatrictimes.com/topics/schizophrenia","_key":"cf67a9076898","nofollow":true,"blank":true,"_type":"link"}],"children":[{"_type":"span","marks":[],"text":"The overwhelming majority of patients fit the picture of anorexia nervosa (AN) but we do occasionally admit patients with bulimia nervosa or other disordered eating behaviors. When patients are admitted for malnutrition in the context of avoidant/restrictive food intake disorder (ARFID), we alter the protocol to better align with the unique needs of those patients. We currently have a multidisciplinary work group collaborating to formalize a separate protocol for ARFID admissions. When the diagnosis remains unclear or points toward a non–eating-disordered psychiatric reason for malnutrition, such as severe depression, ","_key":"ae4905dc5b1e0"},{"_type":"span","marks":["cf67a9076898"],"text":"psychosis","_key":"f958acc1c77d"},{"_type":"span","marks":[],"text":", obsessive-compulsive disorder, or catatonia, the CL team collaborates with the medical providers to devise a treatment plan that is best suited for the presentation.","_key":"412ef9100869"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"The Protocol","_key":"ac0c5523d9050"}],"_type":"block","style":"normal","_key":"6307078c9431"},{"_type":"block","style":"normal","_key":"17af79dd6893","markDefs":[],"children":[{"_type":"span","marks":[],"text":"The CPG outlines specific admission criteria to aid the ED clinicians who first assess these patients. Any questions or uncertainty regarding the appropriateness of admission can be discussed in real time with the on-call AM consultant. Admission criteria include any of the following: acute food refusal for 24 hours with failure to demonstrate 100% completion of a standard meal in the ED; concerning physical signs or symptoms of malnutrition; body mass index (BMI) less than or equal to 75% of the median for age and sex; bradycardia (\u003c 50 beats per minute while awake), hypotension (\u003c 90/45 mm Hg), or hypothermia (\u003c 96 °F, \u003c 36 °C); intractable vomiting or uncontrolled bingeing/purging; or failure of outpatient treatment.","_key":"e10398a067090"},{"_type":"span","marks":["superscript"],"text":"5","_key":"1ad9c1b24a06"}]},{"style":"normal","_key":"9d181c7e57a9","markDefs":[],"children":[{"marks":[],"text":"Once the decision is made to admit the patient, the primary team places a standardized order set, which triggers a specific meal plan, sets up regular laboratory monitoring, and prompts consultation to AM, CL, and the RDN. Efforts are made to transition the patient out of the ED space as soon as possible, as that environment is not ideally suited for following a strict meal plan and supervision protocol. Ultimately, hospital census and acuity guide bed placement. For situations in which prolonged ED boarding is unavoidable, the CPG contains a section outlining adaptations of the protocol for the ED setting.","_key":"c13462ddf97a0","_type":"span"}],"_type":"block"},{"widthP":70,"blank":true,"disableLightBox":true,"disableTextWrap":false,"alt":"TABLE. Medical Monitoring and Diagnostic Testing","_key":"04a9096a3066","_type":"figure","imgcaption":[{"style":"normal","_key":"3b5e25e5fce7","markDefs":[],"children":[{"_key":"04057562ae040","_type":"span","marks":["strong"],"text":"Table. "},{"_type":"span","marks":[],"text":"Medical Monitoring and Diagnostic Testing","_key":"95546b63afc3"}],"_type":"block"}],"alignment":"right","asset":{"_ref":"image-452fd7b2757bc5bc6b877fe55fc0cc2831188c4f-1676x590-png","_type":"reference"}},{"_type":"block","style":"normal","_key":"86e858a42a56","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F452fd7b2757bc5bc6b877fe55fc0cc2831188c4f-1676x590.png%3Ffit%3Dcrop%26auto%3Dformat\u0026w=3840\u0026q=75","_key":"a5b8fa72cbcf"}],"children":[{"_type":"span","marks":[],"text":"Because of the potential development of refeeding syndrome in severely malnourished patients undergoing nutrition repletion, close medical monitoring is paramount. A standard panel of labs and diagnostic testing is collected upon admission and throughout the hospital stay, as outlined in the ","_key":"dfb5e06d5a170"},{"_type":"span","marks":["strong","a5b8fa72cbcf"],"text":"Table","_key":"c6152116fec8"},{"_type":"span","marks":[],"text":". Fluid balance is closely monitored and a daily fluid goal and free water limit are set. Intravenous (IV) fluids are avoided in favor of enteral nutrition and hydration, but dextrose-containing IV fluids are occasionally necessary to maintain appropriate blood glucose levels or address clinical dehydration or ketonuria. Phosphorus and thiamine supplementation are initiated reflexively for patients with BMI less than 70% of the median for age and sex at the time of admission. Other electrolyte replacement and supplementation is instituted as needed throughout the hospitalization, based on lab monitoring.","_key":"897df64eda8d"},{"_key":"dc291d90e0b4","_type":"span","marks":["superscript"],"text":"5"}]},{"style":"normal","_key":"b563863d5359","markDefs":[],"children":[{"_key":"e141966bf1920","_type":"span","marks":[],"text":"Nutrition is initiated at a level of 1500 kcal per day unless otherwise directed by AM. Calorie level is advanced by 300 kcal/day to until the patient is reliably gaining at least 0.3 kg to 0.4 kg every 2 days. The patient is not told calorie content or goals, and all information labels are removed from food items. The RDN meets with the patient and family upon admission to obtain the dietary history and to allow the patient to select 3 “no” foods for the duration of the hospitalization (these are limited to specific food items and cannot represent an entire food group). Subsequently, the RDN manages the patient’s meal plan entirely, selecting the menu and ordering the trays in accordance with the given kcal level, rate of advancement, known allergies or intolerances, and specified “no” foods."}],"_type":"block"},{"_type":"block","style":"normal","_key":"efb8cef8eeb9","markDefs":[],"children":[{"_type":"span","marks":[],"text":"In the case of vegetarianism or veganism, the context of this preference is critical. If the family has been vegetarian/vegan for years and/or adheres to religious or culturally specified dietary restrictions, efforts are made to accommodate as able. If vegetarianism/veganism arose in the context of disordered eating behaviors, animal sources of food are gradually reintroduced alongside explanatory and supportive discussions with the patient and family. No outside food is permitted throughout the hospitalization to ensure accurate evaluation and monitoring of nutritional and fluid intake and to limit opportunities for negotiation or counterproductive behaviors.","_key":"6f951682c49f0"}]},{"_key":"907e173108dc","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Calorie needs are provided as 3 meals and 3 snacks daily, following a set schedule and adhering to firm time limits to allow for proper digestion and prevent behavioral tactics to prolong meals or avoid food. Meals and snacks are to be completed in 30 min and 15 min, respectively. Food or beverages that are not completed within the time frame are replaced with a commercially available nutritional supplement drink at a concentration of 1.5 kcal/mL. Nursing follows an algorithm in which the proportion of food remaining on the tray at the end of the time limit is estimated, either 1% to 50% or 51% to 99% of total calories, and then cross-referenced to the calorie level for the day to determine the milliliter amount. The patient is allotted 10 to 15 minutes to complete the supplement, depending on the volume. If the patient is unable to take in the necessary dose of nutrition via food and oral supplement within the given time frame, a nasogastric (NG) tube is placed to ensure nutrition delivery. We help patients and families to understand that in the context of an eating disorder, “food is medicine.” The tube is not meant to be a threat or a punishment but rather a tool to provide the medical intervention the patient needs when oral intake has been too difficult to achieve on their own. When an NG tube is needed, it is left in place until the patient has been able to take in 100% of their nutrition orally (food or supplement) for at least 24 hours.","_key":"dd993212d48c0"}],"_type":"block","style":"normal"},{"style":"normal","_key":"9fd7e518dcee","markDefs":[],"children":[{"_key":"3fc0375df0d60","_type":"span","marks":[],"text":"To ensure that energy intake is directed toward organ recovery and weight restoration, energy expenditure is limited as much as possible via activity restriction. For the first 24 hours, the patient is placed on bed rest with assistance to the bathroom. This measure also helps to prevent falls related to syncope or cardiovascular compromise, which are more commonly encountered near the start of admission. Activity is gradually reintroduced with time spent in a bedside chair, seated showers, 30-minute wheelchair rides, and attendance at child life or music therapy events, all based on the clinical assessment of stability for each activity. Exercise of any kind is prohibited and patients are monitored for subtle exercise attempts such as pacing, squatting, or leg lifts in bed. Bathroom use is supervised with the door cracked open, with direct visualization expected for hygiene activities like teeth brushing and hair care but listening only for toileting and showering. These measures allow staff to monitor for purging, exercise, or fluid loading and to observe for signs of distress or syncope. Patients are encouraged to use the bathroom before meals or snacks, and bathroom use is discouraged for 1 hour after."}],"_type":"block"},{"children":[{"_type":"span","marks":[],"text":"Throughout hospitalization, the CL team provides psychoeducation and psychotherapeutic support to the patient and family as they navigate the protocol. Because of the high comorbidity of eating disorders with other psychiatric conditions, a thorough diagnostic evaluation is conducted upon admission, with a special focus on safety assessment.","_key":"f73109a698fa0"},{"_type":"span","marks":["superscript"],"text":"6,7","_key":"bc134f7c67a8"},{"_key":"6ef9889b29d2","_type":"span","marks":[],"text":" In cases where active suicidal ideation raises imminent safety concerns, we institute our hospital’s suicide precautions protocol and reassess daily the need for maintaining that level of care. Suicide risk management also becomes a specific part of the treatment plan, including potential need for a higher level of care after medical stabilization or formal safety planning and lethal means restriction in the discharge planning process."}],"_type":"block","style":"normal","_key":"e0b38d39b8f1","markDefs":[]},{"style":"normal","_key":"c90e4f8a1134","markDefs":[{"_key":"c1e7cacbb995","nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/topics/psychopharmacology"}],"children":[{"text":"Many patients experience high levels of anxiety around mealtimes, especially as food volume increases or as patients detect changes in how their body looks or feels upon gaining weight. When anxiety and distress become so overwhelming as to affect the patient’s ability to eat or otherwise engage in necessary cares, or when distress manifests in severe behavioral dysregulation or aggression, psychotropic medication support can be helpful, either on an as-needed basis or scheduled. When medications are initiated, it is understood that this intervention is likely time limited during this high-acuity period. Medication targets symptom management and psychiatric comorbidities rather than serving as a primary intervention for the eating disorder itself, recognizing the lack of support in the literature for the efficacy of ","_key":"dea5677b3bd60","_type":"span","marks":[]},{"text":"psychopharmacology","_key":"f7ef40e48615","_type":"span","marks":["c1e7cacbb995"]},{"_type":"span","marks":[],"text":" in longer-term eating disorder treatment.","_key":"a6032cb972d2"},{"_type":"span","marks":["superscript"],"text":"8","_key":"eeb49ac767cc"},{"_type":"span","marks":[],"text":" The goal is to enable the patient to restore nutrition enough to engage in evidence-based therapies post discharge. Hydroxyzine and olanzapine are the most frequently utilized medications, with aripiprazole used occasionally and selective serotonin reuptake inhibitors sometimes initiated to address comorbid depression or anxiety.","_key":"915a9aad932e"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"The CL team typically provides patients with psychotherapeutic worksheets relating to insight, self-reflection, and coping, and uses those worksheets as platforms for deeper discussion. For many patients, however, malnutrition is so profound that their ability to engage with executive function–related tasks and higher-order thinking around emotion regulation are significantly impaired, with limited insight into the need for treatment. We advise patients and families that the primary goal during medical hospitalization is to restore nutrition and that mental health interventions at this acute point are purposely focused on psychoeducation and broad emotional support; these are the aims that malnourished brains are best able to target. Therapeutic interventions integrate aspects of family-based treatment (FBT) related to externalizing the eating disorder and promoting parental management of meals and nutrition. When patients do demonstrate insight and interest in processing the emotional and cognitive side of their illness, we do our best to engage in brief and focused psychotherapy as often as possible within the constraints of a busy consultation service. Ultimately, helping to coordinate longer-term mental health supports at the appropriate level of care upon discharge is the most impactful mental health intervention.","_key":"f74242d3d3640"}],"_type":"block","style":"normal","_key":"2ba445d1d1d3"},{"_type":"block","style":"normal","_key":"6acef4e13a62","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Readiness for discharge is determined on a case-by-case basis, but generally is considered when vital signs have improved; short-term labs have normalized; the patient is eating adequately at goal calories (taking oral supplement is occasionally acceptable, depending on percentage of intake coming from supplement alone and the anticipated next level of care); a clear weight-gain trend is noted (if needed); and a follow-up plan is in place. Families meet with the RDN prior to discharge to ensure they understand the caloric needs of the patient and how best to meet these needs with an at-home meal plan. The treatment team coordinates with schools and universities, with permission of the patient and family, to provide guidance on safely acclimating back to typical routines or to request accommodations or temporary academic deferrals.","_key":"9d07f76dde550"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Most patients discharge to outpatient care, a partial hospitalization program (PHP), or an intensive outpatient program (IOP), sometimes in person and sometimes virtually. We are fortunate to have access to an excellent multidisciplinary care center at our own institution, the Comprehensive Eating Disorders Program, which offers an FBT approach at the PHP, IOP, and outpatient levels. For more acute needs, patients might transfer to an inpatient psychiatric unit or discharge to a residential treatment center.","_key":"60ccf03cb5ce0"}],"_type":"block","style":"normal","_key":"c25a6113db56"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Psychoeducation and Family Communication","_key":"4c45c83f8dd50"}],"_type":"block","style":"normal","_key":"b0bc8c32c84f"},{"_type":"block","style":"normal","_key":"72d8385dc8ce","markDefs":[{"href":"https://www.psychiatrictimes.com/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6acf7d5ddd45d1336d7986854fc7e45a0fcf5263-276x658.png%3Ffit%3Dcrop%26auto%3Dformat\u0026w=640\u0026q=75","_key":"1105bf236c8d","nofollow":true,"blank":true,"_type":"link"}],"children":[{"_type":"span","marks":[],"text":"Immediately upon admission, the primary team provides the family with our internally developed guidebook, Inpatient Nutrition Recovery for Children. This 40-page booklet relays information about the multidisciplinary care team, what is happening medically and psychologically relating to the eating disorder, what nutrition recovery entails and why it is important to monitor closely throughout, how the protocol works and why limitations are set, helpful things for parents to say and do, pitfalls to avoid, general information about planning for discharge, and a list of external resources for families to access. The book was written and edited by a multidisciplinary work group and was processed through our institution’s Plain Language Review Board to ensure broad accessibility. With a small internal grant for patient education, we funded professional graphic design and binding for the book and obtained 300 hard copies to distribute. Future goals include translation of the guidebook into additional languages. Families have provided positive feedback about the value of the book in addressing their questions and alleviating their distress about hospitalization. We welcome others to freely access and distribute the digital booklet (see ","_key":"505bb11433010"},{"_type":"span","marks":["strong","1105bf236c8d"],"text":"Figure 1","_key":"4aab48ff9061"},{"_type":"span","marks":["strong"],"text":" ","_key":"700e3769e196"},{"_key":"28b3313dd1c5","_type":"span","marks":[],"text":"for QR code)."}]},{"alt":"FIGURE 1. QR Code for Inpatient Nutrition Recovery for Children Guidebook","asset":{"_ref":"image-6acf7d5ddd45d1336d7986854fc7e45a0fcf5263-276x658-png","_type":"reference"},"disableTextWrap":false,"_type":"figure","_key":"b4ff643a20d0","blank":true,"widthP":40,"imgcaption":[{"markDefs":[],"children":[{"text":"Figure 1. ","_key":"8854d1b525f10","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":"QR Code for Inpatient Nutrition Recovery for Children Guidebook","_key":"4d65f2f7ebac"}],"_type":"block","style":"normal","_key":"8abb8889ad5e"}],"alignment":"right","disableLightBox":true},{"_type":"block","style":"normal","_key":"4da1d2bc51a9","markDefs":[{"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F43ac29c2955c9bc8eddececcb805d51633558b3c-318x528.png%3Ffit%3Dcrop%26auto%3Dformat\u0026w=640\u0026q=75","_key":"985a6fe02ef5","nofollow":true}],"children":[{"_type":"span","marks":[],"text":"Alongside the guidebook, the grant funded the creation of a professionally produced a 12-minute video, Managing Eating Disorder Behaviors, that addresses helpful ways for families to manage common eating disorder behaviors. The video features actors portraying a mother and daughter sitting through a meal and outlines strategies for handling negotiation attempts, food diversion, and emotional outbursts. For hospitalized patients, the video is preloaded onto an internal network that offers informational videos pertinent to each patient’s presenting concerns on the television in their hospital room. Caregivers are also provided with a QR code linking directly to the video so they can watch it on a personal device away from their child (see ","_key":"0e09dd9dc5f90"},{"_type":"span","marks":["strong","985a6fe02ef5"],"text":"Figure 2","_key":"cf051c897361"},{"text":" for QR code).","_key":"18707cb6d5d5","_type":"span","marks":[]}]},{"_key":"7d5d01d7e5a1","disableLightBox":true,"blank":true,"disableTextWrap":false,"alignment":"right","_type":"figure","alt":"FIGURE 2. QR Code for Managing Eating Disorder Behaviors Video","imgcaption":[{"children":[{"_key":"941772eec0370","_type":"span","marks":["strong"],"text":"Figure 2. "},{"_type":"span","marks":[],"text":"QR Code for Managing Eating Disorder Behaviors Video","_key":"621f1512d709"}],"_type":"block","style":"normal","_key":"5ef466099ce3","markDefs":[]}],"asset":{"_ref":"image-43ac29c2955c9bc8eddececcb805d51633558b3c-318x528-png","_type":"reference"},"widthP":40},{"style":"normal","_key":"9a1a2d811a15","markDefs":[],"children":[{"_key":"9596bdb9b0ac0","_type":"span","marks":["strong"],"text":"Acute Behavior Dysregulation"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"It is not uncommon for patients to demonstrate significant behavioral dysregulation during the refeeding process, manifesting as emotional or verbal outbursts, throwing food or other objects, physical aggression toward others, self-harm attempts, or tampering with or removing the NG tube, and this remains an important challenge for care. When verbal de-escalation measures and environmental interventions alone are insufficient, our care team works together with the patient and family to devise a structured behavioral plan (eg, access to electronics or other preferred activities contingent on maintaining safe behaviors and engaging in cares). We are fortunate to have a skilled behavioral support nurse on the CL team who can sit with patients and families during meals and help with coaching and distress tolerance. Oral medications can be helpful for addressing anxiety and agitation. Intramuscular medication is occasionally necessary to ensure the safety of the patient and others around them.","_key":"1a988888f9e90"}],"_type":"block","style":"normal","_key":"99f821294841"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"On rare occasions, patients refuse NG tube placement or go to great lengths to disrupt or remove the tube once it is placed. We have seen patients try to cut or chew through the tubing or pull it out completely, even when bridled. If these behaviors are not manageable with the previously mentioned interventions, and they prevent us from delivering necessary nutrition in the context of severe medical compromise, we sometimes employ physical restraint to ensure that the patient receives the imperative medical care. In these instances, we first consult the Pediatric Ethics Committee and convene with the multidisciplinary team and family to discuss the safest and most appropriate approach to the intervention. Even for minors, whose parents ultimately make medical decisions, we are thoughtful about valuing patient autonomy and the importance of assenting to care. Acknowledging the effects of malnutrition and the eating disorder itself on the patient’s ability to recognize the need for treatment, we work to balance self-determination against the imminent risk of serious medical complications or death. Furthermore, we consider the psychological effects of physical restraint, especially in the context of the patient’s past mental health history and any previous experiences with restraint or forced care. We aim to make the most compassionate and medically safe decision possible in each context.","_key":"74919c4d69790"}],"_type":"block","style":"normal","_key":"8910d773e06b"},{"style":"normal","_key":"867bb0081832","markDefs":[],"children":[{"marks":[],"text":"Modifications to the protocol or changes to the level of staffing are often instituted before proceeding to forced use of an NG tube, and we have had several cases in which these alterations have successfully allowed us to restore nutrition safely without using physical restraint. When implemented, restraint is used only for the duration of the time needed to place the tube and safely administer nutrition; a patient would not be left in restraints between meals for the sake of maintaining the integrity of the tube. If needed, formula administration is consolidated and clustered as is safely possible given the volume to reduce the number of tube administrations or time needed in restraints.","_key":"db7b021442fb0","_type":"span"}],"_type":"block"},{"_key":"315c76df6201","markDefs":[],"children":[{"_key":"4ff1bee323e80","_type":"span","marks":[],"text":"Typically, this level of behavioral dysregulation occurs in the context of the most severe cases of malnutrition, and we see significant and rapid improvement as the brain is refed. After extreme behavioral exacerbations requiring intensive interventions, we prioritize debriefing and processing with staff across disciplines, acknowledging the moral distress that can come with providing care in these difficult situations."}],"_type":"block","style":"normal"},{"style":"normal","_key":"7aa5e47e5e7e","markDefs":[],"children":[{"marks":["strong"],"text":"Decisional Capacity","_key":"e693b250a6f10","_type":"span"}],"_type":"block"},{"children":[{"text":"Implementing the protocol and eliciting patient engagement can be especially challenging for 18- to 24-year-olds, as these patients typically have legal decision-making rights over their care (unless under guardianship/conservatorship). Questions regularly arise regarding the decisional capacity to decline an NG tube or dispositional capacity to leave the hospital before it is medically safe to do so. We can divide these patient types conceptually into 2 groups: those who live at home with their parents (and may still be in high school) or are otherwise dependent on their caregivers, and those who live independently as working adults or college/university students who do not rely on family support for daily living.","_key":"36ca830acf8c0","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"dde19e5dbf19","markDefs":[]},{"_type":"block","style":"normal","_key":"e1de0f9e4b09","markDefs":[],"children":[{"_type":"span","marks":[],"text":"For the first group, parents who align with the treatment team in recognizing the need for care can support their child’s recovery by declining to take them home if the child wants to leave the hospital or enacting firm limits and other forms of “tough love” to encourage their child’s participation in care. In the context of an eating disorder, this may include not paying for cellular telephone service, removing access to preferred activities, or withdrawing tuition support for college/university. We try to help parents and patients understand that these measures are not meant to be punitive but to guide the patient toward sound decision-making when the eating disorder and malnutrition are clouding their judgment. In fact, when parents take these steps to help their child’s recovery, they are actively working toward enabling the young adult to regain autonomy, not just with respect to food but also in other aspects of their life that may have been commandeered by the eating disorder.","_key":"0085d53c6c770"}]},{"_key":"7175dcb04cee","markDefs":[],"children":[{"marks":[],"text":"For young adults who live independently, or for situations in which the parental intervention approach is not possible or is ineffective, questions related to compelling care are more difficult. Comprehensive psychiatric assessment of capacity is required in each case and for each decision point as it cannot be generalized that the presence of a severe eating disorder (or severe malnutrition) necessarily compromises decision-making capacity. Additionally, the risk level for each decision is crucial, especially as it pertains to leaving the hospital before reaching medical stability. Discharging to an apartment with roommates, a sedentary job, established provider connections, and a grocery delivery service is very different from transitioning to a solo apartment with out-of-state parents, a limited friend base, no established care providers, and an on-your-feet job or full academic course load. For students, support through their college/university may also be activated to enhance their support network, including academic accommodations, school-based health programs, and residential advisers. To the extent that patients are willing to engage, we partner with them to mitigate the risks as best as possible before we consider discharging against medical advice.","_key":"3ea5263da6560","_type":"span"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Sometimes, we send patients out with the expectation that we will see them again in the ED very soon, hoping that we can be more effectual with our help the next time. For cases in which patients truly do not demonstrate capacity or willingness to collaborate to mitigate risk, and medical compromise is so severe that the only medically safe decision is to continue treatment in the hospital, we again consult with our Ethics Committee, Clinical Risk and Patient Relations, and our Office of the General Counsel as pursuit of emergency medical guardianship (either by family or a third party) may be necessary.","_key":"4cc3b0b000fe0"}],"_type":"block","style":"normal","_key":"55b2b1391b8f"},{"style":"normal","_key":"882177001103","markDefs":[],"children":[{"_key":"3e0ce70367720","_type":"span","marks":[],"text":"Notably, significant debate continues around the concept of involuntary or compulsory treatment for AN, with varied opinions from medical, ethical, legal, philosophical, psychological, and societal perspectives."},{"_type":"span","marks":["superscript"],"text":"9","_key":"f40d07817d8d"},{"_key":"2c307b89b33f","_type":"span","marks":[],"text":" As providers, our goal is to care for the patient before us. We do our best to act responsibly, compassionately, transparently, and within the bounds of our professional ethics. We learn from every case and we always strive to improve."}],"_type":"block"},{"markDefs":[],"children":[{"_key":"f8be0bf2f9cf0","_type":"span","marks":["strong"],"text":"Barriers to Discharge Planning"}],"_type":"block","style":"normal","_key":"11c339287e5f"},{"_key":"ee80ce35c438","markDefs":[],"children":[{"marks":[],"text":"Unfortunately, resources for eating disorder care are limited and wait lists are long. When transitioning to outpatient-level care, we typically can arrange for weekly weigh-ins and vitals checks at the primary care office, but mental health supports are more challenging to align quickly. Sometimes, the inability to arrange for appropriate outpatient therapy within a reasonable time frame pushes us toward PHP or IOP as the best discharge plan.","_key":"e9ad235b5d8c0","_type":"span"}],"_type":"block","style":"normal"},{"children":[{"_key":"72f5836e62370","_type":"span","marks":[],"text":"In Southeast Michigan, we are fortunate to have several options for PHPs focused on eating disorder care, though only 1 of them (our own) operates under an in-person, family-based treatment model. There are a number of common barriers to accessing any of these programs, including insurance coverage, patient age, and geographic limitations; driving more than an hour each way—twice daily—is often not feasible for working families. Additionally, BMI/weight at discharge can be a limiting factor, as many programs will not accept patients below a BMI of 15 or weight less than 80% of estimated goal. Our own program can be more flexible around this metric as we have ready access to AM, specialized nursing, and the hospital itself. When weight or BMI affect placement options, we must consider prolonging hospitalization to achieve the necessary weight gain vs discharging home for weight restoration, which can be onerous on families and often results in readmission."}],"_type":"block","style":"normal","_key":"e6c30f7490e1","markDefs":[]},{"children":[{"_type":"span","marks":[],"text":"When psychiatric hospitalization is needed, either due to comorbid safety concerns, comorbid psychiatric illnesses, or psychological factors impeding the patient from progressing past tube dependence, our options are significantly limited. Only 2 psychiatric units in our state (ours included) can accommodate NG tubes or will consider admitting patients with an active eating disorder diagnosis. Payer coverage is also challenging, especially if there is not a clear suicide risk. Payers will often authorize only 1 or 2 days of treatment in the context of an eating disorder, which offers little value in helping the patient to progress. If the psychiatric inpatient team cannot successfully advocate for additional covered days, then the options amount to hastening the discharge, billing the family, or (more commonly) positioning the hospital to absorb the cost. Ultimately, clinical need guides decision-making around inpatient psychiatric admission, but the coverage constraints can certainly burden families in an already stressful situation, and they highlight a clear inequity in the provision of care for this population.","_key":"8259ecb54f6f0"}],"_type":"block","style":"normal","_key":"878dbd1ce009","markDefs":[]},{"children":[{"_type":"span","marks":[],"text":"For patients who need residential care, there are no eating disorder–specific facilities that accept children in our state. Medicaid will not cover out-of-state residential care, leaving publicly insured patients without any options. For those with private insurance coverage or who can self-pay, we look regionally or nationally, which involves significant care coordination and supplemental cost to the family for transportation and local lodging. Once again, equitable access to care is a clear problem. Another significant barrier is that the patient must agree to enter the residential program voluntarily, even in cases when the parents are the legal guardians and decision- makers. We have seen many patients 18 years and older refuse residential treatment entirely or check themselves out prematurely, leaving their families with little recourse and often prompting repeat medical admission.","_key":"3540d0600a6b0"}],"_type":"block","style":"normal","_key":"cba38e065558","markDefs":[]},{"style":"normal","_key":"a52aa0ae62cf","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Concluding Thoughts","_key":"e34ec70ec1920"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Caring for patients with malnutrition due to eating disorders presents significant challenges related to patient insight and buy-in, behavior management, and longer-term care planning. Despite these challenges, inpatient medical admission often serves as the first step in recovery and may be perceived as a wake-up call by both patients and families.","_key":"5ab27b6211f30"},{"_type":"span","marks":["superscript"],"text":"10","_key":"022991598829"},{"_type":"span","marks":[],"text":" Implementing a formalized CPG and disseminating standardized psychoeducation materials to patients and families has unquestionably improved the process at our institution. Still, we continue to face challenges in this space. We are hopeful that the resources needed to support patients with this illness can grow and develop at a rate commensurate with the clear increase in disease burden we are all experiencing across the country. We welcome questions, discussion, and open distribution of our materials.","_key":"aac115a2102b"}],"_type":"block","style":"normal","_key":"2de5f439f0b7"},{"style":"normal","_key":"959fde07bec3","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Dr Pierce","_key":"762f53b0c0090"},{"_key":"6837ddd46529","_type":"span","marks":[],"text":" "},{"_type":"span","marks":["em"],"text":"is the medical director of the Pediatric Consultation-Liaison Psychiatry Service and the child and adolescent psychiatry hospital education lead at the C.S. Mott Children’s Hospital, University of Michigan Hospital Systems. She is also a clinical assistant professor in the Department of Psychiatry, Division of Child and Adolescent Psychiatry. ","_key":"2c3873f0cc66"},{"_type":"span","marks":["strong"],"text":"Dr Stoody","_key":"2c1e0db87dd3"},{"_key":"05736f0dfb8d","_type":"span","marks":["strong","em"],"text":" "},{"text":"is an assistant professor at the C.S. 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","_key":"4161c0b52386","_type":"span","marks":["em"]},{"marks":["strong"],"text":"Dr Bravender","_key":"10be47035966","_type":"span"},{"_type":"span","marks":[],"text":" ","_key":"67a6e2bf13a7"},{"_type":"span","marks":["em"],"text":"is the David S. Rosen Collegiate Professor of Adolescent Medicine and clinical professor of pediatrics and psychiatry at the University of Michigan. He also serves as associate chair for faculty affairs in the Department of Pediatrics, Division of Adolescent Medicine director, executive director of the Mott Comprehensive Eating Disorders Program, and comedical director of the University of Michigan Adolescent Health Initiative.","_key":"ada4ed79e064"}],"_type":"block"},{"_key":"273de78cbef0","markDefs":[],"children":[{"_key":"5355f9277e9d0","_type":"span","marks":["strong"],"text":"References"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":[],"text":"1. Otto AK, Jary JM, Sturza J, et al. ","_key":"fbb09b2a8c860"},{"_type":"span","marks":["4efdbe5ae105"],"text":"Medical admissions among adolescents with eating disorders during the COVID-19 pandemic.","_key":"fbb09b2a8c861"},{"_type":"span","marks":[],"text":" ","_key":"ae6f8f96635e"},{"marks":["em"],"text":"Pediatrics","_key":"fbb09b2a8c862","_type":"span"},{"marks":[],"text":". 2021;148(4):e2021052201.","_key":"fbb09b2a8c863","_type":"span"}],"_type":"block","style":"normal","_key":"f683db49ae87","markDefs":[{"_key":"4efdbe5ae105","blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/34244452/"}]},{"markDefs":[{"href":"https://pubmed.ncbi.nlm.nih.gov/35815415/","_key":"ed9d9f285517","blank":true,"_type":"link"}],"children":[{"_type":"span","marks":[],"text":"2. Shum M, Moreno C, Kamody R, et al. ","_key":"3166dc2d1b600"},{"marks":["ed9d9f285517"],"text":"The evolving needs of children hospitalized for eating disorders during the COVID-19 pandemic.","_key":"3166dc2d1b601","_type":"span"},{"_type":"span","marks":[],"text":" ","_key":"f4c4245f2f9d"},{"_type":"span","marks":["em"],"text":"Hosp Pediatr","_key":"3166dc2d1b602"},{"text":". 2022;12(8):696-702.","_key":"3166dc2d1b603","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"aeeace80d63b"},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/38167164/","_key":"e1a0761533be"}],"children":[{"_type":"span","marks":[],"text":"3. Toigo S, Katzman DK, Vyver E, et al. ","_key":"1402dd6803860"},{"marks":["e1a0761533be"],"text":"Eating disorder hospitalizations among children and youth in Canada from 2010 to 2022: a population-based surveillance study using administrative data. ","_key":"1402dd6803861","_type":"span"},{"_type":"span","marks":["em"],"text":"J Eat Disord","_key":"1402dd6803862"},{"_type":"span","marks":[],"text":". 2024;12(1):3.","_key":"1402dd6803863"}],"_type":"block","style":"normal","_key":"6d457b0a2121"},{"_type":"block","style":"normal","_key":"e93d347cf6ee","markDefs":[{"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/18622192/","_key":"f62778a63569","blank":true}],"children":[{"marks":[],"text":"4. Sylvester CJ, Forman SF. ","_key":"6764ee937eed0","_type":"span"},{"marks":["f62778a63569"],"text":"Clinical practice guidelines for treating restrictive eating disorder patients during medical hospitalization.","_key":"6764ee937eed1","_type":"span"},{"_type":"span","marks":[],"text":" ","_key":"bc5bd734bd69"},{"marks":["em"],"text":"Curr Opin Pediatr.","_key":"6764ee937eed2","_type":"span"},{"_type":"span","marks":[],"text":" 2008;20(4):390-397.","_key":"6764ee937eed3"}]},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/37196778/","_key":"1b2839730d76"}],"children":[{"_type":"span","marks":[],"text":"5. Stoody VB, Garber AK, Miller CA, Bravender T. ","_key":"3962d5fd45ce0"},{"_type":"span","marks":["1b2839730d76"],"text":"Advancements in inpatient medical management of malnutrition in children and adolescents with restrictive eating disorders.","_key":"3962d5fd45ce1"},{"_type":"span","marks":["em"],"text":" J Pediatr","_key":"3962d5fd45ce2"},{"_key":"3962d5fd45ce3","_type":"span","marks":[],"text":". 2023;260:113482."}],"_type":"block","style":"normal","_key":"26924e69be7f"},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/35084057/","_key":"52ac767f22c4"}],"children":[{"_type":"span","marks":[],"text":"6. Momen NC, Plana-Ripoll O, Yilmaz Z, et al. ","_key":"345b957b9aba0"},{"_type":"span","marks":["52ac767f22c4"],"text":"Comorbidity between eating disorders and psychiatric disorders.","_key":"345b957b9aba1"},{"_type":"span","marks":[],"text":" ","_key":"bb2d4c6447dc"},{"_type":"span","marks":["em"],"text":"Int J Eat Disord","_key":"345b957b9aba2"},{"_type":"span","marks":[],"text":". 2022;55(4):505-517.","_key":"345b957b9aba3"}],"_type":"block","style":"normal","_key":"dd8dcdcffc0c"},{"_key":"2d1cb67b6d28","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/33118892/","_key":"d0a4edd90927"}],"children":[{"_type":"span","marks":[],"text":"7. Iwajomo T, Bondy SJ, de Oliveira C, et al. ","_key":"d0f5f6bef03b0"},{"_type":"span","marks":["d0a4edd90927"],"text":"Excess mortality associated with eating disorders: population-based cohort study.","_key":"d0f5f6bef03b1"},{"text":" ","_key":"cf60a7cb6e7d","_type":"span","marks":[]},{"marks":["em"],"text":"Br J Psychiatry","_key":"d0f5f6bef03b2","_type":"span"},{"_key":"d0f5f6bef03b3","_type":"span","marks":[],"text":". 2021;219(3):487-493."}],"_type":"block","style":"normal"},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/37415200/","_key":"ad74ed60cb52"}],"children":[{"marks":[],"text":"8. Rodan SC, Bryant E, Le A, et al; National Eating Disorder Research Consortium. 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Four strategies to manage this uncertainty include gathering comprehensive data, involving patients and families in decision-making, initiating psychotherapy (including digital therapeutics), and comparing treatment risks. Gathering data involves using tools like the \"MoodCheck\" questionnaire. Patient education and reliable internet resources are crucial. Digital therapeutics offer promising alternatives to traditional therapy, with new CPT codes proposed for reimbursement. These strategies aim to improve diagnostic accuracy and treatment outcomes in complex mood disorders.","factCheckAuthors":null,"documentGroup":null,"_rev":"fS416cKfEI6INbS7bh8GYm","url":"4-ways-to-cope-with-bipolar-uncertainty","_id":"b159cabc-82ab-4562-99dc-147bc12ce5f4","body":[{"alignment":"left","alt":"bipolar","disableTextWrap":false,"disableLightBox":true,"asset":{"_ref":"image-404e1c0468b1b692448c95b34c56c94c7d55a7bd-462x451-jpg","_type":"reference"},"imgcaption":[{"_type":"block","style":"normal","_key":"34b5231761ee","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Vector Tradition/AdobeStock","_key":"35564e2da5040"}]}],"_key":"7dc32f8f9139","_type":"figure","widthP":50},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"The first of this trio of essays noted that research studies conducted after the 2013 ","_key":"0a7d9515f42c0"},{"_type":"span","marks":["em"],"text":"DSM-5","_key":"0a7d9515f42c1"},{"_type":"span","marks":[],"text":" found the following symptoms common in bipolar mixed states:","_key":"0a7d9515f42c2"}],"_type":"block","style":"normal","_key":"d066828a7992"},{"_key":"0eaf3cff44b2","listItem":"bullet","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Agitation, both psychic and physical","_key":"49acb4a121170"}],"level":1,"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"11697f2470b2","listItem":"bullet","markDefs":[],"children":[{"marks":[],"text":"Irritability","_key":"9f683cbf150f0","_type":"span"}],"level":1},{"markDefs":[],"children":[{"marks":[],"text":"Nonstop ideas and distractibility","_key":"3022c35c20200","_type":"span"}],"level":1,"_type":"block","style":"normal","_key":"4817cf673a3b","listItem":"bullet"},{"children":[{"marks":[],"text":"Anxiety","_key":"258cf9e4cd310","_type":"span"}],"level":1,"_type":"block","style":"normal","_key":"bbcd195d0be1","listItem":"bullet","markDefs":[]},{"level":1,"_type":"block","style":"normal","_key":"da71d6103e55","listItem":"bullet","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Decreased sleep","_key":"266da20dadec0"}]},{"style":"normal","_key":"14a384419cc7","markDefs":[{"href":"https://www.psychiatrictimes.com/topics/ptsd","_key":"1ea498eb1a16","nofollow":true,"blank":true,"_type":"link"},{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/topics/personality-disorders","_key":"6364a9ec098f"}],"children":[{"marks":[],"text":"These have been dubbed “The 4 A’s”: anxiety, anger, agitation, and attention problems (plus extreme insomnia). With these symptoms, bipolar mixed states overlap almost completely with those of ","_key":"4e5ff86c7daf0","_type":"span"},{"_type":"span","marks":["1ea498eb1a16"],"text":"posttraumatic stress disorder","_key":"67ebf2a933fc"},{"marks":[],"text":" (PTSD) with depression, generalized anxiety disorder (GAD) with depression, attention deficit disorder (ADD) with depression, and ","_key":"e2ed83948b3e","_type":"span"},{"marks":["6364a9ec098f"],"text":"borderline personality disorder","_key":"329ff50803c8","_type":"span"},{"text":".","_key":"2f62088f407c","_type":"span","marks":[]}],"_type":"block"},{"_type":"block","style":"normal","_key":"a579010d1481","markDefs":[],"children":[{"marks":[],"text":"","_key":"7a378520683c0","_type":"span"}]},{"markDefs":[],"children":[{"_key":"f35dc399e7a80","_type":"span","marks":[],"text":"This essay presents 4 means of coping with the diagnostic uncertainty that results from this overlap."}],"_type":"block","style":"normal","_key":"409bec3037da"},{"markDefs":[],"children":[{"marks":[],"text":"","_key":"f8b63e5eab280","_type":"span"}],"_type":"block","style":"normal","_key":"08be638e487c"},{"_type":"block","style":"normal","_key":"49aed91bd7ef","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"1. 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No diagnosis should be proffered until they are obtained and evaluated.","_key":"06da9a469a8d0","_type":"span"}],"_type":"block","style":"normal","_key":"4ec84dbf939c"},{"_key":"7e8f74f43677","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"a35b7b0349e60"}],"_type":"block","style":"normal"},{"markDefs":[{"_type":"link","href":"https://www.psychiatrictimes.com/view/efficient-assessment-20-questions-about-bipolarity-moodcheck","_key":"1d4afd973797","blank":true}],"children":[{"text":"But the sheer volume of information one is expected to gather in an initial interview can interfere with establishing trust and rapport through open-ended questions and accurate reflective listening. Using questionnaires to gather some of this information is efficient but can be cumbersome: how much can you ask a patient to divulge before meeting you in person? For a short questionnaire designed to capture mood symptoms ","_key":"3d648a40293e0","_type":"span","marks":[]},{"text":"and","_key":"3d648a40293e1","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":" family history, age of onset, illness course, and response to antidepressants, consider “MoodCheck”, described in ","_key":"3d648a40293e2"},{"_type":"span","marks":["em"],"text":"Psychiatric Times","_key":"3d648a40293e3"},{"_type":"span","marks":[],"text":" in ","_key":"3d648a40293e4"},{"text":"2017","_key":"3d648a40293e5","_type":"span","marks":["1d4afd973797"]},{"_type":"span","marks":[],"text":" and available for direct download (no profit or industry connections).","_key":"3d648a40293e6"},{"_type":"span","marks":["superscript"],"text":"3","_key":"fb27cc7d34d6"}],"_type":"block","style":"normal","_key":"424ec05c9df6"},{"_type":"block","style":"normal","_key":"c6bfafb49464","markDefs":[],"children":[{"marks":[],"text":"","_key":"24f6d130b6200","_type":"span"}]},{"style":"normal","_key":"e5f882a4b647","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"2. Recruit the Patient (And Perhaps Family)","_key":"4193a52422500"}],"_type":"block"},{"style":"normal","_key":"9c1deae87048","markDefs":[],"children":[{"text":"Shared decision-making involves more than simply explaining treatment pros and cons. It includes understanding the patient’s beliefs and fears and social milieu. For example, is PTSD a preferred diagnosis because it places causality outside the patient? Is ADD preferred because it is a simple explanation for struggling in school? How much stigma is attached to the word bipolar, in the patient’s mind, and their family’s, and their community?","_key":"ee2c5548804d0","_type":"span","marks":[]}],"_type":"block"},{"_key":"04848dcbb3b0","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"d44a0069a4170"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"08d4d5af8095","markDefs":[],"children":[{"_type":"span","marks":[],"text":"With these insights in hand or in development, a good clinician helps the patient (and perhaps family) understand the diagnostic challenge of mixed states. One might say “There are a couple of ways to explain your symptoms. No single diagnosis is obvious. We have to consider several” (enumerating those most likely, including bipolar without mania). Another variation: “You do not have bipolar disorder, but you do not have plain depression either. You may be somewhere in between.”","_key":"ffb23894da5a0"}]},{"markDefs":[],"children":[{"marks":[],"text":"","_key":"e364a4bc28500","_type":"span"}],"_type":"block","style":"normal","_key":"3f9b3c10f471"},{"_type":"block","style":"normal","_key":"b9ae5a9e4f8c","markDefs":[],"children":[{"_type":"span","marks":[],"text":"When time is limited, especially in an initial interview, it is almost impossible to be this deliberate explaining a complex differential. But many patients, if they leave with limited information, will turn to the internet. Unguided searching can easily lead to misimpressions. You could create your own website, or a handout of recommended sites to direct your patients’ searches. For that list, consider a site built recently for patients with depression that emphasizes all the themes in the essay you are reading now (no profit, no advertising).","_key":"bd5f7bd5e02f0"},{"_type":"span","marks":["superscript"],"text":"4","_key":"16497d1efc3e"}]},{"_type":"block","style":"normal","_key":"3c1600dc27b5","markDefs":[],"children":[{"_key":"01062a9426d70","_type":"span","marks":[],"text":""}]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"3. Start With Psychotherapy, Including Digital Therapeutics","_key":"393b04b5e5f30"}],"_type":"block","style":"normal","_key":"147362824611"},{"markDefs":[{"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/topics/psychotherapy","_key":"f1bdf04d49c7","nofollow":true}],"children":[{"_type":"span","marks":[],"text":"New tools for ","_key":"9074f439d54b0"},{"_type":"span","marks":["f1bdf04d49c7"],"text":"psychotherapy","_key":"343aab0f3170"},{"_type":"span","marks":[],"text":", discussed here, make it more available, and thus a realistic alternative to medication. Psychotherapies have lower risks than medications, even if targeting the “wrong” diagnosis; indeed, several are likely to help even when misdirected.","_key":"1ac8ffc40373"}],"_type":"block","style":"normal","_key":"813b2ac5ccbe"},{"style":"normal","_key":"1a57a9fa4813","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"a8990d1b4beb0"}],"_type":"block"},{"style":"normal","_key":"9c7e13d94e00","markDefs":[],"children":[{"_type":"span","marks":[],"text":"In the face of diagnostic uncertainty, you can offer or refer the patient to a psychotherapy specific for the most likely diagnosis, or therapy likely to benefit any of several diagnostic possibilities. For example, some therapies are PTSD-specific, focusing on trauma, while basic cognitive-behavioral therapy (CBT) may still be of benefit in PTSD through components such as stress management and mindfulness skills. Similarly, CBT is likely to help a patient whose depression is mixed, or even bipolar II depression. A meta-analysis of 409 trials found CBT equally effective as medications for depression in the short term, and better in the long term.","_key":"627ba31e9a3a0"},{"_type":"span","marks":["superscript"],"text":"5","_key":"d38313e2c465"}],"_type":"block"},{"_key":"f9396c3b2c78","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"aa3bb1c3ab200"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"4c21870797ce","markDefs":[],"children":[{"marks":[],"text":"Unfortunately, unless you have a solid referral network, it can be difficult to confidently refer patients for psychotherapy. The best local therapists are often not routinely taking new patients. For online therapy, some websites allow a patient to choose a particular kind of therapy, but you cannot control the quality.","_key":"69922eaa370b0","_type":"span"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"46b370ff497e0"}],"_type":"block","style":"normal","_key":"f8599a3ed871"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Digital therapeutics (DTX) include websites and apps that provide a kind of psychotherapy. Web-based versions of CBT have been shown to be nearly as effective as a live therapist, particularly if guided with some minimal support.","_key":"ae7378618d4e0"},{"marks":["superscript"],"text":"6","_key":"af6584f9cf3c","_type":"span"},{"_type":"span","marks":[],"text":" Online therapies for PTSD also have shown efficacy, although patients are more likely to drop out if the intervention focuses on stabilization (as do the majority of such programs) when they are looking for trauma-focused work.","_key":"b5daf72142f6"},{"_type":"span","marks":["superscript"],"text":"7","_key":"57dc2804b8da"}],"_type":"block","style":"normal","_key":"c3ad4a1af5f9"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"c750da621e810"}],"_type":"block","style":"normal","_key":"e6ed0303cf28"},{"_type":"block","style":"normal","_key":"c2840482743d","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Some of the best studied versions of online CBT rely on patient motivation to work through the modules.","_key":"6e1078fed0820"},{"marks":["superscript"],"text":"8","_key":"7a43e9df9599","_type":"span"},{"marks":[],"text":" Completion rates have been as low as 10% in some of these studies.","_key":"0d6304d98299","_type":"span"},{"_type":"span","marks":["superscript"],"text":"9","_key":"0597a5194280"},{"_type":"span","marks":[],"text":" By contrast, newer DTX programs “push” adherence with programmed messages and limited text-based support. With these, 1 industry-sponsored study demonstrated almost 90% adherence after 12 of 16 sessions.","_key":"fe48900dd3f1"},{"_type":"span","marks":["superscript"],"text":"10","_key":"e95681bcae79"}]},{"children":[{"_type":"span","marks":[],"text":"","_key":"ee4b5841248b0"}],"_type":"block","style":"normal","_key":"07943f40613a","markDefs":[]},{"markDefs":[],"children":[{"marks":[],"text":"In that industry-sponsored study, the absolute difference in the primary outcome measure (MADRS) vs an active control condition was small. But all patients were already on an antidepressant and the control was a very plausible version of the treatment app, perhaps limiting improvement and separation. Data from further research will be of great interest. In the meantime, it appears that the push technology represents a major advance vs older DTXs.","_key":"beaeefab38d60","_type":"span"}],"_type":"block","style":"normal","_key":"a8cd0a74de9d"},{"children":[{"_type":"span","marks":[],"text":"","_key":"679b26ba5e450"}],"_type":"block","style":"normal","_key":"7152a1da38ba","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"As a final reason to more deeply consider adding DTX to your toolkit, note that Medicare and Medicaid Services have proposed new CPT codes that would pay for prescribing and managing these tools. (In an important twist, only “FDA-approved” programs would be allowed, thus excluding several existing programs that have not sought such approval). Code GMBT1 would allow clinicians to bill for giving DTX to patients and teaching them how to use it. The idea is to make DTX rather like giving a vaccine. Code GMBT2 covers the first 20 minutes of “monthly management services,” such as reviewing the data from the DTX device.","_key":"8f248968726f0"},{"_type":"span","marks":["superscript"],"text":"11","_key":"de7dab8a8bfb"}],"_type":"block","style":"normal","_key":"c496c3cbbf2f"},{"children":[{"_type":"span","marks":[],"text":"","_key":"5fa46fc4153c0"}],"_type":"block","style":"normal","_key":"3305fa1be214","markDefs":[]},{"children":[{"marks":["strong"],"text":"4. Compare Treatment Risks","_key":"2fb32e6222360","_type":"span"}],"_type":"block","style":"normal","_key":"1a9e9ab3e57a","markDefs":[]},{"_type":"block","style":"normal","_key":"0e1e0631dfde","markDefs":[],"children":[{"_type":"span","marks":[],"text":"If beginning with a medication treatment rather than a psychotherapy, a fourth means of coping with diagnostic uncertainty is to help the patient compare the risks of treatment options associated with possible diagnoses. This approach is detailed in Part 3 of this series.","_key":"709ecdf704770"}]},{"style":"normal","_key":"340b73a3e070","markDefs":[],"children":[{"marks":[],"text":"","_key":"50f0439333cd0","_type":"span"}],"_type":"block"},{"markDefs":[],"children":[{"marks":["strong"],"text":"Concluding Thoughts","_key":"6029913f51c40","_type":"span"}],"_type":"block","style":"normal","_key":"ec6f1eb38e1b"},{"markDefs":[],"children":[{"_key":"e692eaca9ba70","_type":"span","marks":[],"text":"Because of overlapping symptoms, distinguishing mixed states from other common presentations of depression can be nearly impossible. This essay describes 4 means of coping with that uncertainty, including respective clinical tools: "},{"_type":"span","marks":["em"],"text":"gathering data","_key":"e692eaca9ba71"},{"text":" using a broad but brief questionnaire; ","_key":"e692eaca9ba72","_type":"span","marks":[]},{"_type":"span","marks":["em"],"text":"patient education","_key":"e692eaca9ba73"},{"text":", augmented with reliable internet sources; starting with a ","_key":"e692eaca9ba74","_type":"span","marks":[]},{"text":"psychotherapy","_key":"e692eaca9ba75","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":", including DTX; and patient education ","_key":"e692eaca9ba76"},{"marks":["em"],"text":"comparing treatment risks","_key":"e692eaca9ba77","_type":"span"},{"_type":"span","marks":[],"text":".","_key":"e692eaca9ba78"}],"_type":"block","style":"normal","_key":"bceb3730b6f6"},{"_key":"52e6fed7438a","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"56939e5608990"}],"_type":"block","style":"normal"},{"children":[{"text":"Dr Phelps","_key":"ec89bee9541f0","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":" ","_key":"ec89bee9541f1"},{"_type":"span","marks":["em"],"text":"is retiring from 30 years of treating complex mood disorders, and recently founded another website, DepressionEducation.org. He is the bipolar disorder section editor for ","_key":"ec89bee9541f2"},{"_type":"span","marks":[],"text":"Psychiatric Times®","_key":"ec89bee9541f3"},{"_type":"span","marks":["em"],"text":" and the author of","_key":"ec89bee9541f4"},{"_type":"span","marks":[],"text":" ","_key":"ec89bee9541f5"},{"_key":"ec89bee9541f6","_type":"span","marks":["ca2683fb96a4"],"text":"A Spectrum Approach to Mood Disorders"},{"_key":"ec89bee9541f7","_type":"span","marks":["em"],"text":" for clinicians and"},{"text":" ","_key":"ec89bee9541f8","_type":"span","marks":[]},{"_type":"span","marks":["c778ff5bea03"],"text":"Bipolar, Not So Much","_key":"ec89bee9541f9"},{"_type":"span","marks":[],"text":" ","_key":"ec89bee9541f10"},{"text":"for patients and their families","_key":"ec89bee9541f11","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":".","_key":"ec89bee9541f12"}],"_type":"block","style":"normal","_key":"7805dc0c6f64","markDefs":[{"blank":true,"_type":"link","href":"https://wwnorton.com/books/A-Spectrum-Approach-to-Mood-Disorders/","_key":"ca2683fb96a4"},{"_key":"c778ff5bea03","blank":true,"_type":"link","href":"https://wwnorton.com/books/Bipolar-Not-So-Much/"}]},{"children":[{"_type":"span","marks":[],"text":"","_key":"2f6e7f2155cb0"}],"_type":"block","style":"normal","_key":"28abf4f6a063","markDefs":[]},{"_key":"bf014d87bba7","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"References","_key":"67ddc72426800"}],"_type":"block","style":"normal"},{"style":"normal","_key":"3ba195b3cb36","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/18199233/","_key":"c0d37f0aac4a"}],"children":[{"marks":[],"text":"1. Mitchell PB, Goodwin GM, Johnson GF, Hirschfeld RM. ","_key":"7a240a9e93da0","_type":"span"},{"_type":"span","marks":["c0d37f0aac4a"],"text":"Diagnostic guidelines for bipolar depression: a probabilistic approach.","_key":"7a240a9e93da1"},{"_key":"bda32fe24155","_type":"span","marks":[],"text":" "},{"text":"Bipolar Disord","_key":"7a240a9e93da2","_type":"span","marks":["em"]},{"text":". 2008;10(1 pt 2):144-152.","_key":"7a240a9e93da3","_type":"span","marks":[]}],"_type":"block"},{"_key":"f63d8051cf0a","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/18199236/","_key":"b0fb3d72396b"}],"children":[{"marks":[],"text":"2. Phelps J, Angst J, Katzow J, Sadler J. ","_key":"76925323d1ba0","_type":"span"},{"text":"Validity and utility of bipolar spectrum models.","_key":"76925323d1ba1","_type":"span","marks":["b0fb3d72396b"]},{"marks":["em"],"text":" Bipolar Disord.","_key":"76925323d1ba2","_type":"span"},{"_type":"span","marks":[],"text":" 2008;10(1 pt 2):179-193.","_key":"76925323d1ba3"}],"_type":"block","style":"normal"},{"_key":"6f1c01ea31cc","markDefs":[{"_type":"link","href":"https://depressioneducation.org/depression-section-page-1/questionnaire-moodcheck/","_key":"fdcdc08bbfc0","blank":true}],"children":[{"_type":"span","marks":[],"text":"3. MoodCheck. Depression Education. Accessed November 7, 2024. 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","_key":"a6931add4d130"},{"_type":"span","marks":["e9e8fd514891"],"text":"Cognitive behavior therapy vs. control conditions, other psychotherapies, pharmacotherapies and combined treatment for depression: a comprehensive meta‐analysis including 409 trials with 52,702 patients.","_key":"a6931add4d131"},{"_type":"span","marks":[],"text":" ","_key":"c10fb1005472"},{"_type":"span","marks":["em"],"text":"World Psychiatry","_key":"a6931add4d132"},{"_type":"span","marks":[],"text":". 2023;22(1):105-115.","_key":"a6931add4d133"}],"_type":"block"},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/33471111/","_key":"d9fde6da4e47"}],"children":[{"text":"6. Karyotaki E, Efthimiou O, Miguel C, et al. 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