There is a need for new effective treatment options for posttraumatic stress disorder (PTSD), as many people with PTSD do not fully recover despite current treatments. 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy (MDMA-AT) is emerging as a new treatment option. We assessed the current body of MDMA-AT evidence for effectiveness in treating PTSD, associated impairments, and quality of life by conducting a systematic review and meta-analysis of randomized controlled trials. Databases from ClinicalTrials.gov, MEDLINE, PsycInfo, PsycArticles, and Cochrane Library were searched from inception to June 2025. Data from seven randomized control trials (both published and unpublished) compared MDMA-AT with low-dose MDMA or placebo control combined with psychotherapy. Identified studies were not included in recent article retractions. Effect sizes were calculated using standardized mean difference for Clinician-Administered PTSD Scale scores and mean difference for secondary measures. MDMA-AT may significantly improve PTSD, dissociation, depression, and functional impairment, compared to controls, but not sleep quality. These results support MDMA-AT for PTSD core symptoms and quality-of-life measures. The evidence, however, is limited by small sample sizes in some studies, challenges with blinding in psychedelic studies, use of non-standardized therapies, and a common sponsor for all trials. While limitations exist, these findings provide evidence for a new emerging treatment option for PTSD.
Individuals with co-occurring borderline personality disorder and narcissistic personality disorder often present with severe emotional dysregulation, interpersonal instability, identity disturbance, and entrenched patterns of shame, vulnerability, and defensiveness that challenge traditional treatment approaches. This article describes the treatment model of the Gunderson Residence, a highly specialized residential program that provides intensive, milieu-based care for individuals with complex personality pathology through an integrated, evidence-based framework. Grounded in empirically supported therapies primarily driven by Gunderson's good psychiatric management, treatment emphasizes recovery by helping residents understand the connections among their personality vulnerabilities, emotional experiences, and interpersonal functioning while simultaneously promoting engagement in meaningful life roles. Within a structured therapeutic community, residents participate in an integrated model that draws from mentalization-based treatment, transference-focused psychotherapy, and dialectical behavior therapy. Individual psychotherapy, skills training, group therapy, family work, psychiatric care, and the milieu interplay to create a therapeutic context in which challenging interpersonal patterns emerge, can be understood, and are addressed in real time. Particular attention is given to helping residents develop greater capacity for mentalization, emotion regulation, identity integration, and reflective functioning while reducing reliance on rigid narcissistic and borderline defenses. The residential setting provides repeated opportunities to practice new ways of relating, tolerate emotional vulnerability, and receive immediate feedback from peers and staff. The overarching goal extends beyond symptom stabilization; the aim is to foster durable personality change by helping residents develop insight into their vulnerabilities, strengthen interpersonal effectiveness, and generalize these capacities to relationships, work, and independent living following discharge.
OBJECTIVE:This perspective summarizes the literature on curbside consultation (CC) across medical specialties to develop recommendations for its use in inpatient consultation-liaison psychiatry. We address CC's benefits, challenges, and limitations in clinical practice. METHOD:We conducted a narrative review via PubMed using the terms "curbside" AND "consult," and included English-language articles that discuss CC use in any setting, within any discipline, and for any purpose. Then we screened included articles for references that met the same criteria. RESULTS AND DISCUSSION:We included 43 articles and extracted data from 25 of the included studies. The literature indicates that CCs can serve as valuable tools for clinicians seeking informal advice on patient management or wanting to increase general medical knowledge. Significant challenges regarding CC use exist, however, including the potential for inaccurate data exchange, consultant time burden, lack of reimbursement, and liability concerns. CONCLUSIONS:While CCs facilitate communication and collaboration among health care professionals, their use requires careful consideration based on the clinical situation. This perspective provides guidance for inpatient psychiatric consultants on assessing CC request appropriateness and effective CC performance in inpatient settings.
We present a case of repetitive transcranial magnetic stimulation (rTMS) use to treat a 38-year-old male with initial diagnostic uncertainty between major depressive disorder (MDD) with psychotic features and MDD with co-occurring delusional disorder, persecutory type. This patient reported a long-standing history of depressive symptoms and recent onset of paranoid delusions. Prior to receiving rTMS, the patient was treated for three years with a combination of antidepressants, antipsychotics, and cognitive behavioral therapy for psychosis. During this period, his delusions persisted irrespective of changes in mood symptoms, confirming his diagnosis of MDD with co-occurring delusional disorder. He received rTMS for severe, treatment-refractory depression that worsened in the setting of psychosocial stressors. Following treatment, his mood symptoms significantly improved while his paranoid beliefs persisted. This case is significant due to treatment planning difficulty given initial diagnostic uncertainty between MDD with psychotic features and MDD with co-occurring delusional disorder. Additionally, paranoia and delusions respond poorly to current psychotropic medication and psychotherapy treatment options. This case highlights the need for better treatment for delusions and the importance of iteratively assessing treatment response and updating patient formulation when navigating diagnostic uncertainty. In this clinical challenge, experts discuss considerations in differentiating MDD with psychotic features and MDD with co-occurring delusional disorder. Additionally, they weigh implications for rTMS treatment candidacy, evidence supporting rTMS for psychotic disorders, the role of psychotherapy in treating paranoia, and the neural circuits involved in persecutory delusions.
Trauma-informed medical education (TIME) applies trauma-informed care (TIC) frameworks to address the long-term effects of potentially traumatic events and better serve patients, learners, and faculty. Because exposure to trauma and adversity has been linked to negative clinical and educational outcomes, medical educators have the dual responsibilities of teaching students about the effects of trauma and adversity on patients while using TIME methods to support student learning and psychological safety. Despite increasing recognition of the importance of trauma-informed curricular content and educational context, many medical schools have yet to incorporate longitudinal trauma-informed instruction to ensure student clinical competency in TIC practices. As members of an inaugural student-faculty collaborative and resulting medical school-wide TIC curricular theme committee, we reflect on our student and faculty curricular co-creation journeys, including the challenges encountered and strategies employed. Drawing from TIC curricular development literature, we provide suggestions for medical schools and institutions embarking on comprehensive integration of TIME.
LEARNING OBJECTIVES:After participating in this CME activity, the psychiatrist should be better able to. BACKGROUND:Benzodiazepines are widely prescribed, yet long-term use carries risks of adverse clinical outcomes and challenging withdrawal syndromes. Although gradual outpatient tapering remains the standard recommendation for discontinuation, a subset of patients may require more rapid discontinuation in inpatient settings due to complex factors, such as misuse of multiple substances, prior failed tapering attempts, or co-occurring medical and psychiatric conditions. METHODS:This narrative review synthesizes contemporary literature on inpatient benzodiazepine withdrawal. We conducted a targeted review of clinical studies, guidelines, and expert opinion pieces published from 2000-2024, with a focus on real-world applicability. DISCUSSION:We assess recent findings and best-practice recommendations on benzodiazepine discontinuation and propose a systematic, individualized tapering strategy to guide inpatient withdrawal management. Additionally, we review medication selection, long-acting benzodiazepines and phenobarbital protocols, adjunctive pharmacotherapy, and behavioral interventions while emphasizing co-occurring disorders, risk management, and protracted withdrawal symptoms. CONCLUSION:Our proposed approach may enhance systematic and safe management of inpatient benzodiazepine withdrawal, especially for complex patient populations.
Across the United States, significant disparities persist in mental health care. Individuals with lower socioeconomic status (SES) face increased barriers to accessing and engaging in treatment. In response, mobile health (mHealth) advancements have emerged as promising tools to address practical and clinical barriers to mental health care access. While mHealth has enabled greater access, strategies for sustaining mHealth engagement need more attention, as increased engagement is associated with improved outcomes. In this article, we present four innovative mHealth approaches and discuss strategies to increase engagement among individuals with low SES: (1) guided mHealth, combining asynchronous telehealth with clinician supervision; (2) simulated therapeutic communication via generative artificial intelligence; (3) real-time, personalized support with just-in-time adaptive interventions; and (4) streamlined clinician referrals via artificial intelligence software. We detail advantages that facilitate engagement, limitations that risk early drop-off, and suggestions for improving equity and cultural relevance in mHealth tools and platforms. We also outline ethical considerations, cultural and place-based adaptations, and community-engaged participatory design, as these efforts are paramount for aligning mHealth with the needs of under-resourced communities.
BACKGROUND:Climate change is a global health crisis with substantial mental health consequences. Despite its growing impact, climate-related mental health topics remain insufficiently integrated into medical education. This review synthesizes studies describing educational interventions and assessment tools that address the intersection of climate change and mental health. METHOD:We conducted a narrative literature review across PubMed, Education Resources Information Center, and PsycINFO in March 2025. Studies were included if they described an educational intervention related to climate-health topics with mental health content or relevance, involved learners in health-related fields, and reported outcomes using validated or author-developed instruments. RESULTS:Fifteen studies met inclusion criteria. Seven described educational interventions, including longitudinal curricula, clerkship sessions, telementoring, and innovative formats such as narrative medicine and reflective tool kits. Fourteen studies included assessment tools, though only one reported psychometric validation (Cronbach's α=0.90). To characterize heterogeneity, studies were grouped by type of climate-health educational focus: direct clinical mental health education (n=9), general climate health education with mental health implications (n=3), and climate-health curricular gap analyses (n=3). Across interventions, outcomes demonstrated improved knowledge, confidence, and preparedness to address climate-related psychological impacts, but barriers remain, particularly limited faculty training, institutional constraints, and absence of validated evaluation frameworks. CONCLUSION:Current efforts to integrate climate-mental health topics into medical education are promising but still fragmented. Advancing the field requires standardized curricula with explicit and related mental health content, validated assessment tools, interdisciplinary faculty development, learner-centered approaches, climate justice and health equity principles in training, inclusion in board exams, and long-term evaluation.
Structural influences on mental health and mental health care have been a core focus from the origins of population-based mental health research. This perspective piece provides context for current work by discussing a selection of theoretical ideas and empirical study examples. The goal is to illustrate several basic concepts that have guided research over the past century and a half and highlight a selection of recent empirical findings that continue presenting challenges to the field. The examples emphasize that, despite the long history of research and theory connecting social structure and mental health, major, robust findings remain unexplained. These examples demonstrate the importance of continuing to research structural influences on mental health. Doing so will guide our understanding of causality and policy design to address inequities in illness burden and treatment.
The United States' epidemic of youth firearm suicide represents both a clinical challenge and an existential crisis, with firearm suicide rates increasing yearly. Efforts to mount effective responses, however, are thwarted by cultural, social, and political barriers that affect our ability to understand youth firearm practices, develop risk-reduction strategies, and communicate those strategies to families. The psychological autopsy, a methodology wherein researchers interview the family members and associates of youth firearm suicide decedents, offers tremendous potential for reconstructing the lived experience of children and adolescents lost to suicide. Since its introduction in the 1950s, however, the psychological autopsy has largely developed into a tool that filters lived experience through the lens of clinical scales and validated batteries to facilitate quantitative analysis of suicide risk factors. I argue that we cannot build a deep or actionable understanding of the cultural, sociological, and historical circumstances that subtend youth firearm suicide if we rely solely upon analytical models rooted in the quantitative analysis of clinical constructs. To attain an actional understanding of this tragic epidemic, we must develop practices that apply psychological autopsy methodologies in the service of generating thick descriptions of youth firearm practice and suicide. Several disciplinary traditions, including anthropological ethnography and oral history practice, offer insights that can help us realize psychological autopsy's potential to generate new knowledge, develop interventions to stem the rising tide of youth firearm suicide, and communicate these interventions in an increasingly polarized political environment.
Economic hardship-including poverty, housing insecurity, unemployment, food insecurity, and debt-is among the most consistently documented determinants of mental health. Extensive epidemiologic and social science research shows that adverse economic conditions increase the risk, severity, and persistence of depression, anxiety, suicidality, and severe mental illness. Although social policies can improve mental health outcomes, relatively few interventions within mental health systems target economic determinants. Those that do are often professionally designed and limited in scope. In this perspective article, we argue that advancing effective and equitable interventions that address economic determinants of mental health requires meaningful participation of people with lived experiences of economic hardship and mental health challenges. Drawing on epistemological and empirical literatures, we conceptualize lived experience as a form of expertise and contend that its systematic exclusion constitutes epistemic injustice and a barrier to intervention relevance and effectiveness. Using the International Association for Public Participation's Spectrum of Public Participation, we propose a framework for integrating lived experience expertise across the intervention cycle (i.e., needs assessment, design, implementation, and evaluation). Emphasizing collaboration and empowerment, we illustrate this framework with examples from the literature and highlight both its promise and limitations. We then identify systemic factors underlying these challenges-such as funding structures, governance, regulatory constraints, and capacity gaps-and offer practice-informed recommendations to address them. We conclude with a call to psychiatry and clinical professions to act as allies in redistributing epistemic and decision-making authority, positioning lived expertise as essential to interventions addressing economic determinants of mental health.
Poverty is a key upstream determinant of mental health and a driver of persistent inequities in the United States (US). There is growing recognition that we need to target upstream social drivers of mental health inequities, particularly through economic policies aimed at reducing poverty. This article describes the relationship between poverty and mental health and synthesizes evidence on the mental health impacts of major US income support pol-icies, including the Earned Income Tax Credit, Child Tax Credit, Temporary Assistance for Needy Families, minimum wage laws, and unemployment insurance. Existing literature suggests that income support policies, especially those delivering reliable and unconditional aid, can alleviate psychological distress and promote mental well-being. The reach and effectiveness of these policies, however, are constrained by complex eligibility criteria, administrative burdens, restrictive conditions, and insufficient generosity-disproportionately limiting access for those with mental illness or those in deepest poverty. Additionally, lump-sum payments only provide temporary relief, underscoring the potential benefits of more regular disbursements. Significant gaps in the evidence base remain for several pol-icies, hindering evidence-based decision-making. To fully realize the mental health benefits of income policies, clinicians, researchers, and advocates can take specific actions to enhance patient take-up of income supports, promote policy reforms that reduce administrative barriers and expand access, invest in improved data infrastruc-ture, and integrate social policy training into mental health education. A multisector, equity-oriented approach is essential to support population-level mental health and advance health equity amidst an evolving policy landscape.
Understanding trauma and posttraumatic stress disorder (PTSD) requires a contextual perspective that considers historical legacies, social environments, and cultural realities. This paper draws on empirical evidence from Kenya and Uganda to demonstrate the limitations of applying trauma frameworks developed in high-income countries to African contexts. Findings from the Orphaned and Separated Children's Assessment Related to Their Health and Well-Being (OSCAR) study challenge assumptions about care environments. The study reveals higher PTSD rates among orphans in family-based settings compared to institutional care, and highlights the protective roles of religion and social support. The Neuropsychiatric Genetics of African Populations-Psychosis (NeuroGAP-Psychosis) study provides crucial insights into context-specific trauma types often overlooked by standardized Western assessment tools. These categories, along with a detailed breakdown of "other" traumas, are essential for a nuanced understanding of distress in regions like Kenya. PTSD patterns vary significantly among countries, reflecting unique regional and historical influences. These findings emphasize the importance of culturally grounded research and trauma-informed interventions tailored to local contexts and realities. A sensitive, context-aware approach is vital to accurately understanding the experiences of trauma survivors and to developing effective, ethically responsible mental health interventions that resonate with and empower communities in resource-limited settings.
Smartphone-based cognitive assessments have emerged as promising tools for frequent and ecologically valid monitoring of cognitive function in real-world settings. These tools enable continuous capture of cognitive and behavioral patterns, including intra-individual variability, practice-related improvement, and contextual influences. Repeated assessments offer a unique opportunity to detect subtle cognitive changes over time. The interpretability and clinical utility of the metadata generated by such assessments, however, remain underexplored. In this review, we consider the current landscape of smartphone-derived cognitive metadata in the context of cognitive and affective disorders. We focus on emerging evidence linking metadata features to functional outcomes and symptom fluctuations across conditions such as schizophrenia, bipolar disorder, and depression. Additionally, we discuss methodological considerations for optimizing metadata analysis, including test design, sampling frequency, and analytical strategies. We propose that cognitive metadata may serve as sensitive indicators of early cognitive change and support personalized mental health monitoring and targeted intervention.
Anti-GAD65 encephalitis-like other autoimmune encephalitis conditions-poses a significant diagnostic challenge; its heterogeneous neuropsychiatric phenotypes mimic primary psychiatric disorders. The broad pathophysiological spectrum, ranging from limbic dysfunction to catatonia, underscores the need for systematic approaches that integrate immunotherapy with neuromodulation when standard interventions fail. We present a 78-year-old woman with no prior psychiatric history who developed acute-onset catatonia with visual hallucinations. Neurological evaluation revealed markedly elevated anti-GAD65 antibodies despite unremarkable neuroimaging and electroencephalography. Initial treatment with lorazepam and intravenous immunoglobulin achieved partial response. Recurrent catatonia and treatment-refractory psychosis prompted a trial of electroconvulsive therapy (ECT), which led to sustained remission through maintenance ECT. This case illustrates three critical clinical practice points: (1) late-onset catatonia necessitates comprehensive evaluation of autoimmune etiologies, including paired serum-cerebrospinal fluid antibody testing; (2) partial response to immunotherapy does not preclude more aggressive symptomatic management; and (3) ECT can effectively treat catatonia secondary to autoimmune illnesses. We conclude that successful management of anti-GAD65 encephalitis necessitates a multidisciplinary team for thorough neuro-immunological assessment, nuanced psychopharmacology, and timely neuromodulation.
Clinicians are commonly asked to make complex and potentially risky decisions in the face of uncertainty and incomplete information. Physicians frequently employ heuristics, or mental shortcuts, to convert challenging clinical questions into much simpler ones. Psychiatrists often encounter such challenges when asked to comment on the safety of intravenous haloperidol (IVH), particularly regarding risks of prolonging the corrected QT interval (QTc) or developing Torsades de Pointes (TdP). In light of the 2007 Food and Drug Administration warning about the risk of developing TdP with IVH, some providers, and even some institutions, have used QTc cut-off values to indicate when one can and cannot use IVH safely for managing acute agitation. In this perspective, we argue that (1) this practice represents an inappropriate use of a heuristic rather than a necessary risk-benefit calculation, and (2) that our updated understanding of the complex relationships among IVH, QTc, and TdP does not support the use of QTc cut-off values. We address some common misconceptions about the associations among IVH, QTc, and TdP, and discuss how reframing the decision-making process related to this dilemma may improve clinical care.
As a racial group, Asian Americans are often perceived as having few or no mental health issues. Such a perception is perpetuated by data that has, historically, captured the experiences of Asian Americans in the aggregate. While there is growing recognition of heterogeneity among Asian Americans, the recent political climate threatens to undo efforts toward reaching mental health equity. In this perspective article, we argue for the importance of data disaggregation among Asian Americans to identify and reduce mental health disparities. We contextualize the social experiences of different Asian American ethnic groups and highlight how their mental health experiences can differ. We also review current obstacles to data disaggregation and mental health equity, outline a potential path forward, and examine limitations.
Scientific research on the mental health effects of disasters has primarily focused on short-term consequences. This review aims to provide a long-term perspective, examining multiple contributing factors simultaneously. We registered this review (PROSPERO 2020, CRD42020108528), and searched Medline, PsycInfo, PTSDpubs, Web of Science, and SocINDEX from inception to July 2024. After screening 33,205 titles and abstracts, we extracted epidemiological longitudinal data from 71 studies, with up to six waves and a total of 137,004 participants. Disaster type (natural/human-made), category (e.g., earthquakes, floods, terrorist attacks), mental health outcome (e.g., posttraumatic stress disorder, depression, anxiety), population type (children/adolescents, adults), disaster year, measurement month, study quality, and country income were included in a multilevel meta-analysis. Pooled average prevalence of current or recent mental health problems was 22.1% (95% CI [10.95-39.57]). When controlling for the other factors, prevalence did not differ by disaster type, category, mental health outcome, population type, year, study quality, or country income. Despite high heterogeneity, the mental health burden in exposed populations decreased from month 1 to 300 after an initial peak in the first months, followed by a second peak after approximately a decade, before declining again ( p <0.001). Mental health burdens post-disaster may be more universally distributed than previously believed. Earlier studies identifying gradual post-disaster recovery may have underestimated the long-term effects. The analysis revealed a shortage of high-quality studies with measurements beyond four years. The topic requires further investigation with consistently repeated measurements at standard intervals to confirm the presence and early predictors of both larger and smaller peaks.
Converging evidence indicates the importance of prenatal life to subsequent risk for psychopathology across the lifespan, suggesting that potential intervention during this period of heightened brain plasticity may also have enduring protective effects. We describe a novel experimental approach, the "learning" birth cohort, that couples observational and interventional methods over multiple investigation cycles, wherein high-throughput data collected in each wave are canvassed to discover, develop, and implement new interventions in subsequent waves. As illustrated, we can harness both family- and population-level data to effect iterative changes in the prenatal environment, with the goal of improved neurodevelopmental outcomes.
Disaster-related prenatal maternal stress, whether due to natural or human-made crises, can have profound effects on offspring health and development. This narrative review synthesizes research findings on the epigenetic mechanisms through which prenatal maternal stress influences long-term offspring health outcomes. Focusing primarily on DNA methylation, we examine how exposure to stress during gestation alters the epigenetic profile and may contribute to mental, cognitive, and physical health vulnerabilities. Studies were categorized based on disaster type, including time-limited events such as hurricanes, floods, and earthquakes, and stressors like the COVID-19 pandemic and famine. Key findings highlight the timing of exposure, sex-specific epigenetic effects, and the potential for epigenetic markers to mediate stress-induced health outcomes. While considerable progress has been made, our review emphasizes the need for further research on how epigenetics may mediate mental health outcomes and the development of interventions that target these molecular mechanisms.
