It is clear that exercise can be a source of great support for patients with major depressive disorder. However, it is important to recognize that several multifactorial and intersecting challenges are associated with exercise for this patient population. Group fitness programs for this patient population have the potential to be cost-effective while serving as an avenue of social interaction for participants. From an administrative perspective, it is challenging to balance satisfaction and adherence in group fitness programs targeting patients with major depressive disorder. This article presents a proposal that highlights what the challenges may look like in practice and discusses 3 strategies for improving satisfaction and adherence with a group fitness program: diagnosis and needs assessment, exercise diversity, and ongoing evaluation.

While considerable research has focused on maladaptive perfectionism as a risk factor for social anxiety, little attention has been given to the mechanisms that mediate the effects. We integrated perfectionism with the bivalent fear of evaluation model of social anxiety to investigate 2 hypothesized mechanisms: hostile attribution bias and disqualification of positive social outcomes (DPSO). Specifically, we hypothesized that individuals with maladaptive perfectionism develop hostile attribution biases which then lead to DPSO, which in turn predisposes them to social anxiety. Participants were 242 individuals from the general population who completed measures of perfectionism, hostile attribution bias, DPSO, and social anxiety. A test of multiple mediators using bootstrapping supported the hypothesized multiple mediator models. The results suggested that maladaptive perfectionism predisposes an individual to social anxiety through hostile attribution bias and DPSO. The results further suggested that DPSO but not hostile attribution bias operates as an individual mediator in the perfectionism-social anxiety relationship. The findings from this study provide support for the bivalent fear of evaluation model of social anxiety; however, the use of a cross-sectional design limited our ability to find true cause-and-effect relationships.

Antidepressant-induced pancreatitis is a rare, albeit serious, adverse effect, with a frequency of occurrence that is not equally distributed among antidepressant drugs. The goal of this study was to investigate the association and causal relationship between mirtazapine treatment of patients with depression and pancreatitis. The study was designed as a systematic review of the literature, accompanied by the description of a new case of mirtazapine-associated acute pancreatitis. Nine cases of mirtazapine-associated pancreatitis have been reported, involving 7 female patients and 2 male patients with a mean age of 46.4 years (range: 26 to 83y of age). All of the patients were hospitalized, with an average length of stay of 16.2 days (range: 3 to 34d). In 6 cases, "de-challenge" followed by improvement was reported. The patients for whom the outcome was reported (7 of 9) recovered completely. Although a rare adverse effect, mirtazapine-induced pancreatitis should be considered when patients taking mirtazapine report abdominal discomfort.

Supervision of psychotherapy is recognized as fundamental for attaining competency in psychotherapy. However, there is a lack of training in "best practices" of supervisory skills, and some supervisors may lack contemporary knowledge to support supervisees adequately. Training program leadership challenged by limited time and resources to provide supervisors with the necessary education and support can benefit from additional resources for developing psychotherapy supervisors. The authors present 3 core elements of navigating supervisory challenges: training, open dialogue in supervision, and a formal program-level process. Common issues in psychotherapy supervision are then presented in a case-based format. Reflection questions are included to provide an opportunity to consider a personal approach to the case, while specific guidance based on the literature addresses critical aspects of the case examples. Complex supervisory conflicts can challenge programs, but they are normative to the learning process and promote growth in our supervisors.

Supervision of psychotherapy is recognized as fundamental for attaining competency in psychotherapy. However, there is a lack of training in "best practices" of supervisory skills, and some supervisors may lack contemporary knowledge to support supervisees adequately. Training program leadership challenged by limited time and resources to provide supervisors with the necessary education and support can benefit from additional resources for developing psychotherapy supervisors. The authors present 3 core elements of navigating supervisory challenges: training, open dialogue in supervision, and a formal program-level process. Common issues in psychotherapy supervision are then presented in a case-based format. Reflection questions are included to provide an opportunity to consider a personal approach to the case, while specific guidance based on the literature addresses critical aspects of the case examples. Complex supervisory conflicts can challenge programs, but they are normative to the learning process and promote growth in our supervisors.

Although disorders arising from sex chromosome and sex steroid abnormalities are well characterized from the perspectives of endocrinology, dysmorphology, and reproductive health, relatively little is known about neuropsychiatric development, gender identity, incongruence, and dysphoria in the populations with these disorders. In this report, we describe the case of a 21-year-old gender nonbinary individual identified as male at birth who presented to an academic psychiatry consultation clinic because of life-long gender dysphoria. The patient was found to have a complex sex chromosomal rearrangement and associated hormonal abnormalities that may, at least in part, explain the patient's history. In addition to describing a novel genetic change, this case and the accompanying review of the existing literature highlight the need for an increased focus on the psychiatric perspective, and sex and gender issues in particular, among all patients with sex chromosome abnormalities and inborn errors of steroid metabolism.

Copy number variations, which manifest primarily as deletions and duplications, contribute significantly to the genetic risk of schizophrenia. Specific syndromes associated with copy number variations, exemplified by the 22q11 deletion syndrome, confer both congenital abnormalities and an elevated risk of schizophrenia. We report the case of a patient with a deletion of exons 2 through 8 of GPR143. In addition to having the ophthalmologic disorder ocular albinism type 1 (OA1), a well-established consequence of mutations of GPR143, the patient is also intellectually impaired and impulsive, and he developed schizophrenia at age 15. Psychiatric manifestations of OA1 have not previously been reported, yet remain plausible, as the GPR143 protein is widely distributed in the brain and may function as an L-DOPA receptor. However, the patient described here also had a family history of psychiatric disorders independent of OA1, in utero exposure to heroin and cocaine, and challenging family circumstances. We suggest that the relationship between his GPR143 mutation and his psychiatric disorders is complex. The mutation may have directly contributed to his cognitive and psychiatric disorders, but we also suspect that OA1, present in multiple family members, contributed to multigenerational familial instability. Further, OA1 likely exacerbated our patient's cognitive and social impairment by interfering with his education, while his neuropsychiatric status frequently interfered with the assessment and treatment of his OA1. We conclude that the psychiatric and nonpsychiatric manifestations of a genetic syndrome are best managed in parallel and that psychiatrists and other mental health providers may be in the best position to assure that patients receive appropriate genetic and medical care.

Electroconvulsive therapy (ECT) is one of the most effective treatments for depression. However, significant stigma from the media and the antipsychiatry movement has biased the public toward ECT, leading to underutilization, particularly among those most in need. This report reviews some of the key historical events in the rise, fall, and resurgence of ECT and how modern ECT knowledge and practice are more refined, including an improved understanding of its mechanisms of action and optimal treatment parameters.

This first column in a 2-part series focuses on the pharmacokinetics of the 3 Food and Drug Administration-approved dual orexin receptor antagonists, daridorexant, lemborexant, and suvorexant, specifically as they relate to their use as sleep medications. Although other classes of sleep medications are not discussed, the same pharmacokinetic principles also apply to them.

November, 2022. In a recent article entitled “The Extraordinary Importance of Sleep,” Worley1 reports on the “relationships between inadequate sleep and a wide range of disorders, including hypertension, obesity and type-2 diabetes, impaired immune functioning, cardiovascular disease and arrhythmias, mood disorders, neurodegeneration and dementia, and even loneliness.” She quotes David F. Dinges, PhD, Professor and Chief of the Division of Sleep and Chronobiology at the University of Pennsylvania Perelman School of Medicine, who said “We know … that sleep is critical for waking cognition—that is, for the ability to think clearly, to be vigilant and alert, and sustain attention. We also know that memories are consolidated during sleep, and that sleep serves a key role in emotional regulation.” In fact, in the last decade especially, there has been an explosion of scientific research studying the health benefits of sleep, the perils of sleep deprivation, and the importance of good sleep hygiene. DSM-5 states that the “essential feature of insomnia disorder is dissatisfaction with sleep quantity or quality with complaints of difficulty initiating or maintaining sleep,”2(p363) and that it causes significant distress or impairment in functioning. There must be adequate opportunity for sleep, and the difficulty must occur at least 3 nights per week for at least 3 months. So let’s think about this for a minute. Right away, my mind jumps to Ukraine and the impossibility for the troops to have “adequate opportunity for sleep.” In which case, they would not be diagnosed with insomnia disorder, but that doesn’t mean they aren’t sleep-deprived, on top of unimaginable and relentless stress, putting their brains and bodies at even greater risk, while dodging bullets and bombs. And that’s just one example; these days, the list of disaster zones is long. But even in day-to-day life, far from danger, where there is indeed adequate opportunity to sleep, insomnia gets in the way all too often. What to do about it? Does social media have the answers? Websites promoting sleep products and strategies abound, but how to evaluate their credibility? Luckily, reputable institutions such as the NIH, the American Academy of Sleep Medicine, and advice from sleep experts in the world of academic medicine provide valuable, readily available guidance. In this issue of the Journal, Seow and colleagues provide a systematic review of guidelines that have been developed for the treatment of insomnia disorder. On the basis of their review, they reported that a good number of the clinical practice guidelines “recommended pharmacotherapy only if cognitive behavioral therapy for insomnia or other nonpharmacological interventions were unavailable, unsuccessful, or declined by patients.” In terms of the guidelines’ recommendations for medications for insomnia disorder, they found that “[o]ther than indications for initiating pharmacotherapy, there was little agreement on other considerations, such as the type, dose, and duration of medication, adverse effects for which clinicians should be alert, and treatment alternatives.” The prevalence of medication use for insomnia is well-known but far from risk-free, and this look at what the evidence shows, even though limited, is welcome. Also in this issue, Preskorn reviews the pharmacokinetics of three new FDA-approved medications to treat insomnia. After summarizing a few basics about the normal sleep cycle, he provides important clinical guidance about the appropriate and safe use of these newer medications. As is the case for other medications for insomnia, these new compounds should be prescribed judiciously, in combination with nonpharmacological treatment approaches.