A Realistic Comparison of SSRI and Heroin WIthdrawal

With all the quotes in the media about these withdrawal syndromes – I thought I would add a few facts.  These facts are based on science, my 22 years in acute care psychiatry, and another decade at a large facility specializing in substance use disorders.  I have been involved in the care of thousands of people with these disorders, and the care has improved substantially over that period of time largely due to the availability of Medications for Opioid Use Disorder (MOUD).  Before that there was a major problem treating anyone with an Opioid Use Disorder (OUD) if they were not enrolled in a methadone maintenance program. 

To cite a few examples, in acute care psychiatry it is common to receive emergency admissions of people with severe depression or psychosis.  Many have associated drug and alcohol problems.  In the case of heroin and other opioids, there was a rule extending up into the early 2000s that unless a person was enrolled in a methadone maintenance program, only acute detox could be done with methadone.  Additional medications were offered like clonidine to cover hyperadrenergic symptoms of opioid withdrawal.  Clonidine was often the only detox medication. The situation was not better in substance use disorder (SUD) treatment programs who often had an array of “comfort medications” designed to treat all of the peripheral symptoms of withdrawal.  The problem with this approach was twofold: first it was rarely adequate to treat acute withdrawal. Second, when the patient was discharged in a week, they had ongoing symptoms of withdrawal that essentially guaranteed an immediate relapse to opioid use.

The introduction of buprenorphine (Suboxone, Subutex, Sublocade) resulted in a marked improvement in the quality of care in this scenario. The acute and chronic withdrawal symptoms of opioids could be adequately treated and the risk of relapse mitigated. During the time of this transition, the large SUD treatment center where I was working went from using buprenorphine for acute detox to buprenorphine maintenance treatment.  I was responsible for treating depression and anxiety in these patients.  I observed that no matter what treatment I prescribed the anxiety, insomnia, irritability, and depression persisted for months as protracted opioid withdrawal symptoms until they were treated with buprenorphine.  At that point the withdrawal symptoms resolved immediately and completely.  The depression, anxiety, insomnia, and craving for opioids all resolved.  That massive improvement in care cannot be emphasized enough.  I went from discharging people after 1-3 months who I knew would relapse immediately to confidently discharging people who were stable and had a much better chance to recover.

I am posting this introduction because the historical window for this innovation was very brief and I doubt that many physicians ever saw it.  The advantage for patients was so clear that the medical director of the treatment program where I worked changed it from an abstinence-based program to MOUD.  The research at the time was clear.  MOUD saved lives by decreasing relapse rates, accidental overdoses, and decreased risk of infections (HIV, HCV).

In my previous post, I examined the rhetoric of comparing selective serotonin reuptake inhibitor (SSRI) withdrawal to heroin withdrawal.  But what about the popular myths and the science?  The popular view of opioid withdrawal is that once the acute phase is over – it is over.  The popular view promoted with SSRI withdrawal is that it is typically universal, severe, and long lasting.  Neither of those views are accurate.

The time course of symptoms is outlined in the diagram at the top of this post.  Acute symptoms have a characteristic pattern and can start as soon as hours after a last dose of heroin.  In the case of antidepressants, the time course is more dependent on the mechanism of action and half-life of the medication being studied. Since opioids are all mu opioid receptor (MOR) agonists – there are no known medications in this class that do not cause withdrawal, but what accounts for the differences in severity and percentages of people affected is not known. Pharmacokinetics and pharmacodynamics likely play a role – I will defer that discussion to later post.

The main qualitative differences in opioid and SSRI withdrawal are the lack of cravings and observable physical symptoms in SSRI withdrawal.  Opioids reinforce their own use and for that reason have street values.  SSRIs do not and have no street value. The withdrawal symptoms from SSRIs are largely subjective but that does not mean they are not real or serious.  

In the case of SSRIs and other antidepressants, the mechanism precipitating withdrawal is thought to be a precipitous fall in extraneuronal serotonin.  All SSRIs are orthosteric inhibitors of the serotonin transport protein (SERT).  Orthosteric inhibitors act like serotonin at the same binding site on SERT.  Allosteric modulators bind at a site that is topographically distinct from the site that the endogenous ligand (in this case serotonin or 5-HT) binds to.  Escitalopram has an additional effect on SERT as an allosteric modulator.  Trazodone, vilazodone, and nefazodone are all allosteric non-competitive inhibitors of SERT (1-4).  Withdrawal reaction have been described by both but not to the same degree as heroin withdrawal.   

In the case of heroin withdrawal, a series of studies done from 1962 to 1969 showed very high relapse rates (>90%) in heroin users who had been treated in a controlled environment. Thise studies led to early experiments with MOUD and eventually methadone maintenance.  A direct comparison of the likelihood of moderate withdrawal symptoms for each category is 3-31% for SSRIs and 100% for opioids.   Those numbers are qualified by several caveats.  First, opioid withdrawal has been studied for a much longer time, is more well characterized, and fewer medications are involved.  Second, study methodology for the SSRI withdrawal is much more varied from looking at short term randomized controlled studies to surveys of long-term use selected for withdrawal symptoms.  The former will underestimate withdrawal effects but identify a drug attributable effect by subtracting out placebo and the latter will overestimate effects .  The overestimate can be compounded by not subtracting a nocebo effect and publicity effects that may increase nocebo.  In clinical practice, using antidepressants with lower withdrawal risk – I found the incidence to be closest to that of Henzler, et al (7) at about one in six or seven people.    

In conclusion, discontinuing many medications can cause a withdrawal syndrome. Not all withdrawal syndromes indicate an addiction and some can be life-threatening.  They are difficult to study for several reasons.  First, the response to discontinuing the medication varies significantly from person to person even at the same dose and duration of use. That range is significant from no effect to severe and in some cases (alcohol, sedative hypnotics) life-threatening effects.  That includes a placebo response where that can be safely implemented.  Second, there is also a lack of high-quality evidence for many of these syndromes. The best evidence is for alcohol and sedative hypnotics because they are obvious and have been treated for decades.  But even then there are consensus guidelines such as the ASAM guideline on benzodiazepine tapering.  Third, there is limited standardization across guidelines.  Fourth, there are pharmaceutical limitations.  In some cases, very small doses of medication are needed to complete the protocol that may require a liquid form, pill cutting, or substitution with an equivalent medication with a longer half-life.  In some cases, all of these changes may not be enough.  Fifth, in clinical trials where medications were tapered and discontinued there may not be enough reported details to replicate the protocol in clinical practice (5).  Sixth, the outcomes of discontinuation of a medication are complex and include resolution of adverse drug effects, relapse to the treated condition, a unique withdrawal syndrome, or a rebound effect involving the physiological systems that were being treated – like rebound tachycardia after stopping beta-blockers.  Seventh, context is important especially with medications and substances that reinforce their own use.  Adherence to any tapering protocol on an outpatient basis is much less likely to happen.  Eighth, the medicolegal dimension may be a concern.  Because of the all of these factors, there is a lot of uncertainty involved in any tapering and discontinuation protocol.  There is seldom a protocol that will work well for everyone. Because of this risk some guidelines advise clinicians to seek legal or administrative consultation when attempting these protocols.  There is additional risk if relapse to the original condition occurs after a medication has been successfully stopped.

Despite all these concerns tapering and discontinuing medications is foundational medicine in any medical specialty. None of these problems are unique to psychiatry or medication for mental disorders.  As interns most physicians learning how to detoxify acute care patients with substance use disorders – the most common condition remains alcohol use disorder.  In their respective specialties – they learn more about how to do this with specific medications used in their specialty. That has resulted in protocols that can differ from hospital to hospital in the same town. In some cases, the protocols differ in the same hospital over a period of years.  To cite one example, I am aware of a hospital that used oxazepam followed by diazepam and then chlordiazepoxide or phenobarbital as their detox agents from alcohol and benzodiazepines. In some of the standard orders, anticonvulsants were also used to minimize seizure risk.

As more societies and government agencies get involved there is a gradual move to standardization.   Even if we get to that point – individual assessments and close monitoring will still need to be done.  The risk of a withdrawal syndrome from any medication is one that is necessary to medically treat various problems.  It is a decision that physicians and patients do not take lightly.  It is important to discuss that potential risk in the informed consent discussion.    

 

George Dawson, MD, DFAPA

 

References:

1:  Plenge P, Yang D, Salomon K, Laursen L, Kalenderoglou IE, Newman AH, Gouaux E, Coleman JA, Loland CJ. The antidepressant drug vilazodone is an allosteric inhibitor of the serotonin transporter. Nat Commun. 2021 Aug 20;12(1):5063. doi: 10.1038/s41467-021-25363-3. PMID: 34417466; PMCID: PMC8379219.

2:  Sanchez C, Reines EH, Montgomery SA. A comparative review of escitalopram, paroxetine, and sertraline: Are they all alike? Int Clin Psychopharmacol. 2014 Jul;29(4):185-96. doi: 10.1097/YIC.0000000000000023. PMID: 24424469; PMCID: PMC4047306.

3:  El-Kasaby A, Boytsov D, Kasture A, Krumpl G, Hummel T, Freissmuth M, Sandtner W. Allosteric Inhibition and Pharmacochaperoning of the Serotonin Transporter by the Antidepressant Drugs Trazodone and Nefazodone. Mol Pharmacol. 2024 Jun 18;106(1):56-70. doi: 10.1124/molpharm.124.000881. PMID: 38769018.

4:  Murray KE, Ressler KJ, Owens MJ. In vivo investigation of escitalopram's allosteric site on the serotonin transporter. Pharmacol Biochem Behav. 2016 Feb;141:50-7. doi: 10.1016/j.pbb.2015.11.010. Epub 2015 Nov 24. PMID: 26621784; PMCID: PMC4724252.

5:  Dirven T, Turner C, Thio SL, Blom J, Muth C, van Driel ML. Room for improvement in reporting of trials discontinuing long-term medication: a systematic review. J Clin Epidemiol. 2020 Mar;119:65-74. doi: 10.1016/j.jclinepi.2019.11.013. Epub 2019 Nov 29. PMID: 31786152.

6:  Goldberg JF, McIntyre RS, Swartz HA, et al. American Society of Clinical Psychopharmacology Task Force on the Deprescribing of Psychotropic Medications. Recommendations for the Deprescribing of Psychotropic Medications: A Consensus Statement From the American Society of Clinical Psychopharmacology Task Force. JAMA Netw Open. 2026 Feb 2;9(2):e260043. doi: 10.1001/jamanetworkopen.2026.0043. PMID: 41739481.

7:  Henssler J, Schmidt Y, Schmidt U, Schwarzer G, Bschor T, Baethge C. Incidence of antidepressant discontinuation symptoms: a systematic review and meta-analysis. Lancet Psychiatry. 2024 Jul;11(7):526-535. doi: 10.1016/S2215-0366(24)00133-0. Epub 2024 Jun 5. Erratum in: Lancet Psychiatry. 2024 Sep;11(9):e11. doi: 10.1016/S2215-0366(24)00253-0. PMID: 38851198.

 

 

 

 

The Politics of Deprescribing: Deconstructing the HHS Mental Health Agenda

Since May 2026, Department of Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. has promoted an initiative to restructure U.S. mental health delivery. The plan heavily emphasizes "prevention and holistic treatments" while actively discouraging the use of psychiatric medications, under the premise that they are widely overprescribed—especially in children.

A May 4, 2026 memo outlines the core strategy: addressing the "mental health crisis" by making deprescribing (tapering and discontinuing medications) and annual pharmacological reviews reimbursable services, alongside launching federal webinars to teach clinicians how to taper patients off medications.

While these proposals may sound progressive to the public, they collapse under scientific scrutiny for three primary reasons.

1. The Myth of Overprescribing

The administration's central premise—that the mental health crisis is driven by overmedication—is medically inaccurate.

• The Reality of Undertreatment: Up to 23% of the U.S. population has a treatable psychiatric condition warranting antidepressants, yet only a fraction of those individuals receive a prescription.  An estimated 90–95% of suicide decedents had a diagnosable psychiatric disorder, but postmortem toxicological screening consistently finds antidepressants in only 12–29% of cases, with particularly low detection rates among men and younger individuals.  Nearly half of suicide decedents had at least one recently dispensed medication undetected at autopsy, directly evidencing non-adherence. 

  [3]Discontinuation of antidepressants is associated with a 1.6-fold increased risk of suicide attempt compared to continued therapy, and the first 28 days after both starting and stopping antidepressants represent periods of peak vulnerability. [4-5] At the population level, higher SSRI prescribing rates correlate inversely with national suicide rates, supporting the premise that adequate antidepressant treatment confers a protective effect. [6] These findings suggest that the problem is not antidepressant exposure but the failure to initiate, maintain, and monitor adequate pharmacotherapy in individuals with depression who are at risk for suicide (15-19). [7-8]

• Non-Psychiatric Indications: Antidepressants are heavily prescribed for non-psychiatric, FDA-approved or clinically indicated conditions, including migraines, tension headaches, chronic pain, fibromyalgia, and smoking cessation. Studies show that 50% to 64% of all antidepressant prescriptions are written for these non-psychiatric diagnoses [4-8].

• The Gap: When accounting for these physical health prescriptions, only about a quarter of Americans who actually need antidepressants for psychiatric conditions are receiving them. The real crisis is undertreatment, not overmedication [11-13]. Primary care settings miss or misdiagnose depression 40% to 50% of the time, and there is a 90% gap between individuals diagnosed with depression and those receiving clinically effective treatment [14].

2. Redundant "Solutions" to Standard Medical Training

The proposal to have HHS educate doctors on tapering is highly redundant and ignores existing clinical infrastructure.

• Tapering and Discontinuing Medication is Foundational Medicine: Psychiatrists and primary care physicians are already trained in tapering and discontinuing medications. Clinicians have been acutely aware of antidepressant discontinuation syndrome since the first case report in 1959, and it has been standard textbook material since at least 1993.

• Complex Cross-Tapering: In practice, stopping a medication rarely happens in a vacuum. Clinicians routinely manage highly complex transitions—such as cross-tapering (stopping one drug while initiating another) or managing patients who arrive with shopping bags full of conflicting medical and psychiatric prescriptions.

• Existing Resources: Detailed clinical guidance on switching and stopping antidepressants has been readily available in industry-standard databases like UpToDate for over 18 years [9,10]. Rather than funding political webinars, a far more effective HHS initiative would be providing free UpToDate access to all practicing U.S. clinicians.

• Routine Care vs. Political Incentives: Assessing medication efficacy, side effects, and whether to continue, adjust, or stop a drug is already a mandatory component of every standard psychiatric visit. Rebranding this routine care as a newly incentivized "deprescribing service" is purely rhetorical.

3. The Clinical Danger of Forced Deprescribing

Both the American Psychiatric Association (APA) and the American Foundation for Suicide Prevention (AFSP) have issued sharp responses to the HHS initiative:

• The APA strongly objects to defining the mental health crisis as an issue of "overprescribing."

• The AFSP warns that aggressive, medically unsupported "deprescribing" carries severe risks, including increased all-cause mortality, cardiovascular mortality, suicidal behavior, completed suicides, decreased quality of life, and long-term disability.

The Double Standard: Fast-Tracking Psychedelics

While the administration seeks to restrict standard, rigorously studied psychiatric medications, it simultaneously pushes to expedite the review and approval of innovative psychedelics (e.g., psilocybin, noribogaine, and methylone/MDMC) under "Right to Try" laws [19-23].

This presents a glaring policy contradiction:

• High Risks: These compounds carry documented risks of severe psychiatric, cardiac, and systemic side effects (such as QT interval prolongation and arrhythmias linked to ibogaine) [22,23].

• No Infrastructure: Administering psychedelic therapy safely requires intensive, highly staffed clinical infrastructure that the current healthcare system does not possess and likely will never adequately fund.

• Hypocrisy: It is ideologically inconsistent to demand less medication use while fast-tracking high-risk, under-studied substances with relaxed regulatory oversight.

The Broader Landscape of Public Health Misinformation

The antidepressant initiative is part of a broader, systemic pattern of health policy distortion outlined below (and in the lead table):

Scientific Debunking vs. Public Policy (from lead table)

Misinformation Claim	Scientific & Empirical Reality	Citation(s)
Vaccines cause autism	Long-debunked conspiracy theory; actively promoted by RFK Jr. to undermine public trust in vaccines.	[1]
SSRIs cause mass shootings	Debunked. Mass shootings correlate heavily with firearm density, not antidepressant use. Meanwhile, the administration is actively rolling back firearm restrictions for the mentally ill.	[1]
Diet/Keto replaces schizophrenia meds	No clinical evidence supports this. While RFK Jr. claims a ketogenic diet can "cure" schizophrenia, medical consensus remains that clozapine and standard antipsychotics are the gold standard.	[2, 16]
SSRIs are more addictive than heroin	Scientifically false statements made by RFK Jr. during his confirmation hearings. Retraction was formally demanded by 25 members of Congress in March 2025.	[2]
Acetaminophen causes autism	Not supported by rigorous sibling-controlled genetic analyses.	[3, 4]
Alcohol is a healthy social beverage	Promoted by CMS Administrator Mehmet Oz. Directly debunked by modern dietary analyses showing no safe level of alcohol consumption.	[14, 15]

The Policy Fallout: Cutting Resources While Mandating Treatment

The administration's legislative agenda, highlighted by H.R. 1 / One Big Beautiful Bill Act (OBBBA) and Executive Orders 14321, 14379, and 14401, represents a systematic defunding of the mental health safety net under the guise of reform.

1. The Homelessness Mandate (EO 14321)

This order effectively ends "Housing First" policies by making federal housing assistance contingent upon unhoused individuals entering mandatory psychiatric and substance use treatment [17].

• The Error: It ignores the reality that homelessness increases are driven primarily by a lack of affordable housing, not sudden spikes in mental illness.

• No Support: It broadens civil commitment powers without building the clinical infrastructure or beds needed to house or treat these individuals.

2. Dismantling Harm Reduction (EO 14379 & 14401)

The "Great American Recovery Initiative" restructures national addiction policy by stripping away proven harm reduction tools [18].

• The Damage: It bans the distribution of fentanyl test strips, defunds medication-assisted treatment (MOUD) programs that do not force annual drug tapering, and bans the very term "harm reduction" from federal programs.

• Data Blackout: It effectively suspended the National Survey on Drug Use and Health (NSDUH), blinding researchers to national addiction and mental health trends, while imposing sweeping budget cuts on SAMHSA.

3. Stripping Medicaid (OBBBA / H.R. 1)

Medicaid is the nation's largest payer of mental health and substance use disorder care, and the primary funding vehicle for addressing Social Determinants of Health (SDOH) (housing, food security, and transportation) [24-29].

• The Cuts: The bill slashes $911 billion from Medicaid over the next decade to offset $4.5 trillion in tax cuts.

• The Toll: Economists estimate these cuts will strip health coverage from 7.6 million to 16 million Americans, resulting in 16,642 to over 140,000 medically preventable deaths annually [24,26].

• The Demographics: These cuts disproportionately harm rural communities, Black and Hispanic populations, perinatal care, and those seeking addiction treatment—all while 92% of Medicaid recipients already meet work and eligibility requirements.

Conclusion: Rhetoric Over Reality

When health policy is systematically distorted, we must look at the underlying political strategy. The current administration relies heavily on creating rigid in-groups and out-groups, framing public health officials, scientists, academics, and social advocates as "enemies" who are oppressing their core demographic.

The HHS antidepressant and "deprescribing" initiative is not a sincere effort to improve clinical care. It is a rhetorical distraction. By framing the mental health crisis as a personal failure of "overprescribing" doctors and "drugged" citizens, the administration conveniently avoids addressing the structural, economic, and social determinants of health—all while actively dismantling the financial and clinical infrastructure that keeps vulnerable Americans alive.

 

George Dawson, MD, DFAPA

 

Supplementary 1:  Not loving the table.  I tried everything possible to convert my 4 page Word table that is the basis for this post to a single continuous image.  I also tried pasting it directly into this post without any success.  The table alone was too large for the Blogger format and I could not find any way in the HTML to modify the size.  The expected continuous images were too narrow and I could not resize them.  Until I find a way - just click on each table page and it is readable.  The references in the table are in the table and not at the bottom of the post.

Supplementary 2:  A reader pointed out that RFK never explicitly said that SSRIs are “more addictive than heroin.”  That is a common paraphrase and I think if you read any of the following direct quotes it is easy to see how people come to that conclusion. Further his “expertise” only gets him so far.  I happen to be trained in addiction psychiatry and it is a common misconception that opioid withdrawal is miserable but it is over in 4 or 5 days.  In fact, it can persist for 6 months or longer with prominent symptoms of insomnia, anxiety, depression, and cravings that do not respond to usual care.  Those symptoms do respond to Medications for Opioid Use Disorder (MOUD) and it is the main reason that those medications are effective in preventing relapse and accidental overdoses. More details in the next post on this blog. See direct quotes and sources below:    

Direct RFK quotes:

1:  "I happen to be an actual expert on this, because I was addicted to heroin for 14 years... I've watched people come off of SSRIs and it is, it's not even comparable."

 – RFK Jr talks heroin addiction, SSRI views in speech to MAHA.  USA Today May 5, 2026.

2:  “Kennedy reiterated earlier remarks that heroin is easier to come off of than antidepressants. "I happen to be an actual expert on this because I was addicted to heroin for 14 years," he said. He then appeared to get teary speaking about a family member he said was suicidal while she withdrew from an antidepressant. "I've heard that from hundreds and hundreds of people," he said.” 

White LE, McKay B. RFK Jr. Wants to Wean Some Americans Off Antidepressants; HHS will encourage doctors to consider lifestyle changes, not drugs, to treat depression Wall Street Journal. May 4, 2026.

3: .RFK Senate Confirmation Hearing January 30, 2025 direct excerpts

 “Exactly, and that's the solution. 15% of American youth are now on Adderall or some other ADHD medication. Even higher percentages are on SSRIs and benzos. We are not just over medicating our children, we are over medicating our entire population. Half the pharmaceutical drugs on earth are now sold here. 70% of the profits from pharmaceutical companies are from the United States, even though we only have 4.2% of the world's population. Not only that, but a recent study by Cochrane collaboration founder Peter Gøtzsche found that pharmaceutical drugs are the third-largest cause of death in our country after heart attacks and cancers. They're not making us healthier. We need community health initiatives. We need access to treatment, we need exercise, we need better food

“They should have the availability. Listen, I know people, including members of my family, who've had a much worse time getting off of SSRIs than people have getting off heroin. The withdrawal period is… And it's written on the label. It's all documented.”

4:  Address to MAHA Institute May 2026:

“The United States does not just face a mental health crisis, we face a dependency crisis. Driven by overmedicalization. The data is clear. 1 in 6 American adults takes an antidepressant, 1 in 10 children are on prescription medication for their mental health. 30% of college students report using psychiatric medications in the past year, and in nursing homes, more than half of the residents are on prescribed antidepressants.”

References:

1:  WTAS: HHS Launches MAHA Action Plan to Curb Psychiatric Overprescribing.  https://www.hhs.gov/press-room/wtas-hhs-launches-maha-action-plan-curb-psychiatric-overprescribing.html

An embarrassing collection of attention seekers and compromisers.  Note how the APA position reads compared with the link above.

2: Centers for Medicare & Medicaid Services.  The Mental Health Parity and Addiction Equity Act (MHPAEA): https://www.cms.gov/marketplace/private-health-insurance/mental-health-parity-addiction-equity  (accessed 07/13/2026)

3: Kessler, Glenn (January 23, 2021). "Trump made 30,573 false or misleading claims as president. Nearly half came in his final year". The Washington Post. Archived from the original on January 24, 2021.

4:  Mojtabai R, Olfson M. Proportion of antidepressants prescribed without a psychiatric diagnosis is growing. Health Aff (Millwood). 2011 Aug;30(8):1434-42. doi: 10.1377/hlthaff.2010.1024. PMID: 21821561.

5: Rhee TG, Rosenheck RA. Initiation of new psychotropic prescriptions without a psychiatric diagnosis among US adults: Rates, correlates, and national trends from 2006 to 2015. Health Serv Res. 2019; 54: 139–148. https://doi.org/10.1111/1475-6773.13072

6:  Wong J, Motulsky A, Abrahamowicz M, Eguale T, Buckeridge DL, Tamblyn R. Off-label indications for antidepressants in primary care: descriptive study of prescriptions from an indication based electronic prescribing system. BMJ. 2017 Feb 21;356:j603. doi: 10.1136/bmj.j603. PMID: 28228380; PMCID: PMC5320934.

7:  Zhang X, Nie X, Shi L. Treatment indications for antidepressants prescribed in primary health care facilities in Beijing, China. Int Psychogeriatr. 2025 Aug;37(4):100057. doi: 10.1016/j.inpsyc.2025.100057. Epub 2025 Mar 12. PMID: 40074596.

8:  Camacho-Arteaga LF, Gardarsdottir H, Ibañez L, Souverein PC, van Dijk L, Hek K, Vidal X, Ballarín E, Sabaté M. Indications related to antidepressant prescribing in the Nivel-PCD database and the SIDIAP database. J Affect Disord. 2022 Apr 15;303:131-137. doi: 10.1016/j.jad.2022.02.001. Epub 2022 Feb 5. PMID: 35134393.

9: Hirsch M, Birnbaum RJ.  Antidepressant discontinuation syndrome and discontinuing antidepressants in adults.  UpToDate.  Accessed 7/15/2026:  https://www.uptodate.com/contents/antidepressant-discontinuation-syndrome-and-discontinuing-antidepressants-in-adults

10:  Hirsch M, Birnbaum RJ.  Switching antidepressant medications in adults.  UpToDate.  Accessed 7/15/2026:  https://www.uptodate.com/contents/switching-antidepressant-medications-in-adults

11:  US Preventive Services Task Force. Screening for Depression and Suicide Risk in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2023;329(23):2057–2067. doi:10.1001/jama.2023.9297

12:  Jackson-Triche  ME, Unützer  J, Wells  KB.  Achieving mental health equity: collaborative care.   Psychiatr Clin North Am. 2020;43(3):501-510. doi:10.1016/j.psc.2020.05.008

13:  Wang  PS, Angermeyer  M, Borges  G,  et al.  Delay and failure in treatment seeking after first onset of mental disorders in the World Health Organization’s World Mental Health Survey Initiative.   World Psychiatry. 2007;6(3):177-185.

14:  Vigo D, Haro JM, Hwang I, et al. Toward measuring effective treatment coverage: critical bottlenecks in quality- and user-adjusted coverage for major depressive disorder. Psychol Med. 2022 Jul;52(10):1948-1958. doi: 10.1017/S0033291720003797. Epub 2020 Oct 20. PMID: 33077023; PMCID: PMC9341444.

15:  Isacsson G, Holmgren P, Druid H, Bergman U. Psychotropics and suicide prevention. Implications from toxicological screening of 5281 suicides in Sweden 1992-1994. Br J Psychiatry. 1999 Mar;174:259-65. doi: 10.1192/bjp.174.3.259. PMID: 10448453.

16:  Gravensteen IK, Ekeberg Ø, Thiblin I, Helweg-Larsen K, Hem E, Rogde S, Tøllefsen IM. Psychoactive substances in natural and unnatural deaths in Norway and Sweden - a study on victims of suicide and accidents compared with natural deaths in psychiatric patients. BMC Psychiatry. 2019 Jan 18;19(1):33. doi: 10.1186/s12888-019-2015-9. PMID: 30658618; PMCID: PMC6339417.

17:  Chitty KM, Buckley NA, Lim J, Ali Z, Schumann JL, Cairns R, Daniels B, Pearson SA, Preen DB, Schaffer AL. Psychotropic and other medicine use at time of death by suicide: a population-level analysis of linked dispensing and forensic toxicology data. Med J Aust. 2023 Jul 17;219(2):63-69. doi: 10.5694/mja2.51985. Epub 2023 May 25. PMID: 37230472; PMCID: PMC10952140.

18:  Valuck RJ, Orton HD, Libby AM. Antidepressant discontinuation and risk of suicide attempt: a retrospective, nested case-control study. J Clin Psychiatry. 2009 Aug;70(8):1069-77. doi: 10.4088/JCP.08m04943. PMID: 19758520.

19:  Coupland C, Hill T, Morriss R, Arthur A, Moore M, Hippisley-Cox J. Antidepressant use and risk of suicide and attempted suicide or self harm in people aged 20 to 64: cohort study using a primary care database. BMJ. 2015 Feb 18;350:h517. doi: 10.1136/bmj.h517. PMID: 25693810; PMCID: PMC4353276.

20:  White A, Thornton RLJ, Greene JA. Remembering Past Lessons about Structural Racism - Recentering Black Theorists of Health and Society. N Engl J Med. 2021 Aug 26;385(9):850-855. doi: 10.1056/NEJMms2035550. PMID: 34469642

21:  McCoy J, Rahman T, Somer M. Polarization and the global crisis of democracy: Common patterns, dynamics, and pernicious consequences for democratic politics. American behavioral scientist. 2018 Jan;62(1):16-42.

22:  Mason L. Uncivil agreement: How politics became our identity. University of Chicago Press; 2022 Dec 22.

When politics is your identity merged with other identities like race, religion, local culture – the intensity toward out-group hostility intensifies because it seems like an existential threat - but - it is not.

Table References (enlarged):  

 1:  Shim R. Conspiracy Theories Are Incompatible With Effective Health Policies. JAMA Health Forum. 2026;7(4):e261472. doi:10.1001/jamahealthforum.2026.1472

2:  Rubin R. HHS Says Psychiatric Medications Are Overprescribed, but Are They? JAMA. Published online June 26, 2026. doi:10.1001/jama.2026.8946

3:  Gostin LO, Wetter SA, Lurie P. Can a New Commission Make America Healthy Again? JAMA Health Forum. 2025;6(3):e251304. doi:10.1001/jamahealthforum.2025.1304

4:  Cortese S. Pharmacologic treatment of attention deficit–hyperactivity disorder. New England Journal of Medicine. 2020 Sep 10;383(11):1050-6.

5:  Greenhill LL, Pliszka S, Dulcan MK, et al. American Academy of Child and Adolescent Psychiatry. Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry. 2002 Feb;41(2 Suppl):26S-49S. doi: 10.1097/00004583-200202001-00003. PMID: 11833633.

6:  Smith WR, Sharfstein SS, Appelbaum PS. The Make America Healthy Again Commission and Mental Health Distrust. Psychiatr Serv. 2026 Jan 1;77(1):70-73. doi: 10.1176/appi.ps.20250228. Epub 2025 Oct 30. PMID: 41163425.

7:  Alegría M, Alvarez K, Cheng M, Falgas-Bague I. Recent Advances on Social Determinants of Mental Health: Looking Fast Forward. Am J Psychiatry. 2023 Jul 1;180(7):473-482. doi: 10.1176/appi.ajp.20230371. PMID: 37392038; PMCID: PMC12096341.

8:  Cotton NK, Shim RS. Social Determinants of Health, Structural Racism, and the Impact on Child and Adolescent Mental Health. J Am Acad Child Adolesc Psychiatry. 2022

 Nov;61(11):1385-1389. doi: 10.1016/j.jaac.2022.04.020. Epub 2022 May 6. PMID: 35533798.

9:  Patel VR, Liu M, Jena AB. Clinical Trials Affected by Research Grant Terminations at the National Institutes of Health. JAMA Intern Med. 2026 Jan 1;186(1):126-128. doi: 10.1001/jamainternmed.2025.6088. PMID: 41247710; PMCID: PMC12624462.

10:  Jalali MS, Hasgul Z. Potential Trade-Offs of Proposed Cuts to the US National Institutes of Health. JAMA Health Forum. 2025;6(7):e252228. doi:10.1001/jamahealthforum.2025.2228

11: U.S. Department of the Treasury. Fiscal Service, Federal Debt: Total Public Debt [GFDEBTN], retrieved from FRED, Federal Reserve Bank of St. Louis; https://fred.stlouisfed.org/series/GFDEBTN, July 14, 2026

12:  Jeste DV, Gyan E. Social Determinants of Health in Psychiatric Disorders: Exciting Opportunities for Biopsychosocial Research and Clinical Care. Am J Psychiatry. 2026 Jul 1;183(7):450-460. doi: 10.1176/appi.ajp.20260402. Epub 2026 Jul 1. PMID: 42380754.

13:  Baird S, Choonara S, Azzopardi PS, et al. A call to action: the second Lancet Commission on adolescent health and wellbeing. Lancet. 2025 May 31;405(10493):1945-2022. doi: 10.1016/S0140-6736(25)00503-3. Epub 2025 May 20. PMID: 40409329.

14:  George S, Naimi TS, Keyes K, et al. Alcohol Intake and Health Study: No Protective Effect at Low Levels, With Mortality Increasing to 1 in 25 at 14 Drinks Per Week. J Stud Alcohol Drugs. 2026 Jul;87(4):621-638. doi: 10.15288/jsad.25-00435. PMID: 42420014.

15:  Dietary Guidelines for Americans, 2025-2030:  https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf

16:  Walrath-Holdridge M. RFK Jr. says keto can 'cure' schizophrenia. Can a diet alleviate mental illness?  USA Today Feb 19, 2026:  https://www.usatoday.com/story/news/health/2026/02/19/rfk-jr-keto-diet-cure-schizophrenia/88739528007/

17:  Saunders H, Rudowitz R.  A Look at the New Executive Order and the Intersection of Homelessness and Mental Illness.  KFF.  August 15, 2025:  https://www.kff.org/mental-health/a-look-at-the-new-executive-order-and-the-intersection-of-homelessness-and-mental-illness/

18:  Panchal N, Saunders H.   Tracking Key Mental Health and Substance Use Policy Actions Under the Trump Administration.  KFF.  July 10, 2026: https://www.kff.org/mental-health/tracking-key-mental-health-and-substance-use-policy-actions-under-the-trump-administration/

19:  Cohen IG, Lynch HF, McGuire AL. The Psychedelic Therapies Executive Order: On Approval and Clinical Readiness. JAMA. Published online July 01, 2026. doi:10.1001/jama.2026.11892  

20: Hinkle JT, Graziosi M, Nayak SM, Yaden DB. Adverse Events in Studies of Classic Psychedelics: A Systematic Review and Meta-Analysis. JAMA Psychiatry. 2024;81(12):1225–1235. doi:10.1001/jamapsychiatry.2024.2546

 21:  Ghaznavi S, Ruskin JN, Haggerty SJ, King F 4th, Rosenbaum JF. Primum Non Nocere: The Onus to Characterize the Potential Harms of Psychedelic Treatment. Am J Psychiatry. 2025 Jan 1;182(1):47-53. doi: 10.1176/appi.ajp.20230914. PMID: 39741443.

22: Brunt TM. Rare but relevant: Ibogaine and cardiovascular complications-prolonged QT interval and ventricular arrhythmias. Addiction. 2026 Jun;121(6):1616-1621. doi: 10.1111/add.70319. Epub 2026 Jan 20. PMID: 41560340; PMCID: PMC13155281.

23: Edwards EP, Gray LA, Elamin MEMO, Veiraiah A, Thanacoody RHK, Coulson JM. A case series of ibogaine toxicity reported to the United Kingdom National Poisons Information Service (NPIS) over a 10-year period. Clin Toxicol (Phila). 2025 Mar;63(3):212-216. doi: 10.1080/15563650.2024.2447500. Epub 2025 Jan 30. PMID: 39882933.

 

24:  Gaffney A, Himmelstein DU, Woolhandler S. Projected Effects of Proposed Cuts in Federal Medicaid Expenditures on Medicaid Enrollment, Uninsurance, Health Care, and Health. Ann Intern Med. 2025 Sep;178(9):1334-1342. doi: 10.7326/ANNALS-25-00716. Epub 2025 Jun 17. PMID: 40523288.

25:  Cutler DM. The Worst Piece of Health Care Legislation Ever. JAMA Health Forum. 2025;6(8):e254626. doi:10.1001/jamahealthforum.2025.4626

26:  Gaffney A, McCormick D, Bor D, Himmelstein DU, Woolhandler S. What Happens When Coverage is Cut? Looking Backward and Forward From the One Big Beautiful Bill. Milbank Q. 2026 Jun;104(2):324-360. doi: 10.1111/1468-0009.70082. Epub 2026 Apr 30. PMID: 42063224.

27:  Frank RG. Medicaid Reforms in the One Big Beautiful Bill Act and Mental Health Care. Psychiatr Serv. 2026 Jun 24:appips20260012. doi: 10.1176/appi.ps.20260012. Epub ahead of print. PMID: 42337436.

28:  Lin Y, Li H, Nahata MC, Zhang C, Ramey OL, Liu L. Treatment Patterns and Barriers to Care Among U.S. Adults With Co-Occurring Substance Use Disorder and Mental Illness. Am J Psychiatry. 2026 Jul 8:appiajp20251314. doi: 10.1176/appi.ajp.20251314. Epub ahead of print. PMID: 42415254.

29: Berkowitz SA, Archibald J, Yu Z, et al. Medicaid Spending and Health-Related Social Needs in the North Carolina Healthy Opportunities Pilots Program. JAMA. 2025;333(12):1041–1050. doi:10.1001/jama.2025.1042

More Lessons From Dermatology......

 

I have several dermatological ailments and fortunately a very good clinic of dermatologists.  The main problems have been atopic dermatitis (eczema) that did not start until I was 65 and rosacea starting slightly later.  I have posts on the pathophysiology of these conditions at the links.  I have the predisposing factors including genetics, ethnicity (fair-skinned individuals of Celtic and northern European heritage (Fitzpatrick skin types I–II), and associated conditions (childhood and adult allergic asthma) but did not get the associated atopic dermatitis at the time.  One of my siblings had both in childhood.  My father probably had rosacea but he lived during a time when dermatology treatment was generally not done by dermatologists and quite primitive. By primitive I mean, physicians tried to excise inflammatory areas from his face instead of treating them medically like they do now.

The global prevalence of rosacea is estimated at 5.46% (4).  Women are affected more than men and peak prevalence occurs in middle age (45-60 years old).  In a study that looked at how many people were untreated – the prevalence was 12.3% in Germany and 5% in Russia.  Nearly half of those affected had not received any care in the previous year despite 1/3 endorsing a significant effect on quality of life (5).  In addition to cosmetic effects rosacea is a cause of dry eyes and other significant ocular complications and sensitive skin lowering the threshold for pain and irritation.

I was doing quite well until I needed a change in sleep apnea treatment.  Three months ago I changed from APAP to BiPAP because of an increasing AHI.  Because it was running at much higher pressure, they suggested using a mask rather than nasal CPAP.  That mask led to a flareup of rosacea that required a month of treatment with doxycycline.  But even after that treatment I was left with a 4-5 mm inflammatory nodule beneath my right eye that did not resolve. 

I saw a new dermatologist today and the conversation went something like this:

Me:  “This started about 3 months ago when I tried a CPAP mask and it caused a flare-up of rosacea.  This nodular area did not clear with doxycycline.  At about 2 weeks the area of inflammation extended up into the orbital area but stopped there ever since.

Derm:  “Are you still using the triple cream?”

Me:  “Yes twice a day.  It generally works great.”

Derm:  Inspects the area with a dermatoscope in detail and then: ’Yes, it looks like inflammation.  There may be some microabscesses in the area.  It does not look like cancer or infection.  What we need to do is try a different antibiotic for a month and then if it doesn’t clear up – do a biopsy.  I am going to prescribe cefuroxime after we make sure there are no drug interactions.  I notice you are on flecainide.  We were told never to prescribe it so I want to make sure it does not interact.”

His scribe ran a drug interaction check. I set up an appointment to see him in a month and picked up the prescription for cefuroxime.  On the way to the pharmacy, I recalled enrolling patients in a cefuroxime trial for urinary tract infections.  And then I tried to recall all of the serious side effects of cephalosporins – the class of antibiotics that cefuroxime is in.  That is just the way my mind works. 

What are the lessons about psychiatry here?  I don’t think the lessons are for psychiatrists because we know better.  The lessons are basically to counter all of the misinformation about psychiatric treatment and medications from antipsychiatrists, health and wellness influencers, and other critics who don’t seem to know very much about the field.  Here goes:

1:  Diagnoses are not easy – and experts are more likely to make them and even then most are provisional.  In all my teaching about diagnostic thinking in medicine pattern matching is a significant component.  Dermatologists and ophthalmologists are the examples I typically used comparing their diagnoses to other physicians. In this case, the question is what any other physician would have diagnosed the mark on my face as and how it would have been treated.  I have actually been there and done that and it would vary from no diagnosis or treatment to acne and metronidazole. 

2:  Transdiagnostic – yes probably – you would think the term had been invented for psychiatry in the last 10 years.  It is typically used as a criticism of categorical diagnosis as in “there are just so many transdiagnostic symptoms nothing is specific?”  And "all of this comorbidity is a strike against categorical diagnoses."  The reality is there are many so-called transdiagnostic symptoms across all of medicine and many of them are more robust than psychiatric symptoms.  Rash is one of the more robust.  Rashes are transdiagnostic across the 2,000 to 3,000 conditions that produce similar rashes across disorders as well as many different rashes within the same category in the same person.  There are many different rashes (intermediate phenotypes) presenting as rosacea for example, in this case a solitary inflammatory papule.

3:  No labs?  There is no lab test for rosacea or most dermatology conditions. They are clinical diagnoses made on that basis considering all of the findings at the time of the exam.

4:  Is there a biopsy result specific for rosacea?  This is a familiar criticism of psychiatric diagnoses – there is no specific test that rules in the diagnosis. From reference 1 below: “A skin-biopsy specimen is obtained only to rule out other diagnoses, since the histopathological features of rosacea are typically not specific to rosacea.”  Rosacea is a clinical diagnosis based on history and phenotypic criteria and no specific diagnostic test is needed to confirm it (3).

4:  Prevalence and Quality of Life Considerations – prevalence and quality of life considerations for rosacea and common psychiatric disorders are similar. 

 

Rosacea studies looked at pooled prevalence (5.46%) and geographic prevalence (Germany 2.1–12.3%, Russia 5.0%, U.K. incidence rate 1.65 per 1,000 person-years (the only study to quantify incidence) rather than interval prevalence (4-6).  Rosacea is not reported in the same intervals as psychiatric disorders because it is considered a chronic relapsing condition even though a segment of these specific psychiatric disorders has that same property.  There is no cure - another frequent criticism of psychiatric diagnoses.  

Although dermatology and psychiatry use different quality of life (QoL) impairment scales, in the respective disorders about 11% of rosacea patients report severe impairment and anxiety and depressive disorders report ranges of 26-85% using a cut-off of 2 standard deviations over average community ratings (7).  There are also comorbidity considerations with high percentages of rosacea patients reporting significant levels of depression and anxiety. 

5:  Under and missed diagnoses – deference to expert diagnosis is a time-honored tradition in medicine with a more recently established empirical basis. Overall diagnostic accuracy for dermatology conditions is 37-57%.  Roughly ½ of these conditions are incorrectly diagnosed in primary care compared with dermatologists (8). That rate of misdiagnoses is similar to the rate for anxiety and depressive disorders in primary care of 40-50% (9-11).

6:  Under treatment – undertreatment follows underdiagnosis in most cases, but undertreatment can also occur when the diagnosis has been established.  In the case of rosacea delayed diagnosis can lead to progressive (granulomatous) disease and ocular complications. Seborrheic dermatitis is also a frequently co-occurring condition and patients are often unaware that they have this condition as well.

Not treating depression and anxiety on a timely basis leads to similar chronicity and conditions more resistant to treatment.  It increases both the risk of suicide and self harm with chronicity. Untreated depression and anxiety are risk factors for cardiovascular disease and substance use. Chronic pain can be increased.  Both conditions are well documented causes of significant disability.

7:  Uncertain pathophysiology – The pathophysiology of most psychiatric disorders where the possible cause has been ruled out is not known.  The same is true for rosacea.  In any similar group of medical disorders there are commonly suggested hypotheses that can be grouped by general mechanism as indicated in the table below:

8:  Uncertain medication mechanism of action/placebo response -  Since the underlying pathophysiological is unknown the mechanisms of action of the recommended treatments is unknown for rosacea and psychiatric disorders.   This means that clinical trials are needed to test the efficacy and safety of treatments and clinical care follows.

Comparisons of response rates in a selection of antidepressant and rosacea medication trials show significant placebo response in both with a slightly higher response rate in the rosacea trials (66% v. 50%).  At the same time the metrics used for effect size in both tables are not comparable.  If we change to a comparable metric like Number Needed to Treat (NNT) we see ranges of 3-8 for rosacea and 4-6 for antidepressants.  On that basis it is fair to say that response rates to rosacea medication and antidepressants are generally comparable.

The strict comparison is limited by the fact that studies have different outcome measures.  Rosacea studies use a clinician rated global improvement score.  Antidepressant trials may also have a global improvement score but more likely use clinical scales like the HAM-D or MADRS.  Both types of ratings have a consensus marker for improvement but they are not calibrated against one another.    The placebo response rates may have different mechanisms.  Both may have a regression to the mean and clinical care/therapeutic alliance component but the rosacea trials can also be affected by atmospheric conditions and additional topicals that can affect skin moisture.  Rosacea trials tend to be longer than antidepressant trials (12-16 weeks versus 8-12 weeks).

There is a question of real-world effectiveness with both conditions.  It has been studied in depression (12). It was found that for MDD, there is a 90% gap between those with the diagnosis and this receiving effective treatment (41.8% receive treatment and of those only 23.2% of those diagnosed received effective treatment.)  The RISE study (5) suggests that in a screened population for rosacea,  80% were never previously diagnosed.  Of the 20% who were 47.5% had received no rosacea care whatsoever, and only 23.7% had received topical and/or systemic drugs suggesting similar underdiagnosis and treatment as depression.   

Whenever clinical trials of antidepressant are discussed, some critics say that the lack of hard outcomes (all-cause mortality, cause-specific mortality (MI, stroke, suicide), hospitalization) as opposed to symptom-based outcomes is a major problem.  In the comparison with rosacea – all of the outcome measures are symptom-based and no evidence that treatment prevents associated or long-term complications like rhinophyma, telangiectasia, or ocular complications.  There are register based/naturalistic studies (outside of clinical trial design) that show long term use of antidepressants reduces all cause mortality, suicidal ideation, and cardiovascular mortality (13-17).  Not all analyses agree and in some cases the argument was made that it was an antidepressant class effect (18,19).  Rosacea on the other hand has not been studied against an all cause mortality endpoint because it is not associated with increased mortality.    

9:  On label - off-label -  There are currently 40 FDA approved medication for depression and 10 FDA approved medications for rosacea.  Antidepressant development dates back to the 1950s  when it was discovered that medications used to treat tuberculosis also had positive effects on mood.  Rosacea medication development began as an early topical antibiotic treatment (Sodium sulfacetamide 10%/sulfur 5% for papules/pustules).  That early treatment was before 1962.  The next development did not occur until topical metronidazole in 1988.  The only oral antibiotic approved is doxycycline 40 mg MR (Oracea) that is a combination of doxycycline 30 mg IR and doxycycline 10 mg delayed release (DR).  There are no combination medications approved despite the fact that there are compounded formulations.  As an example the Rosacea triple cream contains metronidazole, ivermectin, and azelaic acid.  Each component is FDA approved for monotherapy.    

10: Politicalization – the only real criticism I have seen of dermatologists was comedic. In an episode of Seinfeld, Jerry was trivializing what dermatologists do until he was reminded that they diagnose and treat skin cancer.  Despite the parallels to psychiatry, they have no anti-factions or health and wellness influencers suggesting they are creating more problems than they solve or negative media coverage or high visibility criticism by experts in their own field.  The head of HHS is not suggesting their treatments are overprescribed.

There is no great agitation over dermatology – their methods or treatments despite similar levels of uncertainty and clinical methods with psychiatry.  I am not suggesting there should be.  I am suggesting that psychiatry should be approached by outsiders with the same levels of acceptance that they have for dermatology.  I am also suggesting that if you have a skin condition and nobody seems to be able to diagnose or treat it – see a dermatologist. The advice applies to a mental disorder.  See an expert in that field. 

I know this does happen but there is always a delay.  And there is always plenty of misinformation about the field.  As I have posted here before – practically all of the people I saw over my 40-year career had seen somebody else first – often many different people over a number of years before they decided to see a psychiatrist. It was often the result of a referral decision.  But most importantly – don’t believe what you read in the papers whether it is health and wellness advice or recommendations by the current Secretary of HHS. 

If there is a serious problem with your mental state – see the right person.

 

George Dawson, MD, DFAPA

 

1:  van Zuuren EJ. Rosacea. N Engl J Med. 2017 Nov 2;377(18):1754-1764. doi: 10.1056/NEJMcp1506630. PMID: 29091565.

2:  Frazier W, Zemtsov RK, Ge Y. Rosacea: Common Questions and Answers. Am Fam Physician. 2024 Jun;109(6):533-542. PMID: 38905551.

3:  Dirr MA, Ahmed A, Schlessinger DI, et al. Rosacea Core Domain Set for Clinical Trials and Practice: A Consensus Statement. JAMA Dermatol. 2024 Jun 1;160(6):658-666. doi: 10.1001/jamadermatol.2024.0636. PMID: 38656294.

4:  van Zuuren EJ, Arents BWM, van der Linden MMD, Vermeulen S, Fedorowicz Z, Tan J. Rosacea: New Concepts in Classification and Treatment. Am J Clin Dermatol. 2021 Jul;22(4):457-465. doi: 10.1007/s40257-021-00595-7. Epub 2021 Mar 23. PMID: 33759078; PMCID: PMC8200341.

4:  Gether L, Overgaard LK, Egeberg A, Thyssen JP. Incidence and prevalence of rosacea: a systematic review and meta-analysis. Br J Dermatol. 2018 Aug;179(2):282-289. doi: 10.1111/bjd.16481. Epub 2018 May 31. PMID: 29478264.

5:  Tan J, Schöfer H, Araviiskaia E, Audibert F, Kerrouche N, Berg M; RISE study group. Prevalence of rosacea in the general population of Germany and Russia - The RISE study. J Eur Acad Dermatol Venereol. 2016 Mar;30(3):428-34. doi: 10.1111/jdv.13556. PMID: 26915718; PMCID: PMC5067643.

6:  Hilbring C, Augustin M, Kirsten N, Mohr N. Epidemiology of rosacea in a population-based study of 161,269 German employees. Int J Dermatol. 2022 May;61(5):570-576. doi: 10.1111/ijd.15989. Epub 2021 Dec 12. PMID: 34897653.

7:  Rapaport MH, Clary C, Fayyad R, Endicott J. Quality-of-life impairment in depressive and anxiety disorders. Am J Psychiatry. 2005 Jun;162(6):1171-8. doi: 10.1176/appi.ajp.162.6.1171. PMID: 15930066.

8:  Bridges C, Morris C, McElroy JA, Quinn K, Dyer J, Becevic M. Utility of Dermatology Extension for Community Healthcare Outcomes (ECHO) sessions in the adult and paediatric population. J Telemed Telecare. 2021 Jul;27(6):376-381. doi: 10.1177/1357633X19874200. Epub 2019 Sep 16. PMID: 31526083.

9:  US Preventive Services Task Force. Screening for Depression and Suicide Risk in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2023;329(23):2057–2067. doi:10.1001/jama.2023.9297

10:  Jackson-Triche  ME, Unützer  J, Wells  KB.  Achieving mental health equity: collaborative care.   Psychiatr Clin North Am. 2020;43(3):501-510. doi:10.1016/j.psc.2020.05.008

11:  Wang  PS, Angermeyer  M, Borges  G,  et al.  Delay and failure in treatment seeking after first onset of mental disorders in the World Health Organization’s World Mental Health Survey Initiative.   World Psychiatry. 2007;6(3):177-185.

12:  Vigo D, Haro JM, Hwang I, et al. Toward measuring effective treatment coverage: critical bottlenecks in quality- and user-adjusted coverage for major depressive disorder. Psychol Med. 2022 Jul;52(10):1948-1958. doi: 10.1017/S0033291720003797. Epub 2020 Oct 20. PMID: 33077023; PMCID: PMC9341444.

13:  Chan JKN, Solmi M, Lo HKY, Chan MWY, Choo LLT, Lai ETH, Wong CSM, Correll CU, Chang WC. All-cause and cause-specific mortality in people with depression: a large-scale systematic review and meta-analysis of relative risk and aggravating or attenuating factors, including antidepressant treatment. World Psychiatry. 2025 Oct;24(3):404-421. doi: 10.1002/wps.21354. PMID: 40948054; PMCID: PMC12434377.

14:  Lagerberg T, Fazel S, Sjölander A, Hellner C, Lichtenstein P, Chang Z. Selective serotonin reuptake inhibitors and suicidal behaviour: a population-based cohort study. Neuropsychopharmacology. 2022 Mar;47(4):817-823. doi: 10.1038/s41386-021-01179-z. Epub 2021 Sep 24. PMID: 34561608; PMCID: PMC8882171.

15:  Gusmão R, Quintão S, McDaid D, Arensman E, Van Audenhove C, Coffey C, Värnik A, Värnik P, Coyne J, Hegerl U. Antidepressant Utilization and Suicide in Europe: An Ecological Multi-National Study. PLoS One. 2013 Jun 19;8(6):e66455. doi: 10.1371/journal.pone.0066455. PMID: 23840475; PMCID: PMC3686718.

16:  Korkeila J, Salminen JK, Hiekkanen H, Salokangas RK. Use of antidepressants and suicide rate in Finland: an ecological study. J Clin Psychiatry. 2007 Apr;68(4):505-11. doi: 10.4088/jcp.v68n0403. PMID: 17474804.

17:  Pan YJ, Yeh LL. Associations between mortality and exposure to psychotropic medication: A population-based cohort study for depressive disorders. Aust N Z J Psychiatry. 2023 Sep;57(9):1253-1262. doi: 10.1177/00048674221145337. Epub 2023 Jan 11. PMID: 36629047.

18:  Zhou S, Wang C, Zhang Y. Antidepressant use and all-cause mortality in depressed individuals: A real-world cohort study. PLoS One. 2025 Jul 11;20(7):e0327844. doi: 10.1371/journal.pone.0327844. PMID: 40644427; PMCID: PMC12250549.

19:  Zhuang X, Chen W, Zhan Y, Feng X, Liu C. Antidepressant selection modifies survival in depression: A National Cohort Study Using NHANES 2005 - 2018 data. Gen Hosp Psychiatry. 2026 Jan-Feb;98:33-40. doi: 10.1016/j.genhosppsych.2025.12.001. Epub 2025 Dec 3. PMID: 41351935.

20:  Andrade C. A Primer on How to Critically Read an Observational Study on Adverse Medical Outcomes Associated With Long-Term Antidepressant Drug Use. J Clin Psychiatry. 2022 Dec 7;83(6):22f14733. doi: 10.4088/JCP.22f14733. PMID: 36479952.

21:  Egeberg A, Fowler JF Jr, Gislason GH, Thyssen JP. Nationwide Assessment of Cause-Specific Mortality in Patients with Rosacea: A Cohort Study in Denmark. Am J Clin Dermatol. 2016 Dec;17(6):673-679. doi: 10.1007/s40257-016-0217-1. PMID: 27480418.

22:  Egeberg A, Hansen PR, Gislason GH, Thyssen JP. Assessment of the risk of cardiovascular disease in patients with rosacea. J Am Acad Dermatol. 2016 Aug;75(2):336-9. doi: 10.1016/j.jaad.2016.02.1158. PMID: 27444070.