But first: a pair of work besties who already felt like brother and sister found out that they really are siblings. Listen to their story in the first 7 minutes of this episode of The Happy Pod from the BBC.

Bigorexia is not recognized by insurers — and men and boys suffer for it

Men make up roughly one-third of people who struggle with eating disorders in the U.S. Some estimates show that as many as 14% will experience an eating disorder by age 40 — and they may be more likely to die from them than women. Unfortunately, appropriate medical recognition hasn’t caught up to reality, says Dr. Jason Nagata, an expert in male eating disorders. Nowhere is that gap wider, the UCSF professor told STAT News, than with muscle dysmorphia.

Also known as bigorexia, this condition overwhelmingly affects boys and men by convincing them that they are never muscular enough. Categorized under obsessive-compulsive and related disorders in the American Psychiatric Association’s Diagnostic and Statistical Manual, it frequently involves extreme dieting.

Its current classification is a problem for both patients and providers, Nagata says, since the disorder is rarely adequately recognized. He argues that muscle dysmorphia should be deemed an eating disorder in the next edition of the DSM. Situating muscle dysmorphia among obsessive-compulsive disorders makes the diagnosis mutually exclusive with eating disorders, he said, meaning that if a patient meets the threshold for one condition, they definitionally cannot be diagnosed with the other. This distinction is out of alignment with the experiences of the people Nagata treats in his clinic.

“You can’t really separate exercise and nutrition; they go hand in hand. Some people have an eating disorder…because they’re trying to become muscular, and there is no specific eating disorder diagnosis that captures muscularity concerns,” said Nagata. “It’s much more common for people to have some combination of muscularity concerns and a change in their eating in a disordered way.”

In practice, this also becomes a problem for people seeking treatment through insurance. Some patients meet every diagnostic criterion for muscle dysmorphia but one — the rule that says they can’t also have an eating disorder. So they are instead coded as having an “unspecified feeding and eating disorder,” a catchall that names nothing specific and points nowhere useful.

Coding in that way could also put providers in billing trouble, because “if you were to follow the DSM-5 definition, you should not be coding for muscle dysmorphia and an eating disorder,” Nagata said. “If they’re seeing both symptoms, some providers will code for both…but this puts them in a difficult position…[that] could theoretically get them in trouble for misdiagnosis and attract more scrutiny by insurance companies…just to get patients the treatment they need.”

Affected boys and men often carry a double stigma — the ordinary shame of an eating disorder, compounded by the fear of being outed with a condition perceived as effeminate. This can also lead to treatment delays. When patients do land in a treatment program, it’s often one where nearly everyone else is being treated for anorexia and weight loss, deepening the isolation.

Though some experts counter that muscle dysmorphia’s current placement is accurate and can be paired with an eating disorder diagnosis when needed, Nagata says that the right diagnosis is the key to everything else: better screening, more clinicians trained to spot the condition and more avenues for research to improve treatments and outcomes for all.

Antidepressants don’t always work, but alternative treatments may help

Juan Rivera first noticed his mental health waning in college, when the things he loved — nights out with friends chief among them — stopped feeling fun. “I would be with my friends but not enjoying it fully and just sort of feeling flat,” he told The New York Times. On the worst days, getting out of bed was the most he could manage, he said. After speaking to a psychiatrist about the change, she diagnosed him with depression, later prescribing an antidepressant to treat the condition. 

Unfortunately, Rivera says, the medication didn’t work. Now 35, he said that the psychiatrist prescribed various other antidepressants over the years, all of which failed to relieve his symptoms and led to a new diagnosis: treatment-resistant depression. There is no standard definition for the condition that affects roughly 31% of those treated for depression in the United States, said Dr. Gerard Sanacora, director of the Yale Depression Research Program. He says depression is generally deemed treatment-resistant if a person’s symptoms don’t improve by at least 50% after two consecutive periods of treatment with two different antidepressants.

People with certain genetic differences are at greater risk, as are those with a history of childhood trauma, anxiety, certain vitamin deficiencies, thyroid disease, heart disease or sleep apnea, said Dr. Debra Kahn, director of the Advanced Psychiatric Therapeutics Clinic at UC Davis Health. Several of those conditions can mimic or worsen depression symptoms like fatigue, making the underlying illness harder to treat. A patient’s own diminishing hope for improvement after each failed antidepressant can also stand in the way. Still, treatment-resistant doesn’t mean untreatable. Alternative strategies, including other pharmaceuticals, can help.

Talk therapy combined with antidepressants is often a first line of defense, Kahn said, but if that should fail, clinicians might try a low-dose antipsychotic or test for another medical condition that could affect brain health. 

Transcranial magnetic stimulation, or TMS, is another relatively new option, having only been cleared by the Food and Drug Administration to treat depression in 2008. Yielding no long-term serious side effects, the procedure uses magnetic pulses to spark the release of mood-lifting chemicals in the brain, including norepinephrine, dopamine and serotonin, she said. A 2023 meta-analysis of 19 clinical trials found that patients on TMS plus an antidepressant were nearly three times as likely to experience remission as those who received an antidepressant with a placebo TMS treatment.

The surgical anesthetic ketamine is also growing in popularity as a depression treatment. The drug is believed to help the brain forge new or stronger connections in the circuitry that governs mood and cognition, Kahn said. A derivative, esketamine, is sold as the FDA-approved nasal spray Spravato. In a 2019 trial, just over half of patients who paired esketamine with an antidepressant saw their symptoms significantly ease, compared to about 31% of those on an antidepressant with a placebo. Spravato is the latest treatment Rivera has tried — and he’s finally reporting some success, saying it’s clearing the “negative filter” that has long tinted his mood.

Still, experts emphasize that no pill or medication can heal depression on its own. “You can take the medicine, but you also have to do the other physical and social interventions that are so important,” Yale’s Dr. Sanacora said. In practice, that means maintaining the ordinary, hard-to-sustain work of living well — getting good nutrition, adequate sleep, moving your body, breathing fresh air and building real connections with other people.

In other news…

The National Guard’s Washington, D.C. mission is disillusioning its troops: One year in, members of the National Guard are struggling amid their deployment in Washington, D.C., three members told NPR on condition of anonymity. Barred from speaking publicly, they described a slow erosion of morale, including embarrassment at being involved in a mission that is “wasting everyone’s time.” Originally sent by the Trump Administration to help law enforcement during a “crime emergency” despite the city’s 30-year low in violent crime, one member said he no longer wants to think about the Guard at all, or perform his normal duties, “just because of the abuses of the National Guard in this D.C. mission.”

The biggest blow to morale came last November, when two guard members from West Virginia who were patrolling near the White House were shot by a gunman, resulting in the death of 20-year-old Spc. Sarah Beckstrom. One member, still thinking of her nearly every day and sometimes visiting the spot where she died, called her death “absolutely futile” and said the mission became emotionally untenable afterward. Another has worked in therapy on guilt over not being present when the shooting happened. “We were made a target,” he said, “and I don’t know that anybody did a very good job of planning for the worst-case scenario.”