Therapists phone it in and keep more patients

Telephone therapy retains more patients than face-to-face sessions and improves depression CHICAGO --- Phoning it in is more effective than the therapist's couch when it comes to keeping patients in psychotherapy. New Northwestern Medicine research shows patients who had therapy sessions provided over the phone were more likely to complete 18 weeks of treatment than those who had face-to-face sessions. The study, published in the June 6 issue of the Journal of the American Medical Association, is the first large trial to compare the benefits of face-to-face and telephone therapy. Phone therapy is a rapidly growing trend among therapists. About 85 percent of psychologists now deliver some of their services over the phone because competing demands, transportation time and other problems make it difficult for many patients to get to their offices social worker continuing education "Now therapists can make house calls," said David Mohr, the lead author and a professor of preventive medicine at Northwestern University Feinberg School of Medicine. "Our study found psychotherapy conveniently provided by telephone to patients wherever they are is effective and reduces dropout. This suggests these services now should be covered by insurance." While telephone therapy was as effective as face-to-face sessions in reducing depression during treatment, the improvement ebbed slightly six months after treatment ended compared to face-to-face therapy. The randomized control trial included 325 primary care patients with major depressive disorder. The results showed 20.9 percent of patients who had cognitive behavioral therapy over the phone dropped out compared to 32.7 percent for face-to-face therapy. Patients in both therapies showed equally good improvement in their depression when treatment ended. Six months after treatment ended, all patients remained much improved. However, patients who had the telephone therapy scored three points higher on a depression scale than those who had face-to-face sessions. "The three point difference is of questionable clinical significance but it raises the question whether some individuals are at risk of worsening after treatment with telephone therapy compared to face-to-face," Mohr said. It may be that the slight worsening seen in the telephone therapy after the end of treatment was because patients who had more mental health difficulties and who would have dropped out of face-to-face sessions were retained in telephone therapy, Mohr noted. Thus, this may not be a real finding. "But we can't rule out the possibility that it may be true and there is something about face-to-face treatment that creates better results for some people," Mohr said. "The physical presence of the therapist may be therapeutic in a way that helps some patients maintain their improvement in mood. There may be a unique quality about the human contact that increases resilience and maintains the skills learned to manage depression after treatment has ended." Mohr said he hopes the study results will encourage insurance providers including Medicare to reimburse telephone therapy sessions, which many companies currently don't cover. "There is good reason to reimburse these sessions," Mohr said. "Many people can't get to a therapist's office, but they want to talk to someone. Telephone therapy is highly effective and offers a solution to people with depression who otherwise would be left out." This is particularly true for disabled people or those who live where care is unavailable, such as in rural areas, he noted. Research shows people prefer talk therapy to antidepressant medication, but many quickly drop out of treatment or don't follow up on a referral from their primary care physicians, likely the result of obstacles that prevent them from getting to the therapist's office. ### Other Northwestern authors include: Joyce Ho, Jenna Duffecy, Michelle Nicole Burns, Ling Jin and Juned Siddique. This study was funded by the National Institute of Mental Health of the National Institutes of Health research grant NIMH R01-MH059708.

When being scared twice is enough to remember

One of the brain's jobs is to help us figure out what's important enough to be remembered. Scientists at Yerkes National Primate Research Center, Emory University have achieved some insight into how fleeting experiences become memories in the brain. Their experimental system could be a way to test or refine treatments aimed at enhancing learning and memory, or interfering with troubling memories. The results were published recently in the Journal of Neuroscience. The researchers set up a system where rats were exposed to a light followed by a mild shock. A single light-shock event isn't enough to make the rat afraid of the light, but a repeat of the pairing of the light and shock is, even a few days later. "I describe this effect as 'priming'," says the first author of the paper, postdoctoral fellow Ryan Parsons. "The animal experiences all sorts of things, and has to sort out what's important. If something happens just once, it doesn't register. But twice, and the animal remembers." Parsons was working with Michael Davis, PhD, Robert W. Woodruff professor of psychiatry and behavioral sciences at Emory University School of Medicine, who has been studying the molecular basis for fear memory for several years. Even though a robust fear memory was not formed after the first priming event, at that point Parsons could already detect chemical changes in the amygdala, part of the brain critical for fear responses. Long term memory formation could be blocked by infusing a drug into the amygdala. The drug inhibits protein kinase A, which is involved in the chemical changes Parsons observed. It is possible to train rats to become afraid of something like a sound or a smell after one event, Parsons says. However, rats are less sensitive to light compared with sounds or smells, and a relatively mild shock was used. Fear memories only formed when shocks were paired with light, instead of noise or nothing at all, for both the priming and the confirmation event. Parsons measured how afraid the rats were by gauging their "acoustic startle response" (how jittery they were in response to a loud noise) in the presence of the light, compared to before training began. Scientists have been able to study the chemical changes connected with the priming process extensively in neurons in culture dishes, but not as much in live animals. The process is referred to as "metaplasticity," or how the history of the brain's experiences affects its readiness to change and learn. "This could be a good model for dissecting the mechanisms involved in learning and memory," Parsons says. "We're going to be able to look at what's going on in that first priming event, as well as when the long-term memory is triggered." "We believe our findings might help explain how events are selected out for long-term storage from what is essentially a torrent of information encountered during conscious experience," Parsons and Davis write in their paper social worker ceus ### The research was supported by the National Institute of Mental Health (R37 MH047840 and F32 MH090700). Reference: R.G. Parsons and M. Davis. A metaplasticity-like mechanism supports the selection of fear memories: role of protein kinase A in the amygdala. J. Neurosci 32: 7843-7851 (2012).

Study identifies factors related to violence in veterans

CHAPEL HILL, N.C. – A national survey identifies which U.S. military veterans may be at most risk of aggression after deployment and what strategies could potentially help reduce likelihood of violence when service members return home counselor ceus The study examined protective factors that are important in preventing violence, including employment, meeting basic needs, living stability, social support, spiritual faith, ability to care for oneself, perceived self-determination, and resilience (ability to adapt to stress). Veterans with these factors in place were 92 percent less likely to report severe violence than veterans who did not endorse these factors. The majority of veterans (over three-quarters of those studied) did endorse most of these protective factors and thus posed a low threat of violence. These findings are reported in an article published June 25, 2012 in the Journal of Clinical Psychiatry of a National Institute of Mental Health-funded study led by Eric B. Elbogen, PhD, Research Director of the Forensic Psychiatry Program in the University of North Carolina School of Medicine and Psychologist in the U.S. Department of Veterans Affairs. "When you hear about veterans committing acts of violence, many people assume that post-traumatic stress disorder (PTSD) or combat exposure are to blame," Elbogen said. "But our study shows that is not necessarily true." The national survey revealed that other factors are just as important to understanding violence in veterans, including alcohol misuse, criminal background, as well as veterans' living, work, social, and financial circumstances. In fact, the survey found that veterans who didn't have enough money to cover basic needs were more likely to report aggressive behavior than veterans with PTSD. "Our study suggests the incidence of violence could be reduced by helping veterans develop and maintain protective factors in their lives back home," Elbogen said. The survey was conducted between July 2009 and April 2010. Responses were collected from 1,388 veterans who served in the Iraq and Afghanistan War era and theater after Sept. 11, 2001. The sample included veterans from all branches of the U.S. military and all 50 states. One-third of survey respondents self-identified committing an act of aggression towards others in the past year, most of which involved relatively minor aggressive behavior. Eleven percent of the sample reported more severe violence. Elbogen noted, "Although the majority of study participants did not report aggression, the potential for violence does remain a significant concern among a subset of returning veterans." Dr. Sally Johnson, co-author and Professor in the UNC Forensic Psychiatry Program, points out "Some veterans do not cope well with the loss of the structure, social, and financial support available in the military environment. Attention to helping veterans establish psychosocial stability in the civilian environment can help reduce post-deployment adjustment problems including aggression." ### The other co-authors H. Ryan Wagner, PhD, Virginia M. Newton, PhD Christine Timko, PhD, Jennifer J. Vasterling, PhD, and Jean C. Beckham, PhD are affiliated with the Department of Veterans Affairs.

Avatars may help children with social anxiety overcome fears

A principal standing in the hallway says, "You are one of my favorite students!" In class, a smart girl says, "You are the nicest person in our class!" Many children would smile and eagerly return those compliments, but some with social anxiety may be too terrified to respond. Researchers at the University of Central Florida's Anxiety Disorders Clinic and the Atlanta-based company Virtually Better want to give more children with social anxiety the practice they need to become comfortable in social situations. They have developed a new, one-of-a-kind computer simulation program that enables children to interact with avatars playing the roles of classmates, teachers and a principal. The simulation, designed for children ages 8 to 12, allows clinicians to play the roles of the avatars while the children sit at a computer in a different room and respond to situations they encounter routinely. The children practice greetings, giving and receiving compliments, being assertive and asking and answering questions. "These kids come in and say, 'I don't know how to make a friend,'" said Deborah Beidel, director of the Anxiety Disorders Clinic and a psychology professor at UCF. "We have to teach them the skills that most people learn from being around other people." The National Institute of Mental Health, part of the National Institutes of Health, provided a $500,000 grant to fund the development of the software and a 12-week study that will begin this summer. The study will involve 30 Central Florida children ages 8 to 12. Many children are nervous and slow to warm up in new social situations, but those with social anxiety disorders have severe distress that doesn't go away, Beidel said. "If a fear is so severe that it prevents a child from doing something he or she should be doing, such as going to school, playing on a sports team, being in a dance recital, going to birthday parties or making friends, then a parent should call a mental health professional," she said. Under Beidel's leadership, the UCF Anxiety Disorders Clinic has treated children with anxiety disorders for five years. The clinic offers what Beidel calls the "gold standard" of treatments. Children with anxiety disorders are paired with socially comfortable peers for outings to places such as bowling alleys, restaurants and miniature golf courses. The new study will give parents multiple treatment options at UCF. But parents in most communities aren't so fortunate. Many clinicians who treat children don't have the time or resources to recruit socially comfortable children and organize regular outings. Guiding clients through a simulation in the office may be the only feasible solution for them continuing education for counselors The simulation features a realistic school setting, designed with the help of elementary school teachers. The pre-programmed responses of the avatar classmates – which include a cool girl, a smart girl and a bully -- were recorded by children to ensure the language reflects how they talk. "The most important thing is that this was designed by clinicians with a very specific intention to help people get better. That's the big difference between this and a game, and there is nothing like this on the market," said Josh Spitalnick, clinical psychologist and director of research and clinical services at Virtually Better, an Atlanta-based company bringing interactive technologies to behavioral healthcare for treatment and training. The six characters and the varying levels of difficulty in the simulation allow clinicians to design scenarios appropriate for their patients. More challenging scenarios include dealing with a bully who is demanding that a child give up some of her lunch money. If the initial trial goes well, researchers hope to conduct a yearlong trial with more children. If that is successful, the simulation could then become available to clinicians. The program eventually could be expanded to include other settings, such as playgrounds, and to serve other children who need help improving social skills. ### For more information about UCF's Anxiety Disorders Clinic, go to http://anxietyclinic.cos.ucf.edu. For more information about Virtually Better Technologies, visit www.virtuallybetter.com.

UCLA study uncovers new tools for targeting genes linked to autism

Findings could lead to future therapeutic targets UCLA researchers have combined two tools – gene expression and the use of peripheral blood -- to expand scientists' arsenal of methods for pinpointing genes that play a role in autism. Published in the June 21 online edition of the American Journal of Human Genetics, the findings could help scientists zero in on genes that offer future therapeutic targets for the disorder. "Technological advances now allow us to rapidly sequence the genome and uncover dozens of rare mutations," explained principal investigator Dr. Daniel Geschwind, the Gordon and Virginia MacDonald Distinguished Professor of Human Genetics and a professor of neurology at the David Geffen School of Medicine at UCLA. "But just because a particular genetic mutation is rare doesn't mean it's actually causing disease. We used a new approach to tease out potential precursors of autism from the occasional genetic glitch." Geschwind and his colleagues studied DNA contained in blood samples from 244 families with one healthy child and one child on the autism spectrum. The team used a hybrid method that blended tests that read the order of DNA bases with those that analyze gene expression, the process by which genes make cellular proteins. "Monitoring gene expression provides us with another line of data to inform our understanding of how autism develops," said Geschwind, who is also director of the Center for Autism Research and Treatment at the Semel Institute for Neuroscience and Behavior at UCLA. "Integrating this method with the sequencing of DNA bases expands our ability to find mutations leading to the disease." Gene expression offers a molecular signpost pointing scientists in the right direction by narrowing the field and highlighting specific areas of the genome. For example, if a gene is expressed at substantially higher or lower levels in a patient, researchers will review the patient's DNA to check if that gene has changed. "We found that we can use gene expression to help understand whether a rare mutation is causing disease or playing a role in disease development," said Geschwind. "A true mutation will alter a gene's sequence, modifying the protein or RNA it produces -- or preventing the gene from producing them entirely. "A gene mutation accompanied by a change in expression clues us to a hot spot on the genome and directs us where to look next," he added. "Not all mutations will influence gene expression, but this approach improves our ability to pinpoint those that do." The researchers used the combined method to prioritize gene targets that merit closer investigation, potentially explaining why one person develops autism and their sibling does not. Their search turned up new regions in the genome where genetic variations showed strong links to autism and altered expression patterns. Genes in these regions were more likely to be mutated in the autistic children than in their unaffected siblings. "When we looked at genes associated with nervous-system function we found significantly more genes were expressed at higher or lower levels in the children diagnosed with autism than we did in their siblings unaffected by the disorder," said Geschwind. Finally, the research team discovered that the DNA contained in peripheral blood can help shed light on diseases of the central nervous system. Brain cells and genes related to synaptic function are expressed in the blood, offering a window into gene expression. "Brain tissue from people with autism is not readily available for study, and some people are reluctant to use non-neural tissue in psychiatric disease," explained Geschwind. "But our study demonstrates that even peripheral blood can expand our knowledge of neurological disease." The team's next step will be to replicate their findings in a larger population. ### Autism is a complex brain disorder that strikes in early childhood. The condition disrupts a child's ability to communicate and develop social relationships and is often accompanied by acute behavioral challenges. Autism spectrum disorders are diagnosed in one in 110 children in the United States, affecting four times as many boys as girls. Diagnoses have expanded tenfold in the last decade. The research was supported by grants from the Simons Foundation, the National Institute of Mental Health (5R01 MH081754-04), the Wellcome Trust and Autism Speaks. Geschwind's coauthors included first author Rui Luo, Irina Voineagu, Lambertus Klei, Chaochao Cai, Jing Ou, Jennifer Lowe and Matthew State of UCLA; Stephan Sanders of Yale University; Ni Huang and Matthew Hurles of the Wellcome Trust Sanger Institute; and Su Chu and Bernie Devlin of Carnegie Mellon University. The UCLA Center for Autism Research and Treatment provides diagnosis, family counseling, clinical trials and treatment for patients with autism. UCLA is one of eight centers in the National Institutes of Health–funded Studies to Advance Autism Research and Treatment network and one of 10 original Collaborative Programs for Excellence in Autism social worker ceus

Adaptable decision making in the brain

Front-most part of the cortex involved in making short-term predictions about what will happen next Researchers at the University of Iowa, together with colleagues from the California Institute of Technology and New York University, have discovered how a part of the brain helps predict future events from past experiences. The work sheds light on the function of the front-most part of the frontal lobe, known as the frontopolar cortex, an area of the cortex uniquely well developed in humans in comparison with apes and other primates. Making the best possible decisions in a changing and unpredictable environment is an enormous challenge. Not only does it require learning from past experience, but it also demands anticipating what might happen under previously unencountered circumstances. Past research from the UI Department of Neurology was among the first to show that damage to certain parts of the frontal lobe can cause severe deficits in decision making in rapidly changing environments. The new study from the same department on a rare group of patients with damage to the very frontal part of their brains reveals a critical aspect of how this area contributes to decision making. The findings were published June 19 in the Journal of Neuroscience. "We gave the patients four slot machines from which to pick in order to win money. Unbeknownst to the patients, the probability of getting money from a particular slot machine gradually and unpredictably changed during the experiment. Finding the strategy that pays the most in the long run is a surprisingly difficult problem to solve, and one we hypothesized would require the frontopolar cortex," explains Christopher Kovach, Ph.D., a UI post-doctoral fellow in neurosurgery and first author of the study. Contrary to the authors' initial expectation, the patients actually did quite well on the task, winning as much money, on average, as healthy control participants. "But when we compared their behavior to that of subjects with intact frontal lobe, we found they used a different set of assumptions about how the payoffs changed over time," Kovach says. "Both groups based their decisions on how much they had recently won from each slot machine, but healthy comparison subjects pursued a more elaborate strategy, which involved predicting the direction that payoffs were moving based on recent trends. This points towards a specific role for the frontopolar cortex in extrapolating recent trends." Kovach's colleague and study author Ralph Adolphs, Ph.D., professor of neuroscience and psychology at the California Institute of Technology, adds that the study results "argue that the frontopolar cortex helps us to make short-term predictions about what will happen next, a strategy particularly useful in environments that change rapidly -- such as the stock market or most social settings." Adolphs also hold an adjunct appointment in the UI Department of Neurology. The study's innovative approach to understanding the function of this part of the brain uses model-based analyses of behavior of patients with specific and precisely characterized areas of brain damage. These patients are members of the UI's world-renowned Iowa Neurological Patient Registry, which was established in 1982 and has more than 500 active members with selective forms of damage, or lesions, to one or two defined regions in the brain. "The University of Iowa is one of the few places in the world where you could carry out this kind of study, since it requires carefully assessed patients with damage to specific parts of their brain," says study author Daniel Tranel, Ph.D., UI professor of neurology and psychology and director of the UI Division of Behavioral Neurology and Cognitive Neuroscience. In a final twist to the finding, the strategy taken by lesion patients was actually slightly better than the one used by comparison subjects. It happened that the task was designed so that the trends in the payoffs were, in fact, random and uninformative. "The healthy comparison subjects seemed to perceive trends in what was just random noise," Kovach says. This implies that the functions of the frontopolar cortex, which support more complex and detailed models of the environment, at times come with a downside: setting up mistaken assumptions. "To the best of my knowledge this is the first study which links a normal tendency to see a nonexistent pattern in random noise, a type of cognitive bias, to a particular brain region," Kovach notes. The researchers next want to investigate other parts of the frontal cortex in the brain, and have also begun to record activity directly from the brains of neurosurgical patients to see how single cells respond while making decisions. The work is also important to understand difficulties in decision making seen in disorders such as addiction. ### The study, "Anterior prefrontal cortex contributes to action selection through tracking of recent reward trends," also included authors David Rudrauf from the University of Iowa, John O'Doherty from the California Institute of Technology, and Nathaniel Daw from New York University. The research was funded in part by grants from the National Institute of Neurological Disorders and Stroke (Grant P50 NS19632), the National Institute on Drug Abuse (Grant DA022549), the National Institute of Mental Health (Grant MH080721) and the Tamagawa University Global Centers of Excellence Program of the Japanese Ministry of Education, Culture, Sports, and Technology CADC I & II Continuing Education

Survey Finds More Evidence That Mental Disorders Often Begin in Youth

About 8 percent of U.S. teens meet current criteria for having a serious emotional disturbance, according to two NIMH-funded studies published in the April 2012 issue of the Archives of General Psychiatry. Background A September 2010 study using data from the NIMH-funded National Comorbidity Survey-Adolescent Supplement (NCS-A) found that about 20 percent of youth are affected by a mental disorder sometime in their lifetime. The NCS-A is a nationally representative, face-to-face survey of more than 10,000 teens ages 13 to 18. Parents or caregivers were also asked to complete a corroborating questionnaire after teens were interviewed. The NCS-A used criteria established by the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV) to assess for a wide range of mental disorders including mood and anxiety disorders, behavior disorders like attention deficit hyperactivity disorder (ADHD), eating disorders, and substance use disorders. In this most recent analysis, Kathleen Merikangas, Ph.D., of NIMH, Ron Kessler, Ph.D., of Harvard University, and colleagues examined the prevalence of mental disorders, as well as the severity of the disorders, within a 12-month period to estimate the rate of serious emotional disturbances (SED) in youth. SED was defined by the Substance Abuse and Mental Health Administration (SAMHSA) as a “mental, behavioral, or emotional disorder … that resulted in functional impairment which substantially interferes with or limits the child’s role or functioning in family, school, or community activities.” Results of the Study The researchers found that about 8 percent of all respondents had SED. Those with behavior disorders were most likely to be considered to have a severe disorder. Those with three or more coexisting disorders were also more likely to be severely affected. Similar to adults, anxiety disorders were the most common conditions in adolescents. Echoing many other studies, girls were more likely to have a mood or anxiety disorder or eating disorder, while boys were more likely to have a behavior disorder like ADHD or substance use disorder. Contrary to regional studies, this report showed a lower rate of depression among Hispanics compared to whites. Significance The findings in this study reflect the widely held belief that most psychiatric disorders first manifest in childhood or adolescence and tend to persist or recur throughout a person’s life. The researchers conclude that the high prevalence rate of mental disorders in U.S. adolescents underscores the need for more research focused on changing the trajectory of mental disorders in youth. What’s Next More research is needed to better understand the differences in prevalence rates among cultural and ethnic groups in different regions of the country ceus for nurses Citations Kessler R, Avenevoli S, Costello J, Georgiades K, Green JG, Gruber M, He J, Koretz D, McLaughlin K, Petukhova M, Sampson N, Zaslavsky A, Merikangas K. Prevalence, persistence and Sociodemographic correlates of DSM-IV disorders in the National Comorbidity Survey Replication Adolescent Supplement. Archives of General Psychiatry. April 2012; 69(4):372-380. Kessler R, Avenevoli S, Costello J, Green JG, Gruber M, McLaughlin K, Petukhova M, Sampson N, Zaslavsky A, Merikangas K. Severity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication Adolescent Supplement. Archives of General Psychiatry. April 2012; 69(4):381-389.

Marital problems in childhood affect teen adjustment

Marital discord is a significant social problem for children, sometimes leading to problems in health and well-being. A new longitudinal study finds that the impact of marital problems on children in their kindergarten years is long lasting and can lead to emotional problems that contribute to difficulties in adolescence. The study, by researchers at the University of Notre Dame and the University of Rochester, appears in the journal Child Development ceus for social workers "The results further highlight the possibility that there will be persistent negative effects of children's early experiences when there is conflict between their parents, at least when their emotional insecurity increases as a result of the conflict," according to E. Mark Cummings, professor and Notre Dame Endowed Chair in Psychology at the University of Notre Dame, the study's lead author. "This study has important implications for clinicians and parents," he added. Cummings and his colleagues examined 235 primarily middle-class mothers, fathers, and children over seven years, focusing on the links between marital conflict when the children were in kindergarten, children's emotional insecurity in the early school years, and subsequent problems when the children were teens. Children's emotional security about family ties is related to their sense of protection, safety, and security, and has implications for how they do socially and emotionally. The researchers observed parents discussing a topic they had identified as hard to handle, rating specific conflict behaviors. They also asked parents to report on their conflicts. The study found that conflict between parents when their children are young predicted children's emotional insecurity later in childhood, which, in turn, predicted adjustment problems in adolescence, including depression and anxiety. "Emotional insecurity appears to be an explanation for the effects of marital conflict on children's later problems," Cummings explained. "This mechanism lasts across relatively long periods of time and across the transition between childhood and adolescence." ###