Couple’s Therapy Appears to Decrease PTSD Symptoms, Improve Relationship

CHICAGO – Among couples in which one partner was diagnosed as having posttraumatic stress disorder (PTSD), participation in disorder-specific couple therapy resulted in decreased PTSD symptom severity and increased patient relationship satisfaction, compared with couples who were placed on a wait list for the therapy, according to a study in the August 15 issue of JAMA, a theme issue on violence and human rights. “There are well-documented associations between PTSD and intimate relationship problems, including relationship distress and aggression, and studies demonstrate that the presence of PTSD symptoms in one partner is associated with caregiver burden and psychological distress in the other partner. Although currently available individual psychotherapies for PTSD produce overall improvements in psychosocial functioning, these improvements are not specifically found in intimate relationship functioning. Moreover, it has been shown that even when patients receive state-of-the-art individual psychotherapy for the disorder, negative interpersonal relations predict worse treatment outcomes,” according to background information in the article. Candice M. Monson, Ph.D., of Ryerson University, Toronto, Canada, and colleagues conducted a study to examine the effect of a cognitive-behavioral conjoint therapy (CBCT) for PTSD, designed to treat PTSD and its symptoms and enhance intimate relationships in couples. The randomized controlled trial, conducted from 2008 to 2012, included heterosexual and same-sex couples (n = 40 couples; n = 80 individuals) in which one partner met criteria for PTSD according to the Clinician-Administered PTSD Scale. Symptoms of PTSD, co-existing conditions, and relationship satisfaction were collected by assessors at the beginning of the study, at mid treatment (median [midpoint], 8 weeks after baseline), and at post-treatment (median, 16 weeks after baseline). An uncontrolled 3-month follow-up was also completed. Couples were randomly assigned to take part in the 15-session cognitive-behavioral conjoint therapy for PTSD protocol immediately (n = 20) or were placed on a wait list for the therapy (n = 20). Clinician-rated PTSD symptom severity was the primary outcome; intimate relationship satisfaction, patient- and partner-rated PTSD symptoms, and co-existing symptoms were secondary outcomes. The researchers found that PTSD symptom severity and patients’ intimate relationship satisfaction were significantly more improved in couple therapy than in the wait-list condition. Also, change ratios (calculated by dividing the change in the CBCT condition from pretreatment to post-treatment by the change in the wait-list condition over this period) indicated that PTSD symptom severity decreased almost 3 times more in CBCT from pretreatment to post-treatment compared with the wait list; and patient-reported relationship satisfaction increased more than 4 times more in CBCT compared with the wait list. The secondary outcomes of depression, general anxiety, and anger expression symptoms also improved more in CBCT relative to the wait list. Treatment effects were maintained at 3-month follow-up. “This randomized controlled trial provides evidence for the efficacy of a couple therapy for the treatment of PTSD and comorbid symptoms, as well as enhancements in intimate relationship satisfaction. These improvements occurred in a sample of couples in which the patients varied with regard to sex, type of trauma experienced, and sexual orientation. The treatment effect size estimates found for PTSD and comorbid symptoms were comparable with or better than effects found for individual psychotherapies for PTSD. In addition, patients reported enhancements in relationship satisfaction consistent with or better than prior trials of couple therapy with distressed couples and stronger than those found for interventions designed to enhance relationship functioning in nondistressed couples,” the authors write. “Cognitive-behavioral conjoint therapy may be used to efficiently address individual and relational dimensions of traumatization and might be indicated for individuals with PTSD who have stable relationships and partners willing to engage in treatment with them.” (JAMA. 2012;308[7]:700-709. Available pre-embargo to the media at http://media.jamanetwork.com) Editor’s Note: This study was supported by a National Institute of Mental Health grant to Dr. Monson. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc. Editorial: Expanding the Boundaries of PTSD Treatment Lisa M. Najavits, Ph.D., of the Veterans Affairs Boston Healthcare System and Boston University School of Medicine, comments in an accompanying editorial on the 2 studies in this issue of JAMA on treating PTSD. “The results of the trials by Mills at al and Monson et al are important scientific attempts to study new options for treatment of PTSD. Overall, comparative studies of PTSD therapies find that they rarely outperform each other in efficacy. Thus, the cost and appeal of treatments to clinicians and patients, their intensity of intervention, and clinical setting and training issues may ultimately be as or more relevant than comparative efficacy in choosing a course of treatment for PTSD. In the current era, there is a focus on short-term treatments (in part an antidote to the overly long psychotherapies of much of the 20th century). However, it is not clear how long treatment needs to be maintained to produce enduring positive outcomes, especially for patients with PTSD and comorbidities and difficult social circumstances. The field of PTSD therapy is still young, and the pursuit of clinically meaningful treatments for all types of patients, like the process of recovery for patients with PTSD, is an ongoing challenge.” (JAMA. 2012;308[7]:714-716. Available pre-embargo to the media at http://media.jamanetwork.com) Editor’s Note: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of interest and reported receiving royalties from Guilford Press and New Harbinger Press and that she is director of Treatment Innovations, which provides consultation, training, and materials related to psychotherapy lcsw ceus # # #

Air Force Suicide Prevention Program Reduces Suicide Rate

U.S. Air Force Photo/ Staff Sgt. Angelita M. LawrenceA U.S. Air Force suicide prevention program is associated with reduced suicide rates among Air Force personnel during times in which the program was rigorously implemented and monitored, according to an NIMH-funded study published online ahead of print May 13, 2010, in the American Journal of Public Health. LCSW CEUs
Background
The Air Force Suicide Prevention Program (AFSPP) was implemented in 1997. Based on the premise that individuals at risk for suicide exhibit early warning signs, AFSPP emphasizes leadership and community involvement in reducing suicide by encouraging Air Force leaders to actively support and get involved with suicide prevention efforts. It trains commanders in how and when to seek out mental health services for their troops, provides training to all military and civilian personnel in suicide prevention, and incorporates other community-based components.

Kerry Knox, Ph.D., of the University of Rochester Medical Center, and colleagues studied the impact of AFSPP in reducing suicide among Air Force personnel from 1997 until 2008. They examined suicide rates from 1981 to 2008 to provide historical context during three military conflicts, and a downsizing of the Air Force that occurred in the 1990s.

Results of the Study
The researchers found that suicide rates were significantly lower after the program was launched than before—an average of two suicides per 100,000 per quarter occurred during the intervention period compared to three suicides per 100,000 per quarter prior to the intervention rollout. During the third quarter of 2004, however, suicide rates increased. Knox and colleagues suggest that the upward spike may have been the result of a diminished implementation of ASFPP due to increased demands from the two ongoing wars in Iraq and Afghanistan. In response, Air Force leadership took steps to strengthen implementation of the program and ensure compliance of its components, according to the authors.

Significance
The results suggest that the program is effective but its success is contingent on continuous implementation efforts and ongoing monitoring. The program cannot be maintained by "inherent momentum," the authors concluded.

What's Next
The authors suggest that the program, if maintained and monitored for compliance, can continue to keep suicide rates low in the Air Force. They also suggest that the program could be implemented in other communities and organizations to prevent suicide and reduce the stigma associated with the mental and psychosocial problems that often precipitate suicide attempts.

Reference
Knox K, Pflanz S, Talcott GW, Campise RL, Lavigne JE, Bajorska A, Tu X, Caine ED. The US Air Force Suicide Prevention Program: Implications for Public Health Policy. American Journal of Public Health. Online ahead of print May 13, 2010.

New Food-Addiction Link Found

Mere sight/smell of food spikes levels of brain “pleasure” chemical
UPTON, NY — Scientists at the U.S. Department of Energy’s Brookhaven National Laboratory have found that the mere display of food — where food-deprived subjects are allowed to smell and taste their favorite foods without actually eating them — causes a significant elevation in brain dopamine, a neurotransmitter associated with feelings of pleasure and reward. This activation of the brain’s dopamine motivation circuits is distinct from the role the brain chemical plays when people actually eat, and may be similar to what addicts experience when craving drugs. LCSW CEUs
“Eating is a highly reinforcing behavior, just like taking illicit drugs,” said psychiatrist Nora Volkow, the study’s lead investigator. “But this is the first time anyone has shown that the dopamine system can be triggered by food when there is no pleasure associated with it since the subjects don’t eat the food. This provides us with new clues about the mechanisms that lead people to eat other than just for the pleasure of eating, and in this respect may help us understand why some people overeat.” The study will appear in the June 1, 2002 issue of Synapse (now available online ).

Brookhaven scientists have done extensive research showing that addictive drugs increase the levels of dopamine in the brain, and that addicts have fewer dopamine receptors than non-addicts. Last year, in an effort to understand the relationship of the dopamine system to obesity, they found that obese individuals also had fewer dopamine receptors than normal control subjects.

In the new study, the scientists investigated the role of dopamine in food intake in healthy, non-obese individuals. The researchers used positron emission tomography (PET), a brain-scanning technique, to measure dopamine levels in 10 food-deprived volunteers. Each volunteer was given an injection containing a radiotracer, a radioactive chemical “tag” designed to bind to dopamine receptors in the brain. The PET camera picks up the radioactive signal to measure the level of tracer. Since the tracer competes with dopamine for binding to the receptor, the amount of bound tracer can be used to infer the concentration of dopamine (more bound tracer = less dopamine).


These brain scans can be used to infer brain dopamine levels in the four experimental conditions (with and without food stimulation, paired with and without an oral dose of Ritalin). Note that the tracer signal in the Ritalin + food scan is significantly lower than the others. This is because the radiotracer competes with natural brain dopamine for binding to the receptor. When there is a lot of tracer bound (the first three conditions), it means there is not as much natural brain dopamine. When there is little tracer bound (as in the Ritalin + food scan), there is more natural brain dopamine occupying the receptor sites. So, it is an inverse relationship (a low tracer signal = a high dopamine level). Hi-res image (300 dpi jpeg).



Study subjects’ brains were scanned four times over a two-day period, with and without food stimulation, paired with and without an oral dose of methylphenidate. Methylphenidate (Ritalin) is known to block the reabsorption of dopamine into nerve cells. The researchers wanted to see if it would amplify any subtle changes in dopamine levels.

For food stimulation, the volunteers were presented with foods they had previously reported as their favorites. The food was warmed to enhance the smell and the subjects were allowed to view and smell it, as well as taste a small portion placed on their tongues with a cotton swab. As a control, during scans when food stimulation was not used, subjects were asked to describe in as much detail as possible their family genealogy. Study participants were also instructed to describe, on a scale of 1 to 10, whether they felt hungry or desired food prior to food stimulation and then at five-minute intervals for a total of 40 minutes.

The researchers found that food stimulation in combination with oral methylphenidate produced a significant increase in extracellular dopamine in the dorsal striatum. There was also a correlation between the increase in dopamine triggered by food stimulation and methylphenidate and the changes in self-reports of ‘hunger’ and ‘desire for food.’ “This suggests the dopamine increases during the food/methylphenidate condition reflect the responses to food stimulation and not the isolated effects of methylphenidate,” Volkow said.

The study demonstrates that methylphenidate, when used at low doses, amplifies weak dopamine signals. It also shows, for the first time, that the dopamine system in the dorsal striatum plays a role in food motivation in the human brain.

This relationship was not observed in the ventral striatum, which includes the nucleus accumbens, the area of the brain thought to be responsible for food reward. “We and others previously thought the nucleus accumbens was the primary brain region associated with regulating food intake by modulating reward and pleasure while eating,” said study coauthor Gene-Jack Wang. “These findings challenge that belief.”

This study was funded by the U.S. Department of Energy, which supports basic research in a variety of scientific fields, and the National Institute on Drug Abuse.

Faith, Spirituality & Mental Illness CEUs

Evidence is growing of the value that faith-based organizations offer to people with mental illnesses.

Faith-based communities often contribute to recovery by promoting hope and by offering solace and comfort in troubled times; and many consumers acknowledge the positive impact of spirituality and faith on their recovery and ability to cope with life's stresses.

However, not all faith-based organizations are equally knowledgeable about how best to serve people with mental health disorders.

The information available on this Web page can help faith-based communities - both clergy and congregants - increase their awareness of mental health issues and find ways to welcome and support people with mental illnesses, thus reducing discrimination and increasing social inclusion.

1 in 4 households in your church is afraid to tell you this secret
By Carlene Hill Byron

How many families in your church have a loved one who struggles with mental health problems? That’s kind of a trick question. People don’t talk about mental health problems. You’re more likely to hear
them describe their child’s condition as “something like autism,” as the elder of one church we know says. Or they might cover up entirely, as does an elder’s wife in another congregation. When her bipolar disorder swung into mania after childbirth, her family, already managing the added responsibilities of a newborn, had
to manage her condition as well. But because her condition is a secret, they did so without any support beyond the usual “new baby” dinners. The answer to the question is, if your congregation is representative of the U.S. population, one in four
households will struggle with someone’s mental health problems over their lifetime. That’s schizophrenia, bipolar disorder, obsessive compulsive disorder, disabling chronic depression,and various anxiety disorders. Look at the faces seated around you this Sunday. Someone is probably hurting. And they’re probably afraid to tell you.

The least acceptable disability
A study where people ranked disabilities by their “acceptability” returned these results, in order--most acceptable: obvious physical disabilities, blindness, deafness, a jail record, learning disabilities, and alcoholism. Least acceptable: mental health problems. People with mental health problems frighten us because when people become mentally ill, they become someone we don’t know. A bright boy who was his family’s bright hope may find he just can’t cut it anymore as schizophrenia turns him paranoid, disoriented, unmotivated in the extreme, and overwhelmed by
delusional voices that tell him, over and over, how worthless he is. Or, in the case of bipolar disorder, a girl who was a well-liked and active member of her Teen Challenge group may suddenly turn promiscuous, run away from home, and make a new home in the streets of a strange city. Laziness. Promiscuity. Violence. Sin.
That’s what many people see when they look at those with mental health problems. It’s hard to believe that people may behave in such unacceptable ways and not be in control of their behavior. Having a mental health problem is a lot like being on alcohol or drugs, without being able to stop. Medications “work” for
about two-thirds of us. That means that a third of us can’t ever get off the chemical ride that our brains produce. For those of us who can use medications, the side effects can be daunting. Many people become so frustrated with side effects that they stop taking medications. Only about half of us
accept treatment. Even when we are treated, not everyone regains their status as a fully functioning adult.

The challenging good news is that when people with mental illness turn to someone outside “the system” for help, the church is first to get the call 40 percent of the time. Is your church ready?
MFT CEUs, LCSW CEUs
Carlene Hill Byron is the former Director of Communications for Vision New England. Through NAMI—the Nation’s Voice on Mental Illness, she and her husband, James, train churches to effectively serve people within the congregation with mental health problems and also teach NAMI’s class for families of people
with mental health problems. They are members of Asbury United Methodist Church in Raleigh, North Carolina, where James serves on staff.
First published by Vision New England’s Ministries with the Disabled, Acton, Massachusetts.

MFT Continuing Education, LCSW Continuing Education, LPC Continuing Education

Alabama
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Alaska
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW) and Marriage and Family Therapists (MFT, LMFT)
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)

Arizona
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Arkansas
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)
No CE Provider status approval required for CE credit for licensed Social Workers (LCSW, LSW)

California
Approved by the California Board of Behavioral Sciences for licensed Marriage and Family Therapists (MFT, LMFT), Marriage and Family Therapist Interns/Trainee (MFTI), Licensed Clinical Social Workers (LCSW) and Associate Clinical Social Workers (ASW).
Approved by the California Certification Board of Alcohol and Drug Counselors for licensed Drug and Alcohol Abuse Counselors (CADC I & II, CPS, CSS, CADCA)

Colorado
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Connecticut
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Delaware
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Mental Health Counselors (MHC)
Meets qualifications in Rule 7.2.5 for licensed Social Workers (LCSW, LSW) (check with state board for further clarification)

Florida
Approved by the Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)

Georgia
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Hawaii
No continuing education requirements for license renewal for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Idaho
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Not approved for licensed Social Workers (LCSW, LSW)

Illinois
Not pre-approved for licensed Marriage and Family Therapists (MFT, LMFT) and Social Workers (LCSW, LSW) (check with state board for CE requirements)
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)

Indiana
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Iowa
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)
Meets requirements stated in Rule 645-281.3 standards of the Iowa Administrative Rules (see state board for further clarification) for licensed Social Workers (LCSW, LSW)

Kansas
No CE Provider status approval required for CE credit for licensed Social Workers (LCSW, LSW), Marriage and Family Therapist and Mental Health Counselors (MHC)

Kentucky
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW)
Check state board for approval requirements for licensed Marriage and Family Therapists (MFT, LMFT)

Louisiana
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)
Check state board for approval requirements for licensed Marriage and Family Therapists (MFT, LMFT)

Maine
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Check state board for approval requirements for licensed Social Workers (LCSW, LSW)

Maryland
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Check state board for approval requirements for licensed Social Workers (LCSW, LSW)

Massachusetts
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Mental Health Counselors (MHC)
Check state board for approval requirements for licensed Marriage and Family Therapists (MFT, LMFT)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Michigan
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)
No continuing education requirements for license renewal for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Minnesota
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
No CE Provider status approval required for CE credit for licensed Social Workers (LCSW, LSW)
Check with board for approval requirements for licensed Marriage and Family Therapists (MFT, LMFT)

Mississippi
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
Not pre-approved for licensed Marriage and Family Therapists (MFT, LMFT) and Social Workers (LCSW, LSW) (check with state board for CE requirements)

Missouri
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Montana
Approved by the Montana Board of Social Work Examiners, Professional Counselors & Marriage and Family Therapists for licensed Social Workers (LCSW, LSW), Professional Counselors (LPC, LPCC), and licensed Marriage and Family Therapists (MFT, LMFT)

Nebraska
Meets criteria of an approved continuing education program provider for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Nevada
No CE Provider status approval required for CE credit for licensed Marriage and Family Therapist and Professional Counselors (LPC, LPCC)
Not pre-approved for licensed Social Workers (LCSW, LSW) (check with state board for CE requirements)

New Hampshire
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)

New Jersey
Accepts approval from the National Board for Certified Counselors (NBCC) for Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Not approved for Licensed Social Workers (LCSW, LSW)


New Mexico
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
No CE Provider status approval required for CE credit for licensed Social Workers (LCSW, LSW)

New York
No continuing education requirements for license renewal for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

North Carolina
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
No CE Provider status approval required for CE credit for licensed Marriage and Family Therapists (MFT, LMFT)
Not approved for licensed Social Workers (LCSW, LSW)

North Dakota
No CE Provider status approval required for CE credit for licensed Marriage and Family Therapist and Professional Counselors (LPC, LPCC)
Not pre-approved for licensed Social Workers (LCSW, LSW) (check with state board for CE requirements)

Ohio
Approved by the Counselor, Social Worker and Marriage and Family Therapist Board of Ohio for licensed Marriage and Family Therapists (MFT, LMFT)
Approved by the Counselor, Social Worker and Marriage and Family Therapist Board of Ohio for licensed Mental Health Counselors (MHC)
Not approved for licensed Social Workers (LCSW, LSW)

Oklahoma
Approved by the Oklahoma State Department of Health - Professional Counselor Licensing Board for licensed Marriage and Family Therapists (MFT, LMFT) and Licensed Professional Counselors (LPC)
Not approved for licensed Social Workers (LCSW, LSW)

Oregon
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Pennsylvania
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Rhode Island
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)
Not approved for licensed Social Workers (LCSW, LSW)

South Carolina
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

South Dakota
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Tennessee
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Meets requirements stated in Rule 1365-01-.09 for CE credit for licensed Social Workers (LCSW, LSW) (see state board for further clarification)

Texas
Approved by the Texas Board of Examiners of Marriage and Family Therapists (MFT, LMFT) for licensed Marriage and Family Therapists (MFT, LMFT)
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Utah
Meets requirements stated in rule R156-60b-304 for licensed Marriage and Family Therapists (MFT, LMFT) (see state board for further clarification on CE requirements)
Meets requirements stated in rule R156-60c-304 for licensed Professional Counselors (LPC, LPCC) (see state board for further clarification on CE requirements)
Not pre-approved for licensed Social Workers (LCSW, LSW) (see state board for further clarification on CE requirements)

Vermont
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)
Meets requirements stated in rule 3.3 Formal Activities (2), 3.4(2)(3) for licensed Social Workers (LCSW, LSW) (see state board for further clarification on CE requirements)

Virginia
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)
Accepts approval from the California Board of Behavioral Sciences (CA BBS) for licensed Social Workers (LCSW, LSW)

Washington
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Mental Health Counselors (MHC)

West Virginia
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Professional Counselors (LPC, LPCC)
Not pre-approved for licensed Marriage and Family Therapists (MFT, LMFT) (check with state board for CE requirements)
No CE Provider status approval required for Category II (Individual Professional Activities) CE credit for licensed Social Workers (LCSW, LSW)

Wisconsin
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Social Workers (LCSW, LSW), Marriage and Family Therapists (MFT, LMFT) and Professional Counselors (LPC, LPCC)

Wyoming
Accepts approval from the National Board for Certified Counselors (NBCC) for licensed Mental Health Counselors (MHC)
Not pre-approved for licensed Marriage and Family Therapists (MFT, LMFT) and Social Workers (LCSW, LSW) (check with state board for CE requirements)


MFT Continuing Education

LCSW Continuing Education

LPC Continuing Education Units, Credits, Hours

Drug and Alchohol Counselor Continuing Education CEUs

HIPAA

HIPAA
Many Americans have had some personal experience with the Federal Government's Health Insurance Portability and Accountability Act (HIPAA). To ensure privacy, for example, they may have been asked to stand farther away from a customer in line to pick up prescriptions at the pharmacy counter. Or, they've been asked by their physician's office staff to read a "Notice of Privacy Practices" and to sign an acknowledgment of receipt of that information.

"While these may be small day-to-day changes, they reflect larger changes taking place behind the scenes that will benefit everyone," says Sarah A. Wattenberg, L.C.S.W.-C, a public health advisor at SAMHSA's Center for Substance Abuse Treatment (CSAT) and the SAMHSA HIPAA Coordinator.

HIPAA can be complex at times, but the U.S. Department of Health and Human Services (HHS) is working hard to develop resources that can help people better understand the requirements, and SAMHSA is contributing to these efforts.

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Streamlining the System
HIPAA was born out of frustration with the inefficiency—and spiraling costs—of the Nation's health care system. As a result of the Act, passed in 1996, HHS was required to create regulations for the electronic exchange of certain kinds of health information and for the security and privacy of that information. Some of the regulations, promulgated over several years, include the following:

Standards for Electronic Transactions and Code Sets Rule and its Modifications Rule, which had a compliance date of October 16, 2002 (the Administrative Simplification Compliance Act extended this rule for an additional year if covered entities submitted HIPAA compliance plans).
Privacy Rule and its Modifications Rule, with a compliance date of April 14, 2003.
Employer Identifier Rule, with a compliance date of July 30, 2004.
Security Rule, with a compliance date of April 21, 2005. (The additional year for small health plans for Transactions and Code Sets and its Modifications ended October 16, 2003.)
Three types of "covered entities" are subject to HIPAA: health plans, health care clearinghouses that health care providers
and plans can use to process and submit their transaction data in a HIPAA-approved manner, and health care providers who electronically exchange health information for which HIPAA has adopted a particular standard. Covered entities must comply with all HIPAA standards, not just one or two.

In addition, business associates of covered entities who have contact with a patient's health information are required
to sign contracts agreeing to protect that information. Business associates could include an attorney reviewing a patient's file, or an organization that collects information to evaluate patient care, among others.

What kind of information does HIPAA cover? HIPAA protects any patient information that is created or received by a covered entity and that identifies the individual or could be used to identify an individual, whether the information is in oral, written, or electronic format.

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Electronic Transactions Standards
Until now, every health care organization had its own codes
for billing and other types of transactions. The result was babel, with health insurers and providers unable to use the same language to "talk to each other." To create a common language, HIPAA's electronic transaction regulations require covered entities to use a standardized content and format when transmitting certain health care information electronically. Standards have been adopted so far for the exchange of information related to plan eligibility, health plan enrollment and disenrollment, premium payments, referral certification and authorization, claims and encounter information, claim status, payment and remittance advice, and benefit coordination.

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A National Code
Standard code sets for diagnosis and treatment have not existed up to this point. States have typically used "home-grown" codes for treatment procedures. Now, HIPAA requires that national, uniform codes be used. Certain code sets have been adopted by the HHS Secretary as national standards: the International Classification of Diseases, 9th Edition, Clinical Modification (Volumes 1, 2, and 3); the Current Procedural Terminology; the Centers for Medicare & Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS); the Code on Dental Procedures and Nomenclature; and the National Drug Codes.

Unfortunately, says Ronald W. Manderscheid, Ph.D., Chief of the Survey and Analysis Branch of the Division of State and Communities Systems Development within SAMHSA's Center for Mental Health Services (CMHS), these code sets did not originally include codes for many of the services offered by mental health and substance abuse treatment providers.

For the past 2 years, CSAT, the CMHS Decision Support 2000+ Initiative, and other groups worked to solve the problem by creating a more complete code set for behavioral health services and proposing them for inclusion into the CMS HCPCS code set. The large majority of these codes were adopted by the CMS and are now posted on the CMS Web site.

Also, while some providers may be able to adapt existing systems to comply with HIPAA's electronic transactions provision, most will need outside help, Dr. Manderscheid says. Providers can use health care clearinghouses to translate their transaction data into acceptable formats or purchase software to do the job.

Either way, Dr. Manderscheid's advice is the same: caveat emptor (buyer beware). "The burden of proof concerning the accuracy of the data ultimately lies with the provider or plan," he explains. Providers who go the software route should consult SAMHSA's handbooks for each of the eight electronic transactions to ensure that they're meeting the standards. (See "Resources")

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Protecting Privacy
"Before HIPAA, patients were very concerned about how the general health care system was handling information about them," says Ms. Wattenberg. "In fact, in 1999, the California HealthCare Foundation conducted a survey and found that one out of seven Americans reported evasive actions to avoid inappropriate use of their health care information. For example, someone wouldn't tell the truth to their primary care physician about a chronic physical condition for fear the information might get back to their employer," says Ms. Wattenberg. "That's a pretty upsetting statistic. It means that patients may not be giving their doctors important health information that's needed for appropriate and effective treatment," she added.


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Before HIPAA, patients were very concerned about how the general health care system was handling information about them.

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For this reason, HIPAA requires that covered entities obtain authorization from patients before they use or disclose information. This applies unless otherwise allowed by the Privacy Rule, such as, for example, information can be shared without authorization for treatment (so that your physician can discuss your x-rays with another provider, like a radiologist); for payment (e.g., so that information can be used to process claims); or for operations (e.g., so that information can be used or disclosed to oversee the quality of the health care you are receiving).

Among other requirements, covered entities also need to establish privacy policies, put privacy safeguards in place, train staff, designate a privacy officer, and establish a grievance process.

Consumers of health care services also have new rights under HIPAA and they need to be informed of these rights. For example, patients can review their medical records, make a copy of the records, and request changes.


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While some providers may be able to adapt existing systems to comply with HIPAA's electronic transactions provision, most will need outside help.

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"Mental health and substance abuse treatment providers should not have a hard time complying with HIPAA's privacy rule," says Ms. Wattenberg. "For mental health providers, state laws and professional ethics have always dictated high standards for protecting the sensitive information treatment providers create or receive about their clients."

"For substance abuse providers, most treatment programs have been required for decades to comply with the Federal Confidentiality of Alcohol and Drug Abuse Patient Records regulation, 42 C.F.R. Part 2," says senior program management officer Captain Ann G. Mahony, M.P.H., of CSAT's Division of Systems Improvement. "Covered entities should read both laws together," she advises. When HIPAA conflicts with the "Part 2" regulations or with state laws, the more stringent rule applies.

Patients will enjoy even more protection when HIPAA's security standard goes into effect. The standard will require covered entities to assign a security officer who will be responsible for conducting risk assessments and other measures to assure the integrity, confidentiality, and availability of identifiable health information that covered entities store, maintain, or transmit

National Strategy for Suicide Prevention

National Strategy for Suicide Prevention:
Goals and Objectives for Action

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Preface from the Surgeon General:
Suicide exacts an enormous toll from the American people. Our Nation loses 30,000 lives to this tragedy each year, another 650,000 receive emergency care after attempting to take their own lives. The devastating trauma, loss, and suffering is multiplied in the lives of family members and friends. This document, National Strategy for Suicide Prevention – Goals and Objectives for Action, lays the foundation of our Nation's strategy to confront this serious public health problem.

At this document's source are countless dedicated individuals representing every facet of our Nation's communities. They include representatives to a 1993 United Nations/World Health Organization Conference who played key roles in establishing guidelines for national suicide prevention strategies. They include the passionate grassroots activists whose work stimulated Congressional Resolutions declaring suicide prevention a national priority and calling for our own national strategy. They include dedicated public servants and private individuals who jointly organized and participated in the first National Suicide Prevention Conference in 1998 to consolidate a scientific base for this critical endeavor. These people and their efforts led directly to publication of the Surgeon General's Call to Action to Prevent Suicide - 1999 with its most important recommendation, the completion of the National Strategy for Suicide Prevention.

After listening to the concerns of the American people, Government leaders helped bring stakeholders together in a shining example of public- private collaboration to achieve this major milestone in public health. Those who have invested their hearts and minds in this effort believe it effectively points the way for organizations and individuals to curtail the tragedy of suicide and suicidal behavior. Though it does not specify all the details, it provides essential guidance and suggests the fundamental activities that must follow–activities based on the best available science.

Nearly half of the States are engaged in suicide prevention and many have already committed significant resources to implement programs. Their leadership in evaluating the effectiveness of these programs will help guide the efforts of States that follow in their paths. Most of these plans recognize that much of the work of suicide prevention must occur at the community level, where human relationships breathe life into public policy. American communities are also home to scores of faith-based and secular initiatives that help reduce risk factors and promote protective factors associated with many of our most pressing social problems, including suicide.

As you read further, keep in mind that the National Strategy for Suicide Prevention is not the Surgeon General's strategy or the Federal government's strategy; rather, it is the strategy of the American people for improving their health and well-being through the prevention of suicide. I congratulate each person who played a role in bringing it to completion. You have served your fellow Americans well.

Sincerely yours,
David Satcher, M.D., Ph.D.
Surgeon General

Specific Treatments for Episodes of Depression and Mania

Specific Treatments for Episodes of Depression and Mania
This section describes specific types of pharmacotherapies and psychosocial therapies for episodes of depression and mania. Treatment generally targets symptom patterns rather than specific disorders. Differences in the treatment strategy for unipolar and bipolar depression are described where relevant.

Treatment of Major Depressive Episodes

Pharmacotherapies
Antidepressant medications are effective across the full range of severity of major depressive episodes in major depressive disorder and bipolar disorder (American Psychiatric Association, 1993; Depression Guideline Panel, 1993; Frank et al., 1993). The degree of effectiveness, however, varies according to the intensity of the depressive episode. With mild depressive episodes, the overall response rate is about 70 percent, including a placebo rate of about 60 percent (Thase & Howland, 1995). With severe depressive episodes, the overall response rate is much lower, as is the placebo rate. For example, with psychotic depression, the overall response rate to any one drug is only about 20 to 40 percent (Spiker, 1985), including a placebo response rate of less than 10 percent (Spiker & Kupfer, 1988; Schatzberg & Rothschild, 1992). Psychotic depression is treated with either an antidepressant/antipsychotic combination or ECT (Spiker, 1985; Schatzberg & Rothschild, 1992).

There are four major classes of antidepressant medications. The tricyclic and heterocyclic antidepressants (TCAs and HCAs) are named for their chemical structure. The MAOIs and SSRIs are classified by their initial neurochemical effects. In general, MAOIs and SSRIs increase the level of a target neurotransmitter by two distinct mechanisms. But, as discussed below, these classes of medications have many other effects. They also have some differential effects depending on the race or ethnicity of the patient.

The mode of action of antidepressants is complex and only partly understood. Put simply, most antidepressants are designed to heighten the level of a target neurotransmitter at the neuronal synapse. This can be accomplished by one or more of the following therapeutic actions: boosting the neurotransmitter’s synthesis, blocking its degradation, preventing its reuptake from the synapse into the presynaptic neuron, or mimicking its binding to postsynaptic receptors. To make matters more complicated, many antidepressant drugs affect more than one neurotransmitter. Explaining how any one drug alleviates depression probably entails multiple therapeutic actions, direct and indirect, on more than one neurotransmitter system (Feighner, 1999).

Selection of a particular antidepressant for a particular patient depends upon the patient’s past treatment history, the likelihood of side effects, safety in overdose, and expense (Depression Guideline Panel, 1993). A vast majority of U.S. psychiatrists favor the SSRIs as“first-line” medications (Olfson & Klerman, 1993). These agents are viewed more favorably than the TCAs because of their ease of use, more manageable side effects, and safety in overdose (Kapur et al., 1992; Preskorn & Burke, 1992). Perhaps the major drawback of the SSRIs is their expense: they are only available as name brands (until 2002 when they begin to come off patent). At minimum, SSRI therapy costs about $80 per month (Burke et al., 1994), and patients taking higher doses face proportionally greater costs.

Four SSRIs have been approved by the FDA for treatment of depression: fluoxetine, sertraline, paroxetine, and citalopram. A fifth SSRI, fluvoxamine, is approved for treatment of obsessive-compulsive disorder, yet is used off-label for depression.11 There are few compelling reasons to pick one SSRI over another for treatment of uncomplicated major depression, because they are more similar than different (Aguglia et al., 1993; Schone & Ludwig, 1993; Tignol, 1993; Preskorn, 1995). There are, however, several distinguishing pharmacokinetic differences between SSRIs, including elimination half-life (the time it takes for the plasma level of the drug to decrease 50 percent from steady-state), propensity for drug-drug interactions (e.g., via inhibition of hepatic enzymes), and antidepressant activity of metabolite(s) (DeVane, 1992). In general, SSRIs are more likely to be metabolized more slowly by African Americans and Asians, resulting in higher blood levels (Lin et al., 1997).

The SSRIs as a class of drugs have their own class-specific side effects, including nausea, diarrhea, headache, tremor, daytime sedation, failure to achieve orgasm, nervousness, and insomnia. Attrition from acute phase therapy because of side effects is typically 10 to 20 percent (Preskorn & Burke, 1992). The incidence of treatment-related suicidal thoughts for the SSRIs is low and comparable to the rate observed for other antidepressants (Beasley et al., 1991; Fava & Rosenbaum, 1991), despite reports to the contrary (Breggin & Breggin, 1994).

Some concern persists that the SSRIs are less effective than the TCAs for treatment of severe depressions, including melancholic and psychotic subtypes (Potter et al., 1991; Nelson, 1994). Yet there is no definitive answer (Danish University Anti-depressant Group, 1986, 1990; Pande & Sayler, 1993; Roose et al., 1994; Stuppaeck et al., 1994).

Side effects and potential lethality in overdose are the major drawbacks of the TCAs. An overdose of as little as 7-day supply of a TCA can result in potentially fatal cardiac arrhythmias (Kapur et al., 1992). TCA treatment is typically initiated at lower dosages and titrated upward with careful attention to response and side effects. Doses for African Americans and Asians should be monitored more closely, because their slower metabolism of TCAs can lead to higher blood concentrations (Lin et al., 1997). Similarly, studies also suggest that there may be gender differences in drug metabolism and that plasma levels may change over the course of the menstrual cycle (Blumenthal, 1994b).

In addition to the four major classes of antidepressants are bupropion, which is discussed below, and three newer FDA-approved antidepressants that have mixed or compound synaptic effects. Venlafaxine, the first of these newer antidepressants, inhibits reuptake of both serotonin and, at higher doses, norepinephrine. In contrast to the TCAs, venlafaxine has somewhat milder side effects (Bolden-Watson & Richelson, 1993), which are like those of the SSRIs. Venlafaxine also has a low risk of cardiotoxicity and, although experience is limited, it appears to be less toxic than the others in overdose. Venlafaxine has shown promise in treatment of severe (Guelfi et al., 1995) or refractory (Nierenberg et al., 1994) depressive states and is superior to fluoxetine in one inpatient study (Clerc et al., 1994). Venlafaxine also occasionally causes increased blood pressure, and this can be a particular concern at higher doses (Thase, 1998).

Nefazodone, the second newer antidepressant, is unique in terms of both structure and neurochemical effects (Taylor et al., 1995). In contrast to the SSRIs, nefazodone improves sleep efficiency (Armitage et al., 1994). Its side effect profile is comparable to the other newer antidepressants, but it has the advantage of a lower rate of sexual side effects (Preskorn, 1995). The more recently FDA-approved antidepressant, mirtazapine, blocks two types of serotonin receptors, the 5-HT2 and 5-HT3 receptors (Feighner, 1999). Mirtazapine is also a potent antihistamine and tends to be more sedating than most other newer antidepressants. Weight gain can be another troublesome side effect.

Figure 4-2 presents summary findings on newer pharmacotherapies from a recent review of the treatment of depression by the Agency for Health Care Policy and Research (AHCPR, 1999). There have been few studies of gender differences in clinical response to treatments for depression. A recent report (Kornstein et al., in press) found women with chronic depression to respond better to a SSRI than a tricyclic, yet the opposite for men. This effect was primarily in premenopausal women. The AHCPR report (1999) also noted that there were almost no data to address the efficacy of pharmacotherapies in post partum or pregnant women.

Alternate Pharmacotherapies
Regardless of the initial choice of pharmacotherapy, about 30 to 50 percent of patients do not respond to the initial medication. It has not been established firmly whether patients who respond poorly to one class of antidepressants should be switched automatically to an alternate class (Thase & Rush, 1997). Several studies have examined the efficacy of the TCAs and SSRIs when used in sequence (Peselow et al., 1989; Beasley et al., 1990). Approximately 30 to 50 percent of those not responsive to one class will respond to the other (Thase & Rush, 1997).

Among other types of antidepressants, the MAOIs and bupropion are important alternatives for SSRI and TCA nonresponders (Thase & Rush, 1995). These agents also may be relatively more effective than TCAs or SSRIs for treatment of depressions characterized by atypical or reversed vegetative symptoms (Goodnick & Extein, 1989; Quitkin et al., 1993b; Thase et al., 1995). Bupropion and the MAOIs also are good choices to treat bipolar depression (Himmelhoch et al., 1991; Thase et al., 1992; Sachs et al., 1994). Bupropion also has the advantage of a low rate of sexual side effects (Gardner & Johnston, 1985; Walker et al., 1993).

Bupropion’s efficacy and overall side effect profile might justify its first-line use for all types of depression (e.g., Kiev et al., 1994). Furthermore, bupropion has a novel neurochemical profile in terms of effects on dopamine and norepinephrine (Ascher et al., 1995). However, worries about an increased risk of seizures delayed bupropion’s introduction to the U.S. market by more than 5 years (Davidson, 1989). Although clearly effective for a broad range of depressions, use of the MAOIs has been limited for decades by concerns that when taken with certain foods containing the chemical tyramine (for example, some aged cheeses and red wines); these medications may cause a potentially lethal hypertensive reaction (Thase et al., 1995). There has been continued interest in development of safer, selective and reversible MAOIs.

Hypericum (St. John's Wort). The widespread publicity and use of the botanical product from the yellow-flowering Hypericum perforatum plant with or without medical supervision is well ahead of the science database supporting the effectiveness of this putative antidepressant. Controlled trials, mainly in Germany, have been positive in mild-to-moderate depression, with only mild gastrointestinal side effects reported (Linde et al., 1996). However, most of those studies were methodologically flawed, in areas including diagnosis (more similar to adjustment disorder with depressed mood than major depression), length of trial (often an inadequate 4 weeks), and either lack of placebo control or unusually low or high placebo response rates (Salzman, 1998).

Post-marketing surveillance in Germany, which found few adverse effects of Hypericum, depended upon spontaneous reporting of side effects by patients, an approach that would not be considered acceptable in this country (Deltito & Beyer, 1998). In clinical use, the most commonly encountered adverse effect noted appears to be sensitivity to sunlight.

Figure 4-2. Treatment of depression-newer pharmacotherapies: Summary findings
Newer antidepressant drugs* are effective treatments for major depression and dysthymia.


They are efficacious in primary care and specialty mental health care settings:


–Major depression:
50 percent response to active agent
32 percent response to placebo


–Dysthymia (fluoxetine, sertraline, and amisulpride):
59 percent response to active agent
37 percent response to placebo


Both older and newer antidepressants demonstrate similar efficacy.


Drop-out rates due to all causes combined are similar for newer and older agents:


Drop-out rates due to adverse effects are slightly higher for older agents.


Newer agents are often easier to use because of single daily dosing and less titration.


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*SSRIs and all other antidepressants marketed subsequently. Source: AHCPR, 1999.


Basic questions about mechanism of action and even the optimal formulation of a pharmaceutical product from the plant remain; dosage in the randomized German trials varied by sixfold (Linde et al., 1996). Several pharmacologically active components of St. John's wort, including hypericin, have been identified (Nathan, 1999); although their long half-lives in theory should permit once daily dosing, in practice a schedule of 300 mg three times a day is most commonly used. While initial speculation about significant MAO-inhibiting properties of hypericum have been largely discounted, possible serotonergic mechanisms suggest that combining this agent with an SSRI or other serotonergic antidepressant should be approached with caution. However, data regarding safety of hypericum in preclinical models or clinical samples are few (Nathan, 1999). At least two placebo-controlled trials in the United States are under way to compare the efficacy of Hypericum with that of an SSRI.

Augmentation Strategies
The transition from one antidepressant to another is time consuming, and patients sometimes feel worse in the process (Thase & Rush, 1997). Many clinicians bypass these problems by using a second medication to augment an ineffective antidepressant. The best studied strategies of this type are lithium augmentation, thyroid augmentation, and TCA-SSRI combinations (Nierenberg & White, 1990; Thase & Rush, 1997; Crismon et al., 1999).

Increasingly, clinicians are adding a noradrenergic TCA to an ineffective SSRI or vice versa. In an earlier era, such polypharmacy (the prescription of multiple drugs at the same time) was frowned upon. Thus far, the evidence supporting TCA-SSRI combinations is not conclusive (Thase & Rush, 1995). Caution is needed when using these agents in combination because SSRIs inhibit metabolism of several TCAs, resulting in a substantial increase in blood levels and toxicity or other adverse side effects from TCAs (Preskorn & Burke, 1992).

Psychotherapy and Counseling
Many people prefer psychotherapy or counseling over medication for treatment of depression (Roper, 1986; Seligman, 1995). Research conducted in the past two decades has helped to establish at least several newer forms of time-limited psychotherapy as being as effective as antidepressant pharmacotherapy in mild-to-moderate depressions (DiMascio et al., 1979; Elkin et al., 1989; Hollon et al., 1992; Depression Guideline Panel, 1993; Thase, 1995; Persons et al., 1996). The newer depression-specific therapies include cognitive-behavioral therapy (Beck et al., 1979) and interpersonal psychotherapy (Klerman et al., 1984). These approaches use a time-limited approach, a present tense (“here-and-now”) focus, and emphasize patient education and active collaboration. Interpersonal psychotherapy centers around four common problem areas: role disputes, role transitions, unresolved grief, and social deficits. Cognitive-behavioral therapy takes a more structured approach by emphasizing the interactive nature of thoughts, emotions, and behavior. It also helps the depressed patient to learn how to improve coping and lessen symptom distress.

There is no evidence that cognitive-behavioral therapy and interpersonal psychotherapy are differentially effective (Elkin et al., 1989; Thase, 1995). As reported earlier, both therapies appear to have some relapse prevention effects, although they are much less studied than the pharmacotherapies. Other more traditional forms of counseling and psychotherapy have not been extensively studied using a randomized clinical trial design (Depression Guideline Panel, 1993). It is important to determine if these more traditional treatments, as commonly practiced, are as effective as interpersonal psychotherapy or cognitive-behavioral therapy.

The brevity of this section reflects the succinctness of the findings on the effectiveness of these interventions as well as the lack of differential responses and“side effects.” It does not reflect a preference or superiority of medication except in conditions such as psychotic depression where psychotherapies are not effective.

Bipolar Depression
Treatment of bipolar depression12 has received surprisingly little study (Zornberg & Pope, 1993). Most psychiatrists prescribe the same antidepressants for treatment of bipolar depression as for major depressive disorder, although evidence is lacking to support this practice. It also is not certain that the same strategies should be used for treatment of depression in bipolar II (i.e., major depression plus a history of hypomania) and bipolar I (i.e., major depression with a history of at least one prior manic episode) (DSM-IV).

Pharmacotherapy of bipolar depression typically begins with lithium or an alternate mood stabilizer (DSM-IV; Frances et al., 1996). Mood stabilizers reduce the risk of cycling and have modest antidepressant effects; response rates of 30 to 50 percent are typical (DSM-IV; Zornberg & Pope, 1993). For bipolar depressions refractory to mood stabilizers, an antidepressant is typically added. Bipolar depression may be more responsive to nonsedating antidepressants, including the MAOIs, SSRIs, and bupropion (Cohn et al., 1989; Haykal & Akiskal, 1990; Himmelhoch et al., 1991; Peet, 1994; Sachs et al., 1994). The optimal length of continuation phase pharmacotherapy of bipolar depression has not been established empirically (DSM-IV). During the continuation phase, the risk of depressive relapse must be counterbalanced against the risk of inducing mania or rapid cycling (Kukopulos et al., 1980; Wehr & Goodwin, 1987; Solomon et al., 1995). Although not all studies are in agreement, antidepressants may increase mood cycling in a vulnerable subgroup, such as women with bipolar II disorder (Coryell et al., 1992; Bauer et al., 1994). Lithium is associated with increased risk of congenital anomalies when taken during the first trimester of pregnancy, and the anticonvulsants are contraindicated (see Cohen et al., 1994, for a review). This is problematic in view of the high risk of recurrence in pregnant bipolar women (Viguera & Cohen 1998).

Pharmacotherapy, Psychosocial Therapy, and Multimodal Therapy
The relative efficacy of pharmacotherapy and the newer forms of psychosocial treatment, such as interpersonal psychotherapy and the cognitive-behavioral therapies, is a controversial topic (Meterissian & Bradwejn, 1989; Klein & Ross, 1993; Munoz et al., 1994; Persons et al., 1996). For major depressive episodes of mild to moderate severity, meta-analyses of randomized clinical trials document the relative equivalence of these treatments (Dobson, 1989; Depression Guideline Panel, 1993). Yet for patients with bipolar and psychotic depression, who were excluded from these studies, pharmacotherapy is required: there is no evidence that these types of depressive episodes can be effectively treated with psychotherapy alone (Depression Guideline Panel, 1993; Thase, 1995). Current standards of practice suggest that therapists who withhold somatic treatments (i.e., pharmacotherapy or ECT) from such patients risk malpractice (DSM-IV; Klerman, 1990; American Psychiatric Association, 1993; Depression Guideline Panel, 1993).

For patients hospitalized with depression, somatic therapies also are considered the standard of care (American Psychiatric Association, 1993). Again, there is little evidence for the efficacy of psychosocial treatments alone when used instead of pharmacotherapy, although several studies suggest that carefully selected inpatients may respond to intensive cognitive-behavioral therapy (DeJong et al., 1986; Thase et al., 1991). However, in an era in which inpatient stays are measured in days, rather than in weeks, this option is seldom feasible. Combined therapies emphasizing both pharmacologic and intensive psychosocial treatments hold greater promise to improve the outcome of hospitalized patients, particularly if inpatient care is followed by ambulatory treatment (Miller et al., 1990; Scott, 1992).

Combined therapies—also called multimodal treatments—are especially valuable for outpatients with severe forms of depression. According to a recent meta-analysis of six studies, combined therapy (cognitive or interpersonal psychotherapy plus pharmacotherapy) was significantly more effective than psychotherapy alone for more severe recurrent depression. In milder depressions, psychotherapy alone was nearly as effective as combined therapy (Thase et al., 1997b). This meta-analysis was unable to compare combined therapy with pharmacotherapy alone or placebo due to an insufficient number of patients.

In summary, the DSM-IV definition of major depressive disorder spans a heterogenous group of conditions that benefit from psychosocial and/or pharmacological therapies. People with mild to moderate depression respond to psychotherapy or pharmacotherapy alone. People with severe depression require pharmacotherapy or ECT and they may also benefit from the addition of psychosocial therapy.

Preventing Relapse of Major Depressive Episodes

Recurrent Depression. Maintenance pharmacotherapy is the best-studied means to reduce the risk of recurrent depression (Prien & Kocsis, 1995; Thase & Sullivan, 1995). The magnitude of effectiveness in prevention of recurrent depressive episodes depends on the dose of the active agent used, the inherent risk of the population (i.e., chronicity, age, and number of prior episodes), the length of time being considered, and the patient’s adherence to the treatment regimen (Thase, 1993). Early studies, which tended to use lower dosages of medications, generally documented a twofold advantage relative to placebo (e.g., 60 vs. 30 percent) (Prien & Kocsis, 1995). In a more recent study of recurrent unipolar depression, the drug-placebo difference was nearly fivefold (Frank et al., 1990; Kupfer et al., 1992). This trial, in contrast to earlier randomized clinical trials, used a much higher dosage of imipramine, suggesting that full-dose maintenance pharmacotherapy may improve prophylaxis. Indeed, this was subsequently confirmed in a randomized clinical trial comparing full- and half-dose maintenance strategies (Frank et al., 1993).

There are few published studies on the prophylactic benefits of long-term pharmacotherapy with SSRIs, bupropion, nefazodone, or venlafaxine. However, available studies uniformly document 1-year efficacy rates of 80 to 90 percent in preventing recurrence of depression (Montgomery et al., 1988; Doogan & Caillard, 1992; Claghorn & Feighner, 1993; Duboff, 1993; Shrivastava et al., 1994; Franchini et al., 1997; Stewart et al., 1998). Thus, maintenance therapy with the newer agents is likely to yield outcomes comparable to the TCAs (Thase & Sullivan, 1995).

How does maintenance pharmacotherapy compare with psychotherapy? In one study of recurrent depression, monthly sessions of maintenance interpersonal psychotherapy had a 3-year success rate of about 35 percent (i.e., a rate falling between those for active and placebo pharmacotherapy) (Frank et al., 1990). Subsequent studies found maintenance interpersonal psychotherapy to be either a powerful or ineffective prophylactic therapy, depending on the patient/treatment match (Kupfer et al., 1990; Frank et al., 1991a; Spanier et al., 1996).

Bipolar Depression. No recent randomized clinical trials have examined prophylaxis against recurrent depression in bipolar disorder. In one older, well-controlled study, recurrence rates of more than 60 percent were observed despite maintenance treatment with lithium, either alone or in combination with imipramine (Shapiro et al., 1989).

Treatment of Mania
Acute Phase Efficacy
Success rates of 80 to 90 percent were once expected with lithium for the acute phase treatment of mania (e.g., Schou, 1989); however, lithium response rates of only 40 to 50 percent are now commonplace (Frances et al., 1996). Most recent studies thus underscore the limitations of lithium in mania (e.g., Gelenberg et al., 1989; Small et al., 1991; Freeman et al., 1992; Bowden et al., 1994). The apparent decline in lithium responsiveness may be partly due to sampling bias (i.e., university hospitals treat more refractory patients), but could also be attributable to factors such as younger age of onset, increased drug abuse comorbidity, or shorter therapeutic trials necessitated by briefer hospital stay (Solomon et al., 1995). The effectiveness of acute phase lithium treatment also is partially dependent on the clinical characteristics of the manic episode: dysphoric/mixed, psychotic, and rapid cycling episodes are less responsive to lithium alone (DSM-IV; Solomon et al., 1995).

A number of other medications initially developed for other indications are increasingly used for lithium-refractory or lithium-intolerant mania. The efficacy of two medications, the anticonvulsants carbamazepine and divalproex sodium, has been documented in randomized clinical trials (e.g., Small et al., 1991; Freeman et al., 1992; Bowden et al., 1994; Keller et al., 1992). Divalproex sodium has received FDA approval for the treatment of mania. The specific mechanisms of action for these agents have not been established, although they may stabilize neuronal membrane systems, including the cyclic adenosine monophosphate second messenger system (Post, 1990). The anticonvulsant medications under investigation for their effectiveness in mania include lamotrigine and gabapentin.

Another newer treatment, verapamil, is a calcium channel blocker initially approved by the FDA for treatment of cardiac arrhythmias and hypertension. Since the mid-1980s, clinical reports and evidence from small randomized clinical trials suggest that the calcium channel blockers may have antimanic effects (Dubovsky et al., 1986; Garza-Trevino et al., 1992; Janicak et al., 1992, 1998). Like lithium and the anticonvulsants, the mechanism of action of verapamil has not been established. There is evidence of abnormalities of intracellular calcium levels in bipolar disorder (Dubovsky et al., 1992), and calcium’s role in modulating second messenger systems (Wachtel, 1990) has spurred continued interest in this class of medication. If effective, verapamil does have the additional advantage of having a lower potential for causing birth defects than does lithium, divalproex, or carbamazepine.

Adjunctive neuroleptics and high-potency benzodiazepines are used often in combination with mood stabilizers to treat mania. The very real risk of tardive dyskinesia has led to a shift in favor of adjunctive use of benzodiazepines instead of neuroleptics for acute stabilization of mania (Chouinard, 1988; Lenox et al., 1992). The novel antipsychotic clozapine has shown promise in otherwise refractory manic states (Suppes et al., 1992), although such treatment requires careful monitoring to help protect against development of agranulocytosis, a potentially lethal bone marrow toxicity. Other newer antipsychotic medications, including risperidone and olanzapine, have safer side effect profiles than clozapine and are now being studied in mania. For manic patients who are not responsive to or tolerant of pharmacotherapy, ECT is a viable alternative (Black et al., 1987; Mukherjee et al., 1994). Further discussion of antipsychotic drugs and their side effects is found in the section on schizophrenia.

Maintenance Treatment to Prevent Recurrences of Mania
The efficacy of lithium for prevention of mania also appears to be significantly lower now than in previous decades; recurrence rates of 40 to 60 percent are now typical despite ongoing lithium therapy (Prien et al., 1984; Gelenberg et al., 1989; Winokur et al., 1993). Still, more than 20 studies document the effectiveness of lithium in preventing suicide (Goodwin & Jamison, 1990). Medication noncompliance almost certainly plays a role in the failure of longer term lithium maintenance therapy (Aagaard et al., 1988). Indeed, abrupt discontinuation of lithium has been shown to accelerate the risk of relapse (Suppes et al., 1993). Medication“holidays” may similarly induce a lithium-refractory state (Post, 1992), although data are conflicting (Coryell et al., 1998). As noted earlier, antidepressant cotherapy also may accelerate cycle frequency or induce lithium-resistant rapid cycling (Kukopulos et al., 1980; Wehr & Goodwin, 1987).

With increasing recognition of the limitations of lithium prophylaxis, the anticonvulsants are used increasingly for maintenance therapy of bipolar disorder. Several randomized clinical trials have demonstrated the prophylactic efficacy of carbamazepine (Placidi et al., 1986; Lerer et al., 1987; Coxhead et al., 1992), whereas the value of divalproex preventive therapy is only supported by uncontrolled studies (Calabrese & Delucchi, 1990; McElroy et al., 1992; Post, 1990). Because of increased teratogenic risk associated with these agents, there is a need to obtain and evaluate information on alternative interventions for women with bipolar disorder of childbearing age.

Service Delivery for Mood Disorders
The mood disorders are associated with significant suffering and high social costs, as explained above (Broadhead et al., 1990; Greenberg et al., 1993; Wells et al., 1989; Wells et al., 1996). Many treatments are efficacious, yet in the case of depression, significant numbers of individuals either receive no care or inappropriate care (Katon et al., 1992; Narrow et al., 1993; Wells et al., 1994; Thase, 1996). Limitations in insurance benefits or in the management strategies employed in managed care arrangements may make it impossible to deliver recommended treatments. In addition, treatment outcome in real-world practice is not as effective as that demonstrated in clinical trials, a problem known as the gap between efficacy and effectiveness (see Chapter 2). The gap is greatest in the primary care setting, although it also is observed in specialty mental health practice. There is a need to develop case identification approaches for women in obstetrics/gynecology settings due to the high risk of recurrence in childbearing women with bipolar disorder. Little attention also has been paid to screening and mental health services for women in obstetrics/gynecology settings despite their high risk of depression (Miranda et al., 1998).

Primary care practice has been studied extensively, revealing low rates of both recognition and appropriate treatment of depression. Approximately one-third to one-half of patients with major depression go unrecognized in primary care settings (Gerber et al., 1989; Simon & Von Korff, 1995). Poor recognition leads to unnecessary and expensive diagnostic procedures, particularly in response to patients’ vague somatic complaints (Callahan et al., 1996). Fewer than one-half receive antidepressant medication according to Agency for Health Care Policy Research recommendations for dosage and duration (Simon et al., 1993; Rost et al., 1994; Katon 1995, 1996; Schulberg et al., 1995; Simon & Von Korff, 1995). About 40 percent discontinue their medication on their own during the first 4 to 6 weeks of treatment, and fewer still continue their medication for the recommended period of 6 months (Simon et al., 1993). Although drug treatment is the most common strategy for treating depression in primary care practice (Olfson & Klerman, 1992; Williams et al., 1999), about one-half of primary care physicians express a preference to include counseling or therapy as a component of treatment (Meredith et al., 1994, 1996). Few primary care practitioners, however, have formal training in psychotherapy, nor do they have the time (Meredith et al., 1994, 1996). A variety of strategies have been developed to improve the management of depression in primary care settings (cited in Katon et al., 1997). These are discussed in more detail in Chapter 5 because of the special problem of recognizing and treating depression among older adults.

Another major service delivery issue focuses on the substantial number of individuals with mood disorders who go on to develop a chronic and disabling course. Their needs for a wide array of services are similar to those of individuals with schizophrenia. Many of the service delivery issues relevant to individuals with severe and persistent mood disorders are presented in the final sections of this chapter.



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10 Nonadherence is defined as lack of adherence to prescribed activities such as keeping appointments, taking medication, and completing assignments.

11 Technically, FDA approves drugs for a selected indication (a disorder in a certain population). However, once the drug is marketed, doctors are at liberty to prescribe it for unapproved (off-label) indications.

12 Bipolar depression refers to episodes with symptoms of depression in patients diagnosed with bipolar disorder.

Common Stress Reactions Following Exposure To Trauma

Common Stress Reactions Following Exposure To Trauma
Psychological and EmotionalInitial euphoria, relief
Guilt about surviving or not having suffered as much as others
Anxiety, fear, insecurity, worry
Pervasive concern about well-being of loved ones
Feelings of helplessness, inadequacy, being overwhelmed
Vulnerability
Loss of sense of power, control, well-being, self-confidence, trust
Shame, anger over vulnerability
Irritability, restlessness, hyperexcitability, impatience, agitation, anger, blaming (anger at source, anger at those exempted, anger at those trying to help, anger “for no apparent reason”)
Outrage, resentment
Frustration
Cynicism, negativity
Mood swings
Despair, grief, sadness
Periods of crying, emotional “attacks” or “pangs”
Feelings of emptiness, loss, hopelessness, depression
Regression
Reawakening of past trauma, painful experiences
Apathy, diminished interest in usual activities
Feelings of isolation, detachment, estrangement, “no one else can understand”
Denial or constriction of feelings; numbness
“Flashbacks,” intrusive memories of the event, illusions, pseudo-hallucinations
Recurrent dreams of the event or other traumas
Cognitive
Poor concentration
Mental confusion, slowness of thinking
Forgetfulness
Amnesia (complete or partial)
Inability to make judgments and decisions
Inability to appreciate importance or meaning of stimuli
Poor judgment
Loss of appropriate sense of reality (denial of reality, fantasies to counteract reality)
Preoccupation with the event
Repetitive, obsessive thoughts and ruminations
Over-generalization, over-association with the event
Loss of objectivity
Rigidity
Confusion regarding religious beliefs/value systems; breakdown of meaning and faith
Self-criticism over things done/not done during trauma
Awareness of own and loved ones’ mortality
http://www.aspirace.com

Autism

What is autism?

Autism, also called autistic disorder, appears in early childhood, usually before age 3 (National Institutes of Health, 2001). Autism prevents children and adolescents from interacting normally with other people and affects almost every aspect of their social and psychological development.

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What are the signs of autism?

Autism has a wide variety of characteristics ranging in intensity from mild to severe. One child with autism does not behave like another child with the same diagnosis. Children and adolescents with autism typically:


Have difficulty communicating with others.
Exhibit repetitious behaviors, such as rocking back and forth, head banging, or touching or twirling objects.
Have a limited range of interests and activities.
May become upset by a small change in their environment or daily routine.
In addition to these characteristics, some children with autism experience hypersensitivity to hearing, touch, smell, or taste. Symptoms of autism can be seen in early infancy, but the condition also may appear after months of normal development. In most cases, however, it is not possible to identify a specific event that triggers the disorder.

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How common is autism?

Studies estimate that as many as 12 in every 10,000 children have autism or a related condition (U.S. Department of Health and Human Services, 1999). Autism is three times more common in boys than in girls (National Institutes of Health, 2001).

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What causes autism?

Researchers are unsure about what causes autism. Several studies suggest that autism might be caused by a combination of biological or environmental factors, or both, including viral exposure before birth, a problem with the immune system, or genetics. Many recently published scientific investigations have examined the possible connection between autism and the measles, mumps, and rubella (MMR) vaccine. At this time, though, the available data do not appear to support a causal link.

Studies of families and twins suggest a genetic basis for the disorder. It is important for scientists to find the genes responsible for autism, if any, because this knowledge would give physicians new tools to diagnose the disorder and help scientists develop gene-based therapies.

Some studies have found that the brains of people with autism may function differently from those that are considered "normal." Research suggests that an abnormal slowing down of brain development before birth may cause autism. Studies also are looking at how autism-related problems in brain development may affect behavior later in childhood. For example, some researchers are investigating the ways in which infants with autism process information and how the disorder may lead to poor development of social skills, knowledge, and awareness.

Chemicals in the brain also may play a role in autism. As a normal brain develops, the level of serotonin, a chemical found in the brain, declines. In some children with autism, however, serotonin levels do not decline. Researchers are investigating whether this happens only to children with autism or whether other factors are involved.

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What help is available for families?

Since brain development can be influenced during early childhood, the treatment of autism has a greater chance of success when initiated as early as possible. In addition, when children with autism are treated early, the cost of long-term care may be reduced. Services and treatments that may benefit children and adolescents with autism and their families include:


Training in communication, social, learning, and self-help skills.
Programs in which other children help to teach children with autism.
Parent training.
Medications to reduce symptoms related to self-injury, seizures, digestive difficulties, and attention problems.
When services are started soon after a child is diagnosed with autism, the child's language, social, and academic skills and abilities may be greatly improved. On the other hand, some children and adolescents do not respond well to treatment or may experience negative side effects from autism medications. Recent data suggest that some of the newer antipsychotic drugs may have fewer side effects than conventional drugs, but more studies are needed before experts can determine any possible safety advantages over traditional treatments.

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What can parents do?

Parents or other caregivers concerned about a child who shows symptoms of autism should:


Talk with a health care provider about their concerns. He or she can help to determine whether the symptoms are caused by autism, a related disorder, or another condition. If necessary, the health care provider can refer the family to a mental health expert who specializes in treating persons with autism.
Get accurate information from libraries, hotlines, or other sources.
Ask questions about treatments and services.
Talk to other families in their communities who are coping with autism.
Find family network organizations.
People who are not satisfied with the mental health care they receive should discuss their concerns with the provider, ask for information, and/or seek help from other sources.

This is one of many fact sheets in a series on children's mental health disorders. All the fact sheets listed below are written in an easy-to-read style. Families, caretakers, and media professionals may find them helpful when researching particular mental health disorders. To obtain free copies, call 1-800-789-2647 or visit http://mentalhealth.samhsa.gov/child.

Creating a Consumer and Family-Oriented Health Care System

Creating a Consumer and Family-Oriented Health Care System

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The Washington Business group on Health, with Support from CMHS, Has Released a Publication Focusing on An Environmental Scan of Reforms Impacting Mental Health and Substance Abuse Care.

Part I of the paper discusses environmental trends driving change in mental health and substance abuse delivery system models and practices. Trends discussed are:

Industry consolidation and the growth of managed care;

The absence of a federal regulatory framework;

Interest in health care quality and performance; and

Changing perceptions about mental health and substance abuse.
Part II reviews a wide range of public and private sector initiatives intended to enhance consumer-directed care, inform and educate consumers about health care choices and the changing health care system, and involve consumers and their advocates in the planning and monitoring of emerging health care delivery systems. Initiatives are organized under four topic headings:

Empowering consumers with information;

Performance accountability from the consumer perspective;

The consumer and family movements in mental health; and

A systems approach to health care delivery.
Part III identifies three critical challenges to creating a consumer- directed health care system:

Creating meaningful and useful information for consumers;

Stimulating health system accountability for serving people with chronic illnesses and disabilities; and

Enhancing organized consumer and family involvement in health system planning and monitoring.
It is intended as a strategic planning tool and resource document for consumer advocates and others interested in enhancing consumer involvement in improving health system accountability for mental health and substance abuse services. A glossary of terms and contact information for initiatives cited in the document are included.




Consumer Affairs Bulletin
Volume 2, No. 2 Summer 1997

Suicide Prevention

Suicide Prevention

Recent reports by the Institute of Medicine and the World Health Organization have revealed the magnitude and impact of suicide, citing it as the cause of death for 30,000 Americans annually and over one million people worldwide. These reports, as well as the President’s New Freedom Commission Report and the Surgeon General’s National Strategy for Suicide Prevention, call for aggressive efforts to reduce the loss of life and suffering related to suicide.

The Branch supports several key initiatives designed to improve public and professional awareness of suicide as a preventable public health problem and to enhance the capabilities of the systems that promote prevention and recovery, including:

Cooperative Agreements for State-Sponsored Youth Suicide Prevention and Early Intervention Program. Three-year grants to support States and tribes in developing and implementing statewide or tribal youth suicide prevention and early intervention strategies, grounded in public/private collaboration.
Campus Suicide Prevention Grants. Three-year grants to institutions of higher education to enhance services for students with mental and behavioral health problems that can lead to school failure, depression, substance abuse, and suicide attempts.
Cooperative Agreement for the Suicide Prevention Resource Center (SPRC). Funds the continuation of a Federal Suicide Technical Assistance Center to provide guidance to State, tribal, and local grantees in the implementation of the suicide prevention strategy; create standards for data collection; and collect, evaluate, and disseminate data related to specific suicide prevention programs.
Networking and Certifying Suicide Prevention Hotlines. This grant provides funding to manage a toll-free national suicide prevention hotline network utilizing a life affirming number which routes calls from anywhere in the United States to a network of local crisis centers that can link callers to local emergency, mental health and social service resources.
Linking Adolescents at Risk to Mental Health Services Grant Program. This initiative is one of SAMHSA's Service-to-Science Grants programs. The purpose of the Adolescents at Risk program is to evaluate voluntary school-based programs that focus on identification and referral of high school youth who are at risk for suicide or suicide attempts. Eligible applicants are local educational agencies or nonprofit entities in conjunction with local educational agencies.
Collectively, these initiatives will further awareness of suicide, will promote suicide prevention and intervention efforts, and will reduce the numbers of lives lost and disrupted by suicide.

LCSW CEU Requirements

LCSW CEU Requirements

The Board of Behavioral Sciences for California has determined that all ceus may be earned by homestudy.

What is the difference between an Online Interactive CE Course and a Homestudy Course?
If you submit a completed course/exam to the CE provider via regular mail, then you have taken a homestudy course. If the course/exam is completed and submitted online, then the hours are approved as regular continuing education. Many state boards, such as the California Board of Behavioral Services, allow all required continuing education to be earned from online interactive continuing education courses. Check with your respective board to determine the amount of hours/units are permitted online.

LCSW CEUs

LCSW CEU's
LCSW CEUs
LCSW Continuing Education Online
California LCSW CEUs

Online Continuing Education for LMFT, MFTI, LCSW, ASW

Satisfy your CE requirements conveniently anywhere you have online access.
Take your test and even print your completion certificate at any time.
Take as much time as needed to complete the exam.
Take the exam as many times necessary to receive a 70% passing score.
Pay only after you have passed your exam.
Earn hours for passing exams based on books you may have already read.
Listen to selected audio courses directly from your computer or MP3 player.
Take some time to browse our courses, and become a part of the Aspira family.

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Domestic Violence/Spousal and Partner Abuse
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