Atypical antipsychotic more effective than older drugs in treating childhood mania, but side effects can be serious

The antipsychotic medication risperidone is more effective for initial treatment of mania in children diagnosed with bipolar disorder compared to other mood stabilizing medications, but it carries the potential for serious metabolic side effects, according to an NIMH-funded study published online ahead of print January 2, 2012, in the Archives of General Psychiatry social worker continuing education

Background

Childhood bipolar disorder is a relatively rare but seriously impairing condition. It is also associated with an increased risk of substance use disorders and suicide. To treat symptoms of mania, a key symptom of the disorder, medications such as mood stabilizers or antipsychotics are often prescribed. However, no prior study has addressed the question of which medication to try first.

In the Treatment of Early Age Mania (TEAM) study, Barbara Geller, M.D., of Washington University in St. Louis, and colleagues randomized 290 children ages 6-15 years diagnosed with bipolar I disorder (having mixed or manic symptoms) to treatment with lithium, divalproex sodium or risperidone for an 8-week trial. None of the children had taken an anti-manic medication before. Lithium has been used to treat bipolar disorder for many years. Divalproex sodium is an anticonvulsant mood stabilizer commonly prescribed to treat bipolar disorder as well. Risperidone is an atypical antipsychotic that has been approved by the U.S. Food and Drug Administration for the treatment of mania in youth age 10 and older.

Results of the Study

After eight weeks, 68.5 percent of the children taking risperidone showed improvement in manic symptoms, compared to 35.6 percent of those taking lithium and 24 percent of those taking divalproex sodium. Overall, 24.7 percent discontinued the trial, but more children taking lithium—32.2 percent—discontinued the trial compared to those taking risperidone (15.7 percent discontinued) or divalproex sodium (26 percent discontinued.)

However, those taking risperidone also gained more weight than those on the other medications—an average of more than 7 lbs compared to around 3 lbs for those taking lithium and 3.7 lbs for those taking divalproex sodium. Those taking risperidone were also more likely to experience other metabolic side effects, such as an increase in cholesterol levels, compared to those on the other medications.

Significance

The researchers concluded that risperidone was significantly more effective than lithium or divalproex sodium for initial treatment of childhood mania. In addition, the children were less likely to discontinue the drug compared to those taking lithium or divalproex sodium, indicating a higher tolerance for it. This finding is consistent with other studies that have compared second-generation antipsychotics like risperidone to placebo in treating childhood mania.

However, the researchers caution that risperidone is associated with adverse metabolic effects that can increase the risk for diabetes and cardiovascular problems. They note that many children responded to low doses of the medication, suggesting that clinicians should be conservative when determining how to dose the medication. A lower dose may minimize the potential for serious side effects. The researchers also caution that because diagnostic measures for childhood bipolar disorder are not always consistent across studies, and because the validity of such a diagnosis in younger children is under debate, TEAM findings may not generalize to patients diagnosed using other measures.

What’s Next

More research is needed to develop safer, more effective interventions for children with early onset bipolar disorder for both initial and longer term treatment.

Reference

Geller B, Luby J, Josh P, Wagner KD, Emslie G, Walkup JT, Axelson DA, Bolhofner K, Robb A, Wolf DV, Riddle MA, Birmaher B, Ryan ND, Severe J, Vitiello B, Tillman R, Lavori P. A randomized controlled trial of risperidone, lithium and divalproex sodium for initial treatment of bipolar I disorder, manic or mixed phase, in children and adolescents. Archives of General Psychiatry. Online ahead of print January 2, 2012.

Adding Psychotherapy to Medication Treatment Improves Outcomes in Pediatric OCD

Source: NIMH

Youth with obsessive compulsive disorder (OCD) who are already taking antidepressant medication benefit by adding a type of psychotherapy called cognitive behavior therapy (CBT), according to an NIMH-funded study published September 21, 2011, in the Journal of the American Medical Association social worker continuing education

Background

Several studies have shown that, among adults with OCD, a form of CBT involving controlled exposure to feared situations plus training that helps the person refrain from compulsions is effective both alone and in combination with antidepressant medication. However, few studies of this type of combination therapy have been conducted among children. In addition, many children with OCD tend to respond only partially to antidepressant medication. Studies have found that among adults who only partially respond to antidepressant medication, adding CBT can be effective. However, until now, there have been no studies testing this same approach in youth.

Martin Franklin Ph.D., of the University of Pennsylvania, Jennifer Freeman Ph.D., of Brown University, John March M.D.,MPH, of Duke University, and colleagues set out to determine whether CBT can effectively augment antidepressant treatment in children who partially respond to the medication. Among 124 children ages 7-17, they compared three treatment options:
Medication management only (MM), prescribed and managed by a physician. All patients were taking a type of antidepressant known as a selective serotonin reuptake inhibitor (SSRI).
MM plus Instructional CBT (I-CBT), a shorter, less intensive version of CBT administered by the prescribing physician.
MM plus CBT provided by a trained CBT therapist. The CBT included a type of therapy called exposure plus response prevention (ERP), in which children are exposed to feared situations and taught how to respond to the resulting anxiety without engaging in compulsions.

Results

After 12 weeks of treatment, nearly 69 percent of those receiving MM+CBT had responded to treatment, compared to 34 percent receiving MM+I-CBT and 30 percent receiving MM. Those receiving MM+CBT showed more improvement in all respects, compared to those receiving MM and MM+I-CBT.

Significance

The findings are consistent with other studies demonstrating that ERP is an effective treatment strategy for OCD, both alone and in combination with SSRIs. The researchers conclude that the full version of CBT with ERP should be widely disseminated as opposed to a brief version that may not be effective.

What’s next

The researchers were unsure why there was so little difference in treatment response between the MM group and the MM+I-CBT group. They reasoned that the I-CBT was generally ineffective because it was brief and less intensive than the CBT. It also did not include key treatment components that are central to the full CBT protocol, such as exposure practices during the treatment sessions themselves. Future efforts should focus on making the full CBT with ERP more widely available in community settings, they concluded.

Citation

Franklin ME, Sapyta J, Freeman JB, Khanna M, Compton S, Almirall D, Moore P, Choate-Summers M, Garcia A, Edson AL, Foa EB, March JS. Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive compulsive disorder: the Pediatric OCD Treatment Study (POTS II) randomized controlled trial. Journal of the American Medical Association. 21 Sept 2011

Depressed Teens with History of Abuse Less Likely to Respond to Combination Treatment

Adolescents with treatment-resistant depression who have a history of abuse—especially physical abuse—are less likely to respond to combination treatment than to medication alone, according to data from the NIMH-funded Treatment of Resistant Depression in Adolescents (TORDIA) study. The new study was published in the March 2011 issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

Background
Although the relationship between childhood abuse and risk for depression or other mental disorder is well-established, few studies have examined whether a history of abuse may affect response to treatment, especially among adolescents. Some studies have suggested that a history of abuse is associated with a lower response to cognitive behavioral therapy (CBT), a type of psychotherapy that emphasizes problem-solving and behavior change social worker ceus

In the Treatment of Resistant Depression in Adolescents (TORDIA) study, teens whose depression had not improved after an initial course of selective serotonin reuptake inhibitor (SSRI) antidepressant treatment were randomly assigned to one of four interventions for 12 weeks:

Switch to another SSRI—paroxetine (Paxil), citalopram (Celexa) or fluoxetine (Prozac)
Switch to a different SSRI plus CBT
Switch to venlafaxine (Effexor), a different type of antidepressant called a serotonin and norepinephrine reuptake inhibitor (SNRI)
Switch to venlafaxine plus CBT
As reported in May 2010, about 40 percent of those who completed 24 weeks of treatment achieved remission, regardless of the treatment to which they had initially been assigned. The risk for relapse remained high, however.

About 13 percent of TORDIA participants had a history of physical abuse, 17 percent had a history of sexual abuse, and 5 percent had a history of both. In this most recent study, Wael Shamseddeen, M.D., MPH, of Rosalind Franklin University of Medicine and Sciences in North Chicago, and colleagues examined the association between having a history of physical or sexual abuse and response to combination treatment among TORDIA participants.

Results of the Study
The researchers found that teens without a history of abuse had a higher response rate to combination therapy compared to medication-only therapy (63 percent vs. 37.6 percent). Those with a history of sexual abuse responded similarly to combination and medication-only therapy (48 percent vs. 42 percent). However, those with a history of physical abuse had a much lower response rate to combination therapy (18.4 percent) compared to medication-only (52.4 percent).

Significance
The researchers were unable to identify the specific mechanism that might affect response to combination therapy among teens with a history of physical abuse. They suggest that because abuse can affect a child's brain development, abused youth may need psychotherapeutic approaches that target trauma before engaging in traditional CBT designed to treat depression. The researchers also suggest that abused youth may have a tendency to avoid unpleasant emotions, and therefore may have been averse to CBT. It is possible that therapeutic approaches that focus more on behavior and do not rely heavily on the processing of negative thoughts and emotions may be more acceptable and effective for these youth.

What's Next
The researchers concluded that more research is needed into the ways in which abuse history can confer treatment resistance among teens with hard-to-treat depression, and in developing alternative treatment approaches that are more effective.

Reference
Shamseddeen W, Asarnow JR, Clarke G, Vitiello B, Wagner KD, Birmaher B, Keller MB, Emslie G, Iyengar S, Ryan ND, McCracken JT, Porta G, Mayes T, Brent D. Impact of physical and sexual abuse on treatment response in the Treatment of Resistant Depression in Adolescents Study (TORDIA). Journal of the American Academy of Child and Adolescent Psychiatry. 2011 March. 50(3):293-301.

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Most Teens with Eating Disorders Go Without Treatment

About 3 percent of U.S. adolescents are affected by an eating disorder, but most do not receive treatment for their specific eating condition, according to an NIMH-funded study published online ahead of print March 7, 2011, in the Archives of General Psychiatry. Social Worker Continuing Education
Background
Kathleen Merikangas, Ph.D., of NIMH and colleagues analyzed data from the National Comorbidity Study-Adolescent Supplement (NCS-A), a nationally representative, face-to-face survey of more than 10,000 teens ages 13 to 18. Previously published results found that about 20 percent of youth are affected by a severe mental disorder, and a substantial proportion of these youth do not receive mental health care.

In this new study, the authors tracked the prevalence of eating disorders and the proportion of those youth who received treatment for these disorders.

Results of the Study
According to the data, 0.3 percent of youth have been affected by anorexia, 0.9 percent by bulimia, and 1.6 percent by binge-eating disorder. The researchers also tracked the rate of some forms of eating disorders not otherwise specified (ED-NOS), a catch-all category of symptoms that do not meet full criteria for specific disorders but still impact a person’s life. ED-NOS is the most common eating disorder diagnosis. Overall, another 0.8 percent had subthreshold anorexia, and another 2.5 percent had symptoms of subthreshold binge-eating disorder.

In addition,

Hispanics reported the highest rates of bulimia, while Whites reported the highest rates of anorexia.
The majority who had an eating disorder also met criteria for at least one other psychiatric disorder such as depression.
Each eating disorder was associated with higher levels of suicidal thinking compared to those without an eating disorder.
Significance
The prevalence of these disorders and their association with coexisting disorders, role impairment, and suicidal thinking suggest that eating disorders represent a major public health concern. In addition, the significant rates of subthreshold eating conditions support the notion that eating disorders tend to exist along a spectrum and may be better recognized by doctors if they included a broader range of symptoms. In addition, the findings clearly underscore the need for better access to treatment specifically for eating disorders.

Reference
Swanson SA, Crow SJ, LeGrange D, Swendsen J, Merikangas KR. Prevalence and correlates of eating disorders in adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement. Archives of General Psychiatry. Online ahead of print March 7, 2011.

Brain Activity Patterns in Anxiety-Prone People Suggest Deficits in Handling Fear

Anxiety as a personality trait appears to be linked to the functioning of two key brain regions involved in fear and its suppression, according to an NIMH-funded study. Differences in how these two regions function and interact may help explain the wide range of symptoms seen in people who have anxiety disorders. The study was published February 10, 2011 in the journal, Neuron. Social Worker Continuing Education
Background
Anxiety disorders are characterized by an excessive, irrational dread of everyday situations. Some people may experience general, chronic anxiety, while others become anxious in response to one or more specific triggers. Many studies have implicated two brain regions in anxiety—the amygdala in fear responses and the ventral prefrontal cortex (vPFC) in suppressing or regulating fear. Questions remain, however, about how trait anxiety—a person's typical anxiety level on any given day—affects amygdala and vPFC functioning.

To explore these questions, Sonia Bishop, Ph.D., of the University of California Berkeley (at the University of Cambridge (UK) at the time of data collection), and colleagues designed a series of experiments to determine how the amygdala and vPFC responded in three types of situations:

Cued fear—a neutral signal or cue is followed by an aversive event. In this study, the cue was an actor in a video placing his hands over his ears and the aversive event was a loud scream. The cue provided a reliable prediction of the aversive event. Cued fear can be compared to the situation-specific type of anxiety experienced by those with a specific phobia, such as a fear of heights.
Contextual fear—a neutral cue and an aversive event occur independently of each other. The cue did not provide a reliable prediction of the aversive event. Contextual fear may be similar to the non-specific anxiety that affects people with generalized anxiety disorder.
Safety—a neutral signal or cue occurs alone without an aversive event. The safety situation served as a comparison for the other two situations.
The researchers assessed the level of trait anxiety of 23 healthy study participants, ages 18 to 41. Each participant underwent a training session that exposed them to the above conditions. Two days after the training session, participants had their brain activity recorded through functional magenetic resonance imaging (fMRI), a noninvasive imaging method, while re-exposed to the cued fear, contextual fear, and safety conditions in the scanner.

Results from the Study
Participants with high trait anxiety showed greater amygdala response to cued fear situations compared to those with low trait anxiety. According to the researchers, this finding suggests that individual differences in amygdala response may contribute to differences in vulnerability to cue-specific anxiety disorders, such as specific phobia.

Participants with low trait anxiety showed increased vPFC activity in response to cued fear and more strongly sustained vPFC activity during contextual fear situations, compared to those with high trait anxiety. Notably, vPFC activity in participants with low trait anxiety occurred before the aversive event had ceased. The researchers suggest that this process—engaging brain areas that help to suppress fear even when the source of fear is still present—may help to protect against chronic anxiety disorders even when stressful life events are ongoing.

Significance
The study's findings support a potential role of the amygdala in vulnerability to anxiety disorders and a potential role of the vPFC in protection against them.

"Individual differences in the functioning of one or both of these brain regions may help account for the variability in symptoms across different anxiety disorders," said Bishop. "A better understanding of these processes may help inform treatment choice and predict treatment response."

This study was supported in part by a Biobehavioral Research Award for Innovative New Scientists (BRAINS) from NIMH. Dr. Bishop was one of 12 researchers to receive this award in 2010.

Reference
Indovina I, Robbins TW, Núñez-Elizalde AO, Dunn BD, Bishop SJ. Fear-Conditioning Mechanisms Associated with Trait Vulnerability to Anxiety in Humans. Neuron. 2011 Feb 10;69(3):563-71.

Combination Treatment for Psychotic Depression Holds Promise

A combination of an atypical antipsychotic medication and an antidepressant known as a selective serotonin reuptake inhibitor (SSRI) may be more effective in treating psychotic depression than an atypical antipsychotic alone, according to results from an NIMH-funded clinical study. Social Worker Continuing Education
Background
Psychotic depression is characterized by major depression accompanied by symptoms such as hallucinations, delusions, and breaks with reality. A person with psychotic depression may be unwilling or unable to care for him or herself and often is admitted to the hospital. Typically, psychotic depression is treated with electroconvulsive therapy (ECT), known to be effective but not always acceptable to patients and their families. It is less commonly treated with an antipsychotic or an antipsychotic plus an antidepressant.

Results of the Study
In a 12-week trial, all 259 participants were required to have psychotic depression with at least one delusion or irrational belief, although not all had hallucinations. Participants were randomly assigned to one of two treatments—the atypical antipsychotic olanzapine (Zyprexa) plus the SSRI sertraline (Zoloft) (combination therapy), or to olanzapine plus a placebo, or inactive, pill (monotherapy). Barnett S. Meyers, M.D., of Cornell University, and colleagues compared rates of remission and side effects among the participants. They also compared the responses of the 117 patients younger than 60 with the responses of the 142 patients older than 60 to determine if the two age groups responded differently.

The researchers conducted assessments at the beginning of the trial, weekly for the first six weeks, and then every other week until week 12. They found that 42 percent of those on combination therapy remitted compared to 24 percent of those on the monotherapy, with no significant differences in remission rates between age groups. Combination therapy's superiority became most evident between weeks eight and 12 of the trial.

Overall, the two age groups experienced comparable side effects. Both groups experienced significant increases in cholesterol and triglyceride levels, and both gained weight. However, the younger age group gained twice as much on average—about 14 pounds—compared to the older group, which gained an average of 7 pounds. This finding is consistent with other reports that have found older adults tend to gain less weight with atypical antipsychotics, specifically olanzapine, the researchers said. However, older participants also tended to be on lower doses of the antipsychotic than the younger adults, which may partially explain the disparity in weight gain, according to the researchers.

Unexpectedly, older participants had no more difficulty tolerating the medications than younger participants, nor were they any more likely to experience falls, sedation or have greater movement disorder symptoms than younger participants.

Overall, about 45 percent of participants dropped out of the study, although the drop-out rate was lower in the combination treatment group (37 percent) compared to the monotherapy group (53 percent).

Significance
Because the drop-out rate was relatively high and no follow-up data on those who discontinued were collected, the authors caution against applying the study's results to clinical practice prematurely. Still, the authors suggest that combination therapy holds promise as an alternative therapy to ECT. "Psychotic depression is difficult to treat," said NIMH Director Thomas R. Insel, M.D. "This study provides insight into one approach to treatment that may be a valid alternative for many patients who cannot or will not undergo ECT."

What's Next
Longer-term studies are needed to evaluate side effects. "Future research must weigh the benefits of continuing atypical antipsychotic medication beyond 12 weeks against the risks of associated metabolic side effects," lead author Meyers concluded.

Reference
Meyers BS, Flint AJ, Rothschild AJ, Mulsant BH, Whyte EM, Peasley-Miklus C, Papademetriou E, Leon AC, Heo M for the STOP-PD study group. A double-blind randomized controlled trial of olanzapine plus sertraline versus olanzapine plus placebo for psychotic depression—The Study of Pharmacotherapy of Psychotic Depression (STOP-PD). Archives of General Psychiatry. 2009;66(3):838-847.

Prescription Drug Abuse in the Workplace

Illicit drugs and misuse of alcohol are not the only substances that can affect health and safety in workplaces. Prescription drugs, when used without a prescription and without the supervision of a doctor, can also have adverse effects. Workers can become sleepy or anxious or depressed or confused, from the improper use of prescription drugs. As important, when these drugs are used improperly, they can pose risks to employees, their coworkers, and the overall workplace itself. The risks associated with nonmedical use of prescription drugs in workplaces can escalate when workers’ jobs require caution and safety to prevent injury, such as those of transportation workers, assembly line workers, construction workers, nuclear-power plant workers, and the like. Social Worker Continuing Education

What Is Prescription Drug Abuse?
Prescription drug abuse has been identified as a growing problem in American workplaces. In the National Survey on Drug Use and Health (NSDUH), SAMHSA defines prescription drug abuse as the use of prescription pain relievers, tranquilizers, stimulants, or sedatives without a prescription of the respondent’s own or simply for the experience or feeling the drug causes. This definition covers a wide range of behaviors, from misusing prescription medications to get high, stay awake, or get to sleep to using someone else’s medication to address a legitimate medical need. What may seem like a harmless sharing of medications can lead to addiction, misdiagnosis of illnesses, life-threatening circumstances, and death.

Are Prescription Drugs Safe?
Prescription drugs are safe when they are taken as directed under a doctor’s orders. Fear of addiction and dependence should not stop an individual from taking medications that can help treat his or her problems, nor prevent a physician from prescribing appropriate medications. Proper usage of prescription drugs can help workers protect their health and thus perform more productively in the workplace. However, when taken for nonmedical or recreational purposes, prescription drugs are no safer than illicit or street drugs. The misconception of prescription drugs as legal and “safe,” even when abused, is particularly strong among young adults.

Most prescription drug abusers obtain their drugs free from a friend or relative. In 2006, 55.7 percent of individuals 12 and older who had used pain relievers nonmedically in the previous 12 months said they got their drugs this way.2 Other ways of acquiring prescription drugs include “doctor shopping” to get multiple prescriptions, taking them from a friend or relative, or buying them from a friend, relative, or dealer. It appears that the Internet is not a significant source of prescription drugs, such as opioid analgesics, for most users.

Prescription Drug Abuse Is a Growing Problem
Multiple sources of data make it clear that this problem is a growing one, especially for teens and young adults, which means that employers need to be aware of the problem. Data from the Treatment Episode Data Set show that admissions for treatment
of prescription and over-the-counter (OTC) drug abuse rose from 3 percent of all admissions in 1999 to 4 percent in 2002. The escalation seems to come from
increased rates of abuse of narcotic painkillers, which more than doubled between 1992 and 2002. As of 2003, 3 percent of admissions were for abuse of nonheroin opiates. According to the Drug Abuse Prescription drugs are safe when taken as directed under a doctor’s orders and as dispensed.

Seasonal Affective Disorder

Seasonal affective disorder (SAD), also known as winter depression or winter blues, is a mood disorder in which people who have normal mental health throughout most of the year, experience depressive symptoms in the winter or, less frequently, in the summer,spring or autumn, repeatedly, year after year. In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), SAD is not a unique mood disorder, but is "a specifier of major depression". Once regarded skeptically by the experts, seasonal affective disorder is now well established. Epidemiological studies estimate that its prevalence in the adult population of the US ranges from 1.4 percent (Florida) to 9.7 percent (New Hampshire). Social Worker Continuing Education
The US National Library of Medicine notes that "some people experience a serious mood change when the seasons change. They may sleep too much, have little energy, and may also feel depressed. Though symptoms can be severe, they usually clear up."[4] The condition in the summer is often referred to as reverse seasonal affective disorder, and can also include heightened anxiety.

SAD was first formally described and named in 1984 by Norman E. Rosenthal and colleagues at the National Institute of Mental Health.

There are many different treatments for classic (winter-based) seasonal affective disorder, including light therapy with sunlight or bright lights, antidepressant medication, cognitive-behavioral therapy, ionized-air administration,and carefully timed supplementation of the hormone melatonin.

Symptoms

Symptoms of SAD may consist of difficulty waking up in the morning, morning sickness, tendency to oversleep as well as to overeat, and especially a craving for carbohydrates, which leads to weight gain. Other symptoms include a lack of energy, difficulty concentrating on completing tasks, and withdrawal from friends, family, and social activities. All of this leads to the depression, pessimistic feelings of hopelessness, and lack of pleasure which characterize a person suffering from this disorder.

Diagnostic criteria

According to the American Psychiatric Association DSM-IV criteria, Seasonal Affective Disorder is not regarded as a separate disorder. It is called a "course specifier" and may be applied as an added description to the pattern of major depressive episodes in patients with major depressive disorder or patients with bipolar disorder. The "Seasonal Pattern Specifier" must meet four criteria: depressive episodes at a particular time of the year; remissions or mania/hypomania at a characteristic time of year; these patterns must have lasted two years with no nonseasonal major depressive episodes during that same period; and these seasonal depressive episodes outnumber other depressive episodes throughout the patient's lifetime. The Mayo Clinic describes three types of SAD, each with its own set of symptoms. In the popular culture, sometimes the term "seasonal affective disorder" is applied inaccurately to the normal shift to lower energy levels in winter, leading people to believe they have a physical problem that should be addressed with various therapies or drugs.

Physiology

Seasonal mood variations are believed to be related to light. An argument for this view is the effectiveness of bright-light therapy. SAD is measurably present at latitudes in the Arctic region, such as Finland (64º 00´N) where the rate of SAD is 9.5%. Cloud cover may contribute to the negative effects of SAD.

The symptoms of SAD mimic those of dysthymia or even major depressive disorder. There is also potential risk of suicide in some patients experiencing SAD. One study reports 6-35% of sufferers required hospitalization during one period of illness. At times, patients may not feel depressed, but rather lack energy to perform everyday activities.

Various proximate causes have been proposed. One possibility is that SAD is related to a lack of serotonin, and serotonin polymorphisms could play a role in SAD, although this has been disputed. Mice incapable of turning serotonin into N-acetylserotonin (by Serotonin N-acetyltransferase) appear to express "depression-like" behavior, and antidepressants such as fluoxetine increase the amount of the enzyme Serotonin N-acetyltransferase, resulting in an antidepressant-like effect. Another theory is that the cause may be related to melatonin which is produced in dim light and darkness by the pineal gland, since there are direct connections, via the retinohypothalamic tract and the suprachiasmatic nucleus, between the retina and the pineal gland.

Subsyndromal Seasonal Affective Disorder is a milder form of SAD experienced by an estimated 14.3% (vs. 6.1% SAD) of the U.S. population. The blue feeling experienced by both SAD and SSAD sufferers can usually be dampened or extinguished by exercise and increased outdoor activity, particularly on sunny days, resulting in increased solar exposure. Connections between human mood, as well as energy levels, and the seasons are well documented, even in healthy individuals. Mutation of a gene expressing melanopsin has been implicated in the risk of having Seasonal Affective Disorder.

Take Your Holiday Spirit into the New Year by Linda Davis

The holiday season is a time of great generosity as people reflect on the previous year, think about why they are thankful, and look for ways to support those in need. It is important to remember that homelessness organizations need your help year-round. When you feel like donating your time or money this holiday season, consider waiting until another time next year. If you are a provider, don’t be afraid to ask volunteers and donors to extend their generosity into the New Year. Here are some ideas. Content:

Consider throwing a holiday party at a local homeless service agency in January, February or March, rather than in November or December. The holidays are often a time of abundance for these programs. Many special meals, donations and services are provided by an army of volunteers that are eagerly anticipated, and soon disappear after December.

If you are considering volunteering during the holiday season, why not put it off until later in the winter, or even in the spring or summer? The months after the holidays can be especially trying for people who are homeless and your volunteer efforts would be a true gift.

At any time of year, join forces with colleagues from work, civic groups or spiritual communities. You could create and serve meals, develop care packages, or raise money to help a family with first and last month’s rent and a security deposit.

Not sure what to do and when to do it? Contact your local homeless service provider network. Decide which program you want to support and contact them to determine what they need, and when it would be most helpful.

Here are some links to help you do your holiday homework:

Continuum of Care Contacts (organized by state/region):
http://hudhre.info

United Way:
www.211.org

VolunteerMatch
www.volunteermatch.org

Idealist
www.idealist.org

Volunteers are essential to many homeless service agencies. Whether you are new to an organization or a seasoned pro, these tips will help you to make the most of your time as a volunteer. If your organization counts on volunteers, share these tips with the team – and add your own! Social Worker Continuing Education
1. Dress comfortably.
You will probably be on your feet so make sure that your shoes and clothes can go the distance.

2. Show up on time and ready to work.
Chances are your program relies on volunteers, so be punctual and let someone know when you will be late or absent.

3. Let your supervisor know when you arrive.
Even if you are a regular volunteer, check in at the beginning of your shift to find out where you can pitch in.

4. Don’t be afraid to ask questions.
Staff appreciate the gift of your time and want you to feel comfortable. Asking questions helps to clarify expectations for everyone.

5. Know where and when to have conversations with consumers and staff.
Many programs have rules about loitering in certain areas and prefer that volunteers finish their assigned tasks before spending time talking with consumers and team members.

6. Be open-minded.
As a volunteer, you may be asked to assist with a variety of tasks, depending on the changing needs of your agency. Don’t be afraid to step outside of your comfort zone and try something new.

7. Know your boundaries.
Burnout is an issue for direct service providers and volunteers. Be a sensitive listener, but understand the limitations of your role. Volunteers are not expected to do the work of case managers or clinicians.

8. Have a sense of humor.
Working in homeless services brings many challenges and rewards. When you are faced with a tough situation, a little humor goes a long way.

9. Don’t be afraid to make suggestions.
You bring a different perspective that can be very valuable.

10. Remember that your contribution matters.

FEMA Highlights Holiday Gifts That Increase Preparedness

Release Number: HQ-09-149

WASHINGTON, D.C. -- This year Federal Emergency Management Agency (FEMA) has assembled a list of gift ideas for the holidays to help keep your family and friends prepared. Emergencies can happen at any moment; these gifts can serve as a great starting point to ensure that your friends and family have an emergency communications plan, a disaster supply kit, and stay informed about emergencies in their area.

“Disasters can happen anytime, anywhere and the holiday season provides a great opportunity to ensure that you and your loved ones are taking simple steps to be prepared,” said FEMA Administrator Craig Fugate. “As families gather this holiday season, I encourage everyone to take a few minutes and discuss what you would do in case of an emergency or disaster. The public is the most important member of our nation’s emergency response team and the more the public does to be prepared, the more successful this team will be.”

The most important thing any individual can do is take a few minutes to discuss with their family, friends and loved ones what they will do in the case of an emergency or disaster. This includes developing a simple family communications plan and identifying how you would get in touch with loved ones and where you might meet if you are separated when an emergency or disaster takes place.

Additionally, there are simple supplies that can go a long way in the case of an emergency or disaster that would make great gifts this holiday season.

A list of possible gifts that may assist in disasters includes:

•Disaster kits for homes, offices and autos (first aid kits; food, water and prescription medications for 72 hours; i.e., extra clothing, blankets, and flashlights).
•NOAA weather radios with extra batteries.
•Enrollment in a CPR or first-aid class.
•Smoke detectors.
•Fire extinguishers (for kitchen, garage, car, etc.)
•Foldable ladders for second-story escape in a fire.
•Car kits (emergency flares, shovels, ice scrapers, flashlights and fluorescent distress flags).
•Pet Disaster kits (food, water, leashes, dishes and carrying case or crate).
•Battery powered lamps
This year, consider at least one of these ideas. You just may save the life of a friend or family member. For more information and preparedness tips, please visit www.ready.gov and www.fema.gov.

FEMA's mission is to support our citizens and first responders to ensure that as a nation we work together to build, sustain, and improve our capability to prepare for, protect against, respond to, recover from, and mitigate all hazards.
Social Worker Continuing Education http://www.aspirace.com

Older Adult Depression During the Holidays

According to Mental Health America, more than two million of the 34 million Americans age 65 and older suffer from some form of depression - and during the holidays this number climbs. For many Americans, the holiday season is a time of good cheer, family celebrations, and socialization with friends. Yet for some people, particularly the elderly, it's a time of loneliness, reflections of the past and anxiety about the future. During the holidays, older adults may feel more acutely the absence of loved ones, the distance of family members, and the passing of time. Traditions and reunions that were once observed may no longer be possible which may result in an absence of holiday meaning and significance for the elderly individual. Some major factors contributing to holiday depres-sion in the elderly include:

. Being alone or separated from loved ones,
. Loss of independence,
. Financial limitations,
. Failing eyesight (inability to read or write personal holiday correspondence),
. Loss of mobility and/or the inability to attend religious services.

Although sadness and grief are a normal part of life, depression is not a normal part of growing older. Depression is an illness which can be prevented and treated. Some of the warning signs of late-life depression include:

. Persistent sadness
. Lack of energy or interest in things that were once enjoyable
. Withdrawal from regular social activities
. Feelings of worthlessness or helplessness
. Frequent tearfulness
. Slowed thinking or response
. Excessive worry about health or finances
. Weight changes
. Pacing and fidgeting
. Changes in sleep patterns
. Inability to concentrate
. Staring off into space or at the television for prolonged periods of time

For many older adults there may be stigma attached to asking for help and they may have trouble discussing depression or mental illness. Understand that open communication is needed and that it may take more than one conversation to get the individual to agree to get help. If necessary, offer to call the individual's doctor or clergy and accompany the senior to an appointment. It is important to let the older adult know that depression is not part of growing old, that it is treatable, and that their lives can be better.

The National Registry for Evidence-based Programs and Practices

An Introduction

The Substance Abuse and Mental Health Services Administration (SAMHSA) developed the National Registry of Effective Prevention Programs in 1998 to better facilitate effective identification and dissemination of prevention programs targeting substance abuse. The newly revamped system, now the National Registry of Evidence-based Programs and Practices (NREPP), has expanded to include programs and practices for preventing and/or treating mental health and substance use disorders.

NREPP seeks to bridge the science to service gap by providing easily accessible information on the best practices and programs.

Without the identification, broad dissemination, and implementation of evidence-based practices (EBPs) for older adults, this vulnerable population faces delivery of services that are unsystematic and possibly ineffective or harmful. Delivery of effective and reliable services to older adults can decrease the disabilities and impairments associated with mental health problems and substance abuse in late life, while increasing the quality of life for this rapidly growing population.

Inclusion within NREPP is highly valued and potentially advantageous. SAMHSA and many other Federal and State agencies are increasingly awarding grants to programs that utilize EBPs. Because of NREPP's strong adherence to promoting EBPs, it serves as a rich resource for states, communities, public and private researchers and specific programs seeking to implement or promote specific evidence-based mental health and substance abuse prevention and treatment services for older adults.

The TAC is positioned to assist interested programs, practitioners, and researchers to learn more about NREPP and help determine whether they would be solid candidates for NREPP consideration. Programs targeted for the NREPP process are thoroughly evaluated, focusing on program outcomes. As a preliminary step prior to NREPP submission, the TAC analyzes program strengths and gaps to determine if the program is suitable for NREPP review, i.e., has sufficient supporting evidence for submission. If a program is found to be in need of further technical assistance in order to get NREPP-ready, TAC staff is available to work with program staff regarding gaps and ways to address these issues. For those programs ready for submission, the TAC will package their materials and submit them for review and evaluation by three independent NREPP reviewers on the basis of scientific merit and utility.

Programs reviewed by NREPP are placed into one of five categories: (5) Effective Program or Practice, (4) Conditionally Effective Program or Practice, (3) Emerging Program or Practice, (2) Program or Practice of Interest and (1) Insufficient Current Support.

Recently, the TAC highlighted the NREPP process in a poster presentation at the 3rd National Prevention Summit held in Washington, DC. We look forward to the further identification of and coordination with potential NREPP programs. If you are aware of a successful program serving older adults, please contact us at OlderAmericansTAC@westat.com or 1-888-281-8010 and provide the program name, along with contact information. In addition to the identification of programs and support throughout the NREPP process, TAC staff receives frequent requests regarding evidence-based practices and programs. While NREPP itself is unable to focus on knowledge dissemination, the TAC can assist with disseminating successful programs and practices and promote the use of recognized evidence-based activities.
LCSW and Social Worker Continuing Education

2009-2010 Influenza (Flu) Season

What was the 2009-2010 flu season like?
Flu seasons are unpredictable in a number of ways, including when they begin, how severe they are, how long they last and which viruses will spread. There were more uncertainties than usual going into the 2009-2010 flu season because of the emergence of the 2009 H1N1 influenza virus (previously called "novel H1N1" or "swine flu") in the spring of 2009. This virus caused the first influenza pandemic (global outbreak of disease caused by a novel influenza virus) in more than 40 years. The United States experienced its first wave of 2009 H1N1 activity in the spring of 2009, followed by a second, larger wave of 2009 H1N1 activity in the fall and winter, during typical “flu season” time for the U.S. For information about 2009 H1N1 flu, visit the CDC 2009 H1N1 website.

The 2009-2010 flu season began very early, with 2009 H1N1 viruses predominating and causing high levels of flu activity much earlier in the year than during most regular flu seasons. Activity peaked in October and then declined quickly to below baseline levels by January. While activity was low and continuing to decline, 2009 H1N1 viruses were still reported in small numbers through the spring and summer of 20101. Additional information about flu activity during the 2009-2010 season can be found in the MMWR article "Update: Influenza Activity – United Sates, 2009-10 Season."

1Mustaquim, D et al. Update: Influenza Activity – United States, 2009-10 Season. 2010; 59: 901-908.

When did the flu season peak?
The weekly percentage of outpatient visits for influenza-like illness (ILI) peaked at the end of October at 7.6%, a level higher than the three previous influenza seasons, as reported by the U.S. Outpatient ILI Surveillance Network (ILINet). This percentage decreased to 1.0% by the middle of May, 2010. The number of states reporting widespread influenza activity peaked at 49 at the end of October, and decreased to zero by the beginning of January. By the middle of May, no states were reporting widespread or regional influenza activity and most states were reporting sporadic or no flu activity. In most years, seasonal influenza activity peaks in January or February. (See graph of peak influenza activity by month in the United States from 1976-2009.)

How severe was the season?
2009 H1N1 activity was relatively more severe among people younger than 65 years of age compared with non-pandemic influenza seasons. Influenza activity was associated with significantly higher pediatric mortality, and higher rates of hospitalizations in children and young adults than previous seasons. The 2009-10 influenza season was relatively less severe among people 65 years and older than compared with usual flu seasons. Like seasonal flu, people with certain chronic medical conditions were at greater risk of serious flu complications during the 2009-10 pandemic season, including hospitalizations and deaths. In fact, an estimated 80% of adult hospitalizations and 65% of child hospitalizations related to 2009 H1N1 occurred in people with one or more underlying medical conditions1. Additional information about severity of the 2009-2010 season can be found in the MMWR article “Update: Influenza Activity – United Sates, 2009-10 Season.”

How is severity characterized?
The overall health impact (e.g., illnessess, hospitalizations and deaths) of a flu season varies from year to year. Based on available data from U.S. influenza surveillance systems monitored and reported by CDC, the severity of a flu season can be judged according to a variety of criteria, including:

•The number and proportion of flu laboratory tests that are positive;
•The proportion of visits to physicians for influenza-like illness (ILI);
•The proportion of all deaths that are caused by pneumonia and flu;
•The number of flu-associated deaths among children; and
•The flu-associated hospitalization rate among children and adults.
A season's severity is determined by assessing several of these measures and by comparing them with previous seasons.

How effective is the seasonal flu vaccine?
The ability of flu vaccine to protect a person depends on two things: 1) the age and health status of the person getting vaccinated, and 2) the similarity or "match" between the virus strains in the vaccine and those circulating in the community. If the viruses in the vaccine and the influenza viruses circulating in the community are closely matched, vaccine effectiveness is higher. If they are not closely matched, vaccine effectiveness can be reduced. However, it's important to remember that even when the viruses are not closely matched, the vaccine can still protect many people and prevent flu-related complications. Such protection is possible because antibodies made in response to the vaccine can provide some protection (called cross-protection) against different, but related strains of influenza viruses. The vaccine may be somewhat less effective in elderly persons and very young children, but vaccination can still prevent serious complications from the flu.
For more information about seasonal flu vaccine effectiveness, visit "How Well Does the Seasonal Flu Vaccine Work?"

What did CDC do to monitor effectiveness of flu vaccines for the 2009-10 season?
Every year CDC carries out evaluations and collaborates with outside partners to assess the effectiveness of seasonal flu vaccines.

Were last season’s vaccines a good match for circulating viruses?
Flu viruses are constantly changing (called antigenic drift) – they often change from one season to the next or they can even change within the course of one flu season. Experts must pick which viruses to include in the vaccine many months in advance in order for vaccine to be produced and delivered on time. (For more information about the seasonal flu vaccine virus selection process, visit "Selecting the Viruses in the Influenza (Flu) Vaccine.") Because of these factors, there is always the possibility of a less than optimal match between circulating flu viruses and the viruses in the seasonal flu vaccine.
Because there were few seasonal flu viruses (as opposed to 2009 H1N1 viruses) in circulation during the 2009-2010 season, vaccine effectiveness (VE) studies could not be performed for the 2009-2010 seasonal vaccine. CDC was able to estimate VE for the 2009 H1N1 vaccine. The estimate for overall VE for the 2009 H1N1 vaccine was approximately 62%.

Why were two vaccines needed last season?
The 2009-2010 season was very unusual. The emergence of a new and very different H1N1 virus meant that two vaccines were needed: one to prevent seasonal influenza viruses that were anticipated to spread and another to prevent influenza caused by the newly emerged 2009 H1N1 virus. As usual, components of the seasonal flu vaccine were decided upon well in advance of the season and vaccine production was well underway by the time the new 2009 H1N1 virus emerged. If the 2009 H1N1 virus had emerged sooner, it would have been included in the seasonal vaccine. Therefore, a second flu vaccine was created to protect against the new flu virus. 2009 H1N1 was by far the dominant virus in circulation last season, and the 2009 H1N1 vaccine was a very good match; 99.5% of the 2009 H1N1 virus specimens tested during the season were related to the virus used to develop the 2009 H1N1 vaccine.

The 2010-2011 seasonal flu vaccine will protect against the 2009 H1N1 virus and 2 other flu viruses.

What did CDC do to monitor antiviral resistance in the United States during the 2009-10 season?
Antiviral resistance means that a virus has changed in such a way that antiviral drugs have become less effective in treating or preventing illnesses caused by the virus. Samples of viruses collected from around the United States and the world are studied to determine if they are resistant to any of the four FDA-approved influenza antiviral drugs.

CDC routinely collects viruses through a domestic and global surveillance system to monitor for changes in influenza viruses. CDC conducted surveillance and testing of seasonal influenza viruses and 2009 H1N1 influenza viruses to check for antiviral resistance. CDC also implemented enhanced surveillance across the United States to monitor resistance in 2009 H1N1 viruses. By the end of the 2009-2010 season, almost all (98.9%) of the 2009 H1N1 influenza viruses tested for antiviral resistance at CDC were susceptible to oseltamivir (Tamiflu®), and all of the viruses tested were susceptible to zanamivir (Relenza®). CDC also worked with the state public health departments and the World Health Organization to collect additional information on antiviral resistance in the United States and worldwide. The information collected assisted in making informed public health policy recommendations.

For information about 2009 H1N1 flu, visit http://www.cdc.gov/h1n1flu/
LCSW and Social Worker Continuing Education http://www.aspirace.com