Showing posts with label LPC CEU. Show all posts
Showing posts with label LPC CEU. Show all posts
September 12, 2013
Professional Counselor Continuing Education
November 23, 2011
Older adults in home health care at elevated risk for unsafe meds
New study shows 40 percent of seniors cared for by a home health agency are taking a prescription that is potentially unsafe or ineffective to them
NEW YORK (Nov. 21, 2011) -- Older adults receiving home health care may be taking a drug that is unsafe or ineffective for someone their age. In fact, nearly 40 percent of seniors receiving medical care from a home health agency are taking at least one prescription medication that is considered potentially inappropriate to seniors, a new study in the Journal of General Internal Medicine has revealed LPC Ceus
The study's researchers, led by Dr. Yuhua Bao, assistant professor of public health at Weill Cornell Medical College, found that home health care patients aged 65 and over are prescribed Potentially Inappropriate Medications, or PIMs, at rates three times higher than patients who visit a medical office. The researchers' data shows that home health care patients are taking 11 medications on average, and that the concurrent use of multiple medications is a strong indicator of the presence of PIMs.
"Elderly patients receiving home health care are usually prescribed medications by a variety of physicians, and it's a great challenge for home health care nurses to deal with prescriptions from many sources," says Dr. Bao.
Still, she sees the home health care model offering potential for improving this situation. "Having a medical professional enter an elderly patient's home is an opportunity to do a proper medication review and reconciliation," Dr. Bao explains.
The study used data from the National Home and Hospice Care Survey, conducted in 2007 by the Centers for Disease Control and Prevention (CDC), which is the most recent nationally representative epidemiological survey of home health patients. The 2002 Beers Criteria, an expert-panel-generated list that itemizes 77 medications or groups of medications considered inappropriate for elderly people, was the basis for the PIMs chosen.
In a review of data of 3,124 home health patients 65 years of age or older, the researchers found 38 percent were taking at least one PIM. Senior patients taking 15 or more medications were five to six times as likely to be prescribed PIMs as patients taking seven or fewer medications. Of those seniors taking at least one PIM, 21 percent were taking 15 or more medications.
According to Dr. Bao, the study, if anything, underestimates the prevalence of PIMs taken by home health patients: The researchers were not able to look at potentially problematic drug-to-drug interactions or drug-and-disease interactions because data were not available.
There is no one reason why PIMs are prevalent in home health care settings. "Anecdotal evidence shows that many physicians are not aware of what is on the PIM list," says Dr. Bao. "In our fragmented health care system, we generally don't have an electronic reference for a patient that lists all medications from different physicians, and there isn't a readily available means for professionals to share essential information. Enhanced physician communication with home health care nurses may help to address the problem, as well as better communication among physicians."
Dr. Bao sees incentives for improvement in communication and care coordination in the implementation of the Patient Protection and Affordable Care Act passed by the U.S. Congress in 2010. "The current payment system doesn't provide incentives to optimize coordination of care," says Dr. Bao. "But when providers in different settings as a group are held responsible for outcomes and costs of care through, for example, an accountable care organization -- a concept promoted in the Affordable Care Act -- this could create an impetus to break the communication barriers that currently exist."
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Co-authors include Huibo Shao, Tara F. Bishop, Bruce R. Schackman and Martha L. Bruce -- all from Weill Cornell Medical College.
The study was funded by the National Institute of Mental Health. The authors do not have conflicts of interest.
Weill Cornell Medical College
Weill Cornell Medical College, Cornell University's medical school located in New York City, is committed to excellence in research, teaching, patient care and the advancement of the art and science of medicine, locally, nationally and globally. Physicians and scientists of Weill Cornell Medical College are engaged in cutting-edge research from bench to bedside, aimed at unlocking mysteries of the human body in health and sickness and toward developing new treatments and prevention strategies. In its commitment to global health and education, Weill Cornell has a strong presence in places such as Qatar, Tanzania, Haiti, Brazil, Austria and Turkey. Through the historic Weill Cornell Medical College in Qatar, the Medical College is the first in the U.S. to offer its M.D. degree overseas. Weill Cornell is the birthplace of many medical advances -- including the development of the Pap test for cervical cancer, the synthesis of penicillin, the first successful embryo-biopsy pregnancy and birth in the U.S., the first clinical trial of gene therapy for Parkinson's disease, and most recently, the world's first successful use of deep brain stimulation to treat a minimally conscious brain-injured patient. Weill Cornell Medical College is affiliated with NewYork-Presbyterian Hospital, where its faculty provides comprehensive patient care at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. The Medical College is also affiliated with the Methodist Hospital in Houston. For more information, visit weill.cornell.edu.
November 03, 2011
Advice to divorcees: Go easy on yourself
Divorce is tough, for just about everyone. But some people move through a breakup without overwhelming distress, even if they're sad or worried about money, while others get stuck in the bad feelings and can't seem to climb out. What accounts for the difference? LPC CEUs
Self-compassion, says an upcoming study in Psychological Science, a journal published by the Association for Psychological Science. Self-compassion—a combination of kindness toward oneself, recognition of common humanity, and the ability to let painful emotions pass—"can promote resilience and positive outcomes in the face of divorce," says psychologist David A. Sbarra, who conducted the study with University of Arizona colleagues Hillary L. Smith and Matthias R. Mehl. Independent of other personality traits, that one capacity predicts better adjustment shortly after divorce and up to nine months later.
The findings have implications for helping people learn to weather breakups in better health and better spirits.
"We're not interested in the basic statement, 'People who are coping better today do better nine months from now.' That doesn't help anybody," says Sbarra. "The surprising part here is that when we look at a bunch of positive characteristics"—such as self-esteem, resistance to depression, optimism, or ease with relationships—"this one characteristic—self-compassion— uniquely predicts good outcomes."
The study involved 105 people, 38 men and 67 women, whose mean age was about 40; they'd been married over 13 years and divorced an average of three to four months. On the first visit, participants were asked to think about their former partner for 30 seconds, then talk for four minutes about their feelings and thoughts related to the separation.
Four trained coders listened to the audio files and rated the participants' levels of self-compassion, using a standard measure of the construct. The participants also were assessed for other psychological traits, such as depression and their "relationship style." At the initial visit, three months later, and then after either six or nine months participants reported on their adjustment to the divorce, including the frequency with which they experienced intrusive thoughts and emotions about the separation and their ex-partner.
As expected, the people with high levels of self-compassion at the start both recovered faster and were doing better after a period of months.
How can these data help people going through divorce? Sbarra's friends, knowing what he studies, often ask for such advice.
"It's not easy to say, 'Be less anxious.' You can't change your personality so easily. We also know that women do better than men. But you can't change your sex. What you can change is your stance with respect to your experience." Understanding your loss as part of bigger human experience helps assuage feelings of isolation, he says. Mindfulness—noting jealousy or anger without judgment or rumination—lets you turn your mind to life in the present without getting stuck in the past.
Can all this be taught? The researchers are unsure but optimistic. Says Sbarra: "This study opens a window for how we can potentially cultivate self-compassion among recently separated adults" and help smooth the journey through one of life's most difficult experiences.
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For more information about this study, please contact: David A. Sbarra at sbarra@email.arizona.edu.
The APS journal Psychological Science is the highest ranked empirical journal in psychology. For a copy of the article "When Leaving Your Ex, Love Yourself: Observational Ratings of Self-compassion Predict the Course of Emotional Recovery Following Marital Separation" and access to other Psychological Science research findings, please contact Lucy Hyde at 202-293-9300 or lhyde@psychologicalscience.org.
February 20, 2011
Social Phobia Patients Have Heightened Reactions to Negative Comments
In a study using functional brain imaging, NIMH scientists found that when people with generalized social phobia were presented with a variety of verbal comments about themselves and others ("you are ugly," or "he's a genius," for example) they had heightened brain responses only to negative comments about themselves. Knowledge of the social cues that trigger anxiety and what parts of the brain are engaged when this happens can help scientists understand and better treat this anxiety disorder. LPC Continuing Education
Background
Generalized social phobia (GSP) is the most common of all anxiety disorders. It is marked by overwhelming anxiety and self-consciousness in social situations. One approach to understanding anxiety disorders is to use functional brain imaging (fMRI) to explore how the brain responds to different types of social signals. fMRI can provide information on the relative activity—and thus the engagement—of different parts of the brain by tracking the local demands made for oxygen delivered by circulating blood. Scientists using this technology have reported, for example, that people with GSP have heightened responses to a variety of positive, negative, and neutral facial expressions, not just expressions that others perceive as threatening.
Results of this Study
People with GSP had heightened responses to negative comments (relative to a comparison group without the disorder) in two brain areas: the first, the medial prefrontal cortex (MPFC), is involved in the sense and evaluation of self; the second, the amygdala, is central to emotional processing. The responses revealed by scanning paralleled the participants' self-report of how they felt after seeing the various positive, negative, and neutral comments presented.
Significance
This work, conducted by NIMH intramural investigators Karina Blair, Ph.D., Daniel Pine, M.D., and colleagues, provided information on the specific social cues that trigger anxiety in people with GSP. It adds to previous evidence that the amygdala is involved and, in implicating the MPFC, gives clues for further research to explore on how people with GSP interpret social cues. Functional brain scanning can thus help to define patterns of brain functioning that underlie anxiety disorders, providing information that can inform treatment.
What's Next?
A previous study by these investigators found that the reaction of the brain to facial expressions was different in people with GSP than in those with general anxiety disorder (GAD). This suggests that the two disorders do not represent mild and severe forms in a single spectrum of anxiety disorders, but two neurologically different disorders.
Continuing research will reexamine these differences to see if they occur across different tasks, providing confirmation for understanding them as different disorders, which could lead to more targeted and effective forms of treatment for each disorder. Future studies will also explore more deeply the nature of the thought process underlying the reaction of people with GSP to negative comments about themselves and the interaction of the amygdala and MPFC. Finally, brain scanning offers a means to study the effects of treatment; scanning can, for example, provide information on the effects of medications in these parts of the brain.
Left amygdala (left) and medial prefrontal cortex (circled in yellow, right) activated strongly in people with social phobia (in comparison to those without GSP) in response to criticism of themselves.
References
Blair, K. et al. American Journal of Psychiatry. 2008 Sep;165(9):1193-202. Epub 2008 May 15. PMID: 18483136
Blair, K. et al. Archives of General Psychiatry. 2008 Oct;65(10):1176-1184.
February 04, 2011
Key Molecule in Inflammation-Related Depression Confirmed
Scientists have confirmed the role of an immune-activated enzyme in causing inflammation-related depression-like symptoms in mice. The work clarifies how the immune system can trigger depression and, more broadly, demonstrates the potential of this animal model for exploring the relationship between chronic inflammation—a common feature of diseases such as heart disease, cancer, and diabetes—and depression. LPC Continuing Education
Background
When an individual is infected with viruses or bacteria, cells of the immune system respond by secreting proteins called cytokines. These cytokines not only trigger inflammation and orchestrate the body's immune response against the infection, but they also cause changes in behavior, such as fatigue and withdrawal. Beyond these commonly experienced behavioral signs of illness, previous research has shown that cytokines can also cause depression in people with physical illnesses but who have no prior history of mental illness. For instance, around one-third of patients receiving the cytokine interferon-α for treatment of cancer or hepatitis C develop major depression. Clinical evidence has suggested that an enzyme (IDO) activated by these same cytokines might be a key player.
This Study
In this work, scientists used a weakened form of the tuberculosis relative, bacille Calmette-Guérin (BCG), to model chronic inflammation. This strain of bacteria is used outside the U.S. as a vaccine for tuberculosis. Infection of mice with high doses of BCG persistently activates the immune system; as a consequence, the mice develop depressive-like behavior after initial signs of illness have subsided. This study demonstrated that mice in which the gene for IDO is knocked out, or in which IDO is chemically blocked, do not exhibit depressive-like effects. The authors conclude that IDO is a necessary step in the development of this immunity-related depression.
Significance
The compound used in this work to block IDO may have potential as a treatment for depression in instances when immunotherapy such as interferon-α is used. In addition, chronic, low-grade inflammation is a feature not only of infectious diseases, but conditions like cancer, diabetes, obesity, and heart disease. Depression co-occurs frequently with these common diseases and is associated with poorer prospects for future health. Work in this animal model has the potential to provide insight into the role of chronic inflammation in precipitating depression that is often associated with these chronic conditions.
Scientists at the University of Illinois, Urbana-Champaign, led by Jason O'Connor, Robert Dantzer, and Keith Kelley, conducted this work with collaborators at the Centre National de la Recherche Scientifique, Bordeaux, France, and Miles Herkenham at the National Institute of Mental Health. The National Institute of Mental Health and the National Institute on Aging funded this research.
What's Next
The use of BCG in this mouse model offers a means to explore the molecular cascade induced by IDO that leads to inflammation-associated depression. The exact mechanism by which IDO causes these depressive behaviors is not yet clear; exploration of the downstream effects of IDO may provide additional avenues for developing approaches to blocking the development of immune-related depression.
Reference
O'Connor, J.C., Lawson, M.A., Andre, C., Briley, E.M., Szegedi, S.S., Lestage, J., Castanon, N., Herkenham, M., Dantzer, R., and Kelley, K.W. Induction of IDO by Bacille Calmette-Guerin Is Responsible for Development of Murine Depressive-Like Behavior. Journal of Immunology 2009 Mar 1;182(5):3202-12. PMID: 19234218
January 18, 2011
Symptoms of Bipolar Disorder May Go Undiagnosed in Some Adults with Major Depression
Nearly 40 percent of people with major depression may also have subthreshold hypomania, a form of mania that does not fully meet current diagnostic criteria for bipolar disorder, according to a new NIMH-funded study. The study was published online ahead of print August 15, 2010, in the American Journal of Psychiatry. LPC CEUs
Background
Mania is a symptom of bipolar disorder. According to the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV), it is generally defined as a discrete period of increased energy, activity, euphoria or irritability that leads to marked impairment in one’s daily life. The DSM-IV states that a manic episode lasts for one week or more, and may sometimes require hospitalization. Hypomania is defined as a milder form of mania that lasts for four days at a time, but does not interfere with one’s daily activities. The majority of people diagnosed with bipolar disorder experience repeated episodes of hypomania rather than mania.
For this new study, Kathleen Merikangas, PhD., of NIMH, and colleagues aimed to characterize the full spectrum of mania by identifying hypomanic episodes that last less than four days among those diagnosed with major depression. They described this type of hypomania as subthreshold hypomania. Merikangas and colleagues used data from 5,692 respondents of the National Comorbidity Survey Replication (NCS-R), a nationally representative survey of American adults ages 18 and older.
Results of the Study
The researchers found that nearly 40 percent of those identified as having major depression also had symptoms of subthreshold hypomania. Compared to those with major depression alone, those with depression plus subthreshold hypomania tended to be younger at age of onset and to have had more coexisting health problems, more episodes of depression and more suicide attempts. They also found that among those with subthreshold hypomania, a family history of mania was just as common as it was among people with bipolar disorder.
Significance
According to the researchers, the findings indicate that many adults with major depression may in fact have mild but clinically significant symptoms of bipolar disorder. In addition, because many with subthreshold hypomania had a family history of mania, the researchers suggest that subthreshold hypomania may be predictive of future hypomania or mania. Previous research has indicated that young people with subthreshold hypomania symptoms are more likely to develop bipolar disorder over time, compared to those without subthreshold hypomania, said the authors.
What’s Next
The researchers suggest that depression and mania may be defined as dimensions, rather than as discrete diagnostic categories. Clinicians should be aware that patients who report repeated episodes of subthreshold hypomania may have a risk of developing mania, the researcher concluded.
Reference
Angst J, Cui L, Swendsen J, Rothen S, Cravchik A, Kessler R, Merikangas K. Major depressive disorder with sub-threshold bipolarity in the National Comorbidity Survey Replication. American Journal of Psychiatry. Online ahead of print August 15, 2010.
January 11, 2011
Violence and Mental Illness: The Facts
The discrimination and stigma associated with mental illnesses largely stem from the link between mental illness and violence in the minds of the general public, according to the U.S. Surgeon General (DHHS, 1999). The belief that persons with mental illness are dangerous is a significant factor in the development of stigma and discrimination (Corrigan, et al., 2002). The effects of stigma and discrimination are profound. The Presidents New Freedom Commission on Mental Health found that stigma leads others to avoid living, socializing, or working with, renting to, or employing people with mental disorders - especially severe disorders, such as schizophrenia. It leads to low self-esteem, isolation, and hopelessness. It deters the public from seeking and wanting to pay for care. Responding to stigma, people with mental health problems internalize public attitudes and become so embarrassed or ashamed that they often conceal symptoms and fail to seek treatment (New Freedom Commission, 2003).
This link is often promoted by the entertainment and news media. For example, Mental Health America, (formerly the National Mental Health Association) reported that, according to a survey for the Screen Actors? Guild, characters in prime time television portrayed as having a mental illness are depicted as the most dangerous of all demographic groups: 60 percent were shown to be involved in crime or violence. Also most news accounts portray people with mental illness as dangerous (Mental Health America, 1999). The vast majority of news stories on mental illness either focus on other negative characteristics related to people with the disorder (e.g., unpredictability and unsociability) or on medical treatments. Notably absent are positive stories that highlight recovery of many persons with even the most serious of mental illnesses (Wahl, et al., 2002). Inaccurate and stereotypical representations of mental illness also exist in other mass media, such as films, music, novels and cartoons (Wahl, 1995).
Most citizens believe persons with mental illnesses are dangerous. A longitudinal study of American?s attitudes on mental health between 1950 and 1996 found, ?the proportion of Americans who describe mental illness in terms consistent with violent or dangerous behavior nearly doubled.? Also, the vast majority of Americans believe that persons with mental illnesses pose a threat for violence towards others and themselves (Pescosolido, et al., 1996, Pescosolido et al., 1999).
As a result, Americans are hesitant to interact with people who have mental illnesses. Thirty-eight percent are unwilling to be friends with someone having mental health difficulties; sixty-four percent do not want someone who has schizophrenia as a close co-worker, and more than sixty-eight percent are unwilling to have someone with depression marry into their family (Pescosolido, et al., 1996).
But, in truth, people have little reason for such fears. In reviewing the research on violence and mental illness, the Institute of Medicine concluded, ?Although studies suggest a link between mental illnesses and violence, the contribution of people with mental illnesses to overall rates of violence is small,? and further, ?the magnitude of the relationship is greatly exaggerated in the minds of the general population (Institute of Medicine, 2006). For people with mental illnesses, violent behavior appears to be more common when there?s also the presence of other risk factors. These include substance abuse or dependence; a history of violence, juvenile detention, or physical abuse; and recent stressors such as being a crime victim, getting divorced, or losing a job (Elbogen and Johnson, 2009).
In addition:
•"Research has shown that the vast majority of people who are violent do not suffer from mental illnesses (American Psychiatric Association, 1994)."
•". . . The absolute risk of violence among the mentally ill as a group is still very small and . . . only a small proportion of the violence in our society can be attributed to persons who are mentally ill (Mulvey, 1994)."
People with psychiatric disabilities are far more likely to be victims than perpetrators of violent crime (Appleby, et al., 2001). Researchers at North Carolina State University and Duke University found that people with severe mental illnesses, schizophrenia, bipolar disorder or psychosis, are 2 ½ times more likely to be attacked, raped or mugged than the general population (Hiday, et al., 1999).
People with mental illnesses can and do recover. People with mental illnesses can recover or manage their conditions and go on to lead happy, healthy, productive lives. They contribute to society and make the world a better place. People can often benefit from medication, rehabilitation, talk therapy, self help or a combination of these. One of the most important factors in recovery is the understanding and acceptance of family and friends. LPC CEUs
•"Most people who suffer from a mental disorder are not violent there is no need to fear them. Embrace them for who they are normal human beings experiencing a difficult time, who need your open mind, caring attitude, and helpful support (Grohol, 1998)."
References
American Psychiatric Association. (1994). Fact Sheet: Violence and Mental Illness. Washington, DC: American Psychiatric Association.
Appleby, L., Mortensen, P. B., Dunn, G., & Hiroeh, U. (2001). Death by homicide, suicide, and other unnatural causes in people with mental illness: a population-based study. The Lancet, 358, 2110-2112.
Corrigan, P.W., Rowan, D., Green, A., et al. (2002) .Challenging two mental illness stigmas: Personal responsibility and dangerousness. Schizophrenia Bulletin, 28, 293-309.
DHHS. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999. http://www.surgeongeneral.gov/library/mentalhealth/toc.html
Elbogen, E.B. & Johnson, S.C. (2009). The Intricate Link Between Violence and Mental Disorder Results >From the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry, 66(2):152-161.
Grohol, J. M. (1998). Dispelling the violence myth. Psych Central. Available: http://psychcentral.com/archives/violence.htm
Hiday, V.A., Swartz, M.S., Swanson, J.W., et al. (1999). Criminal victimization of persons with severe mental illness. Psychiatric Services, 50, 62?68.
Institute of Medicine, Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: Institute of Medicine, 2006.
Mental Health America. American Opinions on Mental Health Issues. Alexandria: NMHA, 1999.
Mulvey, E. P. (1994). Assessing the evidence of a link between mental illness and violence. Hospital and Community Psychiatry, 45, 663-668.
New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America. Final Report. DHHS Pub. No. SMA-03-3832. Rockville, MD: 2003.
Pescosolido, B.A., Martin, J.K., Link, B.G., et al. Americans? Views of Mental Health and Illness at Century?s End: Continuity and Change. Public Report on the MacArthur Mental health Module, 1996 General Social Survey. Bloomington: Indiana Consortium for Mental Health Services Research and Joseph P. Mailman School of Public Health, Columbia University, 2000. Available: http://www.indiana.edu/~icmhsr/amerview1.pdf
Pescosolido, B.A., Monahan, J. Link, B.G. Stueve, A., & Kikuzawa, S. (1999). The public?s view of the competence, dangerousness, and need for legal coercion of persons with mental health problems. American Journal of Public Health, 89, 1339-1345.
Wahl, O. (1995). Media Madness: Public Images of Mental Illness. New Brunswick, NJ: Rutgers University Press.
Wahl, O.F., et al. (2002). Newspaper coverage of mental illness: is it changing? Psychiatric Rehabilitation Skills, 6, 9-31.
For more information on how to address discrimination and social exclusion, contact the SAMHSA Resource Center to Promote Acceptance, Dignity, and Social Inclusion Associated with Mental Health (ADS Center), a program of the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services at http://promoteacceptance.samhsa.gov, e-mail promoteacceptance@samhsa.hhs.gov, or call 800?540?0320.
December 21, 2010
A Flu Vaccine that Lasts
NIH Scientists Consider Prospects for a Universal Influenza Vaccine
WHAT:
The costly, time-consuming process of making, distributing and administering millions of seasonal flu vaccines would become obsolete if researchers could design a vaccine that confers decades-long protection from any flu virus strain. Making such a universal influenza vaccine is feasible but licensing it may require innovation on several fronts, including finding new ways to evaluate the efficacy of vaccine candidates in clinical trials, conclude scientists from the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health.
In a Nature Medicine commentary, authors Anthony S. Fauci, M.D., NIAID director, and Gary J. Nabel, M.D., Ph.D., director of the NIAID Vaccine Research Center, contrast the envisioned universal influenza vaccine with today’s seasonal influenza vaccines. Current seasonal flu vaccines prompt immune responses that mimic those made following natural exposure to the flu virus. Both exposure and vaccination elicit antibodies directed at the roundish head portion of a lollypop-shaped flu protein called hemagglutinin (HA). But the composition of HA’s head changes from year to year, gradually becoming unrecognizable to previously made antibodies. Thus, vaccination—which induces antibodies tailored to that year’s HA head region—must be repeated annually to maintain immunity to the virus.
A universal flu vaccine would have to elicit a type of immune response that rarely occurs naturally, note Drs. Fauci and Nabel. A detailed understanding of flu virus structure may make such a vaccine possible, they add. For example, scientists have identified a region of HA’s stem that is shared among diverse strains, and a research group at NIAID’s Vaccine Research Center recently created influenza vaccines that elicit antibodies aimed at this shared region, rather than at the quick-changing head. Animals that received the experimental vaccines were protected from a diverse array of flu virus strains.
In essence, say the authors, thanks to the growing body of knowledge about flu viruses and their interactions with the cells of humans and animals they infect, it may one day be possible to make a universal flu vaccine that improves on nature. They also outline how such a vaccine might proceed through stages of clinical testing and on toward licensing. For example, they sort the 16 known influenza virus subtypes into three tiers based on their likelihood of causing widespread disease in humans. Drs. Fauci and Nabel suggest that vaccine development might be prioritized to produce first-generation universal influenza vaccine candidates that protect against multiple virus strains within the highest priority group. LPC CEUs
For more information about NIAID research on influenza, visit the NIAID flu Web portal.
ARTICLE:
GJ Nabel and AS Fauci. Induction of unnatural immunity: Prospects for a broadly protective universal influenza vaccine. Nature Medicine DOI: nm.2272 (2010).
WHO:
NIAID Director Anthony S. Fauci, M.D., and Gary J. Nabel, M.D., Ph.D., director, Vaccine Research Center, NIAID, are available to discuss their paper.
CONTACT:
To schedule interviews, please contact Anne A. Oplinger in the NIAID Office of Communications at 301-402-1663 or niaidnews@niaid.nih.gov.
December 16, 2010
Coping with the Holidays After the Death of a Loved One or when you Are a Victim/Crime Survivor
You Can Make It Through the Holidays
Many among us have struggled with the cloud of sadness that may surround the holidays when a friend or family has experienced a tragedy such as a sudden violent death or a serious physical or emotional injury. The onslaught of holiday cheer may seem too much to bear. Holidays may give rise to new or returning bouts of depression, panic attacks, and other forms of anxiety for those whose lives have been affected. Victims of crime, family members, friends, and work colleagues may re-experience life-changing traumas through flashbacks, nightmares, and overwhelming sadness. Some have trouble sleeping, while others don't want to get out of bed. Tears may come easily, often when least expected. Old ailments, including headaches, gastrointestinal problems, and other aches and pains may return.
Many victims and families, however, have found that holidays can be manageable if they take charge of the season, rather than letting it take charge of them.
Families who have made this difficult journey offer some suggestions to help those who may be just starting down this path.
Change Traditions
Trying to make this holiday seem like holidays of the past can intensify the difference. Gather the family together early and decide which traditions to keep and which to let go. Change holiday plans to accommodate the needs and wishes of those who are hurting the most. Pay particular attention to the physical needs of someone who has acquired a disability as a result of victimization.
Create a Special Tribute
Some families light a special candle and place it on a holiday table to honor the memory of a loved one who has died. Others keep a chair empty and place a flower or other memorial on the seat. Some write treasured remembrances and place them on a special plate or in a bowl for those who wish to read them. Families of a surviving victim may want to honor that person by openly expressing gratitude for his or her presence.
Consider Carefully Where to Spend the Holidays
Many people think going away will make the holidays easier. This may be helpful if you are traveling to a place where you will feel loved and nurtured. However, if travel is arranged as a means of trying to avoid the holiday atmosphere, remember that American holidays are celebrated throughout this country and in many parts of the world. It is impossible to escape holiday reminders.
Accept grieving friends and family members as they are; don't try to tell them how they should feel or state that you "understand" how they feel. Focus on giving unconditional support.
Balance Solitude With Sociability
Rest and solitude can help renew strength. Friends and family, however, can be a wonderful source of support. If you are invited to holiday outings, make an effort to go. Attend concerts or other cultural events that lift your spirits. You may surprise yourself by enjoying special outings, even if you feel like crying later.
Relive Fond Memories
Attempting to go through the holidays pretending that nothing has happened can be a heavy and unrealistic burden. Think about holiday seasons you have enjoyed in the past and identify memories you want to hold in your heart forever. No one can take those away from you. Celebrate them and be grateful. If feelings of sadness pop up at inappropriate times, such as at work or in a public gathering, try thinking about what you have, rather than what you have lost. Focus on the blessing of the memories in your heart.
Set Aside Some "Letting Go" Time
Schedule time to be alone and release sad and lonely, pent-up feelings. You may want to cry or write about your thoughts and feelings. If someone has died, you may choose to write a letter to say "goodbye," "I love you," or "I'm sorry." Even though it may feel strange, allow your loved one to write back to you through your pen. You may be surprised at what you write. By setting aside special times to allow painful feelings to surface, it becomes easier to postpone expressing them in public.
Counter the Conspiracy of Silence
Family members may consciously or unconsciously conspire to avoid mentioning the tragedy in your family. This is usually a well-intentioned but misguided attempt to protect your feelings. If this seems to be happening, take the initiative and talk to your family about the importance of talking openly about what has happened and sharing your feelings of loss or sadness. Encourage them to tell stories about your loved one and to look for opportunities to refer to him or her by name.
LPC Continuing Education
Notice the Positive
Some people conclude that facing the holidays is simply "awful." But deciding prematurely that "everything about life is awful" is too strong a generalization from a personal tragedy. Although you may have difficult times during the holidays, you also may experience joy. Accept the love and care of others. Reach out to someone else who is suffering. Give yourself permission to feel sad and to experience joy.
Consider shopping online as an alternative to the frenzy of mall shopping-but don't try to "buy" your way out of sad feelings.
Find a Creative Outlet
If you have difficulty talking about your feelings, look for a creative way to express yourself. Write a poem or story that you can share with others. Buy watercolors or oils and put your feelings on paper or canvas, even if only splashes of color. Contribute to a favorite charity or organization in your loved one's memory-either financially or by volunteering to help. Buy gifts for less fortunate children, a hospital, or a nursing home.
Remember the Children
Listen to them. Celebrate them. Cherish them.
Children may have deep feelings that can be overlooked if you spend all your time focusing on yourself. Putting up holiday decorations can be a draining emotional experience, but these symbols are very significant to children. A friend or relative likely will be happy to help decorate or purchase and wrap gifts.
Protect Your Health
Physical and emotional stress changes the chemical balance in your system and can make you ill. Eat healthy food and avoid over-indulging in sweets. Drink plenty of water, even if you don't feel thirsty. Avoid alcohol, which can be a depressant. Take a multivitamin. Get 7 to 8 hours of sleep each night. Talk with your doctor about an antidepressant or anti-anxiety medication if you think it will help. If you are unsure how a medication will affect you, talk to your doctor about your concerns.
The most valuable help usually comes from someone who shares a common experience or understands something about what you're going through.
Call Upon Available Resources
People of faith are encouraged to observe services and rituals offered by their church, synagogue, mosque, temple, or other faith community. Many "veterans of faith" offer serenity, a quiet presence, and healing wisdom. You may want to look for a support group of persons who have suffered similar experiences. The Mental Health America has affiliates around the Nation that keep lists of such local groups. If a group does not exist in your area, you can establish your own short-term group to focus on getting through the holidays. Spend as much time as possible with the people you love the most.
Most important, remember that you can't change the past, but you can take charge of the present and shape the future.
November 24, 2010
Health Department Offers Holiday Mental Health Tips
The holiday season is here, and although this is usually a joyous time of year, it can be an especially stressful time for those who experienced loss because of the recent hurricanes in Louisiana. To help people cope, the Department of Health and Hospitals-Office of Mental Health is offering counseling services and stress-relief tips. LPC CEUs, LPC Continuing Education
“We know this holiday season will be a difficult one for many of our citizens,” said DHH Secretary Dr. Fred Cerise. “The holidays can intensify feelings of grief and loneliness. Also, the contrast to past holidays may aggravate the losses people have experienced in recent months, and the stress of preparing for holidays when money is short and family members are scattered can be overwhelming. We want to let people know that help is available during this time.”
To be able to enjoy the holidays despite these feelings, DHH mental health officials advise citizens to think ahead about ways to adapt traditions to meet the current circumstances. “Don’t put pressure on yourself to have the ‘perfect’ holiday. Planning celebrations that accommodate your feelings can reduce stress and make the holiday a day of healing,” said Dr. Cheryll Bowers-Stephens, DHH-OMH assistant secretary. “Have a holiday that fits how you feel.”
To turn Thanksgiving and other upcoming holidays into a time of healing, it is important for people to acknowledge that things have changed in the past year.
“Prior to the holiday, each person should consider the question, ‘How did I get to this day in this place?’ The answer will include the many traumas of upheaval, but it will also include moments of help, support, togetherness and kindness with loved ones,” Dr. Bowers-Stephens said. “Citizens also can come up with ways to honor those who lost their lives during the hurricanes as part of their activities, as this will help them celebrate their lives. The journey from disaster to recovery takes a long time, but being aware of even small kindnesses is empowering and will help everyone tackle the difficult rebuilding that lies ahead.”
Such observations of the holiday may not help everyone to manage their emotions. Anyone experiencing overwhelming feelings of sadness or loss is encouraged to call the statewide crisis hotline at 1-800-273-TALK (8255) to speak to a certified mental health counselor.
November 15, 2010
OxyContin® Abuse and Addiction Continuing Education CEUs
The media have issued numerous reports about the apparent increase in OxyContin® abuse and addiction. Some of these reports include the following:
• In Madison, Wisconsin, a task force reported a dramatic increase in OxyContin cases since 2003. Most OxyContin making its way onto the streets of Madison and nearby communities was believed to have been stolen from local pharmacies.1
• The police chief in Billerica, Massachusetts, reported a “dramatic increase in OxyContin abuse.”2
• The distribution of OxyContin in Virginia was reported to be well above the national average. In the counties of far southwest Virginia, where the hard physical labor of coal mining and farming leads to a higher incidence of injuries, OxyContin prescriptions were generally 500 percent above the national average.3
• Sixty-nine percent of police chiefs and sheriffs said they have witnessed an increase in the abuse of painkillers such as OxyContin. The areas most affected are eastern Kentucky, New Orleans, southern Maine, Philadelphia, southwestern Pennsylvania, southwestern Virginia, Cincinnati, and Phoenix.4
These reports may reflect some of your experiences: We know many of you are treating clients addicted to OxyContin.
OxyContin has been heralded as a miracle drug that allows patients with chronic pain to resume a normal life. It has also been called pharmaceutical heroin and is thought to have been responsible for a number of deaths and robberies in areas where its abuse has been reported. Patients who legitimately use OxyContin fear that the continuing controversy will mean tighter restrictions on the medication. Those who abuse OxyContin reportedly go to great lengths—legal or illegal—to obtain the powerful drug.
At the Center for Substance Abuse Treatment (CSAT), we are not interested in fueling the controversy about the use or abuse of OxyContin. As the Federal Government’s focal point for addiction treatment information, CSAT is instead interested in helping professionals on the front line of substance abuse treatment by providing you with the facts about OxyContin, its use and abuse, and how to treat individuals who present at your treatment facility with OxyContin concerns. Perhaps these individuals are taking medically prescribed OxyContin to manage pain and are concerned about their physical dependence on the medication. Perhaps you are faced with a young adult who thought that OxyContin was a “safe” recreational drug because, after all, doctors prescribe it. Possibly changes in the availability or quality of illicit opioid drugs in your community have led to abuse of and addiction to OxyContin.
Whatever the reason, OxyContin is being abused, and people are becoming addicted. And in many instances, these people are young adults unaware of the dangers of OxyContin. Many of these individuals mix OxyContin with alcohol and drugs, and the result is all too often tragic.
Abuse of prescription drugs is not a new phenomenon. You have undoubtedly heard about abuse of Percocet®, hydrocodone, and a host of other medications. What sets OxyContin abuse apart is the potency of the drug. Treatment providers in affected areas say that they were unprepared for the speed with which an OxyContin “epidemic” developed in their communities.
We at CSAT want to make sure that you are prepared if OxyContin abuse becomes a problem in your community. This revised issue of the original Substance Abuse Treatment Advisory on OxyContin will help prepare you by
• Answering frequently asked questions about OxyContin
• Providing you with general information about semisynthetic opioids and their addiction potential
• Summarizing evidence-based protocols for treatment
• Providing you with resources for further information
For more information about OxyContin abuse and treatment, see our resource boxes and end of this document. Feel free to copy the information in the Substance Abuse Treatment Advisory and share it with colleagues so that they, too, can have the most current information about this critically important topic.
OxyContin® Frequently Asked Questions
Q: What is OxyContin?
A: OxyContin is a semisynthetic opioid analgesic prescribed for chronic or long-lasting pain. The medication’s active ingredient is oxycodone, which is also found in drugs like Percodan® and Tylox®. However, OxyContin contains between 10 and 80 milligrams (mg) of oxycodone in a timed-release tablet. Painkillers such as Tylox contain 5 mg of oxycodone and often require repeated doses to bring about pain relief because they lack the timed-release formulation.
Q: How is OxyContin used?
A: OxyContin, also referred to as “Oxy,” “O.C.,” and “Oxycotton” on the street, is legitimately prescribed as a timed-release tablet, providing as many as 12 hours of relief from chronic pain. It is often prescribed for cancer patients or those with chronic, long-lasting back pain. The benefit of the medication to people who suffer from chronic pain is that they generally need to take the pill only twice a day, whereas a dosage of another medication would require more frequent use to control the pain. The goal of chronic pain treatment is to decrease pain and improve function.
Q: How is OxyContin abused?
A: People who abuse OxyContin either crush the tablet and ingest or snort it or dilute it in water and inject it. Crushing or diluting the tablet disarms the timed-release action of the medication and causes a quick, powerful high. Those who abuse OxyContin have compared this feeling to the euphoria they experience when taking heroin. In fact, in some areas, the use of heroin is overshadowed by the abuse of OxyContin.
Purdue Pharma, OxyContin’s manufacturer, has taken steps to reduce the potential for abuse of OxyContin and other pain medications. Its Web site lists the following initiatives: funding educational programs to teach healthcare professionals how to assess and treat patients suffering from pain, providing prescribers with tamper-proof prescription pads, developing and distributing more than 1 million brochures to pharmacists and healthcare professionals to help educate them about medication diversion, working with healthcare and law enforcement officials to address prescription drug abuse, and endorsing the development of State and national prescription drug monitoring programs to detect diversion. In addition, the company is attempting to research and develop other pain management products that will be more resistant to abuse and diversion. The company estimates that it will take significant time for such products to be brought to market. For more information, visit Purdue Pharma’s Web site at www.purduepharma.com or call the company at 203–588–8069.
Q: How does OxyContin abuse differ from abuse of other pain prescriptions?
A: Abuse of prescription pain medications is not new. Two primary factors, however, set OxyContin abuse apart from other prescription drug abuse. First, OxyContin is a powerful drug that contains a much larger amount of the active ingredient, oxycodone, than other prescription pain relievers. By crushing the tablet and either ingesting or snorting it, or by injecting diluted OxyContin, people who abuse the opioid feel its powerful effects in a short time, rather than over a 12-hour span. Second, great profits can be made in the illegal sale of OxyContin. A 40-mg pill costs approximately $4 by prescription, yet it may sell for $20 to $40 on the street, depending on the area of the country in which the drug is sold.5
OxyContin can be comparatively inexpensive if it is legitimately prescribed and if its cost is covered by insurance. However, the National Drug Intelligence Center reports that people who abuse OxyContin may use heroin if their insurance will no longer pay for their OxyContin prescription because heroin is less expensive than OxyContin that is purchased illegally.6
Q: Why are so many crimes reportedly associated with OxyContin abuse?
A: Many reports of OxyContin abuse have occurred in rural areas that have housed labor-intensive industries, such as logging or coal mining. These industries are often located in economically depressed areas, as well. Therefore, people for whom the drug may have been legitimately prescribed may be tempted to sell their prescriptions for profit. Substance abuse treatment providers say that the addiction is so strong that people will go to great lengths to get the drug, including robbing pharmacies and writing false prescriptions.
Q: What is the likelihood that a person for whom OxyContin is prescribed will become addicted?
A: Most people who take OxyContin as prescribed do not become addicted. The National Institute on Drug Abuse reports: “Long-term use [of opioids] can lead to physical dependence—the body adapts to the presence of the substance and withdrawal symptoms occur if use is reduced abruptly. This can also include tolerance, which means that higher doses of a medication must be taken to obtain the same initial effects. . . . Studies have shown that properly managed medical use of opioid analgesic compounds is safe and rarely causes addiction. Taken exactly as prescribed, opioids can be used to manage pain effectively.”7
One review found, “A multitude of studies indicate that the rate of opioid addiction in populations of chronic pain sufferers is similar to the rate of opioid addiction within the general population, falling in the range of 1 to 2 percent or less.”8
In short, most individuals who are prescribed OxyContin, or any other opioid, will not become addicted, although they may become dependent on the drug and will need to be withdrawn by a qualified physician. Individuals who are taking the drug as prescribed should continue to do so, as long as they and their physician agree that taking the drug is a medically appropriate way for them to manage pain.
Q: How can I determine whether a person who uses OxyContin is dependent on rather than addicted to OxyContin?
A: When pain patients take an opioid analgesic as directed, or to the point where their pain is adequately controlled, it is not abuse or addiction. Abuse occurs when patients take more than is needed for pain control, especially if they take it to get high. Patients who take their medication in a manner that grossly differs from a physician’s directions are probably abusing that drug.
If a patient continues to seek excessive pain medication after pain management is achieved, the patient may be addicted. Addiction is characterized by the repeated, compulsive use of a substance despite adverse social, psychological, and/or physical consequences. Addiction is often (but not always) accompanied by physical dependence, withdrawal syndrome, and tolerance. Physical dependence is defined as a physiologic state of adaptation to a substance. The absence of this substance produces symptoms and signs of withdrawal. Withdrawal syndrome is often characterized by overactivity of the physiological functions that were suppressed by the drug and/or depression of the functions that were stimulated by the drug. Opioids often cause sleepiness, calmness, and constipation, so opioid withdrawal often includes insomnia, anxiety, and diarrhea.
Pain patients, however, may sometimes develop a physical dependence during treatment with opioids. This is not an addiction. A gradual decrease of the medication dose over time, as the pain is resolving, brings the former pain patient to a drug-free state without any craving for repeated doses of the drug. This is the difference between the patient treated for pain who was formerly dependent and has now been withdrawn from medication and the patient who is opioid addicted: The patient addicted to diverted pharmaceutical opioids continues to have a severe and uncontrollable craving that almost always leads to eventual relapse in the absence of adequate treatment. This uncontrollable craving for another “rush” of the drug differentiates the patient who is “detoxified” but opioid addicted from the former pain patient. Theoretically, a person who abuses opioids might develop a physical dependence but obtain treatment in the first few months of abuse, before becoming addicted. In this case, supervised withdrawal (detoxification) followed by a few months of abstinence-oriented treatment might be sufficient for the patient who is not addicted who abuses opioids. If, however, this patient subsequently relapses to opioid abuse, then that behavior would support a diagnosis of opioid addiction. If the patient has several relapses to opioid abuse, he or she will require long-term treatment for the opioid addiction. (See the section titled Treatment and Detoxification Protocols to learn more about treatment options.)
Q: I work at a facility that does not use medication-assisted treatment. What treatment should I provide to individuals addicted to or dependent on OxyContin?
A: The majority of U.S. treatment facilities do not offer medication-assisted treatment. However, because of the strength of OxyContin and its powerful addiction potential, medical complications may be increased by quickly withdrawing individuals from the drug. Premature withdrawal may cause individuals to seek heroin, and the quality of that heroin will not be known. In addition, these individuals, if injecting heroin, may also expose themselves to HIV and hepatitis. Most people addicted to OxyContin need medication-assisted treatment. Even if individuals have been taking OxyContin legitimately to manage pain, they should not stop taking the drug all at once. Instead, their dosages should be tapered down until medication is no longer needed. If you work in a drug-free or abstinence-based treatment facility, it is important to refer patients to facilities where they can receive appropriate treatment. (See SAMHSA Resources.)
Treatment and Detoxification Protocols
OxyContin® is a powerful drug that contains a much larger amount of the active ingredient, oxycodone, than other prescription opioid pain relievers. Whereas most people who take OxyContin as prescribed do not become addicted, those who abuse their pain medication or obtain it illegally may find themselves becoming rapidly dependent on, if not addicted to, the drug.
Two types of treatment have been documented as most effective for opioid addiction. One is a long-term, residential, therapeutic community type of treatment, and the other is long-term, medication-assisted outpatient treatment. Clinical trials using medications to treat opioid addiction have generally included subjects addicted to diverted pharmaceutical opioids as well as to illicit heroin. Therefore, there is no medical reason to suppose that the patient addicted to diverted pharmaceutical opioids is any less likely to benefit from medication-assisted treatment than the patient addicted to heroin.
Some patients who are opioid addicted who have very good social supports may occasionally be able to benefit from antagonist treatment with naltrexone. This treatment works best if the patient is highly motivated to participate in treatment and has undergone adequate detoxification from the opioid of abuse. Most patients who are opioid addicted in outpatient therapy, however, do best with medication that is either an agonist or a partial agonist. Methadone is the agonist medication most commonly prescribed for opioid addiction treatment in this country. Buprenorphine is the only partial agonist approved by the Food and Drug Administration for opioid addiction treatment.
The guidelines for treating OxyContin addiction or dependence are basically no different than the guidelines the Center for Substance Abuse Treatment (CSAT) uses for treating addiction to or dependence on any opioid. However, because OxyContin contains higher dose levels of opioid than are typically found in other oxycodone-containing pain medications, higher dosages of methadone or buprenorphine may be needed to appropriately treat patients who abuse OxyContin.
Methadone or buprenorphine may be used for OxyContin addiction treatment or, for that matter, treatment for addiction to any other opioid, including the semisynthetic opioids. Medication-assisted treatment for prescription opioid abuse is not a new treatment approach. For instance, in 2002, Alaska estimated that 15,000 people abused prescription opioids in the State and that most patients receiving methadone were not addicted to heroin. In addition, a significant percentage of patients in publicly supported methadone programs were not being treated for heroin addiction but for abuse of semisynthetic opioids (e.g., hydrocodone). The Substance Abuse and Mental Health Services Administration (SAMHSA) Drug Abuse Warning Network emergency room data show that both oxycodone and hydrocodone mentions increased dramatically in the United States between 1995 and 2002.9 And when Arkansas opened its first methadone maintenance clinic in December 1993, the vast majority of its clients were not admitted for heroin addiction but for semisynthetic opioid abuse. These individuals had been traveling to other States for treatment because methadone treatment was not available near their homes.
Using the criteria above describing the difference between addiction to and dependence on OxyContin, you may be able to determine whether a patient requires treatment for opioid addiction. If this is the case, methadone or buprenorphine may be used for withdrawal. For certain patient populations, including those with many treatment failures, methadone or buprenorphine is the treatment of choice.10
“As substance abuse treatment professionals, we have the responsibility for learning as much as we can about OxyContin and then providing appropriate treatment for people addicted to it. Appropriate treatment will nearly always involve prescribing methadone, buprenorphine, or, in some cases, naltrexone,” says H. Westley Clark, M.D., J.D., Director of CSAT. “Programs that do not offer medication-assisted treatment will need to refer patients who are addicted to OxyContin to programs that do,” he adds.
It is important to assess an individual’s eligibility for medication-assisted treatment with methadone or buprenorphine to determine whether he or she is eligible for this type of treatment and whether it would be appropriate. The assessment may take place in a hospital emergency department, central intake unit, or similar place. Final assessment of an individual’s eligibility for medication-assisted treatment must be completed by treatment program staff. The preliminary assessment should include the following areas:11
• Determining the need for emergency care
• Diagnosing the presence and severity of opioid dependence
• Determining the extent of alcohol and drug abuse
• Screening for co-occurring medical and psychiatric conditions
• Evaluating an individual’s living situation, family and social problems, and legal problems
“. . . we have the responsibility for learning as much as we can about OxyContin, and then providing appropriate treatment for people who are addicted to it.”
H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM
Director, CSAT
Treatment Improvement Protocols (TIPs) and Collateral Products Addressing Opioid Addiction Treatment
TIP 40 Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction BKD500
Quick Guide for Physicians Based on TIP 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction QGPT40
KAP Keys for Physicians Based on TIP 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction KAPT40
TIP 43 Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs BKD524
Quick Guide for Clinicians Based on TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs QGCT43
KAP Keys for Clinicians Based on TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs KAPT43
SAMHSA Resources
To find a substance abuse treatment facility near you, visit the Substance Abuse Treatment Facility Locator at www.findtreatment.samhsa.gov. Call the Substance Abuse and Mental Health Services Administration Substance Abuse Treatment Hotline at 800–662–HELP for substance abuse treatment referral information.
For More Information About Treatment for Opioid Addiction
Sign up for SAMHSA’s Information Mailing System (SIMS) to receive information about the following topics:
• Grant announcements
• Funding opportunities such as competitive contract announcements
• Prevention materials and publications
• Treatment- and provider-oriented materials and publications
• Research findings and reports
• Announcements of available research data sets
• Policy announcements and materials
To sign up for this free service, use one of the following methods to contact SIMS:
Web: http://sims.health.org
Mail: SAMHSA’s National Clearinghouse for Alcohol and Drug Information (NCADI)
Attn: Mailing List Manager
P.O. Box 2345
Rockville, MD 20847–2345
Phone: 800–729–6686
Fax: 301–468–6433
Attn: Mailing List Manager
Three Ways To Obtain Free Copies of All CSAT Products:
1. Call SAMHSA’s NCADI at 800–729–6686; TDD (hearing impaired) 800–487–4889
2. Visit NCADI’s Web site, www.ncadi.samhsa.gov
3. Access TIPs on line at www.kap.samhsa.gov
Substance Abuse Treatment Advisory
Substance Abuse Treatment Advisory—published on an as-needed basis for treatment providers—was written and produced under contract number 270-04-7049 by the Knowledge Application Program (KAP), a Joint Venture of JBS International, Inc., and The CDM Group, Inc., for the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). The content of this publication does not necessarily reflect the views or policies of SAMHSA or HHS.
Public Domain Notice: All material in this report is in the public domain and may be reproduced or copied without permission; citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS.
Electronic Access and Copies of Publication: This publication can be accessed electronically through the Internet at www.kap.samhsa.gov. Additional free print copies can be ordered from SAMHSA’s National Clearinghouse for Alcohol and Drug Information at 800–729–6686.
Recommended Citation: Center for Substance Abuse Treatment. “OxyContin®: Prescription Drug Abuse—2006 Revision.” Substance Abuse Treatment Advisory, Volume 5, Issue 1. Rockville, MD: Substance Abuse and Mental Health Services Administration, April 2006.
DHHS Publication No. (SMA) 06-4138
Substance Abuse and Mental Health Services Administration
Printed 2006
Notes
1. WISC-TV. OxyContin: The Good, The Bad, The Deadly. Broadcast transcript. Madison, WI: WISC-TV, February 14, 2006. www.channel3000.com/health/7013912/detail.html [accessed March 2, 2006].
2. Crane, J.P. Drug use by young raises flag. The Boston Globe, February 5, 2006. www.boston.com/news/local/articles/2006/02/05/drug_use_by_young_raises_flag [accessed March 2, 2006].
3. Hammack, L. Painkiller prescriptions up significantly in region. The Roanoke Times, March 28, 2004. www.roanoke.com/roatimes/news/story164817.html [accessed March 2, 2006].
4. Reuters. Powerful painkillers fueling U.S. crime rate. Redmond, WA: MSNBC.com., March 10, 2005. www.msnbc.msn.com/id/7141313 [accessed March 2, 2006].
5. National Drug Intelligence Center. Intelligence Bulletin: OxyContin Diversion, Availability, and Abuse. Johnstown, PA: National Drug Intelligence Center, U.S. Department of Justice, August 2004. www.usdoj.gov/ndic/pubs10/10550/10550p.pdf [accessed March 3, 2006].
6. National Drug Intelligence Center. Pharmaceuticals. In: National Drug Threat Assessment 2004. Johnstown, PA: National Drug Intelligence Center, U.S. Department of Justice, April 2004. www.usdoj.gov/ndic/pubs8/8731/8731p.pdf [accessed March 3, 2006].
7. National Institute on Drug Abuse (NIDA). NIDA Infofacts: Prescription Pain and Other Medications. Washington, DC: NIDA, National Institutes of Health, 2005. www.drugabuse.gov/infofacts/PainMed.html [accessed March 3, 2006].
8. Fisher, F.B. Interpretation of “aberrant” drug-related behaviors. Journal of American Physicians and Surgeons 9(1):25–28, 2004.
9. Substance Abuse and Mental Health Services Administration (SAMHSA). Emergency Department Trends From the Drug Abuse Warning Network: Final Estimates 1995–2002. DAWN Series D-24. DHHS Publication No. (SMA) 03-3780. Rockville, MD: SAMHSA, 2003. dawninfo.samhsa.gov/old_dawn/pubs_94_02/edpubs/2002final [accessed March 2, 2006].
10. Center for Substance Abuse Treatment. Detoxification and Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series 45. DHHS Publication No. (SMA) 06-4131. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2006.
11. Center for Substance Abuse Treatment. Initial screening, admission procedures, and assessment techniques. In: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 05-4048. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005, pp. 43–61.
November 14, 2010
HIV Treatment
According to Stebbing et al. (2008), "preclinical and cohort studies suggest that certain antidepressants are associated with a predisposition to cancer whereas others decrease the risk" (p. 2305). Additionally, "despite extensive data demonstrating that HIV infection and associated immunosuppression predisposes individuals to a wide range of cancers . . . (including non-AIDS-related malignancies . . .), no studies have specifically investigated the association between antidepressant use, length of antidepressant exposure, and the development of both AIDS-related and non-AIDS-related cancers in the highly active antiretroviral therapy (HAART) and pre-HAART eras" (p. 2306).
Stebbing and colleagues therefore set out "to assess whether different classes of antidepressants were associated with changes in cancer incidence in a population of HIV-1 infected individuals, based on duration of exposure" (p. 2305). The investigators found that, within a "cohort of 10,997 patients . . . attending a large HIV center during the pre-HAART and HAART eras, a total of 2,004 (18%) were prescribed antidepressants. . . . A total of 1,607 (15%) individuals were diagnosed with cancer. There were no significant associations between any class of antidepressant and any type of cancer . . . , in either the pre-HAART or HAART era" (p. 2305). Stebbing and colleagues conclude that "antidepressants, irrespective of their class, do not affect cancer risk in HIV-infected individuals" (p. 2305).
Neuropsychological Impairment
In a racially diverse sample of 93 children living with HIV, Hochhauser, Gaur, Marone, and Lewis (2008) "examined the impact of environmental risk factors on the cognitive decline normally observed with pediatric HIV disease progression" (p. 695). The investigators found that "immunosuppression was clearly associated with poorer cognitive outcome in the high-risk children" (p. 695); in other words, there was greater risk for HIV-associated cognitive decline among children living in highly stressful environments. Notably, "this relationship was not seen in those with lower levels of environmental risk" (p. 695). These findings have several implications, according to Hochhauser and colleagues:
First, while medication adherence has been shown to be worse in stressed or disorganized families . . . , it may also be most crucial for those children, as it is they whose neuropsychological functioning is at greatest risk from HIV neurotoxicity. Second, reducing environmental stressors may prove to be neuroprotective. This may be particularly important for patients for whom reducing immunosuppression . . . may be difficult or impossible. In these cases, perhaps their impact on cognitive functioning could be moderated by taking measures to reduce stress. Such interventions might include concrete actions to improve the child's home or family environment . . . or perhaps stress-reduction interventions like psychotherapy or massage therapy. (p. 696)
http://www.aspirace.com/ for lpc continuing education
Adherence to Treatment
Leserman, Ironson, O'Cleirigh, Fordiani, and Balbin (2008) "examine[d] demographic, health behavior and psychosocial correlates (e.g., stressful life events, depressive symptoms) of nonadherence" (p. 403) among 105 men and women residing in South Florida and taking antiretrovirals. Within this sample,
44.8% had missed a medication dose in the past 2 weeks, and 22.1% had missed their medication during the previous weekend. Those with three or more stressful life events in the previous 6 months were 2.5 to more than 3 times as likely to be nonadherent (in the past 2 weeks and previous weekend, respectively) compared to those without such events. Fully 86.7% of those with six or more stresses were nonadherent during the prior 2 weeks compared to 22.2% of those with no stressors. Although alcohol consumption, drug use, and symptoms of depression were related to nonadherence in the bivariate analyses, the effects of these predictors were reduced to nonsignificance by the stressful event measure. (p. 403)
Leserman and colleagues suggest that "having many stressful events may be a more robust correlate of nonadherence than depression. Persons who report more stressful events may have more chaotic lifestyles that may account for their missed medications. . . . These findings suggest that while interventions for depression may be useful, cognitive behavioral interventions that address stress and coping may have a greater impact on adherence to HIV medication" (p. 409).
Malta, Strathdee, Magnanini, and Bastos (2008) conducted a "systematic review of studies assessing adherence to HAART among HIV-positive drug users (DU[s]) and identif[ied] . . . factors associated with non-adherence to HIV treatment" (p. 1242). The investigators selected 41 peer-reviewed studies published between 1996 and 2007; these studies included
a total of 15,194 patients, the majority of whom were HIV-positive DU[s] (n = 11,628, 76.5%). Twenty-two studies assessed adherence using patient self-reports, eight used pharmacy records, three used electronic monitoring [i.e., Medication Event Monitoring Systems (MEMS) caps], six studies used a combination of patient self-report, clinical data and MEMS-caps, and two analyzed secondary data. Overall, active substance use was associated with poor adherence, as well as depression and low social support. Higher adherence was found in patients receiving care in structured settings (e.g.[,] directly observed therapy) and/or drug addiction treatment (especially substitution therapy). (p. 1242)
Malta and colleagues conclude that, although HAART adherence was lower among DUs "than other populations – especially among users of stimulants, incarcerated DU[s,] and patients with psychiatric comorbidities – adherence to HAART among HIV-positive DU[s] can be achieved. Better adherence was identified among those engaged in comprehensive services providing HIV and addiction treatment with psychosocial support" (p. 1242). Moreover, "most papers [included in this review] suggest that the adherence to HAART among HIV-positive [DU]s can be similar to those found among other [people living with HIV/AIDS], once proper timing to initiate treatment is followed, comorbidities are properly managed and treated, psychosocial support is provided, and drug treatment, particularly substitution therapy, is instituted" (p. 1253).
Stress Management
In a departure from the traditional cognitive-behavioral approach to HIV-related stress management (research about which is coincidently and conveniently summarized in the Tool Box in the Summer 2008 issue of mental health AIDS), McCain et al. (2008) conducted a "randomized clinical trial . . . to test effects of three 10-week stress management approaches – cognitive-behavioral relaxation training (RLXN), 4 focused tai chi training (TCHI), 5 and spiritual growth groups (SPRT) 6 – in comparison to a wait-listed control group (CTRL) among 252 individuals with HIV infection" (p. 431). According to the investigators, the "purpose of the research was to determine whether the three 10-week stress management interventions would improve and sustain improvements 6 months later in the domains of psychosocial functioning, quality of life, and physical health among persons with varying stages of HIV infection. These three outcome domains, along with neuroendocrine and immune mediating variables, were measured by multiple indicators derived from the psychoneuroimmunology (PNI) paradigm" (p. 431). "Interventions were conducted with groups of 6-10 participants who met in suitably equipped conference rooms in an office setting for 90-min sessions weekly for 10 weeks. Participants who attended less than 8 of the 10 intervention sessions were deemed as having incomplete treatments and classified as withdrawn from the study" (p. 433).
McCain and colleagues found that, "in comparison to the CTRL group, both the RLXN and TCHI groups less frequently used emotion-focused coping strategies, and all three intervention groups had higher lymphocyte proliferative function. Generally, decreased emotion-focused coping can be considered an enhancement in coping strategies; however, there was no concurrent increase in problem-focused or appraisal-focused coping, making interpretation of this change more tenuous" (p. 437). Similarly, "the consistent finding of increased lymphocyte proliferation indicates the interventions were associated with enhancement in immune system functional status. . . . However, because there was no significant change in salivary cortisol, the mechanism of increased lymphocyte function is not clear. Ongoing assessment of cytokine activity or patterns of production may ultimately yield insight into other mechanisms involved in immune function changes" (pp. 437-438).
Despite these challenges in interpreting the study findings, McCain and colleagues contend that, in general,
study findings support use of the PNI-based model for stress management in individuals living with HIV infection. Despite modest effects of the interventions on psychosocial functioning in this sample, the robust finding of improved immune function with these stress management approaches has important clinical implications, particularly for persons with immune-mediated illnesses. . . . Findings of this study indicate that immune function and possibly coping and quality of life may be enhanced with cognitive-behavioral stress management, tai chi, and spirituality-based interventions. While further research is needed to examine specific effects of various stress management interventions and to expand the repertoire of alternative approaches that might be effective in enhancing adaptational outcomes, this study contributes to a growing body of well-designed research that generally lends support to the integration of stress management strategies into the standard care of individuals living with HIV infection. (p. 439)
Coping, Social Support, & Quality of Life
Murphy, Greenwell, Resell, Brecht, and Schuster (2008) "investigated current autonomy among early and middle adolescents affected by maternal HIV (N = 108), as well as examined longitudinally the children's responsibility taking when they were younger (age 6-11; N = 81) in response to their mother's illness and their current autonomy as early/middle adolescents" (p. 253). Within this sample of primarily low-income Latino and African American families residing in Los Angeles County, "children with greater attachment to their mothers had higher autonomy [when performing household-centered activities], and there was a trend for children who drink or use drugs alone to have lower autonomy. In analyses of management autonomy[, which encompasses activities performed outside the home], attachment to peers was associated with higher autonomy" (p. 253). In their longitudinal analysis of this cohort, Murphy and colleagues found that "those children who had taken on more responsibility for instrumental caretaking roles directly because of their mother's illness showed better autonomy development as early and middle age adolescents" (p. 253). Importantly, the investigators also found that autonomy was associated "with 'positive' characteristics such a mother-child bond and coping self-efficacy" (p. 271). Murphy and colleagues conclude that
"parentification" of young children with a mother with HIV/AIDS – that is, the young children taking on household responsibilities due to the mother's illness – may not negatively affect later autonomy development in these children. While it may indeed have other detrimental effects, such as more absence from school and school performance . . . , in at least this limited sample of children affected by HIV, higher responsibility taking as a result of maternal HIV/AIDS among young children was associated with later early/middle adolescent higher autonomy functioning. . . . Thus, even if they experienced some distress from parentification at an earlier age, it did not interfere with their long-term early and middle adolescent autonomous functioning. (p. 272)
Murphy and colleagues acknowledge that these findings require additional exploration with larger samples. Nevertheless, the investigators stress that if
HIV-positive mothers, due to their fatigue or illness, must rely on their young children at times to perform behaviors that most children their age do not typically perform, then it is critical that there be a strong focus on the mother developing or maintaining: (1) A high level of attachment and bond between herself and the child; and (2) strong support of the child to assist in the child developing strong coping self-efficacy. . . . [I]f a child does indeed have to sometimes function in a "parentified" role, then the data from this study indicate that children with a close attachment to their mother and who have good coping self-efficacy will have higher autonomy as they develop; these are both issues that can be worked on and improved in family therapy. (p. 272)
With a sample of 104 MSM averaging 50 years of age and living with HIV, Dutch investigators (Kraaij, van der Veek, et al., 2008) assessed relationships among "coping strategies, goal adjustment, and symptoms of depression and anxiety" (p. 395). The investigators found that "cognitive coping strategies had a stronger influence on well-being than . . . behavioral coping strategies: positive refocusing, positive reappraisal, putting into perspective, catastrophizing, and other-blame were all significantly related to symptoms of depression and anxiety. In addition, withdrawing effort and commitment from unattainable goals, and reengaging in alternative meaningful goals, in [the] case that preexisting goals can no longer be reached, seemed to be a fruitful way to cope with being HIV[-]positive" (p. 395). With regard to intervention, as Kraaij and colleagues see it, "the focus of treatment could be the content of thoughts and bringing about effective cognitive change, combined with working on goal adjustment. Various studies showed the positive effects of cognitive-behavioral oriented interventions . . . and coping effectiveness training . . . in improving psychological states in HIV-infected men. Future studies should be undertaken looking at the effectiveness of intervention programs focusing on cognitions and life goals" (p. 400).
In another study by this research group with the same sample of MSM (Kraaij, Garnefski, et al., 2008), the investigators found that greater
use of positive refocusing, refocus[ing] on planning, positive reappraisal, putting into perspective, and less use of other-blame, was related to higher levels of personal growth. . . . [P]ositive reappraisal appears to be the most powerful predictor of personal growth.
Another important predictor . . . was goal self-efficacy. Respondents who reported a higher belief in their ability to adjust their goals when important goals are obstructed by being HIV-positive, reported higher levels of personal growth. (p. 303)
As in the study described above (Kraajj, van der Veek, et al., 2008), Kraajj, Garnefski, and colleagues conclude that cognitive-behavioral oriented interventions and coping effectiveness training "could be offered to improve personal growth. The specific focus of treatment could be then the content of thoughts, combined with working on goal adjustment. Ingredients of treatment should be a combination of (positive) cognitive coping strategies and goal self-efficacy" (p. 303).
---- Compiled by Abraham Feingold, Psy.D.
--------------------
4 The structured RLXN training intervention "consisted of physical and mental relaxation skills training, with a focus on individualized combinations of relaxation techniques, as well as active coping strategies for stress management. Participants were expected to routinely practice relaxation techniques during and following the intervention, and daily practice frequency was recorded each week. Each participant was given a set of eight 30-min audiotapes specifically produced for use in this study" (p. 433).
5 A focused short form of TCHI "involving eight movements was developed for this study. The intervention sequence began with a focus on breathing and balance, both key elements in all tai chi exercises. The sequence of movements taught was focused on developing each individual's skills in balancing, focused breathing, gentle physical posturing and movement, and the active use of consciousness for relaxation. Training videotapes were provided to participants for weekly and ongoing practice of the techniques" (p. 434).
6 "The SPRT . . . intervention was designed to facilitate personal exploration of spirituality and to enhance exploration of the spiritual self and awareness of the meaning and expression of spirituality. Each session was designed to explore an aspect of spirituality and included the intellectual process of knowing or apprehending spirituality; the experiential component of interconnecting one's spirit with self, others, nature, God, or a higher power; and an appreciation of the multisensory experience of spirituality. The process of weekly journal entries facilitated increased awareness and the integration of spirituality into daily life" (p. 434).
Stebbing and colleagues therefore set out "to assess whether different classes of antidepressants were associated with changes in cancer incidence in a population of HIV-1 infected individuals, based on duration of exposure" (p. 2305). The investigators found that, within a "cohort of 10,997 patients . . . attending a large HIV center during the pre-HAART and HAART eras, a total of 2,004 (18%) were prescribed antidepressants. . . . A total of 1,607 (15%) individuals were diagnosed with cancer. There were no significant associations between any class of antidepressant and any type of cancer . . . , in either the pre-HAART or HAART era" (p. 2305). Stebbing and colleagues conclude that "antidepressants, irrespective of their class, do not affect cancer risk in HIV-infected individuals" (p. 2305).
Neuropsychological Impairment
In a racially diverse sample of 93 children living with HIV, Hochhauser, Gaur, Marone, and Lewis (2008) "examined the impact of environmental risk factors on the cognitive decline normally observed with pediatric HIV disease progression" (p. 695). The investigators found that "immunosuppression was clearly associated with poorer cognitive outcome in the high-risk children" (p. 695); in other words, there was greater risk for HIV-associated cognitive decline among children living in highly stressful environments. Notably, "this relationship was not seen in those with lower levels of environmental risk" (p. 695). These findings have several implications, according to Hochhauser and colleagues:
First, while medication adherence has been shown to be worse in stressed or disorganized families . . . , it may also be most crucial for those children, as it is they whose neuropsychological functioning is at greatest risk from HIV neurotoxicity. Second, reducing environmental stressors may prove to be neuroprotective. This may be particularly important for patients for whom reducing immunosuppression . . . may be difficult or impossible. In these cases, perhaps their impact on cognitive functioning could be moderated by taking measures to reduce stress. Such interventions might include concrete actions to improve the child's home or family environment . . . or perhaps stress-reduction interventions like psychotherapy or massage therapy. (p. 696)
http://www.aspirace.com/ for lpc continuing education
Adherence to Treatment
Leserman, Ironson, O'Cleirigh, Fordiani, and Balbin (2008) "examine[d] demographic, health behavior and psychosocial correlates (e.g., stressful life events, depressive symptoms) of nonadherence" (p. 403) among 105 men and women residing in South Florida and taking antiretrovirals. Within this sample,
44.8% had missed a medication dose in the past 2 weeks, and 22.1% had missed their medication during the previous weekend. Those with three or more stressful life events in the previous 6 months were 2.5 to more than 3 times as likely to be nonadherent (in the past 2 weeks and previous weekend, respectively) compared to those without such events. Fully 86.7% of those with six or more stresses were nonadherent during the prior 2 weeks compared to 22.2% of those with no stressors. Although alcohol consumption, drug use, and symptoms of depression were related to nonadherence in the bivariate analyses, the effects of these predictors were reduced to nonsignificance by the stressful event measure. (p. 403)
Leserman and colleagues suggest that "having many stressful events may be a more robust correlate of nonadherence than depression. Persons who report more stressful events may have more chaotic lifestyles that may account for their missed medications. . . . These findings suggest that while interventions for depression may be useful, cognitive behavioral interventions that address stress and coping may have a greater impact on adherence to HIV medication" (p. 409).
Malta, Strathdee, Magnanini, and Bastos (2008) conducted a "systematic review of studies assessing adherence to HAART among HIV-positive drug users (DU[s]) and identif[ied] . . . factors associated with non-adherence to HIV treatment" (p. 1242). The investigators selected 41 peer-reviewed studies published between 1996 and 2007; these studies included
a total of 15,194 patients, the majority of whom were HIV-positive DU[s] (n = 11,628, 76.5%). Twenty-two studies assessed adherence using patient self-reports, eight used pharmacy records, three used electronic monitoring [i.e., Medication Event Monitoring Systems (MEMS) caps], six studies used a combination of patient self-report, clinical data and MEMS-caps, and two analyzed secondary data. Overall, active substance use was associated with poor adherence, as well as depression and low social support. Higher adherence was found in patients receiving care in structured settings (e.g.[,] directly observed therapy) and/or drug addiction treatment (especially substitution therapy). (p. 1242)
Malta and colleagues conclude that, although HAART adherence was lower among DUs "than other populations – especially among users of stimulants, incarcerated DU[s,] and patients with psychiatric comorbidities – adherence to HAART among HIV-positive DU[s] can be achieved. Better adherence was identified among those engaged in comprehensive services providing HIV and addiction treatment with psychosocial support" (p. 1242). Moreover, "most papers [included in this review] suggest that the adherence to HAART among HIV-positive [DU]s can be similar to those found among other [people living with HIV/AIDS], once proper timing to initiate treatment is followed, comorbidities are properly managed and treated, psychosocial support is provided, and drug treatment, particularly substitution therapy, is instituted" (p. 1253).
Stress Management
In a departure from the traditional cognitive-behavioral approach to HIV-related stress management (research about which is coincidently and conveniently summarized in the Tool Box in the Summer 2008 issue of mental health AIDS), McCain et al. (2008) conducted a "randomized clinical trial . . . to test effects of three 10-week stress management approaches – cognitive-behavioral relaxation training (RLXN), 4 focused tai chi training (TCHI), 5 and spiritual growth groups (SPRT) 6 – in comparison to a wait-listed control group (CTRL) among 252 individuals with HIV infection" (p. 431). According to the investigators, the "purpose of the research was to determine whether the three 10-week stress management interventions would improve and sustain improvements 6 months later in the domains of psychosocial functioning, quality of life, and physical health among persons with varying stages of HIV infection. These three outcome domains, along with neuroendocrine and immune mediating variables, were measured by multiple indicators derived from the psychoneuroimmunology (PNI) paradigm" (p. 431). "Interventions were conducted with groups of 6-10 participants who met in suitably equipped conference rooms in an office setting for 90-min sessions weekly for 10 weeks. Participants who attended less than 8 of the 10 intervention sessions were deemed as having incomplete treatments and classified as withdrawn from the study" (p. 433).
McCain and colleagues found that, "in comparison to the CTRL group, both the RLXN and TCHI groups less frequently used emotion-focused coping strategies, and all three intervention groups had higher lymphocyte proliferative function. Generally, decreased emotion-focused coping can be considered an enhancement in coping strategies; however, there was no concurrent increase in problem-focused or appraisal-focused coping, making interpretation of this change more tenuous" (p. 437). Similarly, "the consistent finding of increased lymphocyte proliferation indicates the interventions were associated with enhancement in immune system functional status. . . . However, because there was no significant change in salivary cortisol, the mechanism of increased lymphocyte function is not clear. Ongoing assessment of cytokine activity or patterns of production may ultimately yield insight into other mechanisms involved in immune function changes" (pp. 437-438).
Despite these challenges in interpreting the study findings, McCain and colleagues contend that, in general,
study findings support use of the PNI-based model for stress management in individuals living with HIV infection. Despite modest effects of the interventions on psychosocial functioning in this sample, the robust finding of improved immune function with these stress management approaches has important clinical implications, particularly for persons with immune-mediated illnesses. . . . Findings of this study indicate that immune function and possibly coping and quality of life may be enhanced with cognitive-behavioral stress management, tai chi, and spirituality-based interventions. While further research is needed to examine specific effects of various stress management interventions and to expand the repertoire of alternative approaches that might be effective in enhancing adaptational outcomes, this study contributes to a growing body of well-designed research that generally lends support to the integration of stress management strategies into the standard care of individuals living with HIV infection. (p. 439)
Coping, Social Support, & Quality of Life
Murphy, Greenwell, Resell, Brecht, and Schuster (2008) "investigated current autonomy among early and middle adolescents affected by maternal HIV (N = 108), as well as examined longitudinally the children's responsibility taking when they were younger (age 6-11; N = 81) in response to their mother's illness and their current autonomy as early/middle adolescents" (p. 253). Within this sample of primarily low-income Latino and African American families residing in Los Angeles County, "children with greater attachment to their mothers had higher autonomy [when performing household-centered activities], and there was a trend for children who drink or use drugs alone to have lower autonomy. In analyses of management autonomy[, which encompasses activities performed outside the home], attachment to peers was associated with higher autonomy" (p. 253). In their longitudinal analysis of this cohort, Murphy and colleagues found that "those children who had taken on more responsibility for instrumental caretaking roles directly because of their mother's illness showed better autonomy development as early and middle age adolescents" (p. 253). Importantly, the investigators also found that autonomy was associated "with 'positive' characteristics such a mother-child bond and coping self-efficacy" (p. 271). Murphy and colleagues conclude that
"parentification" of young children with a mother with HIV/AIDS – that is, the young children taking on household responsibilities due to the mother's illness – may not negatively affect later autonomy development in these children. While it may indeed have other detrimental effects, such as more absence from school and school performance . . . , in at least this limited sample of children affected by HIV, higher responsibility taking as a result of maternal HIV/AIDS among young children was associated with later early/middle adolescent higher autonomy functioning. . . . Thus, even if they experienced some distress from parentification at an earlier age, it did not interfere with their long-term early and middle adolescent autonomous functioning. (p. 272)
Murphy and colleagues acknowledge that these findings require additional exploration with larger samples. Nevertheless, the investigators stress that if
HIV-positive mothers, due to their fatigue or illness, must rely on their young children at times to perform behaviors that most children their age do not typically perform, then it is critical that there be a strong focus on the mother developing or maintaining: (1) A high level of attachment and bond between herself and the child; and (2) strong support of the child to assist in the child developing strong coping self-efficacy. . . . [I]f a child does indeed have to sometimes function in a "parentified" role, then the data from this study indicate that children with a close attachment to their mother and who have good coping self-efficacy will have higher autonomy as they develop; these are both issues that can be worked on and improved in family therapy. (p. 272)
With a sample of 104 MSM averaging 50 years of age and living with HIV, Dutch investigators (Kraaij, van der Veek, et al., 2008) assessed relationships among "coping strategies, goal adjustment, and symptoms of depression and anxiety" (p. 395). The investigators found that "cognitive coping strategies had a stronger influence on well-being than . . . behavioral coping strategies: positive refocusing, positive reappraisal, putting into perspective, catastrophizing, and other-blame were all significantly related to symptoms of depression and anxiety. In addition, withdrawing effort and commitment from unattainable goals, and reengaging in alternative meaningful goals, in [the] case that preexisting goals can no longer be reached, seemed to be a fruitful way to cope with being HIV[-]positive" (p. 395). With regard to intervention, as Kraaij and colleagues see it, "the focus of treatment could be the content of thoughts and bringing about effective cognitive change, combined with working on goal adjustment. Various studies showed the positive effects of cognitive-behavioral oriented interventions . . . and coping effectiveness training . . . in improving psychological states in HIV-infected men. Future studies should be undertaken looking at the effectiveness of intervention programs focusing on cognitions and life goals" (p. 400).
In another study by this research group with the same sample of MSM (Kraaij, Garnefski, et al., 2008), the investigators found that greater
use of positive refocusing, refocus[ing] on planning, positive reappraisal, putting into perspective, and less use of other-blame, was related to higher levels of personal growth. . . . [P]ositive reappraisal appears to be the most powerful predictor of personal growth.
Another important predictor . . . was goal self-efficacy. Respondents who reported a higher belief in their ability to adjust their goals when important goals are obstructed by being HIV-positive, reported higher levels of personal growth. (p. 303)
As in the study described above (Kraajj, van der Veek, et al., 2008), Kraajj, Garnefski, and colleagues conclude that cognitive-behavioral oriented interventions and coping effectiveness training "could be offered to improve personal growth. The specific focus of treatment could be then the content of thoughts, combined with working on goal adjustment. Ingredients of treatment should be a combination of (positive) cognitive coping strategies and goal self-efficacy" (p. 303).
---- Compiled by Abraham Feingold, Psy.D.
--------------------
4 The structured RLXN training intervention "consisted of physical and mental relaxation skills training, with a focus on individualized combinations of relaxation techniques, as well as active coping strategies for stress management. Participants were expected to routinely practice relaxation techniques during and following the intervention, and daily practice frequency was recorded each week. Each participant was given a set of eight 30-min audiotapes specifically produced for use in this study" (p. 433).
5 A focused short form of TCHI "involving eight movements was developed for this study. The intervention sequence began with a focus on breathing and balance, both key elements in all tai chi exercises. The sequence of movements taught was focused on developing each individual's skills in balancing, focused breathing, gentle physical posturing and movement, and the active use of consciousness for relaxation. Training videotapes were provided to participants for weekly and ongoing practice of the techniques" (p. 434).
6 "The SPRT . . . intervention was designed to facilitate personal exploration of spirituality and to enhance exploration of the spiritual self and awareness of the meaning and expression of spirituality. Each session was designed to explore an aspect of spirituality and included the intellectual process of knowing or apprehending spirituality; the experiential component of interconnecting one's spirit with self, others, nature, God, or a higher power; and an appreciation of the multisensory experience of spirituality. The process of weekly journal entries facilitated increased awareness and the integration of spirituality into daily life" (p. 434).
October 28, 2010
Mental Illness and How You Can Help
Mnetal Illness- How You Can Help
You can help just by being there and offering your reassurance, companionship, emotional strength and acceptance. You can make a difference just by understanding and supporting your friend throughout the course of his or her recovery and beyond. We're here to help you learn how.
Instead of blowing off a person's worries, express your interest and concern. Don't change the subject when a mental illness diagnosis comes up – ask questions, listen to ideas, and be responsive. Ask what you can do to help. If other people make insensitive remarks, don't ignore them – educate people so they understand the facts about mental illness. If someone you work with or go to school with has a mental illness, don't discriminate. Treat people with mental illness just as you would those with any other serious but treatable condition: with respect, compassion and empathy.
You can help just by being there and offering your reassurance, companionship, emotional strength and acceptance. You can make a difference just by understanding and supporting your friend throughout the course of his or her recovery and beyond. We're here to help you learn how.
Instead of blowing off a person's worries, express your interest and concern. Don't change the subject when a mental illness diagnosis comes up – ask questions, listen to ideas, and be responsive. Ask what you can do to help. If other people make insensitive remarks, don't ignore them – educate people so they understand the facts about mental illness. If someone you work with or go to school with has a mental illness, don't discriminate. Treat people with mental illness just as you would those with any other serious but treatable condition: with respect, compassion and empathy.
April 02, 2010
Stressful Life Events
Stressful Life Events
The most common psychological and social stressors in adult life include the breakup of intimate romantic relationships, death of a family member or friend, economic hardships, racism and discrimination, poor physical health, and accidental and intentional assaults on physical safety (Holmes & Rahe, 1967; Lazarus & Folkman, 1984; Kreiger et al., 1993). Although some stressors are so powerful that they would evoke significant emotional distress in most otherwise mentally healthy people, the majority of stressful life events do not invariably trigger mental disorders. Rather, they are more likely to spawn mental disorders in people who are vulnerable biologically, socially, and/or psychologically (Lazarus & Folkman, 1984; Brown & Harris, 1989; Kendler et al., 1995). Understanding variability among individuals to a stressful life event is a major challenge to research. Groups at greater statistical risk include women, young and unmarried people, African Americans, and individuals with lower socioeconomic status (Ulbrich et al., 1989; McLeod & Kessler, 1990; Turner et al., 1995; Miranda & Green, 1999).
Divorce is a common example. Approximately one-half of all marriages now end in divorce, and about 30 to 40 percent of those undergoing divorce report a significant increase in symptoms of depression and anxiety (Brown & Harris, 1989). Vulnerability to depression and anxiety is greater among those with a personal history of mental disorders earlier in life and is lessened by strong social support. For many, divorce conveys additional economic adversities and the stress of single parenting. Single mothers face twice the risk of depression as do married mothers (Brown & Moran, 1997).
The death of a child or spouse during early or midadult life is much less common than divorce but generally is of greater potency in provoking emotional distress (Kim & Jacobs, 1995). Rates of diagnosable mental disorders during periods of grief are attenuated by the convention not to diagnose depression during the first 2 months of bereavement (Clayton & Darvish, 1979). In fact, people are generally unlikely to seek professional treatment during bereavement unless the severity of the emotional and behavioral disturbance is incapacitating.
A majority of Americans never will confront the stress of surviving a severe, life-threatening accident or physical assault (e.g., mugging, robbery, rape); however, some segments of the population, particularly urban youths and young adults, have exposure rates as high as 25 to 30 percent (Helzer et al., 1987; Breslau et al., 1991). Life-threatening trauma frequently provokes emotional and behavioral reactions that jeopardize mental health. In the most fully developed form, this syndrome is called post-traumatic stress disorder (DSM-IV), which is described later in this chapter. Women are twice as likely as men to develop post-traumatic stress disorder following exposure to life-threatening trauma (Breslau et al., 1998.)
More familiar to many Americans is the chronic strain that poor physical health and relationship problems place on day-to-day well-being. Relationship problems include unsatisfactory intimate relationships; conflicted relationships with parents, siblings, and children; and “falling-out” with coworkers, friends, and neighbors. In mid-adult life, the stress of caretaking for elderly parents also becomes more common.
Relationship problems at least double the risk of developing a mental disorder, although they are less immediately threatening or potentially cataclysmic than divorce or the death of a spouse or child (Brown & Harris, 1989). Finally, cumulative adversity appears to be more potent than stressful events in isolation as a predictor of psychological distress and mental disorders (Turner & Lloyd, 1995).
Past Trauma and Child Sexual Abuse
Severe trauma in childhood may have enduring effects into adulthood (Browne & Finkelhor, 1986). Past trauma includes sexual and physical abuse, and parental death, divorce, psychopathology, and substance abuse (reviewed in Turner & Lloyd, 1995).
Child sexual abuse is one of the most common stressors, with effects that persist into adulthood. It disproportionately affects females. Although definitions are still evolving, child sexual abuse is often defined as forcible touching of breasts or genitals or forcible intercourse (including anal, oral, or vaginal sex) before the age of 16 or 18 (Goodman et al., 1997). Epidemiology studies of adults in varying segments of the community have found that 15 to 33 percent of females and 13 to 16 percent of males were sexually abused in childhood (Polusny & Follette, 1995). A recent, large epidemiological study of adults in the general community found a lower prevalence (12.8 percent for females and 4.3 percent for males); however, the definition of sexual abuse was more restricted than in past studies (MacMillan et al., 1997). Sexual abuse in childhood has a mean age of onset estimated at 7 to 9 years of age (Polusny & Follette, 1995). In over 25 percent of cases of child sexual abuse, the offense was committed by a parent or parent substitute (Sedlak & Broadhurst, 1996).
The long-term consequences of past childhood sexual abuse are profound, yet vary in expression. They range from depression and anxiety to problems with social functioning and adult interpersonal relationships (Polusny & Follette, 1995). Post-traumatic stress disorder is a common sequela, found in 33 to 86 percent of adult survivors of child sexual abuse (Polusny & Follette, 1995). In a recent review, Weiss et al. (1999) found that sexual abuse was a specific risk factor for adult-onset depression and twice as many women as men reported a history of abuse. Other long-term effects include self-destructive behavior, social isolation, poor sexual adjustment, substance abuse, and increased risk of revictimization (Browne & Finkelhor, 1986; Briere, 1992).
Very few treatments specifically for adult survivors of childhood abuse have been studied in randomized controlled trials (IOM, 1998). Group therapy and Interpersonal Transaction group therapy were found to be more effective for female survivors than an experimental control condition that offered a less appropriate intervention (Alexander et al., 1989, 1991). In the practice setting, most psychosocial and pharmacological treatments are tailored to the primary diagnosis, which, as noted above, varies widely and may not attend to the special needs of those also reporting abuse history.
Domestic Violence
Domestic violence is a serious and startlingly common public health problem with mental health consequences for victims, who are overwhelmingly female, and for children who witness the violence. Domestic violence (also known as intimate partner violence) features a pattern of physical and sexual abuse, psychological abuse with verbal intimidation, and/or social isolation or deprivation. Estimates are that 8 to 17 percent of women are victimized annually in the United States (Wilt & Olsen, 1996). Pinpointing the prevalence is hindered by variations in the way domestic violence is defined and by problems in detection and underreporting. Women are often fearful that their reporting of domestic violence will precipitate retaliation by the batterer, a fear that is not unwarranted (Sisley et al., 1999).
Victims of domestic violence are at increased risk for mental health problems and disorders as well as physical injury and death. Domestic violence is considered one of the foremost causes of serious injury to women ages 15 to 44, accounting for about 30 percent of all acute injuries to women seen in emergency departments (Wilt & Olsen, 1996). According to the U.S. Department of Justice, females were victims in about 75 percent of the almost 2,000 homicides between intimates in 1996 (cited in Sisley et al., 1999). The mental health consequences of domestic violence include depression, anxiety disorders (e.g., post-traumatic stress disorder), suicide, eating disorders, and substance abuse (IOM, 1998; Eisenstat & Bancroft, 1999). Children who witness domestic violence may suffer acute and long-term emotional disturbances, including nightmares, depression, learning difficulties, and aggressive behavior. Children also become at risk for subsequent use of violence against their dating partners and wives (el-Bayoumi et al., 1998; NRC, 1998; Sisley et al., 1999).
Mental health interventions for victims, children, and batterers are highly important. Individual counseling and peer support groups are the interventions most frequently used by battered women. However, there is a lack of carefully controlled, methodologically robust studies of interventions and their outcomes, according to a report by the Institute of Medicine and National Research Council (IOM, 1998). A research agenda for violence against women was developed (IOM, 1996) and has served as an impetus for an ongoing research program sponsored by the U.S. Departments of Justice and Health and Human Services. Clearly, there is an urgent need for development and rigorous evaluation of prevention programs to safeguard against intimate partner violence and its impact on children.
Interventions for Stressful Life Events
Stressful life events, even for those at the peak of mental health, erode quality of life and place people at risk for symptoms and signs of mental disorders. There is an ever-expanding list of formal and informal interventions to aid individuals coping with adversity. Sources of informal interventions include family and friends, education, community services, self-help groups, social support networks, religious and spiritual endeavors, complementary healers, and physical activities. As valuable as these activities may be for promoting mental health, they have received less research attention than have interventions for mental disorders. Nevertheless, there are selected interventions to help people cope with stressors, such as bereavement programs and programs for caregivers (see Chapter 5) as well as couples therapy and physical activity.
Couples therapy is the umbrella term applied to interventions that aid couples in distress. The best studied interventions are behavioral couples therapy, cognitive-behavioral couples therapy, and emotion-focused couples therapy. A recent review article evaluated the body of evidence on the effectiveness of couples therapy and programs to prevent marital discord (Christensen & Heavey, 1999). The review found that about 65 percent of couples in therapy did improve, whereas 35 percent of control couples also improved. Couples therapy ameliorates relationship distress and appears to alleviate depression. The gains from couples therapy generally last through 6 months, but there are few long-term assessments (Christensen & Heavey, 1999). Similarly, interventions to prevent marital discord yield short-term improvements in marital adjustment and stability, but there is insufficient study of long-term outcomes. The prevention programs receiving the most study are the Couple Communication Program, Relationship Enhancement, and the Prevention and Relationship Enhancement Program (Christensen & Heavey, 1999). Greater research is needed to overcome gaps in knowledge and to extend findings to a broader array of programs, to diverse populations of couples, and to a wider set of outcomes, including effects on children.
Physical activities are a means to enhance somatic health as well as to deal with stress. A recent Surgeon General’s Report on Physical Activity and Health evaluated the evidence for physical activities serving to enhance mental health (U.S. Department of Health and Human Services [DHHS], 1996). Aerobic physical activities, such as brisk walking and running, were found to improve mental health for people who report symptoms of anxiety and depression and for those who are diagnosed with some forms of depression. The mental health benefits of physical activity for individuals in relatively good physical and mental health were not as evident, but the studies did not have sufficient rigor from which to draw unequivocal conclusions (DHHS, 1996).
Prevention of Mental Disorders
A promising development in prevention of a specific mental disorder in adults occurred with the publication of results from the San Francisco Depression Research Project (Munoz et al., 1995). This study investigated 150 primary care patients who did not meet diagnostic criteria for depression and who were being seen in a public clinic for other problems. They were randomized to either psychoeducation—an 8-week cognitive behavioral course to help them control and manage moods—or to a control condition. One year later, those who received psychoeducation were found to have developed significantly fewer depression symptoms than members of the control group. This trial is noteworthy in two major respects: it was a randomized controlled trial and its participants were low-income individuals, with high representation of all major minority groups. Low-income individuals are considered a high-risk population because of studies documenting their higher prevalence of mental disorders. This study demonstrated in a methodologically rigorous fashion that depression may be preventable in some cases. It serves as a model for extending the concept of prevention to many mental disorders. Prevention research is vitally important and needs to be enhanced.
The most common psychological and social stressors in adult life include the breakup of intimate romantic relationships, death of a family member or friend, economic hardships, racism and discrimination, poor physical health, and accidental and intentional assaults on physical safety (Holmes & Rahe, 1967; Lazarus & Folkman, 1984; Kreiger et al., 1993). Although some stressors are so powerful that they would evoke significant emotional distress in most otherwise mentally healthy people, the majority of stressful life events do not invariably trigger mental disorders. Rather, they are more likely to spawn mental disorders in people who are vulnerable biologically, socially, and/or psychologically (Lazarus & Folkman, 1984; Brown & Harris, 1989; Kendler et al., 1995). Understanding variability among individuals to a stressful life event is a major challenge to research. Groups at greater statistical risk include women, young and unmarried people, African Americans, and individuals with lower socioeconomic status (Ulbrich et al., 1989; McLeod & Kessler, 1990; Turner et al., 1995; Miranda & Green, 1999).
Divorce is a common example. Approximately one-half of all marriages now end in divorce, and about 30 to 40 percent of those undergoing divorce report a significant increase in symptoms of depression and anxiety (Brown & Harris, 1989). Vulnerability to depression and anxiety is greater among those with a personal history of mental disorders earlier in life and is lessened by strong social support. For many, divorce conveys additional economic adversities and the stress of single parenting. Single mothers face twice the risk of depression as do married mothers (Brown & Moran, 1997).
The death of a child or spouse during early or midadult life is much less common than divorce but generally is of greater potency in provoking emotional distress (Kim & Jacobs, 1995). Rates of diagnosable mental disorders during periods of grief are attenuated by the convention not to diagnose depression during the first 2 months of bereavement (Clayton & Darvish, 1979). In fact, people are generally unlikely to seek professional treatment during bereavement unless the severity of the emotional and behavioral disturbance is incapacitating.
A majority of Americans never will confront the stress of surviving a severe, life-threatening accident or physical assault (e.g., mugging, robbery, rape); however, some segments of the population, particularly urban youths and young adults, have exposure rates as high as 25 to 30 percent (Helzer et al., 1987; Breslau et al., 1991). Life-threatening trauma frequently provokes emotional and behavioral reactions that jeopardize mental health. In the most fully developed form, this syndrome is called post-traumatic stress disorder (DSM-IV), which is described later in this chapter. Women are twice as likely as men to develop post-traumatic stress disorder following exposure to life-threatening trauma (Breslau et al., 1998.)
More familiar to many Americans is the chronic strain that poor physical health and relationship problems place on day-to-day well-being. Relationship problems include unsatisfactory intimate relationships; conflicted relationships with parents, siblings, and children; and “falling-out” with coworkers, friends, and neighbors. In mid-adult life, the stress of caretaking for elderly parents also becomes more common.
Relationship problems at least double the risk of developing a mental disorder, although they are less immediately threatening or potentially cataclysmic than divorce or the death of a spouse or child (Brown & Harris, 1989). Finally, cumulative adversity appears to be more potent than stressful events in isolation as a predictor of psychological distress and mental disorders (Turner & Lloyd, 1995).
Past Trauma and Child Sexual Abuse
Severe trauma in childhood may have enduring effects into adulthood (Browne & Finkelhor, 1986). Past trauma includes sexual and physical abuse, and parental death, divorce, psychopathology, and substance abuse (reviewed in Turner & Lloyd, 1995).
Child sexual abuse is one of the most common stressors, with effects that persist into adulthood. It disproportionately affects females. Although definitions are still evolving, child sexual abuse is often defined as forcible touching of breasts or genitals or forcible intercourse (including anal, oral, or vaginal sex) before the age of 16 or 18 (Goodman et al., 1997). Epidemiology studies of adults in varying segments of the community have found that 15 to 33 percent of females and 13 to 16 percent of males were sexually abused in childhood (Polusny & Follette, 1995). A recent, large epidemiological study of adults in the general community found a lower prevalence (12.8 percent for females and 4.3 percent for males); however, the definition of sexual abuse was more restricted than in past studies (MacMillan et al., 1997). Sexual abuse in childhood has a mean age of onset estimated at 7 to 9 years of age (Polusny & Follette, 1995). In over 25 percent of cases of child sexual abuse, the offense was committed by a parent or parent substitute (Sedlak & Broadhurst, 1996).
The long-term consequences of past childhood sexual abuse are profound, yet vary in expression. They range from depression and anxiety to problems with social functioning and adult interpersonal relationships (Polusny & Follette, 1995). Post-traumatic stress disorder is a common sequela, found in 33 to 86 percent of adult survivors of child sexual abuse (Polusny & Follette, 1995). In a recent review, Weiss et al. (1999) found that sexual abuse was a specific risk factor for adult-onset depression and twice as many women as men reported a history of abuse. Other long-term effects include self-destructive behavior, social isolation, poor sexual adjustment, substance abuse, and increased risk of revictimization (Browne & Finkelhor, 1986; Briere, 1992).
Very few treatments specifically for adult survivors of childhood abuse have been studied in randomized controlled trials (IOM, 1998). Group therapy and Interpersonal Transaction group therapy were found to be more effective for female survivors than an experimental control condition that offered a less appropriate intervention (Alexander et al., 1989, 1991). In the practice setting, most psychosocial and pharmacological treatments are tailored to the primary diagnosis, which, as noted above, varies widely and may not attend to the special needs of those also reporting abuse history.
Domestic Violence
Domestic violence is a serious and startlingly common public health problem with mental health consequences for victims, who are overwhelmingly female, and for children who witness the violence. Domestic violence (also known as intimate partner violence) features a pattern of physical and sexual abuse, psychological abuse with verbal intimidation, and/or social isolation or deprivation. Estimates are that 8 to 17 percent of women are victimized annually in the United States (Wilt & Olsen, 1996). Pinpointing the prevalence is hindered by variations in the way domestic violence is defined and by problems in detection and underreporting. Women are often fearful that their reporting of domestic violence will precipitate retaliation by the batterer, a fear that is not unwarranted (Sisley et al., 1999).
Victims of domestic violence are at increased risk for mental health problems and disorders as well as physical injury and death. Domestic violence is considered one of the foremost causes of serious injury to women ages 15 to 44, accounting for about 30 percent of all acute injuries to women seen in emergency departments (Wilt & Olsen, 1996). According to the U.S. Department of Justice, females were victims in about 75 percent of the almost 2,000 homicides between intimates in 1996 (cited in Sisley et al., 1999). The mental health consequences of domestic violence include depression, anxiety disorders (e.g., post-traumatic stress disorder), suicide, eating disorders, and substance abuse (IOM, 1998; Eisenstat & Bancroft, 1999). Children who witness domestic violence may suffer acute and long-term emotional disturbances, including nightmares, depression, learning difficulties, and aggressive behavior. Children also become at risk for subsequent use of violence against their dating partners and wives (el-Bayoumi et al., 1998; NRC, 1998; Sisley et al., 1999).
Mental health interventions for victims, children, and batterers are highly important. Individual counseling and peer support groups are the interventions most frequently used by battered women. However, there is a lack of carefully controlled, methodologically robust studies of interventions and their outcomes, according to a report by the Institute of Medicine and National Research Council (IOM, 1998). A research agenda for violence against women was developed (IOM, 1996) and has served as an impetus for an ongoing research program sponsored by the U.S. Departments of Justice and Health and Human Services. Clearly, there is an urgent need for development and rigorous evaluation of prevention programs to safeguard against intimate partner violence and its impact on children.
Interventions for Stressful Life Events
Stressful life events, even for those at the peak of mental health, erode quality of life and place people at risk for symptoms and signs of mental disorders. There is an ever-expanding list of formal and informal interventions to aid individuals coping with adversity. Sources of informal interventions include family and friends, education, community services, self-help groups, social support networks, religious and spiritual endeavors, complementary healers, and physical activities. As valuable as these activities may be for promoting mental health, they have received less research attention than have interventions for mental disorders. Nevertheless, there are selected interventions to help people cope with stressors, such as bereavement programs and programs for caregivers (see Chapter 5) as well as couples therapy and physical activity.
Couples therapy is the umbrella term applied to interventions that aid couples in distress. The best studied interventions are behavioral couples therapy, cognitive-behavioral couples therapy, and emotion-focused couples therapy. A recent review article evaluated the body of evidence on the effectiveness of couples therapy and programs to prevent marital discord (Christensen & Heavey, 1999). The review found that about 65 percent of couples in therapy did improve, whereas 35 percent of control couples also improved. Couples therapy ameliorates relationship distress and appears to alleviate depression. The gains from couples therapy generally last through 6 months, but there are few long-term assessments (Christensen & Heavey, 1999). Similarly, interventions to prevent marital discord yield short-term improvements in marital adjustment and stability, but there is insufficient study of long-term outcomes. The prevention programs receiving the most study are the Couple Communication Program, Relationship Enhancement, and the Prevention and Relationship Enhancement Program (Christensen & Heavey, 1999). Greater research is needed to overcome gaps in knowledge and to extend findings to a broader array of programs, to diverse populations of couples, and to a wider set of outcomes, including effects on children.
Physical activities are a means to enhance somatic health as well as to deal with stress. A recent Surgeon General’s Report on Physical Activity and Health evaluated the evidence for physical activities serving to enhance mental health (U.S. Department of Health and Human Services [DHHS], 1996). Aerobic physical activities, such as brisk walking and running, were found to improve mental health for people who report symptoms of anxiety and depression and for those who are diagnosed with some forms of depression. The mental health benefits of physical activity for individuals in relatively good physical and mental health were not as evident, but the studies did not have sufficient rigor from which to draw unequivocal conclusions (DHHS, 1996).
Prevention of Mental Disorders
A promising development in prevention of a specific mental disorder in adults occurred with the publication of results from the San Francisco Depression Research Project (Munoz et al., 1995). This study investigated 150 primary care patients who did not meet diagnostic criteria for depression and who were being seen in a public clinic for other problems. They were randomized to either psychoeducation—an 8-week cognitive behavioral course to help them control and manage moods—or to a control condition. One year later, those who received psychoeducation were found to have developed significantly fewer depression symptoms than members of the control group. This trial is noteworthy in two major respects: it was a randomized controlled trial and its participants were low-income individuals, with high representation of all major minority groups. Low-income individuals are considered a high-risk population because of studies documenting their higher prevalence of mental disorders. This study demonstrated in a methodologically rigorous fashion that depression may be preventable in some cases. It serves as a model for extending the concept of prevention to many mental disorders. Prevention research is vitally important and needs to be enhanced.
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