Gene Variants Implicated in Extreme Weight Gain Associated with Antipsychotics

Gene Variants Implicated in Extreme Weight Gain Associated with Antipsychotics Source: JupiterExtreme weight gain associated with taking an antipsychotic medication may be linked to certain genetic variants, according to a study published in the September 2012 issue of the Archives of General Psychiatry. Background Antipsychotic medications, especially those known as “second generation” or “atypical” antipsychotics, generally are the first-line of treatment for schizophrenia and other serious mental disorders. They are effective in treating psychotic symptoms, but they are also associated with serious metabolic side effects that can result in substantial weight gain, and other cardiovascular problems.Some people appear to be more susceptible to severe weight gain than others, but it is difficult to predict who is most at risk. To date, there have been few genetic studies of weight gain associated with antipsychotics, in part because it is difficult to control such variables as prior exposure to the medications, and because patients often stop taking the medications prematurely.Anil Malhotra M.D., of the Feinstein Institute for Medical Research, and colleagues set out to identify any common gene variants associated with antipsychotic-induced weight gain in a group of patients who had never taken the medications before and who were carefully monitored to ensure they continued to take the medication over the study period. The initial study included a cohort of 139 pediatric patients who were prescribed a second-generation antipsychotic. Patients were examined over a period of 12 weeks to assess weight and metabolic effects of the medications.To compare and confirm their results, the researchers also conducted similar assessments of three small cohorts with adult patients taking second generation antipsychotics. Results of the Study The researchers found markers in a gene called the melanocortin 4 receptor (MC4R) that were associated with severe weight gain in people taking second generation antipsychotics. The MC4R region overlaps somewhat with another region previously identified as being associated with obesity in the general population. In addition, the results were replicated in the three independent cohorts. Significance In many genetic studies involving obesity, thousands of participants are needed to achieve statistically significant results and to overcome the many environmental factors that can influence a person’s weight. In this study, the critical environmental factor predisposing patients to weight gain was only antipsychotic medication use over a short period of time, thus allowing more control over other variables that could have confounded results. Therefore, even though the study only included 139 individuals, the researchers were able to detect results that implicated specific gene variants.The results also have potential clinical implications. Patients with the identified gene variants that would predispose them to severe weight gain while taking an antipsychotic could be directed to alternative treatments, especially those who do not have a psychotic disorder LPC Continuing Education Although particular gene variants were implicated, the study’s sample size was small. Further research with larger samples is needed to extend the findings. LPC CEUs Reference Malhotra A, et al. Association between common variants near the melanocortin 4 receptor gene and severe antipsychotic drug-induced weight gain. Arch Gen. Psychiatry. 2012 Sep. 69(9):904-912.

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.

Pitt team finds molecular evidence of brain changes in depressed females

PITTSBURGH, Sept. 16 – Researchers at the University of Pittsburgh School of Medicine have discovered molecular-level changes in the brains of women with major depressive disorder that link two hypotheses of the biological mechanisms that lead to the illness. Their results, published online this week in Molecular Psychiatry, also allowed them to recreate the changes in a mouse model that could enhance future research on depression.

Although women are twice as likely as men to develop depression and have more severe and frequent symptoms, very little research has focused on them or been conducted in other female animals, noted senior author Etienne Sibille, Ph.D., associate professor of psychiatry, Pitt School of Medicine.

"It seemed to us that if there were molecular changes in the depressed brain, we might be able to better identify them in samples that come from females," he said. "Indeed, our findings give us a better understanding of the biology of this common and often debilitating psychiatric illness."

The researchers examined post-mortem brain tissue samples of 21 women with depression and 21 similar women without a history of depression. Compared to their counterparts, the depressed women had a pattern of reduced expression of certain genes, including the one for brain-derived neurotrophic factor (BDNF), and of genes that are typically present in particular subtypes of brain cells, or neurons, that express the neurotransmitter gamma-aminobutyric acid (GABA.) These findings were observed in the amygdala, which is a brain region that is involved in sensing and expressing emotion.

In the next part of the project, the researchers tested mice engineered to carry different mutations in the BDNF gene to see its impact on the GABA cells. They found two mutations that led to the same deficit in the GABA subtype and that also mirrored other changes seen in the human depressed brain.

Dr. Sibille noted that researchers have long suspected that low levels of BDNF play a role in the development of depression, and that there also is a hypothesis that reduced GABA function is a key factor.

"Our work ties these two concepts together because we first show that BDNF is indeed low in depression and second that low BDNF can influence specific GABA cells in a way that reproduces the biological profile we have observed in the depressed brain," he said.

The team is continuing to explore the molecular pathway between BDNF and GABA and others that could be important in depression LPC CEUs


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Co-authors include Gaelle Douillard-Guilloux, Ph.D., Rama Kota, Ph.D., Xingbin Wang, Ph.D., George C. Tseng, Ph.D., and David Lewis, M.D., all of the University of Pittsburgh; Jean-Philippe Guilloux, Ph.D, of Pitt and Universite Paris-Sud; Alain Gardier, Ph.D., of Universite Paris-Sud; and, Keri Martinowich, of the National Institute of Mental Health, part of the National Institutes of Health.

The study was funded by the National Institute of Mental Health.



About the University of Pittsburgh School of Medicine


As one of the nation's leading academic centers for biomedical research, the University of Pittsburgh School of Medicine integrates advanced technology with basic science across a broad range of disciplines in a continuous quest to harness the power of new knowledge and improve the human condition. Driven mainly by the School of Medicine and its affiliates, Pitt has ranked among the top 10 recipients of funding from the National Institutes of Health since 1997.

Likewise, the School of Medicine is equally committed to advancing the quality and strength of its medical and graduate education programs, for which it is recognized as an innovative leader, and to training highly skilled, compassionate clinicians and creative scientists well-equipped to engage in world-class research. The School of Medicine is the academic partner of UPMC, which has collaborated with the University to raise the standard of medical excellence in Pittsburgh and to position health care as a driving force behind the region's economy. For more information about the School of Medicine, see www.medschool.pitt.edu.

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.

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.

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

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.

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.

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.

Easy Ways to Reduce Holiday Stress

For many families, the holiday season can feel more stressful than joyful. Stress comes from many directions at this time of year: too much rich food and drink, not enough exercise or sleep and all the rushing around to find the perfect gifts at the lowest prices.

“Although stress is common at this time of year, it is not inevitable,” says registered dietitian Crystelle Fogle of the Cardiovascular Health Program for the Montana Department of Public Health and Human Services. “Virtually every mental health expert agrees that lifestyle habits can help with stress reduction. This is the perfect time to step back from the holiday hustle and find ways to insure that your family is getting daily physical activity, plenty of nutrient-rich foods, and enough sleep every night.”

The typical holiday pattern of overindulgence and sleep deprivation combined with low activity actually adds stress in multiple layers. First, there is the actual physical stress from your body not getting what it needs for optimal health and energy. On top of that stress is layers of guilt and frustration brought on because you’re doing things that are unhealthy. Then, these feelings often lead back to more overeating or additional alcohol consumption.

Fogle points out that stopping this vicious cycle is easier than you may think. “It starts with setting priorities for your family – like fitness, nutrition, and sleep –and then saying ‘no’ to some of the holiday events that interfere with these healthy habits,” Fogle said. “The simple act of taking more control over your daily life can lower stress levels almost immediately.”

Here are a few real easy ways to have your holiday fun and reduce your stress too:

•Eat well. Family meals and nutrient-rich foods are even more important at this time of year. Enjoy simple meals, like steaming soup with salad and rolls, together as often as possible. Take time to establish new family traditions, like making bread from scratch.
•Play well. Being active together creates special memories and improves moods at the same time. Holiday fitness fun is as easy as a family game of Twister® or a stroll around the neighborhood to sing some holiday songs or carols for friends.
•Sleep well. Most adults do best with seven to eight hours sleep a night, while young children need significantly more. Develop family routines that promote healthy sleep habits, like reading holiday stories or listening to calming music together before bedtime.

“The ‘togetherness’ of these stress reduction tips is an important aspect of healthy, happy holidays,” Fogle notes. Connections to family and friends are much more important to holiday comfort and joy than lots of new stuff or plates of high-calorie treats. Starting new family traditions that reduce stress, such as cooking a meal or playing active games together, are gifts that will truly keep on giving for years to come.

Five Easy Ways to Enjoy More Tasty Holiday Nutrition
Although calorie-rich treats and overflowing tables can be the norm during holidays, you can get the nutrition that your body needs. The key is to concentrate on nutrient-rich foods. With bright colors and delicious flavors, nutrient-rich foods are a gift on any holiday table.

Calorie for calorie, these stars of the nutrition world offer more of the vitamins, minerals, protein and fiber that your whole family needs to maintain weight, enhance health, and reduce stress during this hectic time of year. Here are five easy ways to add nutrient-rich foods to all your seasonal feasts and treats.

•Start every day (and holiday) with breakfast. For a high-energy day, always include protein in your morning meal. Enjoy an egg or two, a serving of low-fat yogurt, a handful of nuts on whole grain cereal, or some lean meat, like a sliced turkey and Swiss on whole wheat wrap or bread.
•Snack smart throughout the holidays. Nutrient-rich snacks provide energy, while reducing the tendency to overeat at your next meal. Start with a piece of fresh fruit or some sliced veggies. Add a serving of protein, like a string cheese, a glass of low-fat milk, or leftover meats.
•Feature festive holiday salads at every meal. Fruit salads (any combo of canned, dried, frozen, or fresh fruit) are delicious any time of day. Green salads, bean salads, and veggie salads add color and crunch to lunch and dinner (and they make tasty leftovers for super smart snack times).
•Pack your holiday breadbasket with nutrition. The nutrient-rich goodness of whole grains, nuts, seeds, and dried fruits makes for tasty breads, rolls, and muffins. Bake some at home or check grocery shelves for sunflower whole wheat bread or bran muffins with raisins and walnuts.
•Warm up the holiday with winter vegetables. Root veggies (sweet potatoes, beets, and carrots) and hard winter squashes, like acorn, butternut, pumpkin, and spaghetti, are some the least expensive and most nutritious produce options. Enjoy them roasted, mashed, and made into soup!
Five Ways to Enjoy 10 Minutes of Holiday Fitness Fun
Physical activity is even more important during the holidays than other times of the year. Being active helps relieve holiday stress – and helps balance out the usual increase in holiday calories. To maintain fitness levels and emotional well-being, enjoy at least three 10-minute activity breaks a day – preferably with family or friends.

•Take a brisk 10-minute stroll with a loved one. Something as simple as a 10-minute walk can make all the difference in your physical and mental state. A brisk walk around the block at work or around your neighborhood can improve your mood and kick-start your metabolism in just a few simple steps. For extra holiday fun, invite someone you’ve been missing!
•Play a child’s favorite active game for 10 minutes. It’s often said that holidays are “all about the children.” What better way to be active than to have festive fun with one or more young people! Children often have extra energy to burn during the holidays and even serious adults can enjoy some sledding, get tied up in game of Twister®, or toss around a Koosh® ball.
•Dance for 10 minutes to your favorite holiday tunes. You could “Rock around the Christmas Tree” and just go “Walkin’ in a Winter Wonderland.” Use music to pick up the pace when you are walking or working outside with headphones – or cleaning up the house for a holiday gathering. For the best holiday break of all, take a spin on the dance floor with your sweetie.
•Walk for 10 minutes between stores. You can even fit fitness into a busy shopping day. Take a 10-minute ‘breather’ between each store on your list. Enjoy a quick lap around the perimeter of the mall or a walk around a couple of downtown blocks. You’ll have more energy – and you just might make more reasonable spending decisions too!
•Take a 10-minute stretch break at home or work. Holiday tension can take a toll on backs, shoulders, and jaws. A quick break can relieve physical and mental stress. Check these sites for gentle moves that can be done anywhere you need a stretch: www.lib.msu.edu/ergomsu/stretch.htm and www.will-harris.com/yoga/everyday_yoga.html
BRN Continuing Education http://www.aspirace.com
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Tips for Smart Holiday Shopping

In these tough economic times, smart shopping during the holiday season is more important than ever. Whether consumers are shopping online, by phone, or in stores, the Federal Trade Commission, the nation’s consumer protection agency, has some advice to avoid both debt and unneeded stress.

First, make as accurate and comprehensive a budget as possible – don’t forget to include the cost of incidentals like postage, gift wrap, and decorations. Then, learn to navigate holiday sale ads, make sure to keep careful track of your spending, and make the best of layaway opportunities.

To learn more about smart holiday shopping, see the consumer alert “Holiday Shopping, Circa 2008: Tips from the Federal Trade Commission,” at
http://www.ftc.gov/bcp/edu/pubs/consumer/alerts/alt082.shtm. For more general information about wise money management and savvy shopping, visit ftc.gov/consumer.

The Federal Trade Commission works for consumers to prevent fraudulent, deceptive, and unfair business practices and to provide information to help spot, stop, and avoid them. To file a complaint in English or Spanish, visit the FTC's online Complaint Assistant or call 1-877-FTC-HELP (1-877-382-4357). The FTC enters complaints into Consumer Sentinel, a secure, online database available to more than 1,500 civil and criminal law enforcement agencies in the U.S. and abroad.
LPC Continuing Education http://www.aspirace.com

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.

Resilience

What Is Resilience?

Resilience is the ability to:
Bounce back
Take on difficult challenges and still find meaning in life
Respond positively to difficult situations
Rise above adversity
Cope when things look bleak
Tap into hope
Transform unfavorable situations into wisdom, insight, and compassion
Endure

Resilience refers to the ability of an individual, family, organization, or community to cope with adversity and adapt to challenges or change. It is an ongoing process that requires time and effort and engages people in taking a number of steps to enhance their response to adverse circumstances. Resilience implies that after an event, a person or community may not only be able to cope and recover, but also change to reflect different priorities arising from the experience and prepare for the next stressful situation.

Resilience is the most important defense people have against stress.
It is important to build and foster resilience to be ready for future challenges.
Resilience will enable the development of a reservoir of internal resources to draw upon during stressful situations.
Research (Aguirre, 2007; American Psychological Association, 2006; Bonanno, 2004) has shown that resilience is ordinary, not extraordinary, and that people regularly demonstrate being resilient.

Resilience is not a trait that people either have or do not have.
Resilience involves behaviors, thoughts, and actions that can be learned and developed in anyone.
Resilience is tremendously influenced by a person's environment.
Resilience changes over time. It fluctuates depending on how much a person nurtures internal resources or coping strategies. Some people are more resilient in work life, while others exhibit more resilience in their personal relationships. People can build resilience and promote the foundations of resilience in any aspect of life they choose.

What Is Individual or Personal Resilience?
Individual resilience is a person's ability to positively cope after failures, setbacks, and losses. Developing resilience is a personal journey. Individuals do not react the same way to traumatic or stressful life events. An approach to building resilience that works for one person might not work for another. People use varying strategies to build their resilience. Because resilience can be learned, it can be strengthened. Personal resilience is related to many factors including individual health and well-being, individual aspects, life history and experience, and social support.

Individual Health and Well-Being Individual Aspects Life History and Experience Social Support These are factors with which a person is born.

Personality
Ethnicity
Cultural background
Economic background

These are past events and relationships that influence how people approach current stressors:
Family history
Previous physical health
Previous mental health
Trauma history
Past social experiences
Past cultural experiences

These are support systems provided by family, friends, and members of the community, work, or school environments:
Feeling connected to others
A sense of security
Feeling connected to resources
(Adapted from Simon, Murphy, & Smith, 2008)


Along with the factors listed above, there are several attributes that have been correlated with building and promoting resilience.

The American Psychological Association reports the following attributes regarding resilience:
The capacity to make and carry out realistic plans
Communication and problem-solving skills
A positive or optimistic view of life
Confidence in personal strengths and abilities
The capacity to manage strong feelings, emotions, and impulses

What Is Family Resilience?
Family resilience is the coping process in the family as a functional unit. Crisis events and persistent stressors affect the whole family, posing risks not only for individual dysfunction, but also for relational conflict and family breakdown. Family processes mediate the impact of stress for all of its members and relationships, and the protective processes in place foster resilience by buffering stress and facilitating adaptation to current and future events. Following are the three key factors in family resilience (Wilson & Ferch, 2005):

Family belief systems foster resilience by making meaning in adversity, creating a sense of coherence, and providing a positive outlook.
Family organization promotes resilience by facilitating flexibility, capacity to adapt, connectedness and cohesion, emotional and structural bonding, and accessibility to resources.
Family communication enhances resilience by engaging clear communication, open and emotional expressions, trust and collaborative problem solving, and conflict management.

What Is Organizational Resilience?
Organizational resilience is the ability and capacity of a workplace to withstand potential significant economic times, systemic risk, or systemic disruptions by adapting, recovering, or resisting being affected and resuming core operations or continuing to provide an acceptable level of functioning and structure.

A resilient workforce and organization is important during major decisions or business changes.
Companies and organizations, like individuals, need to be able to rebound from potentially disastrous changes.
The challenge for the incorporation of resilience into a workplace is to identify what enhances the ability of an organization to rebound effectively.
Measuring workplace resilience involves identifying and evaluating the following:
Past and present mitigative mechanisms and practices that increase safety
Past and present mitigative mechanisms and practices that decrease error
Necessary redundancy in systems
Planning and programming that demonstrate collective mindfulness
Anticipation of potential trouble and solutions to potential problems

What Is Community Resilience?
Community resilience is the individual and collective capacity to respond to adversity and change. It is a community that takes intentional action to enhance the personal and collective capacity of its citizens and institutions to respond to and influence the course of social and economic change. For a community to be resilient, its members must put into practice early and effective actions so that they can respond to change. When responding to stressful events, a resilient community will be able to strengthen community bonds, resources, and the capacity to cope. Systems involved with building and maintaining community resilience must work together.
mental health and social work ceus

How Does Culture Influence Resilience?
Cultural resilience refers to a culture’s capacity to maintain and develop cultural identity and critical cultural knowledge and practices. Along with an entire culture fostering resilience, the interaction of culture and resilience for an individual also is important. An individual’s culture will have an impact on how the person communicates feelings and copes with adversity. Cultural parameters are often embedded deep in an individual. A person’s cultural background may influence one deeply in how one responds to different stressors. Assimilation could be a factor in cultural resilience, as it could be a positive way for a person to manage his/her environment. However, assimilation could create conflict between generations, so it could be seen as positive or negative depending on the individual and culture. Because of this, coping strategies are going to be different. With growing cultural diversity, the public has greater access to a number of different approaches to building resilience. It is something that can be built using approaches that make sense within each culture and tailored to each individual.

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What Factors Promote Resilience?
Resilience involves the modification of a person's response to a potentially risky situation. People who are resilient are able to maintain high self-esteem and self-efficacy in spite of the challenges they face. By fostering resilience, people are building psychological defenses against stress. The more resources and defenses available during a time of struggle, the better able to cope and bounce back from adverse circumstances people will be. A person’s ability to regain a sense of normalcy or define a new normalcy after adverse circumstances will be partially based on the resources available to him/her. Resilience building can begin at any time. Following is information regarding applicable ways to implement resilience practices, as well as situations that could inhibit resilience, situations that enhance resilience, and people who help facilitate the growth of resilience.

Resilience


Demonstrating Resilience Vulnerability Factors Inhibiting Resilience Protective Factors Enhancing Resilience Facilitators of Resilience
Individual Resilience
The ability for an individual to cope with adversity and change
Optimism
Flexibility
Self-confidence
Competence
Insightfulness
Perseverance
Perspective
Self-control
Sociability
Poor social skills
Poor problem solving
Lack of empathy
Family violence
Abuse or neglect
Divorce or partner breakup
Death or loss
Lack of social support
Social competence
Problem-solving skills
Good coping skills
Empathy
Secure or stable family
Supportive relationships
Intellectual abilities
Self-efficacy
Communication skills

Individuals
Parents
Grandparents
Caregivers
Children
Adolescents
Friends
Partners
Spouses
Teachers
Faith Community

Organizational Resilience
The ability for a business or industry, including its employees, to cope with adversity and change
Proactive employees
Clear mission, goals, and values
Encourages opportunities to influence change
Clear communication
Nonjudgmental
Emphasizes learning
Rewards high performance
Unclear Expectations
Conflicted expectations
Threat to job security
Lack of personal control
Hostile atmosphere
Defensive atmosphere
Unethical environment
Lack of communication

Open communication
Supportive colleagues
Clear responsibilities
Ethical environment
Sense of control
Job security
Supportive management
Connectedness among departments
Recognition

Employers
Managers
Directors
Employees
Employee assistance programs
Other businesses

Community Resilience
The ability for an individual and the collective community to respond to adversity and change.
Connectedness
Commitment to community
Shared values
Structure, roles, and responsibilities exist throughout community
Supportive
Good communication
Resource sharing
Volunteerism
Responsive organizations
Strong schools

Lack of support services
Social discrimination
Cultural discrimination
Norms tolerating violence
Deviant peer group
Low socioeconomic status
Crime rate
Community disorganization
Civil rivalry
Access to Support services
Community networking
Strong cultural identity
Strong social support systems
Norms against violence
Identification as a community
Cohesive community leadership
Community leaders
Faith-based organizations
Volunteers
Nonprofit organizations
Churches/houses of worship
Support services staff
Teachers
Youth groups
Boy/Girl Scouts
Planned social networking events

(Adapted from Kelly, 2007)
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How Is Personal Resilience Built?
Developing resilience is a personal journey. People do not react the same way to traumatic events. Some ways to build resilience include the following actions:

Making connections with others
Looking for opportunities for self-discovery
Nurturing a positive view of self
Accepting that change is a part of living
Taking decisive actions
Learning from the past
The ability to be flexible is a great skill to obtain and facilitates resilience growth. Getting help when it is needed is crucial to building resilience. It is important to try to obtain information on resilience from books or other publications, self-help or support groups, and online resources like the ones found in this resource collection.

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What Can Be Done to Promote Family Resilience?
Developing family resilience, like individual resilience, is different for every family. The important idea to keep in mind is that an underlying stronghold of family resilience is cohesion, a sense of belonging, and communication. It is important for a family to feel that when their world is unstable they have each other. This sense of bonding and trust is what fuels a family's ability to be resilient. Families that learn how to cope with challenges and meet individual needs are more resilient to stress and crisis. Healthy families solve problems with cooperation, creative brainstorming, openness to others, and emphasis on the role of social support and connectedness (versus isolation) in family resiliency. Resilience is exercised when family members demonstrate behaviors such as confidence, hard work, cooperation, and forgiveness. These are factors that help families withstand stressors throughout the family life cycle.

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How Is Community Resilience Fostered?
Fostering community resilience will greatly depend on the community itself and involves the community working as a whole toward preparedness. It is the capacity for the collective to take preemptive action toward preparedness. Community resilience involves the following factors:

Connection and caring
Collective resources
Critical analysis of the community
Skill building for community members
Prevention, preparedness, and response to stressful events
Resilience is exercised when community members demonstrate behaviors such as confidence, hard work, cooperation, and resourcefulness, and support of those who have needs during particular events. These are factors that help communities withstand challenging circumstances. There are other tips about how to foster community resilience in this resource collection.

Developing resilience is a personal journey. All people do not react the same to traumatic and stressful life events. An approach to building resilience that works for one person might not work for another. People use varying strategies. Resilience involves maintaining flexibility and balance in life during stressful circumstances and traumatic events. Being resilient does not mean that a person does not experience difficulty or distress. Emotional pain and sadness are common in people who have suffered major adversity or trauma in their lives. Stress can be dealt with proactively by building resilience to prepare for stressful circumstances, while learning how to recognize symptoms of stress. Fostering resilience or the ability to bounce back from a stressful situation is a proactive mechanism to managing stress.

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References
Aguirre, B. (2007). Dialectics of vulnerability and resilience. Georgetown Journal of Poverty Law and Policy, 14(39), 1–18.

American Psychological Association. (2006). The road to resilience. Retrieved March 20, 2009, from " target="_blank">http://www.apahelpcenter.org/featuredtopics/feature.php?id=6.

Bonanno, G. (2004). Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59, 20–28.

Kelly, S. (2007). Personal and community resilience: Building it and sustaining it. Retrieved March 23, 2009, from the University of California Los Angeles Bureau for Behavioral Health and Health Facilities at " target="_blank">http://www.wvdhhr.org/healthprep/common/resiliency.ppt#256.

Simon, J., Murphy, J., & Smith, S. (2008). Building resilience: Appreciate the little things in life. British Journal of Social Work, 38, 218–235.

Wilson, S., & Ferch, S. (2005). Enhancing resilience in the workplace through the practice of caring relationships. Organization Development Journal, 23(4), 45–60.

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.