Adding Psychotherapy to Medication Treatment Improves Outcomes in Pediatric OCD

Source: NIMH

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

Background

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

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

Results

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

Significance

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

What’s next

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

Citation

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

Air Force Suicide Prevention Program Reduces Suicide Rate

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

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

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

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

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

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

Brain Emotion Circuit Sparks as Teen Girls Size Up Peers

What is going on in teenagers' brains as their drive for peer approval begins to eclipse their family affiliations? Brain scans of teens sizing each other up reveal an emotion circuit activating more in girls as they grow older, but not in boys. The study by Daniel Pine, M.D., of the National Institute of Mental Health (NIMH), part of National Institutes of Health, and colleagues, shows how emotion circuitry diverges in the male and female brain during a developmental stage in which girls are at increased risk for developing mood and anxiety disorders. LCSW CEUs
"During this time of heightened sensitivity to interpersonal stress and peers' perceptions, girls are becoming increasingly preoccupied with how individual peers view them, while boys tend to become more focused on their status within group pecking orders," explained Pine. "However, in the study, the prospect of interacting with peers activated brain circuitry involved in approaching others, rather than circuitry responsible for withdrawal and fear, which is associated with anxiety and depression."

Pine, Amanda Guyer, Ph.D., Eric Nelson, Ph.D., and colleagues at NIMH and Georgia State University, report on one of the first studies to reveal the workings of the teen brain in a simulated real-world social interaction, in the July, 2009 issue of the Journal Child Development.

Thirty-four psychiatrically healthy males and females, aged 9 to 17, were ostensibly participating in a study of teenagers' communications via Internet chat rooms. They were told that after an fMRI (functional magnetic resonance imaging) scan, which visualizes brain activity, they would chat online with another teen from a collaborating study site. Each participant was asked to rate his or her interest in communicating with each of 40 teens presented on a computer screen, so they could be matched with a high interest participant.

Two weeks later, the teens viewed the same faces while in an fMRI scanner. But this time they were asked to instead rate how interested they surmised each of the other prospective chatters would be in interacting with them.

Only after they exited the scanner did they learn that, in fact, the faces were of actors, not study participants, and that there would be no Internet chat. The scenario was intended to keep the teens engaged –– maintain a high level of anticipation/motivation –– during the tasks. This helped to ensure that the scanner would detect contrasts in brain circuit responses to high interest versus low interest peers.

Although the faces were selected by the researchers for their happy expressions, their attractiveness was random, so that they appeared to be a mix of typical peers encountered by teens.

As expected, the teen participants deemed the same faces they initially chose as high interest to be the peers most interested in interacting with them. Older participants tended to choose more faces of the opposite sex than younger ones. When they appraised anticipated interest from peers of high interest compared with low interest, older females showed more brain activity than younger females in circuitry that processes social emotion.

"This developmental shift suggested a change in socio-emotional calculus from avoidance to approach," noted Pine. The circuit is made up of the nucleus accumbens (reward and motivation), hypothalamus (hormonal activation), hippocampus (social memory) and insula (visceral/subjective feelings).

By contrast, males showed little change in the activity of most of these circuit areas with age, except for a decrease in activation of the insula. This may reflect a waning of interpersonal emotional ties over time in teenage males, as they shift their interest to groups, suggest Pine and colleagues.

"In females, absence of activation in areas associated with mood and anxiety disorders, such as the amygdala, suggests that emotional responses to peers may be driven more by a brain network related to approach than to one related to fear and withdrawal," said Pine. "This reflects resilience to psychosocial stress among healthy female adolescents during this vulnerable period."






Nodes of a brain circuit for social emotion and approach behavior activated more in teenage girls than in boys with age. Functional MRI data (red) superimposed on anatomical MRI images.

Source: NIMH Emotion and Development Branch







Teenage participants were first asked to rate their interest in peers with whom they might communicate in an internet chat room (left). Two weeks later, while in a brain scanner, they were asked to rate how interested the same peers were in interacting with them (right).

Source: NIMH Emotion and Development Branch

Reference
Probing the neural correlates of anticipated peer evaluation in adolescence. Guyer AE, McClure-Tone EB, Shiffrin ND, Pine DS, Nelson EE. July 2009, Child Development.

###
The mission of the NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery and cure. For more information, visit the NIMH website.

The National Institutes of Health (NIH) — The Nation’s Medical Research Agency — includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit the NIH website.

Take Your Holiday Spirit into the New Year by Linda Davis

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

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

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

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

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

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

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

United Way:
www.211.org

VolunteerMatch
www.volunteermatch.org

Idealist
www.idealist.org

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

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

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

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

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

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

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

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

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

10. Remember that your contribution matters.

Stress Free Holidays

This is time of year the family calendar tends to fill up quickly. On top of regular activities and commitments, any free time on evenings and weekends may be overloaded with parties, dinners, other social events, shopping, and possibly a school or religious program or two. You may find yourself thinking, “Just a month or two and this will pass.”

Parents often dream of giving their child(ren) the best or most memorable holiday. Sometimes we need to stop and ask ourselves, “What is the best? and What is the price?” Remember that the stress, excitement, and go, go, go feeling of the holiday season not only takes its toll on you, but also your family. Children will notice when you're stressed or tired. If you're not feeling best, your child may pick up this. If you're feeling irritable, chances are your child may get a case of his or her own grumpies.

Here are some tips that may be able to help your family ease through the extra stress of the season:
•Have limits. Keep in mind, when planning for the holidays, you should have limits or expectations of what will or will not happen. This includes all areas of holiday planning. If appropriate, set a budget for gifts. Let children know in advance what they can expect so there won't be any unrealistic requests.
•Don't spread yourself too thin. It's ok for you or your child not to be actively involved in everything the season offers. If there are certain things you enjoy, individually or as a family, make a list and plans to do these things. If you find your list getting too big or out of control, maybe alternate activities yearly. In addition, saying no to one or two activities a season does not make you a humbug.
•Keep the end in sight. You may feel like the stress is going to bring your holiday happiness to an end or that it will drag on forever. Keep in mind that all too soon, the season will be behind you and life will return to “normal”. Keep an eye on what's important now.

Similarly, keep an eye on your child. If you feel that you child is becoming overwhelmed by activity or just needs a little break go for it. The tears as a result of holiday breakdown, may just add more stress to an already hectic situation.
•Find a shoulder to lean on. Keeping in contact with family and friends may give you the extra support you need to make it though the season. You don't have to do it all on your own. Don't be afraid to delegate tasks or accept offers of assistance from those close to you. If grandma is willing to give you a hand with the little ones while you run to the grocery store, take her up on her offer. Alternate shopping days with a neighbor, so each may have time alone to run errands. Holiday baking can also offer a dose of much needed stress relief as you get together with “the girls (or guys)” and share recipes and laughter.
•Remember you. Most importantly this holiday season, don't forget about keeping track of you and your family. If you're feeling run down or irritable, find something to take your mind off of your stress. Take time for a relaxing bath, a cup of cocoa, or an hour on the treadmill. What ever you want, treat yourself to your own brand of stress relief.
Free CEUs for Social Workers and LCSWs http://www.aspirace.com
The same applies to your family. If your children are getting fussy at the holiday planning tasks, find something to lift their spirits. Stop what you're doing and make a quick holiday treat that involves everyone. Get down on the floor and play a game or color. Find an outdoor activity that the whole family enjoys and take the time to enjoy it. Do something fun and not related to your holiday tasks. •Don't worry about the “To Do” list. It will be there when you get back. If by chance an item gets overlooked, it probably wasn't worth the stress it was causing you anyway. Keep these things in mind through this holiday season and enjoy!

Ten Tips for a Peaceful Holiday Season: Helping Kids Relax

From Patti Teel
Kids get pretty anxious over the holidays. It’s a time of excitement and wonder, and they often have a hard time relaxing, staying calm and sleeping well. Here are some tips to help your kids stay relaxed and on a healthy sleep schedule.
1. Don't overschedule your children. Cut back on the tasks and activities which are likely to overwhelm them. For example, avoid long trips to the mall with young children; short spurts of shopping will be more fun for everyone. Don't try to
change your child's temperament; accept that he or she may be naturally timid and soft-spoken, or boisterous and loud. An activity level that might be comfortable for one child could be overwhelming for another—even in the same family.
2. Have activity-based celebrations. For instance, spend time with children making cards, decorations, cookies and gifts. You may wish to let each child select one activity for the whole family to do over the holidays.
3. Have children stay physically active. Don't allow busy holiday schedules to crowd out active play time. Physical activity is one of the simplest and most effective ways to reduce stress and ensure that a child gets a good night’s sleep. Children
should have at least 30 minutes of moderate-intensity activity every day. (However, vigorous activities should not be done within several hours of bedtime because it raises the metabolic rate and may make it difficult for your child to relax.)
4. When possible, have your children play outdoors. Exposure to daytime sunlight helps children to sleep better at night.
5. Teach your children relaxation skills such as stretching, progressive relaxation, deep breathing and guided visualization. Relaxation can be a delightful form of play and it’s easy to incorporate the holidays in imaginative ways. For example, play a relaxing game of “Santa Says.” Direct children to stretch and relax by curling up like a snowball, to move their arms and legs slowly in and out like a snow angel, or to open their mouths widely to catch snowflakes.
6. Banish bedtime fears and help kids put worries to bed. Make a ceremony out of putting worries or fears away for the night. Have children pretend, or actually draw a picture of what’s bothering them. Fold, (or pretend to fold) the worry or fear
until it’s smaller and smaller. Then put it away in a box and lock it with a key. It’s often helpful for older children and teens to list their worries in a journal before putting them away for the night.
7. Make your home a sanctuary from the overstimulation of the outside world by making family “quiet time” a part of every evening.
• Limit total screen time, including computer games, video games and time spent watching television. Advertisements scandalously target children and the more they watch, the more they soak up the commercial messages of the season…instead of the real spirit of the holidays.
• Tell or read inspiring holiday stories.
• Sing and listen to soothing holiday music.
• Give each other a gentle massage.
8. Maintain the bedtime routine. While routines are likely to be thrown off during the holidays, it’s important to maintain a consistent bedtime, allowing plenty of time for a relaxed bedtime routine. Don't let holiday parties or activities interfere with your child getting a good night’s sleep.
9. Instill compassion and encourage generosity.
• Provide opportunities for your children to help others. Opportunities abound: have your child draw pictures and help bake and deliver food, encourage them to donate some or their clothes, toys or books; or regularly visit an elderly
person who needs companionship.
• Read or tell stories that emphasize giving.
• Perform simple rituals to symbolize your care for others. Light a candle as you and your children send your good wishes or say a prayer for those who are in need.
10. Instill appreciation and gratitude. It’s not possible to be upset and worried while feeling appreciative. Share good things that happened during your day and have your child do the same. They don't need to be major events; emphasize
actions that demonstrate the blessings of the season. It could be a hug, words of love, the sound of the birds in the morning or a beautiful snowfall. Depending on your beliefs, you may wish to incorporate prayers of appreciation and thankfulness.
LMFT and LCSW Continuing Education http://www.aspirace.com

2009-2010 Influenza (Flu) Season

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Getting Through Tough Economic Times

This guide provides practical advice on how to deal with the effects financial difficulties can have on your physical and mental health -- it covers:

•Possible health risks
•Warning signs
•Managing stress
•Getting help
•Suicide warning signs
•Other steps you can take
Possible Health Risks
Economic turmoil (e.g., increased unemployment, foreclosures, loss of investments and other financial distress) can result in a whole host of negative health effects - both physical and mental. It can be particularly devastating to your emotional and mental well-being. Although each of us is affected differently by economic troubles, these problems can add tremendous stress, which in turn can substantially increase the risk for developing such problems as:

•Depression
•Anxiety
•Compulsive Behaviors (over-eating, excessive gambling, spending, etc.)
•Substance Abuse
Warning Signs
It is important to be aware of signs that financial problems may be adversely affecting your emotional or mental well being --or that of someone you care about. These signs include:

•Persistent Sadness/Crying
•Excessive Anxiety
•Lack of Sleep/Constant Fatigue
•Excessive Irritability/Anger
•Increased drinking
•Illicit drug use, including misuse of medications
•Difficulty paying attention or staying focused
•Apathy - not caring about things that are usually important to you
•Not being able to function as well at work, school or home
Managing Stress
If you or someone you care about is experiencing these symptoms, you are not alone. These are common reactions to stress, and there are coping techniques that you can use to help manage it. They include:

•Trying to keep things in perspective - recognize the good aspects of life and retain hope for the future.
•Strengthening connections with family and friends who can provide important emotional support.
•Engaging in activities such as physical exercise, sports or hobbies that can relieve stress and anxiety.
•Developing new employment skills that can provide a practical and highly effective means of coping and directly address financial difficulties.
Getting Help
Even with these coping techniques, however, sometimes these problems can seem overwhelming and you may need additional help to get through "rough patches." Fortunately, there are many people and services that can provide help. These include your:

•Healthcare provider
•Spiritual leader
•School counselor
•Community health clinic
If you need help finding treatment services you can access our Mental Health Services Locator for information and mental health resources near you. Similarly, if you need help with a substance abuse problem you can use our Substance Abuse Treatment Facility Locator.

Specific help for financial hardship is also available, on issues such as:

•Making Home Affordable
•Foreclosure
•Reemployment
•Financial assistance
There are many other places where you can turn for guidance and support in dealing with the financial problems affecting you or someone you care about. These resources exist at the federal, state and community level and can be found through many sources such as:

•Federal and state government
•Civic associations
•Spiritual groups
•Other sources such as the government services section of a phone book
Suicide Warning Signs
Unemployment and other kinds of financial distress do not "cause" suicide directly, but they can be factors that interact dynamically within individuals and affect their risk for suicide. These financial factors can cause strong feelings such as humiliation and despair, which can precipitate suicidal thoughts or actions among those who may already be vulnerable to having these feelings because of life-experiences or underlying mental or emotional conditions (e.g., depression, bi-polar disorder) that place them at greater risk of suicide.

LCSW, MFT, LPC ceus suicide prevention
These are some of the signs you may want to be aware of in trying to determine whether you or someone you care about could be at risk for suicide:

•Threatening to hurt or kill oneself or talking about wanting to hurt or kill oneself
•Looking for ways to kill oneself
•Thinking or fantasying about suicide
•Acting recklessly
•Seeing no reason for living or having no sense of purpose in life
If you or someone you care about are having suicidal thoughts or showing these symptoms SEEK IMMEDIATE HELP. Contact your healthcare provider, mental health crisis center, hospital emergency room or the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) for help.

Other Steps You Can Take
•Acknowledge that economic downturns can be frightening to everyone, but that there are ways of getting through them - from engaging in healthy activities, positive thinking, supportive relationships, to seeking help when needed from health professionals.


•Encourage community-based organizations and groups to provide increased levels of mental health treatment and support to those who are severely affected by the economy.


•Work together to help all members of the community build their resiliency and successfully return to healthy and productive lives.
For further information on mental health or substance abuse issues please visit The Substance Abuse and Mental Health Services Administration (SAMHSA).


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Special Note to Journalists
For ideas on how to best cover sensitive issues like suicide prevention in a thoughtful and constructive manner you can check out suggestions developed by the Annenberg Public Policy Center in conjunction with leading suicide prevention experts and journalists.

NIDA InfoFacts: Understanding Drug Abuse and Addiction

Many people do not understand why individuals become addicted to drugs or how drugs change the brain to foster compulsive drug abuse. They mistakenly view drug abuse and addiction as strictly a social problem and may characterize those who take drugs as morally weak. One very common belief is that drug abusers should be able to just stop taking drugs if they are only willing to change their behavior. What people often underestimate is the complexity of drug addiction—that it is a disease that impacts the brain and because of that, stopping drug abuse is not simply a matter of willpower. Through scientific advances we now know much more about how exactly drugs work in the brain, and we also know that drug addiction can be successfully treated to help people stop abusing drugs and resume their productive lives.

Drug abuse and addiction are a major burden to society. Estimates of the total overall costs of substance abuse in the United States—including health- and crime-related costs as well as losses in productivity—exceed half a trillion dollars annually. This includes approximately $181 billion for illicit drugs,1 $168 billion for tobacco,2 and $185 billion for alcohol.3 Staggering as these numbers are, however, they do not fully describe the breadth of deleterious public health—and safety—implications, which include family disintegration, loss of employment, failure in school, domestic violence, child abuse, and other crimes.


What is drug addiction?

Addiction is a chronic, often relapsing brain disease that causes compulsive drug seeking and use despite harmful consequences to the individual who is addicted and to those around them. Drug addiction is a brain disease because the abuse of drugs leads to changes in the structure and function of the brain. Although it is true that for most people the initial decision to take drugs is voluntary, over time the changes in the brain caused by repeated drug abuse can affect a person’s self control and ability to make sound decisions, and at the same time send intense impulses to take drugs.

It is because of these changes in the brain that it is so challenging for a person who is addicted to stop abusing drugs. Fortunately, there are treatments that help people to counteract addiction’s powerful disruptive effects and regain control. Research shows that combining addiction treatment medications, if available, with behavioral therapy is the best way to ensure success for most patients. Treatment approaches that are tailored to each patient’s drug abuse patterns and any co-occurring medical, psychiatric, and social problems can lead to sustained recovery and a life without drug abuse.

Similar to other chronic, relapsing diseases, such as diabetes, asthma, or heart disease, drug addiction can be managed successfully. And, as with other chronic diseases, it is not uncommon for a person to relapse and begin abusing drugs again. Relapse, however, does not signal failure—rather, it indicates that treatment should be reinstated, adjusted, or that alternate treatment is needed to help the individual regain control and recover.

What happens to your brain when you take drugs?

Drugs are chemicals that tap into the brain’s communication system and disrupt the way nerve cells normally send, receive, and process information. There are at least two ways that drugs are able to do this: (1) by imitating the brain’s natural chemical messengers, and/or (2) by overstimulating the “reward circuit” of the brain.

Some drugs, such as marijuana and heroin, have a similar structure to chemical messengers, called neurotransmitters, which are naturally produced by the brain. Because of this similarity, these drugs are able to “fool” the brain’s receptors and activate nerve cells to send abnormal messages.

Other drugs, such as cocaine or methamphetamine, can cause the nerve cells to release abnormally large amounts of natural neurotransmitters, or prevent the normal recycling of these brain chemicals, which is needed to shut off the signal between neurons. This disruption produces a greatly amplified message that ultimately disrupts normal communication patterns.

Nearly all drugs, directly or indirectly, target the brain’s reward system by flooding the circuit with dopamine. Dopamine is a neurotransmitter present in regions of the brain that control movement, emotion, motivation, and feelings of pleasure. The overstimulation of this system, which normally responds to natural behaviors that are linked to survival (eating, spending time with loved ones, etc.), produces euphoric effects in response to the drugs. This reaction sets in motion a pattern that “teaches” people to repeat the behavior of abusing drugs.

As a person continues to abuse drugs, the brain adapts to the overwhelming surges in dopamine by producing less dopamine or by reducing the number of dopamine receptors in the reward circuit. As a result, dopamine’s impact on the reward circuit is lessened, reducing the abuser’s ability to enjoy the drugs and the things that previously brought pleasure. This decrease compels those addicted to drugs to keep abusing drugs in order to attempt to bring their dopamine function back to normal. And, they may now require larger amounts of the drug than they first did to achieve the dopamine high—an effect known as tolerance.

Long-term abuse causes changes in other brain chemical systems and circuits as well. Glutamate is a neurotransmitter that influences the reward circuit and the ability to learn. When the optimal concentration of glutamate is altered by drug abuse, the brain attempts to compensate, which can impair cognitive function. Drugs of abuse facilitate nonconscious (conditioned) learning, which leads the user to experience uncontrollable cravings when they see a place or person they associate with the drug experience, even when the drug itself is not available. Brain imaging studies of drug-addicted individuals show changes in areas of the brain that are critical to judgment, decisionmaking, learning and memory, and behavior control. Together, these changes can drive an abuser to seek out and take drugs compulsively despite adverse consequences—in other words, to become addicted to drugs.

mft continuing education, lcsw continuing education, ceus for mfts and lpcs
Why do some people become addicted, while others do not?

No single factor can predict whether or not a person will become addicted to drugs. Risk for addiction is influenced by a person’s biology, social environment, and age or stage of development. The more risk factors an individual has, the greater the chance that taking drugs can lead to addiction. For example:

Biology. The genes that people are born with––in combination with environmental influences––account for about half of their addiction vulnerability. Additionally, gender, ethnicity, and the presence of other mental disorders may influence risk for drug abuse and addiction.


Environment. A person’s environment includes many different influences––from family and friends to socioeconomic status and quality of life in general. Factors such as peer pressure, physical and sexual abuse, stress, and parental involvement can greatly influence the course of drug abuse and addiction in a person’s life.


Development. Genetic and environmental factors interact with critical developmental stages in a person’s life to affect addiction vulnerability, and adolescents experience a double challenge. Although taking drugs at any age can lead to addiction, the earlier that drug use begins, the more likely it is to progress to more serious abuse. And because adolescents’ brains are still developing in the areas that govern decisionmaking, judgment, and self-control, they are especially prone to risk-taking behaviors, including trying drugs of abuse.


Prevention is the Key

Drug addiction is a preventable disease. Results from NIDA-funded research have shown that prevention programs that involve families, schools, communities, and the media are effective in reducing drug abuse. Although many events and cultural factors affect drug abuse trends, when youths perceive drug abuse as harmful, they reduce their drug taking. It is necessary, therefore, to help youth and the general public to understand the risks of drug abuse, and for teachers, parents, and healthcare professionals to keep sending the message that drug addiction can be prevented if a person never abuses drugs.

Substance Abuse and Inhalants CEUs

The percentage of adolescents (i.e., youths aged 12 to 17) who used inhalants in the past year was lower in 2007 (3.9 percent) than in 2003, 2004, and 2005 (4.5, 4.6, and 4.5 percent, respectively)

Among adolescents who used inhalants for the first time in the past year (i.e., past year initiates), the rate of use of nitrous oxide or "whippits" declined between 2002 and 2007 among both genders (males: 40.2 to 20.2 percent; females: 22.3 to 12.2 percent)

In 2007, 17.2 percent of adolescents who initiated illicit drug use during the past year indicated that inhalants were the first drug that they used; this rate remained relatively stable between 2002 and 2007

Adolescents have easy access to some dangerous substances—ordinary household products such as glue, shoe polish, and aerosol sprays. These products are safe when used as intended, but they can be dangerous and even deadly when sniffed or "huffed" to get high. Preventing and treating inhalant use problems, as well as raising awareness about the dangers of inhalant use, are important ongoing goals of the Substance Abuse and Mental Health Services Administration (SAMHSA). Monitoring trends in inhalant use is vital to assessing policies intended to reduce inhalant use.
This issue of The NSDUH Report examines trends in the use, dependence or abuse,1 and initiation of inhalants among adolescents (i.e., youths aged 12 to 17). The National Survey on Drug Use and Health (NSDUH) defines inhalants as "liquids, sprays, and gases that people sniff or inhale to get high or to make them feel good." NSDUH collects data not only about the use of any inhalant, but also about the use of specific types of inhalants. Respondents who used inhalants were asked when they first used them, and responses to this question were used to identify persons who had initiated use in the 12 months before the survey. This report uses data from the 2002 through 2007 NSDUHs.

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Use and Dependence or Abuse
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In 2007, almost 1.0 million adolescents used inhalants in the past year; this represents 3.9 percent of adolescents, which was lower than the rate in 2003, 2004, and 2005 (4.5, 4.6, and 4.5 percent, respectively) (Figure 1). Past year dependence on or abuse of inhalants remained relatively stable between 2002 and 2007, with 0.4 percent of adolescents (around 99,000 persons) meeting the criteria for dependence or abuse in 2007.

Figure 1. Trends in Past Year Inhalant Use and Dependence or Abuse among Adolescents: 2002 to 2007



Figure 1 Table. Trends in Past Year Inhalant Use and Dependence or Abuse among Adolescents: 2002 to 2007 Trend 2002 2003 2004 2005 2006 2007
Past Year Use 4.4% 4.5%* 4.6%* 4.5%* 4.4% 3.9%
Past Year Dependence or Abuse 0.4% 0.4% 0.5% 0.4% 0.4% 0.4%
Source: 2002 to 2007 SAMHSA National Surveys on Drug Use and Health (NSDUHs).



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Past Year Initiation of Inhalant Use
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In 2007, 2.1 percent of adolescents who had not previously used inhalants began using them during the 12 months prior to the survey (Figure 2). This rate was lower than the rates of initiation for 2002, 2003, 2004, and 2005.

Figure 2. Trends in Past Year Initiation of Inhalants among Adolescents Who Had Not Previously Used Inhalants: 2002 to 2007**



Figure 2 Table. Trends in Past Year Initiation of Inhalants among Adolescents Who Had Not Previously Used Inhalants: 2002 to 2007** Trend 2002 2003 2004 2005 2006 2007
Past Year Initiation of Inhalants 2.6%* 2.6%* 2.6%* 2.6%* 2.4% 2.1%
Source: 2002 to 2007 SAMHSA National Surveys on Drug Use and Health (NSDUHs).



NSDUH also provides data on the first illicit drug initiated among past year initiates.2 In 2007, 17.2 percent of past year illicit drug initiates indicated that inhalants were the first drug that they used (Table 1). Marijuana was the first drug used by 56.3 percent of past year illicit drug initiates; nonmedically used prescription-type drugs were the first type of drug used by 23.5 percent of past year illicit drug initiates. These rates remained relatively stable between 2002 and 2007.

Table 1. Trends for First Drug Initiated in the Past Year among Adolescents Who Initiated Illicit Drug Use in the Past Year: 2002 to 2007** First Drug Initiated*** 2002
(%) 2003
(%) 2004
(%) 2005
(%) 2006
(%) 2007
(%)
Marijuana and Hashish 59.9% 57.6% 57.3% 55.0% 57.1% 56.3%
Nonmedical Use of Prescription-Type Drugs 22.2% 20.4% 21.3% 22.0% 22.0% 23.5%
Inhalants 14.5% 19.4% 19.2% 19.6% 17.4% 17.2%
Hallucinogens 2.9% 2.3% 2.1% 2.5% 3.0% 2.3%
Cocaine 0.7% 0.4% 0.5% 1.0% 0.9% 0.8%
Source: 2002 to 2007 SAMHSA National Surveys on Drug Use and Health (NSDUHs).


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Use of Specific Inhalants among Past Year Inhalant Initiates
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Among past year inhalant initiates, the percentage using most specific types of inhalants in 2007 did not differ significantly from the percentage in 2002 (Table 2); however, there were a few exceptions. Among past year inhalant initiates, use of nitrous oxide or "whippits" was lower in 2007 than in 2002 (16.3 vs. 31.6 percent), and use of aerosol spray other than spray paint3 was higher in 2007 than 2002 (25.0 vs. 12.6 percent).

Table 2. Trends in Past Year Use of Specific Types of Inhalants among Past Year Inhalant Initiates Aged 12 to 17: 2002 to 2007** Type of Inhalant 2002
(%) 2003
(%) 2004
(%) 2005
(%) 2006
(%) 2007
(%)
Amyl Nitrite, "Poppers," Locker Room Odorizers,
or "Rush" 14.0% 17.0% 12.6% 16.4% 16.5% 19.3%
Correction Fluid, Degreaser, or Cleaning Fluid 15.7% 19.7% 19.6% 19.6% 22.5% 19.3%
Gasoline or Lighter Fluid 26.2% 23.2% 25.3% 26.7% 27.0% 28.1%
Glue, Shoe Polish, or Toluene 32.9% 30.2% 27.6% 31.3% 25.6% 28.8%
Halothane, Ether, or Other Anesthetics 2.9% 2.9% 4.5% 3.4% 4.5% 5.7%
Lacquer Thinner or Other Paint Solvents 13.9% 10.7% 10.8% 13.3% 14.2% 12.8%
Lighter Gases, Such as Butane or Propane 9.3% 9.7% 9.2% 8.1% 7.1% 9.9%
Nitrous Oxide or "Whippits" 31.6% 23.0% 20.1% 21.3% 17.7% 16.3%
Spray Paints 21.4% 23.3% 25.4% 23.9% 28.1% 25.1%
Aerosol Sprays Other than Spray Paints+ 12.6% 17.6% 23.6% 25.4% 23.5% 25.0%
Source: 2002 to 2007 SAMHSA National Surveys on Drug Use and Health (NSDUHs).


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Discussion
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Although the rates of inhalant use and inhalant initiation appeared to be on a downward trend, particularly since 2005, the rates of dependence on or abuse of these substances remained stable between 2002 and 2007. Rates of use of specific types of inhalants among past year initiates generally did not differ significantly from 2002 to 2007, although a few types showed significant changes. Use of nitrous oxide or "whippits" decreased by half, and use of aerosol sprays other than spray paints doubled. Over the period from 2002 to 2007, 15 to 20 percent of past year illicit drug initiates indicated that inhalants were the first illicit drug they had used.

These findings highlight the ongoing need for prevention and treatment of inhalant use and abuse. Continuing efforts are needed among adolescents and their parents, other family members, teachers, service providers, and policymakers to increase awareness of the dangers of inhalant use. Awareness campaigns and prevention efforts may need targeted messages about the use of specific inhalants, such as aerosol air fresheners, aerosol sprays, and aerosol cleaning products.



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End Notes
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1 Substance dependence or abuse is defined using criteria in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which includes symptoms such as withdrawal, tolerance, use in dangerous situations, trouble with the law, and interference in major obligations at work, school, or home during the past year.
2 Illicit drugs refer to marijuana/hashish, cocaine (including crack), inhalants, hallucinogens, heroin, or prescription-type drugs used nonmedically.
3 Aerosol sprays other than spray paint include products such as aerosol air fresheners, aerosol spray, and aerosol cleaning products (e.g., dusting sprays, furniture polish). The aerosol propellants in these products are commonly chlorofluorocarbons. By contrast, nitrous oxide is used as a propellant for whipped cream and is available in 2-inch tapered cylinders called "whippits" that are used to pressurize home whipped-cream charging bottles.


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Figure and Table Notes
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* Difference between this estimate and 2007 estimate is statistically significant at the .05 level.
** Past year initiates are defined as adolescents who used a drug for the first time during the 12 months prior to the survey.
*** First drug initiated is based on the date of the first use for each drug, with imputation for the day of the month and for the month of the year, if not reported. Respondents may be counted in more than one drug category if they reported initiating multiple drugs on the same day the first time that they used drugs.
+ See End Note 3.


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Suggested Citation
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Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (March 16, 2009). The NSDUH Report: Trends in Adolescent Inhalant Use: 2002 to 2007. Rockville, MD.

The National Survey on Drug Use and Health (NSDUH) is an annual survey sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA). The 2002 to 2007 data used in this report are based on information obtained from 136,449 persons aged 12 to 17. The survey collects data by administering questionnaires to a representative sample of the population through face-to-face interviews at their place of residence.

The NSDUH Report is prepared by the Office of Applied Studies (OAS), SAMHSA, and by RTI International in Research Triangle Park, North Carolina. (RTI International is a trade name of Research Triangle Institute.)

Information on the most recent NSDUH is available in the following publication:

Office of Applied Studies. (2008). Results from the 2007 National Survey on Drug Use and Health: National findings (DHHS Publication No. SMA 08-4343, NSDUH Series H-34). Rockville, MD: Substance Abuse and Mental Health Services Administration. Also available online: http://oas.samhsa.gov.

HIPAA

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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


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

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

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

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

Depression and Mood Disorders Continuing Education CEU

Depression and Mood Disorders
The Prevalence of Major Depression and Mood Disorders in Suicide
Mental Health: A Report of the Surgeon General, states that "major depressive disorders account for about 20 to 35 percent of all deaths by suicide" (p. 244). This estimate is based on a review of psychological autopsies conducted by Angst, Angst, and Stassen (1999). This brief review is intended to address this prevalence estimate. It is important to note that this estimate refers only to the prevalence of major depressive disorder among those who commit suicide, not any other mood disorders (e.g., bipolar I & II, dysthymia, adjustment disorder with depressed mood). Prevalence estimates that include other mood disorders in addition to major depression are much higher.

Major depression in suicide
The lower bound of the 20-35% estimate of the prevalence of major depression in suicide is loosely based on one psychological autopsy study; a study where the reliability of the diagnoses are somewhat questionable. This study (Rich, Young & Fowler, 1986) of 204 subjects identified 15% of suicides as having major depressive disorder. However, an additional 30% were reported as having "atypical depression," defined in this study as having a depressive syndrome that followed the onset of substance use. If this ambiguously defined group were to be considered major depression, the estimate climbs to 45%. A number of other studies suggest that the prevalence of major depression in suicide is somewhat over 30%. The four other available psychological autopsy studies that include samples of suicides from the full age range and reliable diagnoses based on structured interviews (Arato, Demeter, Rihmer & Somogyi, 1988; Dorpat & Ripley, 1960; Foster, Gillespie, McClelland & Patterson, 1999; Henriksson et al., 1993) obtained prevalence estimates of major depression ranging from 30-34% of suicides. In addition, several psychological autopsy studies examining more specific subsamples (e.g., the elderly, adolescents, women) find even higher prevalence estimates. In three psychological autopsy studies of adolescents (Brent et al. 1988; Brent et al., 1999; Shaffer et al., 1996) 41%, 43%, and 32% of adolescent suicides were determined to have had major depression prior to death. Two studies of young adults (Lesage et al. 1994; Runeson, 1989) found a prevalence of 40% and 41%, respectively. A study of 104 women by Asgard (1990) found a 35% rate of major depression. One study of 54 older adults over age 65 found a prevalence of 54%. In summary, the available data suggest that the 20-35% estimate for the prevalence of major depressive disorder in completed suicide is probably somewhat conservative and that a 30-40% prevalence estimate is probably more accurate. This estimate includes both secondary and primary depression. Many of these individuals would also be comorbid with other disorders, especially substance abuse.

Mood disorders in suicide
Prevalence estimates for all mood disorders in suicide (including MDD, Bipolar I & II, dysthymia, and adjustment disorder with depressed mood) are much higher than for major depression alone. These rates are probably closer to 60%, although as noted below, this estimate varies because of inconsistency of the criteria used to define a "mood disorder" across investigations. Four studies examining the full age range of suicides estimate that 36%, 48%, and 66%, and 70% of suicides have some sort of "depressive disorder" or "depression" (Foster et al., 1999; Rich et al., 1986, Henriksson et al., 1993, Barraclough, Bunch, Nelson, & Sainsbury, 1974). Three studies of adolescents found prevalence estimates for "mood disorders" or "affective disorders" of 61%, 63%, and 67% respectively (Shaffer et al., 1996; Brent et al. 1988; Marttunen et al., 1992). Two studies of young adults (Lesage et al., 1994; Runeson, 1989) found estimates of 60% and 64%. A study of 104 women by Asgard (1990) found a 59% rate of "mood disorders." In a review of psychological autopsy studies that examined patterns of psychiatric diagnosis across age groups, Conwell and Brent (1995) concluded that depressive disorders increased with age. Overall estimates for the rates of mood disorders range from 36% to 70% with great interstudy variability. This variability is probably partly a combination of unreliable methods of diagnosis and different definitions of what constitutes a "mood disorder." Despite this variability, a number of studies have found a pattern for increasing mood disorders with aging.


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References

Angst, J., Angst, F., and Stassen, H. H. (1999). Suicide risk in patients with major depressive disorder. Journal of Clinical Psychiatry, 60(supp. 2), 57-62.

Arato, M., Demeter, E., Rihmer, Z., & Somogyi, E. (1988). Retrospective psychiatric assessment of 200 suicides in Budapest. Acta Psychiatrica Scandinavica, 77, 454-456.

Asgard, U. (1990). A psychiatric study of suicide among urban women in Sweden. Acta Psychiatrica Scandinavica, 82, 115-124.

Barraclough, B., Bunch, J., Nelson, B., & Sainsbury, P. (1974). A hundred cases of suicide: Clinical aspects. British Journal of Psychiatry, 125,355-373.

Brent, D.A., Perper, J.A., Goldstein, C.E., Kolko, D.J., Allan, M.J., Allman, C.J., & Zelenak, J.P. (1988). Risk factors for adolescent suicide: A comparison of adolescent suicide victims with suicidal inpatients. Archives of General Psychiatry, 45,581-588.

Brent, D. A., Perper, J. A., Moritz, G., Allman, C., Friend, A., Roth, C., Schweers, J., Balach, L., & Baugher, M. (1993). Psychiatric risk factors for adolescent suicide: A case-control study. Journal of the American Academy of Child and Adolescent Psychiatry, 32,521-529.

Clark, D. C. (1991). Final Report to the AARP Adrus Foundation: Suicide Among the Elderly.

Conwell, Y. & Brent, D. (1995). Suicide and aging I: Patterns of psychiatric diagnosis. International Psychogeriatrics, 7, 149-164.

Dorpat, T. L., & Ripley, H. S. (1960). A study of suicide in the Seattle area. Comprehensive Psychiatry, 1, 349-359

Foster, T., Gillespie, K., McClelland, R., & Patterson, C. (1999). Risk factors for suicide independent of DSM-III-R Axis I disorder. British Journal of Psychiatry, 175, 175-179.

Henriksson, M. M., Aro, H. M., Marttunen, M. J., Heikkinen, M. E., Isometa, E. T., Kuoppasalmi, K. I., & Lonqvist, J. K. (1993). Mental disorders and comorbidity in suicide. American Journal of Psychiatry, 150, 935-940.

Lesage, A., Boyer, R., Grunberg, F., Vanier, C., Morissette, R., Menard-Bueeau, C., & Loyer, M. (1994). Suicide and mental disorders: A case-control study of young men. American Journal of Psychiatry, 151, 1063-1068.

Marttunen, M. J., Hillevi, M., Aro, H.M., & Lonnqvist, J. K. (1992). Adolescent suicide: Endpoint of long-term difficulties. Journal of the American Academy of Child and Adolescent Psychiatry, 34(4), 649-654.

Rich, C. L., Young, D., & Fowler, R. C. (1986). San Diego suicide study: Young vs old subjects. Archives of General Psychiatry, 43, 577-582.

Runeson, B. (1989). Mental disorder in youth suicide: DSM-III-R Axes I and II. Acta Psychiatrica Scandinavica, 79, 490-497.

Shaffer, D., Gould, M. S., Fisher, P., Trautmann, P., Moeau, D., Kleinman, M., & Flory, M. (1996). Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 53, 339-348.

Common Stress Reactions Following Exposure To Trauma

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

Autism

What is autism?

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

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What are the signs of autism?

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


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

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How common is autism?

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

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What causes autism?

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

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

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

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

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What help is available for families?

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


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

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What can parents do?

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


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

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

Suicide Prevention

Suicide Prevention

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

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

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

Answers in the Aftermath

Answers in the Aftermath

A guide to mental health concerns for victims of violent crime
As a survivor of violent crime, you may face a wide range of emotional and physical struggles, along with some difficult questions that often surface: Why did this happen to me? How will I ever heal from this? Why can’t I connect with others the way I did before? When will I start to feel “normal” again? While the answers may be different for each individual, there are some striking similarities in how trauma affects nearly all victims. Understanding the nature and impact of violent trauma can be essential to the healing process. This brochure is intended as a guide to help you along the path to healing and to avoid some of the common pitfalls along the way.

What is Post Traumatic Stress Disorder (PTSD)?
PTSD is a mental health condition that can be caused by experiencing or observing virtually any kind of deep emotional trauma, especially one that is unexpected. Millions of people in the United States suffer from PTSD, resulting from many different types of trauma—from enduring years of domestic violence to a single violent attack that lasts but a few seconds. PTSD is characterized by both emotional and physical suffering; many afflicted by it find themselves unintentionally revisiting their trauma through flashbacks or nightmares. PTSD can make you feel isolated, disconnected, and “different” from other people—and it can even begin to affect the most routine activities of everyday life. PTSD is a potentially serious condition that should not be taken lightly.

Why is substance abuse common following a traumatic event?
Since violent trauma can bring about so many changes, questions, and uncertainties, many survivors turn to alcohol and illicit drugs in an attempt to get some relief from their almost round-the-clock emotional turmoil and suffering. Substance abuse and mental health problems often accompany violent trauma. All survivors of trauma manage their experiences in different ways. Substance abuse, however, is not only an ineffective tool in healing from trauma, but it also can present a host of additional problems that make the healing process even more difficult.

What can I do if I am experiencing PTSD or if substance abuse becomes a problem for me?
According to a recent study conducted by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, the most effective way to combat trauma, substance abuse, and mental health problems is through an integrated, holistic approach, taking into account how each individual problem affects the others. To begin, it can help to share your experiences and concerns with a service provider (e.g. counselor, physician, victim witness coordinator) who can assist in developing a plan to address all of your struggles comprehensively. Psychologists and counselors with experience treating trauma survivors can be very helpful in working through PTSD, and there are prescription drugs available to help ease PTSD symptoms.

PTSD can make you feel isolated, disconnected, and “different” from other people—and it can even begin to affect the most routine activities of everyday life.

What can I do to begin the healing process?
There are some positive steps that you can take right away to begin healing. Here are some suggestions:

Recognize your loss.
Establish safety for yourself.
Respect the way you feel and your right to feel that way.
Talk about your feelings with those you trust.
Connect with other survivors of violence, many of whom experience similar difficulties.
Do not be afraid to seek professional help.
Try to recognize triggers that may take you back to the memory and fear of your trauma.
Try to be patient and avoid making rash decisions—it can take time to figure out where you are, where you want to be, and how to get there.
Take care of yourself—exercise, eat right, and take a deep breath when you feel tense.
Try to turn your negative experience into something positive—volunteer, donate, or do something else to constructively channel your energy and emotions.
Do not abandon hope—believe that healing can and will take place.

Mental Health Stigma

Anti-Stigma: Do You Know the Facts?
Stigma is not just a matter of using the wrong word or action. Stigma is about disrespect. It is the use of negative labels to identify a person living with mental illness. Stigma is a barrier. Fear of stigma, and the resulting discrimination, discourages individuals and their families from getting the help they need. An estimated 22 to 23 percent of the U.S. population experience a mental disorder in any given year, but almost half of these individuals do not seek treatment (U.S. Department of Health and Human Services, 2002; U.S. Surgeon General, 2001).

The educational information on this web site encourages the use of positive images to refer to people with mental illness and underscores the reality that mental illness can be successfully treated.

Do you know that an estimated 44 million Americans experience a mental disorder in any given year?

Do you know that stigma is not a matter of using the wrong word or action?

Do you know that stigma is about disrespect and using negative labels to identify a person living with mental illness?

Do you know that stigma is a barrier that discourages individuals and their families from seeking help?

Do you know that many people would rather tell employers they committed a petty crime and served time in jail, than admit to being in a psychiatric hospital?

Do you know that stigma can result in inadequate insurance coverage for mental health services?

Do you know that stigma leads to fear, mistrust, and violence against people living with mental illness and their families?

Do you know that stigma can cause families and friends to turn their backs on people with mental illness?

Do you know that stigma can prevent people from getting access to needed mental health services?

DO'S

Do use respectful language

Do emphasize abilities, not limitations.

Do tell someone if they express a stigmatizing attitude.

DONT'S

Don't portray successful persons with disabilities as super human.

Don't use generic labels such as retarded, or the mentally ill.

Don't use terms like crazy, lunatic, manic depressive, or slow functioning.