Family-Focused Therapy Effective in Treating Depressive Episodes of Bipolar Youth

Adolescents with bipolar disorder who received a nine-month course of family-focused therapy (FFT) recovered more quickly from depressive episodes and stayed free of depression for longer periods than a control group, according to an NIMH-funded study published September 2008 in the Archives of General Psychiatry. MFT Continuing Education
In FFT, the patient and his or her family are heavily involved in psychosocial treatment sessions. They learn to identify the symptoms of bipolar disorder, its course, and how to spot impending episodes or relapses. Patients and families also learn communication and problem-solving skills, and illness management strategies. For this trial, David Miklowitz, Ph.D., of the University of Colorado, and colleagues adapted the therapy to the needs of adolescents and their families.

The 58 participants, ages 12 to 17, were recruited from the University of Colorado and the University of Pittsburgh, and randomly assigned to either 21 50-minute sessions of FFT or to a control intervention called enhanced care (EC). EC included three 50-minute sessions with patients and their families that focused on relapse prevention planning, taking medication as directed, and dealing with conflict at home. All participants took mood-stabilizing medication such as lithium as well. Participants were evaluated every three months during the first year of the two-year study and every six months in the second year.

Although the rate of recovery was high for all participants—91.4 percent—participants in the FFT group recovered faster from depressive symptoms than the EC group. This was especially pronounced in youths who were in the midst of a major depressive episode at the beginning of the study. In the FFT group, the average time to recovery from major depression was 10 weeks, compared to 14 weeks for the EC group. The FFT group also spent less time depressed—about three weeks compared to the EC group’s five weeks—and had less severe depressive symptoms over the two years than the EC group.

The results are similar to those of the NIMH-funded Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), which found that adult participants who received up to 30 sessions of FFT, cognitive behavioral therapy, or interpersonal therapy plus mood stabilizing medications recovered more rapidly from depressive episodes than the participants who received only three psychoeducational sessions in addition to medication.

The adolescent participants in the new study eventually recovered from manic symptoms as well, but neither of the treatments showed a statistically significant advantage in treating mania, a finding also consistent with STEP-BD results. The researchers conclude that for full recovery from adolescent bipolar disorder, FFT may need to be augmented with psychoeducational interventions that are effective against mania symptoms.

Reference
Miklowitz DJ, Axelson DA, Birmaher B, George EL, Taylor DO, Schneck CD, Beresford CA, Dickinson M, Craighead WE, Brent DA. Family-focused treatment for adolescents with bipolar disorder. Archives of General Psychiatry. 2008 Sept; 65(9).

Study Identifies Three Effective Treatments for Childhood Anxiety Disorders

Treatment that combines a certain type of psychotherapy with an antidepressant medication is most likely to help children with anxiety disorders, but each of the treatments alone is also effective, according to a new study funded by the National Institutes of Health’s National Institute of Mental Health (NIMH). The study was published online Oct. 30, 2008, in the New England Journal of Medicine. MFT Continuing Education


“Anxiety disorders are among the most common mental disorders affecting children and adolescents. Untreated anxiety can undermine a child’s success in school, jeopardize his or her relationships with family, and inhibit social functioning,” said NIMH Director Thomas R. Insel, M.D. “This study provides strong evidence and reassurance to parents that a well-designed, two-pronged treatment approach is the gold standard, while a single line of treatment is still effective.”

The Child/Adolescent Anxiety Multimodal Study (CAMS) randomly assigned 488 children ages 7 years to 17 years to one of four treatment options for a 12-week period:

Cognitive behavioral therapy (CBT), a specific type of therapy that, for this study, taught children about anxiety and helped them face and master their fears by guiding them through structured tasks;
The antidepressant sertraline (Zoloft), a selective serotonin reuptake inhibitor (SSRI);
CBT combined with sertraline;
pill placebo (sugar pill).
The children, recruited from six regionally dispersed sites throughout the United States, all had moderate to severe separation anxiety disorder, generalized anxiety disorder or social phobia. Many also had coexisting disorders, including other anxiety disorders, attention deficit hyperactivity disorder, and behavior problems.

John Walkup, M.D., of Johns Hopkins Medical Institutions, and colleagues found that among those in combination treatment, 81 percent improved. Sixty percent in the CBT-only group improved, and 55 percent in the sertraline-only group improved. Among those on placebo, 24 percent improved. A second phase of the study will monitor the children for an additional six months.

“CAMS clearly showed that combination treatment is the most effective for these children. But sertraline alone or CBT alone showed a good response rate as well. This suggests that clinicians and families have three good options to consider for young people with anxiety disorders, depending on treatment availability and costs,” said Walkup.

Results also showed that the treatments were safe. Children taking sertraline alone showed no more side effects than the children taking the placebo and few children discontinued the trial due to side effects. In addition, no child attempted suicide, a rare side effect sometimes associated with antidepressant medications in children.

CAMS findings echo previous studies in which sertraline and other SSRIs were found to be effective in treating childhood anxiety disorder. The study’s results also add more evidence that high-quality CBT, with or without medication, can effectively treat anxiety disorders in children, according to the researchers.

“Further analyses of the CAMS data may help us predict who is most likely to respond to which treatment, and develop more personalized treatment approaches for children with anxiety disorders,” concluded Philip C. Kendall, Ph.D., of Temple University, a senior investigator of the study. “But in the meantime, we can be assured that we already have good treatments at our disposal.”

The six CAMS sites were Duke University; New York State Psychiatric Institute/Columbia University Medical Center; Johns Hopkins University; Temple University/University of Pennsylvania; University of California, Los Angeles; and the Western Psychiatric Institute and Clinic/University of Pittsburgh Medical Center.



Reference
Walkup JT, Albano AM, Piacentini J, Birmaher B, Compton SN, Sherrill J, Ginsburg GS, Rynn MA, McCracken J, Waslick B, Iyengar S, March JS, Kendall PC. Cognitive-behavioral therapy, sertraline and their combination for children and adolescents with anxiety disorders: acute phase efficacy and safety. New England Journal of Medicine. Online ahead of print 30 Oct 2008.

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.

Just Over Half of Americans Diagnosed with Major Depression Receive Care

More Receive Psychotherapy than Medication; Study Provides New Detail on Disparities
Overall, only about half of Americans diagnosed with major depression in a given year receive treatment for it, and even fewer—about one fifth—receive treatment consistent with current practice guidelines, according to data from nationally representative surveys supported by NIMH. Among the ethnic/racial groups surveyed, African Americans and Mexican Americans had the lowest rates of use of depression care; all groups reported higher use of past-year psychotherapy vs. medication for depression. MFT Continuing Education
Background
Depression is a leading cause of disability in the United States. Past research has found that many people with depression never received treatment, and that the percentage of those receiving treatment varies with ethnicity and race. In order to provide comprehensive and up-to-date information on depression care, with a particular emphasis on minority groups, NIMH's Collaborative Psychiatric Epidemiology Surveys initiative (CPES) has combined data from three nationally representative studies: the National Survey of American Life, the National Comorbidity Survey-Replication, and the National Latino and Asian American Study.

This Study
Scientists at Wayne State University, Detroit, MI; the University of Michigan, Ann Arbor; the University of California, Los Angeles; and the Harvard School of Public Health, Boston, MA, carried out the current study, which reports on data from CPES collected between February 2001 and November 2003 from 15,762 residents 18 years and older. The size of the sample makes it possible to examine health care use in ethnic/racial groups with a new level of detail, distinguishing between groups often surveyed as one population. The investigators were able to break out types of care used, and to assess to what extent the care used was consistent with the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorder. Finally, they examined how factors enabling healthcare access—insurance, education, and household income—influenced rates of care.

A central finding was that overall, 51 percent of all those in the study who met criteria for major depression during the prior year received some kind of treatment for it, with only 21 percent receiving care that was consistent with the APA Guidelines.

Other key study findings addressed disparities, types and quality of care received, and factors that enable access to healthcare.

Prevalence and severity of major depression was similar among the five studied ethnic/racial groups—Mexican Americans, Puerto Ricans, Caribbean Blacks, African Americans, and non-Latino Whites. However, African Americans and Mexican Americans were least likely to receive any care or care consistent with practice guidelines. Compared with non-Latino Whites for example, of whom 54 percent with depression received care, 40 percent of African Americans and 34 percent of Mexican Americans did. The rate of care for Puerto Ricans was close to that of Whites, 50 percent.
Across these population groups, psychotherapy was used more frequently than medications (pharmacotherapy). Overall, 34 percent received pharmacotherapy; 45 percent psychotherapy. Psychotherapy was more likely to be consistent with APA guidelines than pharmacotherapy, suggesting that adherence—the extent to which patients completed the recommended therapy—was greater for psychotherapy than pharmacotherapy. The contrast between the rates of Guideline-consistent psychotherapy and pharmacotherapy use was greatest among Caribbean Blacks, African Americans, and Mexican Americans.
Puerto Ricans had rates of treatment use, and treatment that was consistent with care guidelines, that were similar to, or higher than, non-Latino Whites.
Differences in factors enabling healthcare access appeared to contribute substantially to disparities in mental healthcare use, particularly for Mexican Americans. When differences in these enabling factors were controlled for statistically—so in effect, the population groups being compared had the same rates of enabling factors—the degree of disparities in use of care by Mexican Americans was reduced. For Caribbean Blacks and African Americans, statistical control of enabling factors reduced disparities in psychotherapy use, but not use of pharmacotherapy.
Health insurance coverage was associated with a greater likelihood of depression care, but not guideline consistent care. The pattern with education was reversed: education was associated with a greater likelihood of care that was consistent with the APA Guidelines, but not with greater use of care in general.
Significance
This study, with its large sample size and emphasis on minority groups, provides a more nuanced and detailed picture of the care received for major depression among different ethnic/racial groups and of factors that contribute to disparities. Lead author Hector González at Wayne State University said that Mexican-Americans make up over two-thirds of Latinos in the U.S.: "We found in our study that there are some really distinctive differences in mental healthcare use between Mexican Americans and other Latino subgroups that have not been previously reported." Estimates suggest that Latinos will make up close to one-third of the U.S. population by mid-century; the study findings suggest that Mexican Americans should be a focus of efforts to reduce health disparities to ensure the nation's health in coming decades.

All groups were more likely to have received psychotherapy than pharmacotherapy. Caribbean Blacks and African Americans were particularly unlikely to receive pharmacotherapy consistent with APA guidelines; enabling factors such as education, health insurance, and income did not explain the lower rates of medication use. The authors note possible reasons for this, including research indicating that perceived discrimination can shape health care seeking. They speculate that the non-immigrant status of Puerto Ricans—and with that, greater predominance of English language use within this group—may be factors in their relatively high rates of health care use.

Findings from this study will inform future research on adherence to various depression therapies, and the factors that shape differences in care among racial/ethnic groups. "Future studies," say the authors, "should explore the extent to which patients' subjective experiences of racial bias may affect their access and utilization of mental healthcare."

Reference
González, H.M., Vega, W.A., Williams, D.R., Tarraf, W., West, B.T., and Neighbors, H.W. Archives of General Psychiatry 2010;67(1):37-46.

Effects on Personality May Be Mechanism of Antidepressant Effectiveness

Results of a study of antidepressant treatment for major depression suggest that changes in personality traits seen in patients taking the drug paroxetine (Paxil) may not be the result of the medication’s lifting of mood but may instead be a direct effect of this class of drugs and part of the mechanism by which they relieve depression. MFT Continuing Education
Background
People with a high level of the personality trait neuroticism—characterized by a tendency to experience negative emotions and moodiness—are more likely than others to develop depression. Neuroticism is one of five personality traits that psychologists use as an organizing scheme for understanding personality: the other four traits are extraversion, openness, conscientiousness, and agreeableness. People who take anti-depressants report lower levels of neuroticism and increased extroversion, in addition to a lifting of depression. The assumption has been that these changes in personality measures were the result, not the cause, of a lifting of depression.

Studies in twins suggest that to a large degree the same genetic factors underlie both neuroticism and depression risk. Research also suggests that the neurotransmitter serotonin plays a role in the expression of both neuroticism and extraversion. The class of anti-depressant drugs to which paroxetine belongs—the selective serotonin reuptake inhibitors (SSRIs)—increase the neurotransmitter’s availability in the brain.

This Study
To test the relationship between SSRIs and personality, investigator Tony Tang and colleagues at Northwestern University, Evanston, IL, the University of Pennsylvania in Philadelphia, and Vanderbilt University in Nashville, TN, randomly assigned patients with major depressive disorder (MDD) to receive paroxetine (120 patients), placebo (60 patients), or cognitive therapy (60 patients).

After 8 weeks, medication and cognitive therapy (CT) each proved more effective than placebo in reducing depression. In addition, measures of neuroticism (based on standard surveys) in the groups receiving medication or cognitive therapy dropped, while extraversion scores rose. The changes were striking; while patients receiving placebo also reported small changes in both traits, the changes in patients on paroxetine were four to eight times as large. Patients receiving paroxetine had much greater changes in personality traits than patients receiving placebo even when the degree of improvement in depression was the same. This suggested that the effects on personality traits were not the result of the drug’s lifting of depression. After accounting for decreases in depression in patients receiving CT, the improvement in extraversion, but not neuroticism, remained significant.

In further comparison of paroxetine with placebo, patients who had initially taken placebo were given the option after 8 weeks to take paroxetine. During the placebo phase, there were small changes in neuroticism and extraversion; much greater changes occurred after 8 weeks on paroxetine. Finally, those patients on paroxetine with the greatest degree of change in neuroticism (but not extraversion) were least likely to relapse to depression; the degree of changes in personality in those receiving CT did not affect the chances of relapse.

Significance
While the neurochemical effects of SSRIs are known, how those changes act to reduce depression is not clear. These results contradict the prevailing assumption that changes seen in personality traits in patients taking SSRIs are a result of the drugs’ effects on depression. SSRIs may alter personality directly—and thus lift depression—or may act on a third factor that underlies both. CT may alter personality by a different path. Continued research on how these treatments work can provide a clearer understanding of the mechanism of action of SSRIs and how treatment can be best used to reduce depression and minimize relapse.

Reference
Tang, T.Z., DeRubeis, R.J., Hollon, S.D., Amsterdam, J., Shelton, R., and Schalet, B. Personality change during depression treatment. Archives of General Psychiatry 2009 Dec;66(12):1322-30.

Mental Health and Mass Violence

Americans have been exposed to increased levels
of mass violence during the past decade. School
violence, shootings in the workplace, and terrorist
acts both here and abroad—all have affected
individuals, families, communities, and our
country. This report addresses the urgent need to
evaluate the various psychological interventions
that are increasingly among the first responses to
these traumatic events. MFT Continuing Education
At a workshop, 58 disaster mental health experts from
six countries were invited to address the impact of
early psychological interventions and to identify
what works, what doesn’t work, and what the
gaps are in our knowledge. Prior to the workshop,
leading mental health research clinicians from the
United States, Australia, and the United Kingdom
prepared a review of the published, peer-reviewed
literature (tables appear in Appendix G and
references appear in Appendix I).
For the purpose of this workshop and report, an
early intervention is defined as any form of
psychological intervention delivered within the
first four weeks following mass violence or
disasters. Once established, services may remain
in place for the long term. Mental health
personnel will provide some of the components of
early intervention, while other components have
mental health implications but will be provided by
non-mental health personnel.
Workshop participants examined research on
critical issues related to the following questions:
What early interventions can be recommended
in mass violence situations?
What should the key operating principles be?
What are the issues of timing of early
intervention?
What is appropriate screening?
What is appropriate follow-up, for whom,
over what period of time?
What expertise, skills, and training are
necessary for early interventions, at what
level of sophistication?
What is the role of research and evaluation?
What are the ethical issues involved in early
interventions?
What are the key questions for the field of
early intervention that have not yet been
thoroughly researched?
There was general majority consensus among
participants on many points. Where significant
differences in opinion existed, participants were
invited to provide minority opinions (see
Appendix F). Some of those issues have been
reframed as research or ethical questions that can
benefit from further scientific inquiry and
discourse (see pp. 11-12).

Area of Consensus
Key Operating Principles of
Early Intervention
Workshop participants identified key components
of early psychological interventions as including
preparation, planning, education, training, and
service provision evaluation. It is essential that
these components be operationalized and used for
service delivery, research, education, and
consultation activities. Participants also indicated
that early mental health assessment and
intervention should focus on a hierarchy of needs,
e.g., survival, safety, food, shelter, etc. (see
Appendix A).
Conference participants agreed that:
A sensible working principle in the immediate
post-incident phase is to expect normal
recovery;
Presuming clinically significant disorder in
the early post-incident phase is inappropriate,
except when there is a preexisting condition;
Participation of survivors of mass violence in
early intervention sessions, whether
administered to a group or individually,
should be voluntary.
The term “debriefing” should be used only to
describe operational debriefings (see Appendix
D). Although operational debriefings can be
described as “early interventions,” they are
done primarily for reasons other than
preventing or reducing mental disorders.
Guidance on Best Practice Based
on Current Research Evidence
Thoughtfully designed and carefully executed
randomized controlled trials have a critical role in
establishing best practices. There are, however, few
randomized controlled trials of psychological
interventions following mass violence. Existing
randomized controlled trial data, often from studies
of other types of traumatic events, suggest that:
Early, brief, and focused psychotherapeutic
intervention can reduce distress in bereaved
spouses, parents, and children.
Selected cognitive behavioral approaches may
help reduce incidence, duration, and severity
of acute stress disorder, post-traumatic stress
disorder, and depression in survivors.
Early interventions in the form of single oneon-
one recitals of events and emotions evoked
by a traumatic event do not consistently
reduce risks of later post-traumatic stress
disorder or related adjustment difficulties.
There is no evidence that eye movement
desensitization and reprocessing (EMDR) as
an early mental health intervention, following
mass violence and disasters, is a treatment of
choice over other approaches.
Other practices that may have captured public
interest have not been proven effective, and some
may do harm.

Tips in a Time of Economic Crisis.

Tips in a Time of Economic Crisis.

Many Americans report heightened levels of stress during this time of financial crisis. Yet, few realize that this reaction to economic pressures closely resembles the psychological effects experienced after natural disasters such as hurricanes, floods, wildfires, or even the terrorist attacks of 9/11. Stress reduction and mental health promotion are as important now for people affected directly or indirectly by the financial crisis as for those who suffered from effects of natural or man-made disasters.You Should Know While we try to shield our children from financial problems and the economic crisis, they hear, see, and read about what is happening in the world, the nation, and in their own homes. Despite our best efforts as adults, our worries can become their worries. Our stress can become their stress. Part of our responsibility as parents or guardians is to help our children deal with the stress that they lack the understanding or ability to manage on their own. MFT Continuing Education

Signs of Stress in the Young
Children respond to stress in many different ways. However, because certain signs are common at particular ages, adults can recognize when children are under stress and respond appropriately. Children respond to stress based on both their developmental level and their perception of family reactions. Often, the most significant indicator of stress is a change in a child’s behavior, not the behavior itself. Ages 1 to 5: With few coping skills, very young children have a hard time adjusting to change and loss. They must depend on parents, family members, and teachers to help them through difficult times. Very young children often regress to an earlier behavioral stage when under stress. Preschoolers may resume thumb sucking or bed wetting. They may cling to a parent or become very attached to a place where they feel safe. Changes in eating or sleeping habits, hyperactivity, or unusually aggressive or withdrawn behavior may indicate the presence of stress in young children.School-age Children: Those aged 5 to 11 may react to stress in many of the same ways as their younger counterparts. Signs can include regression to behaviors from earlier ages. They also may withdraw from friends, demand more attention from parents, act aggressively, or find it hard to concentrate. Some may complain of physical problems—headache or stomachache—without obvious cause. Adolescents: When under stress, youth in the 12 to 14 age range often have vague physical complaints. They also may abandon schoolwork, chores, and other responsibilities. Many withdraw, resist authority, become disruptive, or begin to experiment with alcohol or drugs. In later adolescence, teens may experience feelings of helplessness and guilt because they are unable to assume full adult responsibilities or to contribute to solving the causes of the family stress. Older teens may also deny the extent of their emotional reactions.How To Help Reassurance is key to helping children cope with stress. To the extent possible, maintain a normal household routine; encourage children to participate in activities at home and in the neighborhood. Very young children need a lot of cuddling and verbal support. Take the cue from older children about hugs and holding hands. But whatever their age, be honest; answer questions with age-appropriate responses and understandable information, whether it’s about scaling back a birthday party or finding ways to pay for college in a year or two. Listen and respond. Talk with, not to, them. Don’t let financial or job issues take over family time. Don’t dwell on details that may frighten a child or unduly upset a teen. Be frank and encourage children and teens to express their feelings in conversation, drawing, writing, or painting. Help them understand that their emotions are healthy and normal. Gently correct any misunderstandings they may have about their situations. Don’t forget to take steps to safeguard your own health. Model healthy stress-relieving behaviors and be proactive about managing your family’s stress. Finally, if stress levels in the family become overwhelming, it’s not a sign of weakness or failure to seek outside help for one or more family members.“Reassurance is key to helping children cope with stress. To the extent possible, maintain a normal household routine; encourage children to participate in activities at home and in the neighborhood.”
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Page 3
Helpful ResourcesSAMHSA’s Health Information Network Toll-free: 1-877-SAMHSA-7 (1-877-726-4727) (English and Español)Web site: http://www.samhsa.gov/shinTreatment LocatorsMental Health Services LocatorToll-free: 800-789-2647 (English and Español)Web site: http://mentalhealth.samhsa.gov/databasesSubstance Abuse Treatment Facility LocatorToll-free: 800-662-HELP (4357) (24/7 English and Español)Web site: http://www.findtreatment.samhsa.govHotlinesNational Suicide Prevention LifelineToll-free: 800-273-TALK (8255)TTY: 800-799-4TTY (4889)Web site: http://www.suicidepreventionlifeline.orgOther ResourcesNational Child Traumatic Stress NetworkWeb site: http://www.nctsn.orgNational Association of School PsychologistsPhone: (301) 657-0270Toll-free: 866-331-NASPWeb site: http://www.nasponline.org/NEATAmerican Academy of Child and Adolescent PsychiatristsPhone: (202) 966-7300Web site: http://www.aacap.orgNote: This list is not exhaustive. Inclusion does not imply endorsement by the Center for Mental Health Services, the Substance Abuse and Mental Health Services Administration, or the U.S. Department of Health and Human Services.Family Talk About Economic Stress • Become a family “team” that works together to solve problems. • Have family meetings to talk about money concerns.• Include all children in family decisions, even if they don’t really understand. Just being there is important for them.• Help children learn about budgeting and the difference between needs (“must haves” like food and housing) and wants(“nice to haves” such as DVDs or a new toy).• Talk about a team approach to saving money and identify ways that everyone can help the family cut expenses. Even young children can help and feel useful by doing such things as remembering to turn off lights. • Identify and plan no-cost activities together: take a family walk, play a board game, or go on a bike ride together.
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Weight Loss: Popular New Year's Resolutions

Weight Loss for Life

■Can I benefit from weight loss?
■How can I lose weight?
■Your Plan for Healthy Eating
■Your Plan for Regular Physical Activity
■What types of weight-loss programs are available?
■Nonclinical Program
■Clinical Program
■Additional Reading
■Other Resources

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Weight Loss for Life There are many ways to lose weight, but it is not always easy to keep the weight off. The key to successful weight loss is making changes in your eating and physical activity habits that you can keep up for the rest of your life. The information presented here may help put you on the road to healthy habits. MFT Continuing Education

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Can I benefit from weight loss?
Some Weight-related Health Problems

■diabetes
■heart disease or stroke
■high blood pressure
■high cholesterol
■gallbladder disease
■some types of cancer
■osteoarthritis (wearing away of the joints)
■sleep apnea (interrupted
breathing during sleep)

Health experts agree that you may gain health benefits from even a small weight loss if:


■You are considered obese based on your body mass index (BMI) (see BMI chart below).
■You are considered overweight based on your BMI and have weight-related health problems or a family history of such problems.
■You have a waist that measures more than 40 inches if you are a man or more than 35 inches if you are a woman.
A weight loss of 5 to 7 percent of body weight may improve your health and quality of life, and it may prevent weight-related health problems, like type 2 diabetes. For a person who weighs 200 pounds, this means losing 10 to 14 pounds.

Even if you do not need to lose weight, you should still follow healthy eating and physical activity habits to help prevent weight gain and keep you healthy over the years.

Body Mass Index

BMI is a tool that is often used to determine whether a person’s health is at risk due to his or her weight. It is a ratio of your weight to your height. A BMI of 18.5 to 24.9 is considered healthy, a BMI of 25 to 29.9 is considered overweight, and a BMI of 30 or more is considered obese. You can find your BMI using the chart below, and you can also see the weight range that is healthy for your height.

BMI
19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Weight
(Pounds)
Height (Inches)
58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167 172 177 181 186 191
59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 178 183 188 193 198
60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179 184 189 194 199 204
61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185 190 195 201 206 211
62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 196 202 207 213 218
63 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 203 208 214 220 225
64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 209 215 221 227 232
65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 216 222 228 234 240
66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 223 229 235 241 247
67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 230 236 242 249 255
68 125 131 138 144 151 158 164 171 177 184 190 197 204 210 216 223 230 236 243 249 256 262
69 128 135 142 149 155 162 169 176 182 189 196 203 210 216 223 230 236 243 250 257 263 270
70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 250 257 264 271 278
71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 257 265 272 279 286
72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 265 272 279 287 294
73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 272 280 288 295 302
74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 280 287 295 303 311
75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279 287 295 303 311 319
76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287 295 304 312 320 328


Source: Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, National Institutes of Health, National Heart, Lung, and Blood Institute, September 1998.

* Without Shoes
**Without Clothes

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How can I lose weight? To lose weight you need to take in fewer calories than you use. You can do this by creating and following a plan for healthy eating and a plan for regular physical activity.

You may also choose to follow a formal weight-loss program that can help you make lifelong changes in your eating and physical activity habits. See below for more information on weight-loss programs.
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Your Plan for Healthy Eating
The Nutrition Facts label from the U.S. Food and Drug Administration (FDA) is found on most packaged foods. It tells you how many calories and how much fat, protein, carbohydrate, and other nutrients are in one serving of the food. For more information on the Nutrition Facts, see “Other Resources” at the end of this brochure.
It may be hard to stick to a weight-loss “diet” that limits your portions to very small sizes or excludes certain foods. You may have difficulty making that work over the long term. Instead, a healthy eating plan takes into account your likes and dislikes, and includes a variety of foods that give you enough calories and nutrients for good health.


Make sure your healthy eating plan is one that:

■Emphasizes fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products.
■Includes lean meats, poultry, fish, bean, eggs, and nuts.
■Is low in saturated fats, trans fats, cholesterol, salt (sodium), and added sugars.
For more specific information about food groups and nutrition values, visit: http://www.healthierus.gov/dietaryguidelines.

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Your Plan for Regular Physical Activity Regular physical activity may help you lose weight and keep it off. It may also improve your energy level and mood, and lower your risk for developing heart disease, diabetes, and some cancers.

According to the 2008 Physical Activity Guidelines for Americans, experts believe all adults should be physically active. Some activity is better than none, and individuals who engage in any amount of physical activity may gain some health benefits. The majority of your physical activity should be moderate to vigorous in intensity. However, adults should aim to include muscle-strengthening activities as well. For more information on the Physical Activity Guidelines, see the “Other Resources” section at the end of this brochure.

You can be physically active every day for one extended period of time, or you can break it up into shorter sessions of 20, 15, or even 10 minutes. Try some of these physical activities:


■walking (15 minutes per mile or 4 miles per hour)
■biking
■tennis
■aerobic exercise classes (step aerobics, kick boxing, dancing)
■energetic house or yard work (gardening, raking, mopping, vacuuming)
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What types of weight-loss programs are available? There are two different types of weight-loss programs—clinical and nonclinical. Knowing what a good program will offer and what to look for may help you choose a weight-loss program that will work for you.

Nonclinical Program

What it is: A nonclinical program may be commercially operated, such as a privately owned weight-loss chain. You can follow a nonclinical program on your own by using a counselor, book, website, or weight-loss product. You can also join others in a support group, worksite program, or community-based program. Nonclinical weight-loss programs may require you to use the program’s foods or supplements.

A safe and effective program will offer:

■Books, pamphlets, and websites that are written or reviewed by a licensed health professional such as a medical doctor (M.D.) or registered dietitian (R.D.).
■Balanced information about following a healthy eating plan and getting regular physical activity.
■Leaders or counselors who show you their training credentials. (Program leaders or counselors may not be licensed health professionals.)

Program cautions:

■If a program requires you to buy prepackaged meals, find out how much the meals will cost—they may be expensive. Also, eating prepackaged meals does not let you learn the food selection and cooking skills you will need to maintain weight loss over the long term.
■Avoid any diet that suggests you eat a certain formula, food, or combination of foods for easy weight loss. Some of these diets may work in the short term because they are low in calories. But they may not give you all the nutrients your body needs and they do not teach healthy eating habits.
■Avoid programs that do not include a physical activity plan.
■Talk to your health care provider before using any weight-loss product, such as a supplement, herb, or over-the-counter medication.
Clinical Program

What it is: A clinical program provides services in a health care setting, such as a hospital. One or more licensed health professionals, such as medical doctors, nurses, registered dietitians, and psychologists, provide care. A clinical program may or may not be commercially owned.

Clinical programs may offer services such as nutrition education, physical activity, and behavior change therapy. Some programs offer prescription weight-loss drugs or gastrointestinal surgery.

Prescription Weight-loss Drugs. If your BMI is 30 or more, or your BMI is 27 or more and you have weight-related health problems, you may consider using prescription weight-loss drugs. Drugs should be used as part of an overall program that includes long-term changes in eating and physical activity habits. Only a licensed health care provider can prescribe these drugs. See “Additional Reading” for more information about prescription medications for the treatment of obesity.

Bariatric Surgery. If your BMI is 40 or more, or your BMI is 35 or more and you have weight-related health problems such as diabetes or heart disease, you may consider bariatric surgery (also called gastrointestinal surgery). Most patients lose weight quickly. To keep the weight off, most will need to eat healthy and get regular physical activity over the long term. Surgery may also reduce the amount of vitamins and minerals that are absorbed by your body. The rapid weight loss as a result of bariatric surgery may also cause gallstones. See the “Additional Reading” section for more information about bariatric surgery.

What a safe and effective program will offer:

■A team of licensed health professionals.
■A plan to help you keep weight off after you have lost it.
Program cautions:

There may be side effects or health risks involved in the program that can be serious. Discuss these with your health care provider.

Regardless of the type of weight-loss program you choose, be sure you have follow-up visits with your health care provider. He or she may suggest ways to deal with setbacks or obstacles you may face along the way, as well as answer any questions you may have as you move forward.

For more detailed information about choosing a safe and successful weight-loss program, see the “Additional Reading” section at the end of this brochure.

It is not always easy to change your eating and physical activity habits. You may have setbacks along the way. But keep trying–you can do it!
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Additional Reading
From the Weight-control Information Network Active at Any Size describes the benefits of being physically active no matter what a person’s size. The brochure presents a variety of activities that large people can enjoy safely.

Bariatric Surgery for Severe Obesity describes the different types of surgery available to treat severe obesity. It explains how gastrointestinal surgery promotes weight loss and the benefits and risks of each procedure.

Changing Your Habits: Steps to Better Health guides readers through steps that can help them determine what “stage” they are in—how ready they are—to make healthy lifestyle changes. Once that stage is determined, strategies on how to make healthy eating and physical activity changes are offered.

Just Enough for You describes the difference between a portion—the amount of food a person chooses to eat—and a measured serving. It offers tips for judging portion sizes and for controlling portions at home and when eating out.

Prescription Medications for the Treatment of Obesity presents information on medications that suppress appetite or reduce the body’s ability to absorb dietary fat. The types of medications and the risks and benefits of each are described.

Walking…A Step in the Right Direction offers tips for getting started on a walking program and illustrates warm-up stretching exercises. It also includes a sample walking program.

Weight and Waist Measurement explains two simple measures—BMI and waist circumference—to help people determine if their weight and/or body fat distribution are putting their health at risk.
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Other Resources U.S. Department of Agriculture. My Pyramid Plan. April 2005.
Available at http://www.mypyramid.gov.

U.S. Food and Drug Administration Center for Food Safety and Applied Nutrition. How to Understand and Use the Nutrition Facts Label. June 2000. Available at http://www.cfsan.fda.gov/~dms/foodlab.html.

U.S. Department of Health and Human Services (DHHS). Physical Activity Guidelines for Americans. October 2008. Available at http://www.health.gov/PAGuidelines.

National Diabetes Information Clearinghouse, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (NIH). Diabetes Prevention Program (DPP). DHHS. NIH Publication No. 09–5099. 2008.
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Weight-control Information Network
1 WIN Way
Bethesda, MD 20892–3665
Phone: (202) 828–1025
FAX: (202) 828–1028
Toll-free number: 1–877–946–4627
Email: win@info.niddk.nih.gov
Internet: http://www.win.niddk.nih.gov

The Weight-control Information Network (WIN) is a national information service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health, which is the Federal Government’s lead agency responsible for biomedical research on nutrition and obesity. Authorized by Congress (Public Law 103–43), WIN provides the general public, health professionals, the media, and Congress with up-to-date, science-based health information on weight control, obesity, physical activity, and related nutritional issues.

Publications produced by WIN are reviewed by both NIDDK scientists and outside experts. This publication was also reviewed by F. Xavier Pi-Sunyer, M.D., M.P.H., Director, New York Obesity Research Center, St. Luke’s-Roosevelt Hospital Center, and English H. Gonzalez, M.D., M.P.H., Community Medicine and Curriculum Development Coordinator, St. Vincent’s East Family Medicine Residency Program in Birmingham, AL.

This publication is not copyrighted. WIN encourages users of this brochure to duplicate and distribute as many copies as desired.

Popular New Year's Resolutions

Popular New Year's Resolutions
Check out some New Year's resolutions that are popular year after year.

•Drink Less Alcohol
•Get a Better Education
•Get a Better Job
•Get Fit
•Lose Weight
•Manage Debt
•Manage Stress
•Quit Smoking Now
•Save Money
•Take a Trip
•Volunteer to Help Others


Drink Less AlcoholSmall changes can make a big difference in reducing your chances of having alcohol-related problems. Here are some strategies to try. Check off some to try the first week, and add some others the next. MFT Continuing Education

Keeping Track
Keep track of how much you drink. Find a way that works for you, such as a 3x5” card in your wallet, check marks on a kitchen calendar, or a personal digital assistant. If you make note of each drink before you drink it, this will help you slow down when needed.

Counting and Measuring
Know the standard drink sizes so you can count your drinks accurately (see back page). One standard drink is 12 ounces of regular beer, 8 to 9 ounces of malt liquor, 5 ounces of table wine, or 1.5 ounces of 80–proof spirits. Measure drinks at home. Away from home, especially with mixed drinks, it can be hard to keep track and at times you may be getting more alcohol than you think. With wine, you may need to ask the host or server not to “top off” a partially filled glass.

Setting Goals
Decide how many days a week you want to drink and how many drinks you’ll have on those days. It’s a good idea to have some days when you don’t drink. Drinking within the limits below reduces the chances of having an alcohol use disorder and related health problems.


For healthy men up to age 65 —
•no more than 4 drinks in a day AND
•no more than 14 drinks in a week.
For healthy women (and healthy men over age 65) —
•no more than 3 drinks in a day AND
•no more than 7 drinks in a week.
Depending on your health status, your doctor may advise you to drink less or abstain.

Pacing and Spacing
When you do drink, pace yourself. Sip slowly. Have no more than one drink with alcohol per hour. Alternate “drink spacers” — non-alcoholic drinks such as water, soda, or juice — with drinks containing alcohol.

Including Food
Don’t drink on an empty stomach — have some food so the alcohol will be absorbed more slowly into your system.

Avoiding “Triggers”
What triggers your urge to drink? If certain people or places make you drink even when you don’t want to, try to avoid them. If certain activities, times of day, or feelings trigger the urge, plan what you’ll do instead of drinking. If drinking at home is a problem, keep little or no alcohol there.

Planning to Handle Urges
When an urge hits, consider these options: Remind yourself of your reasons for changing. Or talk it through with someone you trust. Or get involved with a healthy, distracting activity. Or “urge surf ”— instead of fighting the feeling, accept it and ride it out, knowing that it will soon crest like a wave and pass.

Knowing Your “No”
You’re likely to be offered a drink at times when you don’t want one. Have a polite, convincing “no, thanks” ready. The faster you can say no to these offers, the less likely you are to give in. If you hesitate, it allows time to think of excuses to go along.


Additional Tips for Quitting

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If you want to quit drinking altogether, the last three strategies can help. In addition, you may wish to ask for support from people who might be willing to help, such as a spouse or non-drinking friends. Joining Alcoholics Anonymous or another mutual support group is a way to acquire a network of friends who have found ways to live without alcohol. If you’re dependent on alcohol and decide to stop drinking completely, don’t go it alone. Sudden withdrawal from heavy drinking can cause dangerous side effects such as seizures. See a doctor to plan a safe recovery.



What’s a Standard Drink
In the United States, a standard drink is any drink that contains about 14 grams of pure alcohol (about 0.6 fluid ounces or 1.2 tablespoons). Below are U.S. standard drink equivalents. These are approximate, since different brands and types of beverages vary in their actual alcohol content.

beer or cooler
malt liquor
table wine
80-proof spirits
gin, vodka, whisky, etc.


˜ 5% alcohol:
12 oz.
˜ 7% alcohol:
8.5 oz.
˜ 12% alcohol:
5 oz.
˜ 40% alcohol:
1.5 oz.


Many people don’t know what counts as a standard drink and so don’t realize how many standard drinks are in the containers in which these drinks are often sold. Some examples:

For beer, the approximate number of standard drinks in
•12 oz. = 1
•22 oz. = 2
•16 oz. = 1.3
•40 oz. = 3.3
For malt liquor, the approximate number of standard drinks in
•12 oz. = 1.5
•22 oz. = 2.5
•16 oz. = 2
•40 oz. = 4.5
For table wine, the approximate number of standard drinks in
•a standard 750-mL (25-oz.) bottle = 5
For 80-proof spirits, or “hard liquor,” the approximate number of standard drinks in
•a mixed drink = 1 or more*
•a fifth (25 oz.) = 17
•a pint (16 oz.) = 11
•1.75 L (59 oz.) = 39
*Note: It can be difficult to estimate the number of standard drinks in a single mixed drink made with hard liquor. Depending on factors such as the type of spirits and the recipe, a mixed drink can contain from one to three or more standard drinks.


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Excerpted from NIH Publication No. 07–3769
Reprinted September 2008

Holiday Hints

The holiday season is a time for visiting and reconnecting with family, friends and neighbors. Sometimes this season can be sad or stressful for those caring for a loved one with Alzheimer’s disease. These hints are our gift in wishing you an enjoyable holiday season.

•Holidays can be meaningful, enriching times for both the person with AD and family. Maintaining (or adapting) old family rituals and traditions helps all family members feel a sense of belonging and family identity. For a person with AD, this link with a familiar past is reassuring and builds self-esteem, i.e. “Look at the beautiful family I created!”

•Set your own limits early, and be clear about them with others. You do not have to live up to the expectations of friends or relatives. Your situation is different now.

•Encourage family and friends to visit EVEN IF IT IS PAINFUL FOR THEM. Keep the number of persons visiting at one time to a minimum, or try a few people visiting quietly with the person with AD in a separate room. Most people with AD can pull it together for brief periods, if they have adequate private rest in between.

•Try some simple holiday preparation with the person with AD several days ahead. Just observing your preparations will familiarize him/her with the upcoming festivities; if they participate with you, they experience the pleasure of helping and giving as well as the fun of anticipation and reminiscing.

•Prepare potential quiet distractions (a family photo album or a simple repetitive chore like cracking nuts) to use if the person with AD becomes upset or over-stimulated.

•Try to avoid situations that further confuse or frustrate many people with AD:

◦crowds of people who expect the person with AD to remember them
◦noise, loud conversations or loud music
◦strange or different surroundings
◦changes in light intensity – too bright or too dark
◦over-indulgence in rich or special food or drink (especially alcohol)
◦change in regular routine and sleep patterns

•Try scheduling activities, especially some outdoor exercise, early in the day to avoid the fatigue from added activity at the end of a long day. Familiar holiday music, story-telling, singing or church services (even on TV) may be especially enjoyable.

•If you receive invitations to holiday celebrations which the person with AD cannot attend, GO YOURSELF. Enjoy the chance to be with friends and family who love you and enjoy your company, with or without your relative.

Preparing the Guests

1.Explain as clearly as possible what has happened to the person with AD. Give examples of the unusual behaviors that may take place: incontinence, eating food with fingers, wandering, hallucinations.

2.Explain that it may not be appropriate behavior but the person with AD has a memory loss and does not remember what is expected and acceptable.

3.Remind the visitor through phone calls or letters to be understanding and not to shun the person with AD.

4.If this is the first visit since the person with AD became severely impaired, tell the visitor the visit may be painful. The memory-impaired person may not remember the guest’s name or relationship.

5.Explain that memory loss is the result of the disease and it is not intentional.

6.Stress with the guests that what is important is the meaningfulness of the moment spent together and not what the person remembers.

Preparing the Memory-Impaired Person

1.Begin showing a picture of the guest to the person with AD a week before the arrival.

2.Spend more time each day explaining who the visitor is while showing the picture.

3.Arrange a phone call for the person with AD and the visitor. The conversation may help both. The call gives the visitor an idea what to expect and gives the memory-impaired person an opportunity to familiarize him/herself with the visitor.

4.Keep the memory-impaired person’s routine as close to normal as possible.

5.During the hustle and bustle of the holiday season, guard against fatigue and find time for adequate rest.

For more information see: Holiday Visiting Tips, A Message from the Faith Community and Friends of Alzheimer’s Families (PDF, 381KB), prepared by the Duke University Aging Center Family Support Program and the Education Core, Bryan Alzheimer’s Disease Research Center, Duke University Medical Center

For more information about Alzheimer’s Disease, contact:
The Alzheimer’s Disease Education and Referral (ADEAR) Center:
1-800-438-4380
www.nia.nih.gov/Alzheimers
e-mail: adear@nia.nih.gov

A Service of the National Institute on Aging, part of the National Institutes of Health
U.S. Department of Health and Human Services

MFT Continuing Education

Searching for a Leader in the World of Online CEUs

The internet has been a viable source for finding all kinds of "stuff". It can also be a great source for finding the right CEU provider. The problem lies in sifting through the number of search results generated by whatever search engine being used. Just because a website ranks high in the search engine results, doesn't necessarily mean it is the best option. Companies are constantly battling for rankings. So, here are some things to ask when drudging through the options found on the search engine results pages.

First, "Are they approved in my state for my license?" There are so many choices in the field of online continuing education; however, many are not approved across the United States. Some specialize in a few states that may be key for them. Others just haven't done the work to achieve approval in every state. Even if the provider is approved in your state, they may not be for your particular license. It is always crucial to read the fine print of each provider and make sure they provide an easy to view table with this information.

Second, "Do they offer all the courses I need to renew my license?" Great question to ask. Look thoroughly through their course listing and make sure they have the courses to fulfill the requirements of your particular license. Something else to consider is not only do they have the core courses you need but do they have enough of a selection outside of the core courses to meet your needs in the future as well.

Third, "Can I even find what I am looking for?" How many times have you pulled up a website from a search result and spent way too much time searching for what you were interested in only to end up backing out of that site and returning to the search results list? Sometimes this may be because the site was irrelevant, however, most of the time it was probably because the website was so poorly designed that it made it way too difficult to find anything. Make sure everything is straightforward and easy to find. No wasting time, which is critical in today's busy, fast-paced world.

Fourth, "Are their rates affordable and reasonable?" This is the brass tacks of the matter. What is the cost? It has been said "You get what you pay for." For the most part this is correct. That is why it is a good rule of thumb to never pay the highest amount and at the same time never pay the lowest amount. The highest amount is usually overpriced. The lowest amount is usually stripped of any value and may cost more in the long run in both time and money. Choosing a price more in the middle is usually the best bet.

Aspira works in the fields of online CEUs for MFT continuing education, online CEUs for Social Workers, online CEUs for Counselor continuing education, and online CEUs for Addiction Counselors

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