CWRU study finds mending ruptures in client-therapist relationship during PTSD treatment has positive benefits

In order for prolonged exposure therapy, an evidence-based psychotherapy for PTSD, to reach its full potential, any misperceptions or ruptures in trust and communication between therapist and client need fixing, according to a new Case Western Reserve University study. The study, reported in the Journal of Consulting and Clinical Psychology online article, “Patterns of Therapeutic Alliance: Rupture-Repair Episodes in Prolonged Exposure for PTSD,” is among the first to examine how ruptures in the relationship between the therapist and client can damage a patient’s treatment outcome. An alliance rupture may occur when there is a break in the therapist-client bond. For example, ruptures in the therapeutic relationship may occur when therapeutic progress stalls, negative feelings arise between the therapist and client, or when the work in therapy becomes challenging PTSD - Clinical Practice Guideline for Management of Post Traumatic Stress “We want therapists to know that a rupture in the therapeutic relationship isn’t a bad thing, as long as the therapist tends to it,” said Stephanie Keller, one of the study’s researchers and a Case Western Reserve doctoral student in clinical psychology. “However, if the rupture is not repaired, then your patient may not do as well in treatment.” The research study included 116 people who experienced a traumatic event such as childhood sexual or physical abuse, physical assault, or combat exposure, and had a primary diagnosis of PTSD. Participants engaged in a 10-session treatment program called prolonged exposure (PE) therapy. To help therapists chart progress and examine the therapeutic relationship, each client assessed his or her own PTSD symptoms and perception of their relationship with the therapist during treatment. This helped researchers to identify those clients who experience no ruptures in the therapeutic relationship (a stable relationship), clients who experienced a rupture that was subsequently repaired, and those with ruptures that went unrepaired LCSW Continuing Education The first PE session outlined what would happen over the course of treatment to set specific goals. Exposure-based exercises began in the second session, which included exposure to anxiety-provoking situations that served as trauma-reminders and talking about their traumatic experiences. In this sample, 28 percent of patients experiences a repaired rupture and 18 percent experienced a rupture, or dip in the therapeutic relationship, that was never repaired. An unresolved rupture in the therapist-client relationship became a predictor for a poorer outcome in treatment, Keller said. She also said more research is needed to figure out why these alliance ruptures occur and how to best repair them. The research was funded through a National Institute of Mental Health PTSD research project, directed by Norah Feeny, Ph. D. from Case Western Reserve University and Lori A. Zoellner, Ph. D. from the University of Washington. Other researchers contributing to the project were lead investigator and Case Western Reserve alumna AnnaMaria Aguirre McLauglin, and Eric A. Youngstrom, of the University of North Carolina at Chapel Hill.

Interactive computer program helps patients talk with their physician about depression

(SACRAMENTO, Calif.) – Patients who used an interactive computer program about depression while waiting to see their primary-care doctor were nearly twice as likely to ask about the condition and significantly more likely to receive a recommendation for antidepressant drugs or a mental-health referral from their physician, according to a new study by researchers at UC Davis. The study, published online today in the Journal of the American Medical Association, was conducted to evaluate the effectiveness of a waiting-room intervention that encourages primary- care patients to discuss depression symptoms and care with their physician. While patients who received treatment or a referral for depression did not report improved mental health 12 weeks later, the study did show that providing information to patients about depression is an effective way to start the conversation in a primary-care setting about mental health. "We have developed an easy-to-use tool to help people with depression identify the symptoms, feel more comfortable discussing it with a primary-care provider and accept treatment if it is needed," said Anthony Jerant, professor of family and community medicine at UC Davis and senior author of the study. "This brief and relatively inexpensive intervention could be easily and widely implemented in a variety of health-care settings." Depression is an underrecognized and undertreated condition that can easily be overlooked during a typical primary-care visit. While calculating the number of people suffering from untreated depression is difficult, the Centers for Disease Control estimates that nationally 1-in-10 adults has reported symptoms of depression. The National Institute of Mental Health has said that major depressive disorders affect approximately 14.8 million American adults, or about 6.7 percent of the U.S. population age 18 and older in a given year. When left untreated, depression poses high costs to society, jeopardizing relationships and employment, decreasing quality of life, prompting alcohol and drug abuse and, in some cases, leading to the higher risk of suicide Core Elements in Responding to Mental Health Crises CE Course Three waiting-room interventions tested The new study involved nearly 900 patients and 135 primary-care clinicians at seven Northern California health-care sites. Prior to their medical appointments, patients were screened for depression. All patients were then randomized to view one of three interventions: •A video – similar to a public-service announcement – focused on recognizing depression and talking with doctors about symptoms •An interactive multimedia computer program that provided patients with instant feedback and information tailored to different levels of depressive symptoms and treatment preferences •A non-depression-related video on healthy sleep The clinicians did not know which intervention their patients viewed. Immediately after the patients' appointments, the researchers determined if the patients discussed depression with their clinicians and whether they left with prescriptions for medications to treat depression and if they received a referral for mental-health services. Help for the most depressed The results showed that patients with baseline depression who either watched the informational video or used the computer program were nearly twice as likely as control subjects to request information about depression during their appointment. Those who used the interactive computer program were significantly more likely to receive a prescription or referral for depression (26 percent) than were those who viewed either the depression video (17.5 percent) or the video on sleep (16.3 percent). The computer program had the greatest impact on patients who were most depressed, according to the baseline screening. The investigators also studied the effects of the interventions on people who were not likely to be depressed according to the baseline screening. Among these patients, rates of prescribing and referral were low (about 5 percent) and did not differ by intervention group. According to Richard Kravitz, UC Davis professor of internal medicine and lead author of the study, it is important for public-health interventions to avoid inadvertently expanding unnecessary treatments that can do more harm than good and waste health-care resources. "We were concerned that the interventions could lead to treatment for depression for those who do not actually have it," said Kravitz. "Our interactive computer program, however, increased help for those who needed it the most without increasing treatment for those who didn't." According to Jerant, this study is the largest to compare "targeted" versus "tailored" interventions for stimulating people with depression to seek and accept treatment. Targeted interventions, such as the informational video used in the study, use terms and images most likely to resonate with the target audience, based on specific demographic factors. Four different versions were used in this study, targeted toward gender and income levels. The video took about three minutes to watch. Tailored interventions, such as the study's interactive computer program, integrate patient-specific answers to deliver information and guidance. The program used in the study, developed by the study investigators, prompted users to answer questions about symptoms of depression, informed users as to whether or not they were likely to be depressed, and provided guidance depending on the users' specific needs and interests. Patients assigned to the computer program spent about two to 15 minutes on it, with a median of five minutes. Kravitz speculated that the informational video did not work as well because, like a television commercial advertising a medication, it may require multiple repetitions to be effective. In contrast, the interactive computer program quickly provided a high level of personalization, which may account for its higher degree of effectiveness with a single use. The UC Davis investigators intend to further refine and study the interactive computer model to identify patients who need to receive more extensive treatment for their depression Professional Counselor Continuing Education ### Other UC Davis investigators on the study were Peter Franks, Daniel Tancredi, Christina Slee, Robert Bell, Debora Paterniti, Camille Cipri, Ana-Maria Iosif, Andrew Hudnut, Simon Dvorak and Charles Turner. Additional authors were Maga Jackson-Triche of the Northern California VA Health Care System, Steven Kelly-Reif of Kaiser Permanente Medical Group in Sacramento, Mitchell Feldman and Sarah Olson of UC San Francisco, and Ronald Epstein and Paul Duberstein of University of Rochester in New York. The study, titled "Patient Engagement Programs for Recognition and Initial Treatment of Depression in Primary Care," was supported by grants from the National Institute of Mental Health (1R01MH079387, K24MH072756 and K24MH02712).

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Bad boys: Research predicts whether boys will grow out of it -- or not

ANN ARBOR --- Using the hi-tech tools of a new field called neurogenetics and a few simple questions for parents, a University of Michigan researcher is beginning to understand which boys are simply being boys and which may be headed for trouble. “When young children lie or cheat or steal, parents naturally wonder if they’ll grow out of it,” says Luke Hyde, a U-M psychologist who is studying the development and treatment of antisocial behavior. Hyde, a faculty associate at the U-M Institute for Social Research (ISR) and assistant professor of psychology, is speaking at ISR on November 11 on how genes, experience and the brain work together to heighten or reduce the risks that normal childhood transgressions will develop into full-blown conduct disorders in adolescence and early adulthood. His talk is part of the ISR Research Center for Group Dynamics seminar series on violence and aggression, and is free and open to the public. “The lifetime prevalence of conduct disorder is around 10 percent, and even higher in males and low-income populations,” says Hyde. “The total cost to society is enormous, since these behaviors are often chronic, lasting through adulthood.” MHC Continuing Education With colleagues at U-M, Duke University, the University of Pittsburgh, and other institutions, Hyde has been exploring the role of the environment and biology as they interact over time to shape behavior. In particular, he is using the techniques of a new field called neurogenetics, which combines genetics, neuroscience and psychology, to learn how genes and neural processes interact with harsh environments, including dangerous neighborhoods and harsh parents, and with a child’s own levels of empathy and personality traits, to increase the risk of antisocial behavior. In one recent study, for example, Hyde and colleagues studied subjects with over-reactive amygdala responses . The amygdala is an almond-shaped part of the brain’s primitive limbic system involved in processing fear and other visceral emotions. It has been associated with impulsive, aggressive behavior, as well as anxiety disorders and depression. “Previous research suggests that the amygdala becomes over-reactive probably as a result of both genetics and experience,” says Hyde. “And once the amygdala is over-reactive, people tend to behave in an anxious, over-reactive way to things they see as a potential threat. “Our study found that this tendency is moderated by a person’s environment, including the social support they get. If they’re not getting support from family, friends, neighbors, or professionals, then the link between the amygdala and anxious behavior is much stronger.” In another study, Hyde and colleagues showed that kids who are impulsive are only at higher risk of engaging in antisocial behavior if they live in dangerous neighborhoods. He also identified specific items within childhood behavior checklists that can be used as early as the age of three to identify kids who will likely have worse trajectories for anti-social behavior compared to other children who have similar behavior problems, such as throwing tantrums. These items assess observable behaviors that include whether the child is cruel to animals, doesn’t seem to feel guilty after misbehaving, is sneaky, lies, is selfish or won’t share, and won’t change his or her behavior as a result of punishment. “The results of this test aren’t really meaningful until age three or three-and-a-half,” says Hyde. “Before that, many of these behaviors are fairly common, and don’t predict anything. But after age three, if children are still behaving in these ways, their behavior is more likely to escalate in the following years rather than improve.” There is good news, though. Kids who scored high on this test benefitted just as much as other kids from interventions, according to Hyde. These interventions, often called parent management training, focus on giving parents better skills to manage child behavior problems, including training parents to spend more positive time with their kids, use time-outs instead of physical punishments, and reward good behavior by giving out stickers. “Parents need to know that intervention works, especially if it’s done early,” says Hyde. “They need to go for help if they see signs of trouble. Clinical psychologists, among other professionals, have empirically supported treatments that are quite effective for children, especially in this age period.” ### Funding for this research was provided by The National Institute of Drug Abuse, the National Institute of Mental Health, and the National Heart, Lung and Blood Institute. Established in 1949, the University of Michigan Institute for Social Research (ISR) is the world's largest academic social science survey and research organization, and a world leader in developing and applying social science methodology, and educating researchers and students from around the world. For more information, visit the ISR Web site at http://home.isr.umich.edu

Teens in child welfare system show higher drug abuse rate

PISCATAWAY, NJ – Teenagers in the child welfare system are at higher-than-average risk of abusing marijuana, inhalants and other drugs, according to a study in the November issue of the Journal of Studies on Alcohol and Drugs. However, the study also shows that parental involvement matters. "When youth perceive that their parents or caregivers are actively engaged in their lives, this may steer them away from drugs," according to lead researcher Danielle L. Fettes, Ph.D., of the University of California, San Diego. "Youth who feel supported by parents tend to have a better sense of self and better mental health and, in this case, are less likely to engage in high-risk behaviors—which is important for this already high-risk population." Using data from two national surveys, Fettes and colleagues found that 18 percent of teens in the welfare system admitted to ever smoking marijuana, versus 14 percent of other teens. Meanwhile, 12 percent said they'd abused inhalants, compared with 6 percent of other U.S. kids. In addition, although abuse of "hard drugs," like cocaine and heroin, was less common, teens in child welfare were still at greater risk: Six percent admitted to ever using the drugs, versus 4 percent of other teens. The findings are not necessarily surprising, according to Fettes. It's known that kids who enter the child welfare system typically have some risk factors for drug use—such as a history of domestic abuse or mental health issues. But until now, there had been little research into their actual rates of substance abuse, Fettes said. For their study, she and her colleagues culled data from two national health surveys: one covered 730 12- to 14-year-olds in the child welfare system; the other included 4,445 kids the same age from the general U.S. population. Overall, teens in the welfare system were more likely to have tried marijuana, inhalants or hard drugs—but not alcohol. Around 40 percent of kids in each survey admitted to drinking at some point in their lives LSW Continuing Education That, according to Fettes, may reflect a couple of facts. "Alcohol is readily available to teenagers," she said, "and drinking is something of a normative behavior to them." But whereas drug use was more common among teens in the welfare system, not all of those kids were at equal risk. A key risk factor—for all teens in the study—was delinquency. Teenagers who admitted to things like shoplifting, theft, running away or using a weapon were at increased risk of both drug and alcohol abuse. On the other hand, some family factors seemed to protect kids from falling into drug use. Teens from two-parent homes were generally less likely to report drug use—and so were kids who said they felt close to their parents or other guardian. For the parents and others who care for these kids, Fettes said it's important to be aware of the increased risk of substance abuse. On the wider scale, Fettes said that right now, there are typically multiple, distinct service systems working with teens in the child welfare system. They may also be receiving mental health services and alcohol and other drug counseling, as well as having contact with the criminal justice system. "Often, they don't work together," she noted. "Given the increased risk, the child welfare system may be an ideal venue to incorporate proven prevention and intervention programs for youth substance use," Fettes concluded. "Drug abuse screening and treatment, or referrals for treatment, should be a regular part of kids' case management." ### Fettes, D. L., Aarons, G. A., & Green, A. E. (November 2013). Higher rates of adolescent substance use in child welfare versus community populations in the United States. Journal of Studies on Alcohol and Drugs, 74(6), 825. To arrange an interview with Danielle L. Fettes, Ph.D., please contact Debra Kain at ddkain@ucsd.edu or 619-543-6202. The Journal of Studies on Alcohol and Drugs is published by the Center of Alcohol Studies at Rutgers, The State University of New Jersey. It is the oldest substance-abuse journal published in the United States. To learn about education and training opportunities for addiction counselors and others at the Rutgers Center of Alcohol Studies, please visit AlcoholStudiesEd.rutgers.edu.

Smoking during pregnancy may increase risk of bipolar disorder in offspring

A study published today in the American Journal of Psychiatry suggests an association between smoking during pregnancy and increased risk for developing bipolar disorder (BD) in adult children. Researchers at the New York State Psychiatric Institute and the Department of Epidemiology at the Mailman School of Public Health at Columbia University, in collaboration with scientists at the Kaiser Permanente Division of Research in Oakland, California, evaluated offspring from a large cohort of pregnant women who participated in the Child Health and Development Study (CHDS) from 1959-1966. The study was based on 79 cases and 654 comparison subjects. Maternal smoking during pregnancy was associated with a twofold increased risk of BD in their offspring. Smoking during pregnancy is known to contribute to significant problems in utero and following birth, including low birth weight and attentional difficulties. This is the first study to suggest an association between prenatal tobacco exposure and BD, a serious psychiatric illness marked by significant shifts in mood that alternate between periods of depression and mania. Symptoms typically become noticeable in the late teens or early adulthood. "These findings underscore the value of ongoing public health education on the potentially debilitating, and largely preventable, consequences that smoking may have on children over time," said Alan Brown, MD, MPH, senior author and Professor of Clinical Psychiatry and Epidemiology at the New York State Psychiatric Institute, Columbia University and Mailman School of Public Health. The authors wrote: "Much of the psychopathology associated with prenatal tobacco exposure clusters around the 'externalizing' spectrum, which includes attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder (CD), and substance abuse disorders. Although not diagnostically classified along the externalizing spectrum, BD shares a number of clinical characteristics with these disorders, including inattention, irritability, loss of self-control, and proclivity to drug/alcohol use." In effect, children who were exposed to tobacco smoke in utero may exhibit some symptoms and behaviors that are found in BD. A previous study by Dr. Brown and colleagues found that flu virus in pregnant mothers was associated with a fourfold increased risk that their child would develop BD LCSW Continuing Education ### Funding for the study was provided by the National Institute of Mental Health and the National Institute on Child Health and Development. The authors declare no financial or other conflicts of interest. About Columbia University's Mailman School of Public Health Founded in 1922, Columbia University's Mailman School of Public Health pursues an agenda of research, education, and service to address the critical and complex public health issues affecting New Yorkers, the nation and the world. The Mailman School is the third largest recipient of NIH grants among schools of public health. Its over 450 multi-disciplinary faculty members work in more than 100 countries around the world, addressing such issues as preventing infectious and chronic diseases, environmental health, maternal and child health, health policy, climate change & health, and public health preparedness. It is a leader in public health education with over 1,300 graduate students from more than 40 nations pursuing a variety of master's and doctoral degree programs. The Mailman School is also home to numerous world-renowned research centers including the International Center for AIDS Care and Treatment Programs (ICAP), and the Center for Infection and Immunity. For more information, please visit http://www.mailman.columbia.edu Columbia University Department of Psychiatry & NYS Psychiatric Institute Columbia Psychiatry is ranked among the best departments and psychiatric research facilities in the nation and has contributed greatly to the understanding and treatment of psychiatric disorders. It is home to distinguished clinicians and researchers noted for their clinical and research advances in the diagnosis and treatment of depression, suicide, schizophrenia, BD and anxiety disorders, eating disorders, and childhood psychiatric disorders. Visit http://columbiapsychiatry.org/ for more information. Founded in 1959 by Jacob Yerushalmy at the University of California, Berkeley, The Child Health and Development Studies (CHDS) enrolled 15,000 families who were members of the Kaiser Permanente Medical Care Plan between 1959 and 1967. CHDS scientists discovered ways to make pregnancy safer for mothers and their babies. Now they are discovering connections between early life and cancer, heart disease, diabetes, fertility and mental illness. The National Institute of Child Health and Development of the National Institutes of Health makes this unique research possible through continuing support over 40 years. The CHDS is now a part of the Public Health Institute, Berkeley California. About the Kaiser Permanente Division of Research The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and the society at large. It seeks to understand the determinants of illness and well-being and to improve the quality and cost-effectiveness of health care. Currently, the Division's 550+ staff are working on more than 350 ongoing research studies in behavioral health and aging, cancer, cardiovascular and metabolic conditions, health care delivery and policy, infectious diseases, vaccine safety and effectiveness, and women's and children's health.

Bipolar and pregnant

Bipolar drugs lose effect during pregnancy, so women need higher doses to stay well CHICAGO --- New Northwestern Medicine® research offers one of the first in-depth studies of how physiological changes during pregnancy reduce the effects of a commonly used drug to treat bipolar disorder, making women more vulnerable to recurring episodes. The new findings will help psychiatrists and physicians prevent bipolar manic and depressive symptoms during pregnancy, which are risky for the health of the mother and her unborn child. When a woman with bipolar disorder becomes pregnant, she and her physician often don't realize her medication needs adjusting to prevent the symptoms from coming back – a higher risk during pregnancy. There also is little information and research to guide dosing for psychiatric medications during pregnancy Social Worker Continuing Education Approximately 4.4 million women in the U.S. have bipolar disorder with women of childbearing age having the highest prevalence. The new study shows the blood concentration of the commonly used drug lamotrigine decreases in pregnant women. About half of the women in the study had worsening depressive symptoms as their lamotrigine blood levels dropped. The drug levels fall because women have increased metabolism during pregnancy. "Now physicians change the dose of the drug in response to women's symptoms worsening," said lead investigator Crystal Clark, M.D., an assistant professor of psychiatry and behavioral sciences at Northwestern University Feinberg School of Medicine and a psychiatrist at Northwestern Memorial Hospital. "We need to optimize their medication dosing so they stay well." The study results will help physicians understand how to increase their patients' doses during pregnancy and then reduce them postpartum to avoid toxicity, Clark said. Guidelines for prescribing the drug for pregnant women with the disorder also are included. The study was published Nov. 1 in the American Journal of Psychiatry. Depressive episodes -- as opposed to manic -- are most likely to recur in pregnant women with bipolar disorder. "The safety of the fetus is at risk," Clark said. "Pregnant women that are depressed are less likely to take care of themselves which often leads to poor nutrition, lack of compliance with prenatal care and isolation from family and friends. It has also been linked to premature births and babies with low birth weights among other poor birth outcomes." ### The study was supported by grant R01 MH 075921 from the National Institute of Mental Health of the National Institutes of Health. NORTHWESTERN NEWS: http://www.northwestern.edu/newscenter/