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 social worker 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

Most Teens with Eating Disorders Go Without Treatment

About 3 percent of U.S. adolescents are affected by an eating disorder, but most do not receive treatment for their specific eating condition, according to an NIMH-funded study published online ahead of print March 7, 2011, in the Archives of General Psychiatry. Social Worker Continuing Education
Background
Kathleen Merikangas, Ph.D., of NIMH and colleagues analyzed data from the National Comorbidity Study-Adolescent Supplement (NCS-A), a nationally representative, face-to-face survey of more than 10,000 teens ages 13 to 18. Previously published results found that about 20 percent of youth are affected by a severe mental disorder, and a substantial proportion of these youth do not receive mental health care.

In this new study, the authors tracked the prevalence of eating disorders and the proportion of those youth who received treatment for these disorders.

Results of the Study
According to the data, 0.3 percent of youth have been affected by anorexia, 0.9 percent by bulimia, and 1.6 percent by binge-eating disorder. The researchers also tracked the rate of some forms of eating disorders not otherwise specified (ED-NOS), a catch-all category of symptoms that do not meet full criteria for specific disorders but still impact a person’s life. ED-NOS is the most common eating disorder diagnosis. Overall, another 0.8 percent had subthreshold anorexia, and another 2.5 percent had symptoms of subthreshold binge-eating disorder.

In addition,

Hispanics reported the highest rates of bulimia, while Whites reported the highest rates of anorexia.
The majority who had an eating disorder also met criteria for at least one other psychiatric disorder such as depression.
Each eating disorder was associated with higher levels of suicidal thinking compared to those without an eating disorder.
Significance
The prevalence of these disorders and their association with coexisting disorders, role impairment, and suicidal thinking suggest that eating disorders represent a major public health concern. In addition, the significant rates of subthreshold eating conditions support the notion that eating disorders tend to exist along a spectrum and may be better recognized by doctors if they included a broader range of symptoms. In addition, the findings clearly underscore the need for better access to treatment specifically for eating disorders.

Reference
Swanson SA, Crow SJ, LeGrange D, Swendsen J, Merikangas KR. Prevalence and correlates of eating disorders in adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement. Archives of General Psychiatry. Online ahead of print March 7, 2011.

Brain Activity Patterns in Anxiety-Prone People Suggest Deficits in Handling Fear

Anxiety as a personality trait appears to be linked to the functioning of two key brain regions involved in fear and its suppression, according to an NIMH-funded study. Differences in how these two regions function and interact may help explain the wide range of symptoms seen in people who have anxiety disorders. The study was published February 10, 2011 in the journal, Neuron. Social Worker Continuing Education
Background
Anxiety disorders are characterized by an excessive, irrational dread of everyday situations. Some people may experience general, chronic anxiety, while others become anxious in response to one or more specific triggers. Many studies have implicated two brain regions in anxiety—the amygdala in fear responses and the ventral prefrontal cortex (vPFC) in suppressing or regulating fear. Questions remain, however, about how trait anxiety—a person's typical anxiety level on any given day—affects amygdala and vPFC functioning.

To explore these questions, Sonia Bishop, Ph.D., of the University of California Berkeley (at the University of Cambridge (UK) at the time of data collection), and colleagues designed a series of experiments to determine how the amygdala and vPFC responded in three types of situations:

Cued fear—a neutral signal or cue is followed by an aversive event. In this study, the cue was an actor in a video placing his hands over his ears and the aversive event was a loud scream. The cue provided a reliable prediction of the aversive event. Cued fear can be compared to the situation-specific type of anxiety experienced by those with a specific phobia, such as a fear of heights.
Contextual fear—a neutral cue and an aversive event occur independently of each other. The cue did not provide a reliable prediction of the aversive event. Contextual fear may be similar to the non-specific anxiety that affects people with generalized anxiety disorder.
Safety—a neutral signal or cue occurs alone without an aversive event. The safety situation served as a comparison for the other two situations.
The researchers assessed the level of trait anxiety of 23 healthy study participants, ages 18 to 41. Each participant underwent a training session that exposed them to the above conditions. Two days after the training session, participants had their brain activity recorded through functional magenetic resonance imaging (fMRI), a noninvasive imaging method, while re-exposed to the cued fear, contextual fear, and safety conditions in the scanner.

Results from the Study
Participants with high trait anxiety showed greater amygdala response to cued fear situations compared to those with low trait anxiety. According to the researchers, this finding suggests that individual differences in amygdala response may contribute to differences in vulnerability to cue-specific anxiety disorders, such as specific phobia.

Participants with low trait anxiety showed increased vPFC activity in response to cued fear and more strongly sustained vPFC activity during contextual fear situations, compared to those with high trait anxiety. Notably, vPFC activity in participants with low trait anxiety occurred before the aversive event had ceased. The researchers suggest that this process—engaging brain areas that help to suppress fear even when the source of fear is still present—may help to protect against chronic anxiety disorders even when stressful life events are ongoing.

Significance
The study's findings support a potential role of the amygdala in vulnerability to anxiety disorders and a potential role of the vPFC in protection against them.

"Individual differences in the functioning of one or both of these brain regions may help account for the variability in symptoms across different anxiety disorders," said Bishop. "A better understanding of these processes may help inform treatment choice and predict treatment response."

This study was supported in part by a Biobehavioral Research Award for Innovative New Scientists (BRAINS) from NIMH. Dr. Bishop was one of 12 researchers to receive this award in 2010.

Reference
Indovina I, Robbins TW, Núñez-Elizalde AO, Dunn BD, Bishop SJ. Fear-Conditioning Mechanisms Associated with Trait Vulnerability to Anxiety in Humans. Neuron. 2011 Feb 10;69(3):563-71.

Combination Treatment for Psychotic Depression Holds Promise

A combination of an atypical antipsychotic medication and an antidepressant known as a selective serotonin reuptake inhibitor (SSRI) may be more effective in treating psychotic depression than an atypical antipsychotic alone, according to results from an NIMH-funded clinical study. Social Worker Continuing Education
Background
Psychotic depression is characterized by major depression accompanied by symptoms such as hallucinations, delusions, and breaks with reality. A person with psychotic depression may be unwilling or unable to care for him or herself and often is admitted to the hospital. Typically, psychotic depression is treated with electroconvulsive therapy (ECT), known to be effective but not always acceptable to patients and their families. It is less commonly treated with an antipsychotic or an antipsychotic plus an antidepressant.

Results of the Study
In a 12-week trial, all 259 participants were required to have psychotic depression with at least one delusion or irrational belief, although not all had hallucinations. Participants were randomly assigned to one of two treatments—the atypical antipsychotic olanzapine (Zyprexa) plus the SSRI sertraline (Zoloft) (combination therapy), or to olanzapine plus a placebo, or inactive, pill (monotherapy). Barnett S. Meyers, M.D., of Cornell University, and colleagues compared rates of remission and side effects among the participants. They also compared the responses of the 117 patients younger than 60 with the responses of the 142 patients older than 60 to determine if the two age groups responded differently.

The researchers conducted assessments at the beginning of the trial, weekly for the first six weeks, and then every other week until week 12. They found that 42 percent of those on combination therapy remitted compared to 24 percent of those on the monotherapy, with no significant differences in remission rates between age groups. Combination therapy's superiority became most evident between weeks eight and 12 of the trial.

Overall, the two age groups experienced comparable side effects. Both groups experienced significant increases in cholesterol and triglyceride levels, and both gained weight. However, the younger age group gained twice as much on average—about 14 pounds—compared to the older group, which gained an average of 7 pounds. This finding is consistent with other reports that have found older adults tend to gain less weight with atypical antipsychotics, specifically olanzapine, the researchers said. However, older participants also tended to be on lower doses of the antipsychotic than the younger adults, which may partially explain the disparity in weight gain, according to the researchers.

Unexpectedly, older participants had no more difficulty tolerating the medications than younger participants, nor were they any more likely to experience falls, sedation or have greater movement disorder symptoms than younger participants.

Overall, about 45 percent of participants dropped out of the study, although the drop-out rate was lower in the combination treatment group (37 percent) compared to the monotherapy group (53 percent).

Significance
Because the drop-out rate was relatively high and no follow-up data on those who discontinued were collected, the authors caution against applying the study's results to clinical practice prematurely. Still, the authors suggest that combination therapy holds promise as an alternative therapy to ECT. "Psychotic depression is difficult to treat," said NIMH Director Thomas R. Insel, M.D. "This study provides insight into one approach to treatment that may be a valid alternative for many patients who cannot or will not undergo ECT."

What's Next
Longer-term studies are needed to evaluate side effects. "Future research must weigh the benefits of continuing atypical antipsychotic medication beyond 12 weeks against the risks of associated metabolic side effects," lead author Meyers concluded.

Reference
Meyers BS, Flint AJ, Rothschild AJ, Mulsant BH, Whyte EM, Peasley-Miklus C, Papademetriou E, Leon AC, Heo M for the STOP-PD study group. A double-blind randomized controlled trial of olanzapine plus sertraline versus olanzapine plus placebo for psychotic depression—The Study of Pharmacotherapy of Psychotic Depression (STOP-PD). Archives of General Psychiatry. 2009;66(3):838-847.

Prescription Drug Abuse in the Workplace

Illicit drugs and misuse of alcohol are not the only substances that can affect health and safety in workplaces. Prescription drugs, when used without a prescription and without the supervision of a doctor, can also have adverse effects. Workers can become sleepy or anxious or depressed or confused, from the improper use of prescription drugs. As important, when these drugs are used improperly, they can pose risks to employees, their coworkers, and the overall workplace itself. The risks associated with nonmedical use of prescription drugs in workplaces can escalate when workers’ jobs require caution and safety to prevent injury, such as those of transportation workers, assembly line workers, construction workers, nuclear-power plant workers, and the like. Social Worker Continuing Education

What Is Prescription Drug Abuse?
Prescription drug abuse has been identified as a growing problem in American workplaces. In the National Survey on Drug Use and Health (NSDUH), SAMHSA defines prescription drug abuse as the use of prescription pain relievers, tranquilizers, stimulants, or sedatives without a prescription of the respondent’s own or simply for the experience or feeling the drug causes. This definition covers a wide range of behaviors, from misusing prescription medications to get high, stay awake, or get to sleep to using someone else’s medication to address a legitimate medical need. What may seem like a harmless sharing of medications can lead to addiction, misdiagnosis of illnesses, life-threatening circumstances, and death.

Are Prescription Drugs Safe?
Prescription drugs are safe when they are taken as directed under a doctor’s orders. Fear of addiction and dependence should not stop an individual from taking medications that can help treat his or her problems, nor prevent a physician from prescribing appropriate medications. Proper usage of prescription drugs can help workers protect their health and thus perform more productively in the workplace. However, when taken for nonmedical or recreational purposes, prescription drugs are no safer than illicit or street drugs. The misconception of prescription drugs as legal and “safe,” even when abused, is particularly strong among young adults.

Most prescription drug abusers obtain their drugs free from a friend or relative. In 2006, 55.7 percent of individuals 12 and older who had used pain relievers nonmedically in the previous 12 months said they got their drugs this way.2 Other ways of acquiring prescription drugs include “doctor shopping” to get multiple prescriptions, taking them from a friend or relative, or buying them from a friend, relative, or dealer. It appears that the Internet is not a significant source of prescription drugs, such as opioid analgesics, for most users.

Prescription Drug Abuse Is a Growing Problem
Multiple sources of data make it clear that this problem is a growing one, especially for teens and young adults, which means that employers need to be aware of the problem. Data from the Treatment Episode Data Set show that admissions for treatment
of prescription and over-the-counter (OTC) drug abuse rose from 3 percent of all admissions in 1999 to 4 percent in 2002. The escalation seems to come from
increased rates of abuse of narcotic painkillers, which more than doubled between 1992 and 2002. As of 2003, 3 percent of admissions were for abuse of nonheroin opiates. According to the Drug Abuse Prescription drugs are safe when taken as directed under a doctor’s orders and as dispensed.

FEMA Highlights Holiday Gifts That Increase Preparedness

Release Number: HQ-09-149

WASHINGTON, D.C. -- This year Federal Emergency Management Agency (FEMA) has assembled a list of gift ideas for the holidays to help keep your family and friends prepared. Emergencies can happen at any moment; these gifts can serve as a great starting point to ensure that your friends and family have an emergency communications plan, a disaster supply kit, and stay informed about emergencies in their area.

“Disasters can happen anytime, anywhere and the holiday season provides a great opportunity to ensure that you and your loved ones are taking simple steps to be prepared,” said FEMA Administrator Craig Fugate. “As families gather this holiday season, I encourage everyone to take a few minutes and discuss what you would do in case of an emergency or disaster. The public is the most important member of our nation’s emergency response team and the more the public does to be prepared, the more successful this team will be.”

The most important thing any individual can do is take a few minutes to discuss with their family, friends and loved ones what they will do in the case of an emergency or disaster. This includes developing a simple family communications plan and identifying how you would get in touch with loved ones and where you might meet if you are separated when an emergency or disaster takes place.

Additionally, there are simple supplies that can go a long way in the case of an emergency or disaster that would make great gifts this holiday season.

A list of possible gifts that may assist in disasters includes:

•Disaster kits for homes, offices and autos (first aid kits; food, water and prescription medications for 72 hours; i.e., extra clothing, blankets, and flashlights).
•NOAA weather radios with extra batteries.
•Enrollment in a CPR or first-aid class.
•Smoke detectors.
•Fire extinguishers (for kitchen, garage, car, etc.)
•Foldable ladders for second-story escape in a fire.
•Car kits (emergency flares, shovels, ice scrapers, flashlights and fluorescent distress flags).
•Pet Disaster kits (food, water, leashes, dishes and carrying case or crate).
•Battery powered lamps
This year, consider at least one of these ideas. You just may save the life of a friend or family member. For more information and preparedness tips, please visit www.ready.gov and www.fema.gov.

FEMA's mission is to support our citizens and first responders to ensure that as a nation we work together to build, sustain, and improve our capability to prepare for, protect against, respond to, recover from, and mitigate all hazards.
Social Worker Continuing Education http://www.aspirace.com

Older Adult Depression During the Holidays

According to Mental Health America, more than two million of the 34 million Americans age 65 and older suffer from some form of depression - and during the holidays this number climbs. For many Americans, the holiday season is a time of good cheer, family celebrations, and socialization with friends. Yet for some people, particularly the elderly, it's a time of loneliness, reflections of the past and anxiety about the future. During the holidays, older adults may feel more acutely the absence of loved ones, the distance of family members, and the passing of time. Traditions and reunions that were once observed may no longer be possible which may result in an absence of holiday meaning and significance for the elderly individual. Some major factors contributing to holiday depres-sion in the elderly include:

. Being alone or separated from loved ones,
. Loss of independence,
. Financial limitations,
. Failing eyesight (inability to read or write personal holiday correspondence),
. Loss of mobility and/or the inability to attend religious services.

Although sadness and grief are a normal part of life, depression is not a normal part of growing older. Depression is an illness which can be prevented and treated. Some of the warning signs of late-life depression include:

. Persistent sadness
. Lack of energy or interest in things that were once enjoyable
. Withdrawal from regular social activities
. Feelings of worthlessness or helplessness
. Frequent tearfulness
. Slowed thinking or response
. Excessive worry about health or finances
. Weight changes
. Pacing and fidgeting
. Changes in sleep patterns
. Inability to concentrate
. Staring off into space or at the television for prolonged periods of time

For many older adults there may be stigma attached to asking for help and they may have trouble discussing depression or mental illness. Understand that open communication is needed and that it may take more than one conversation to get the individual to agree to get help. If necessary, offer to call the individual's doctor or clergy and accompany the senior to an appointment. It is important to let the older adult know that depression is not part of growing old, that it is treatable, and that their lives can be better.

The National Registry for Evidence-based Programs and Practices

An Introduction

The Substance Abuse and Mental Health Services Administration (SAMHSA) developed the National Registry of Effective Prevention Programs in 1998 to better facilitate effective identification and dissemination of prevention programs targeting substance abuse. The newly revamped system, now the National Registry of Evidence-based Programs and Practices (NREPP), has expanded to include programs and practices for preventing and/or treating mental health and substance use disorders.

NREPP seeks to bridge the science to service gap by providing easily accessible information on the best practices and programs.

Without the identification, broad dissemination, and implementation of evidence-based practices (EBPs) for older adults, this vulnerable population faces delivery of services that are unsystematic and possibly ineffective or harmful. Delivery of effective and reliable services to older adults can decrease the disabilities and impairments associated with mental health problems and substance abuse in late life, while increasing the quality of life for this rapidly growing population.

Inclusion within NREPP is highly valued and potentially advantageous. SAMHSA and many other Federal and State agencies are increasingly awarding grants to programs that utilize EBPs. Because of NREPP's strong adherence to promoting EBPs, it serves as a rich resource for states, communities, public and private researchers and specific programs seeking to implement or promote specific evidence-based mental health and substance abuse prevention and treatment services for older adults.

The TAC is positioned to assist interested programs, practitioners, and researchers to learn more about NREPP and help determine whether they would be solid candidates for NREPP consideration. Programs targeted for the NREPP process are thoroughly evaluated, focusing on program outcomes. As a preliminary step prior to NREPP submission, the TAC analyzes program strengths and gaps to determine if the program is suitable for NREPP review, i.e., has sufficient supporting evidence for submission. If a program is found to be in need of further technical assistance in order to get NREPP-ready, TAC staff is available to work with program staff regarding gaps and ways to address these issues. For those programs ready for submission, the TAC will package their materials and submit them for review and evaluation by three independent NREPP reviewers on the basis of scientific merit and utility.

Programs reviewed by NREPP are placed into one of five categories: (5) Effective Program or Practice, (4) Conditionally Effective Program or Practice, (3) Emerging Program or Practice, (2) Program or Practice of Interest and (1) Insufficient Current Support.

Recently, the TAC highlighted the NREPP process in a poster presentation at the 3rd National Prevention Summit held in Washington, DC. We look forward to the further identification of and coordination with potential NREPP programs. If you are aware of a successful program serving older adults, please contact us at OlderAmericansTAC@westat.com or 1-888-281-8010 and provide the program name, along with contact information. In addition to the identification of programs and support throughout the NREPP process, TAC staff receives frequent requests regarding evidence-based practices and programs. While NREPP itself is unable to focus on knowledge dissemination, the TAC can assist with disseminating successful programs and practices and promote the use of recognized evidence-based activities.
LCSW and Social Worker Continuing Education

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Continuing education (CEU) courses offered

Aspira Continuing Education’s courses encompass all areas of mental health practice. Whether you are completing CEUs for your certification or maintain your license, our online continuing education courses provide the fastest, low cost, convenient way to fulfill your CEU requirements. We offer courses in the following subjects: Social Worker Continuing Education CEUsAging and Long Term Care CEUs
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