Tag: CBT

Flattening the mental health curve is the next big coronavirus challenge

Some recent projections suggest that deaths stemming from mental health issues could rival deaths directly due to the virus itself.

The mental health crisis triggered by COVID-19 is escalating rapidly. One example: When compared to a 2018 survey, U.S. adults are now eight times more likely to meet the criteria for serious mental distress. One-third of Americans report clinically significant symptoms of anxiety or clinical depression, according to a late May 2020 release of Census Bureau data.

While all population groups are affected, this crisis is especially difficult for students, particularly those pushed off college campuses and now facing economic uncertainty; adults with children at home, struggling to juggle work and home-schooling; and front-line health care workers, risking their lives to save others.

We know the virus has a deadly impact on the human body. But its impact on our mental health may be deadly too. Some recent projections suggest that deaths stemming from mental health issues could rival deaths directly due to the virus itself. The latest study from the Well Being Trust, a nonprofit foundation, estimates that COVID-19 may lead to anywhere from 27,644 to 154,037 additional U.S. deaths of despair, as mass unemployment, social isolation, depression and anxiety drive increases in suicides and drug overdoses.

But there are ways to help flatten the rising mental health curve. Our experience as psychologists investigating the depression epidemic and the nature of positive emotions tells us we can. With a concerted effort, clinical psychology can meet this challenge.

Reimagining mental health care

Our field has accumulated long lists of evidence-based approaches to treat and prevent anxiety, depression and suicide. But these existing tools are inadequate for the task at hand. Our shining examples of successful in-person psychotherapies – such as cognitive behavioral therapy for depression, or dialectical behavioral therapy for suicidal patients – were already underserving the population before the pandemic.

Now, these therapies are largely not available to patients in person, due to physical distancing mandates and continuing anxieties about virus exposure in public places. A further complication: Physical distancing interferes with support networks of friends and family. These networks ordinarily allow people to cope with major shocks. Now they are, if not completely severed, surely diminished.

What will help patients now? Clinical scientists and mental health practitioners must reimagine our care. This includes action on four interconnected fronts.

First, the traditional model of how and where a person receives mental health care must change. Clinicians and policymakers must deliver evidence-based care that clients can access remotely. Traditional “in-person” approaches – like individual or group face-to-face sessions with a mental health professional – will never be able to meet the current need.

Telehealth therapy sessions can fill a small part of the remaining gap. Forms of nontraditional mental health care delivery must fill the rest. These alternatives do not require reinvention of the wheel; in fact, these resources are already readily accessible. Among available options: web-based courses on the science of happiness, open-source web-based tools and podcasts. There are also self-paced, web-based interventions – mindfulness-based cognitive therapy is one – which are accessible for free or at reduced rates.

Democratizing mental health

Second, mental health care must be democratized. That means abandoning the notion that the only path to treatment is through a therapist or psychiatrist who dispenses wisdom or medications. Instead, we need other kinds of collaborative and community-based partnerships.

For example, given the known benefits of social support as a buffer against mental distress, we should enhance peer-delivered or peer-supported interventions – like peer-led mental health support groups, where information is communicated between people of similar social status or with common mental health problems. Peer programs have great flexibility; after orientation and training, peer leaders are capable of helping individual clients or groups, in person, online or via the phone. Initial data shows these approaches can successfully treat severe mental illness and depression. But they are not yet widely used.

Taking a proactive approach

Third, clinical scientists must promote mental health at the population level, with initiatives that try to benefit everyone rather than focusing exclusively on those who seek treatment. Some of these promotion strategies already have clear-cut scientific support. In fact, the best-supported population interventions, such as exercise, sleep hygiene and spending time outdoors, lend themselves perfectly to the needs of the moment: stress-relieving, mental illness-blocking and cost-free.

Finally, we must track mental health on the population level, just as intensely as COVID-19 is tracked and modeled. We must collect much more mental health outcome data than we do now. This data should include evaluations from mental health professionals as well as reports from everyday citizens who share their daily experiences in real time via remote-based survey platforms.

Monitoring population-level mental health requires a team effort. Data must be collected, then analyzed; findings must be shared across disciplines – psychiatry, psychology, epidemiology, sociology and public health, to name a few. Sustained funding from key institutions, like the NIH, are essential. To those who say this is too tall an order, we ask, “What’s the alternative?” Before flattening the mental health curve, the curve must be visible.

COVID-19 has revealed the inadequacies of the old mental health order. A vaccine will not solve these problems. Changes to mental health paradigms are needed now. In fact, the revolution is overdue.

[You need to understand the coronavirus pandemic, and we can help.Read The Conversation’s newsletter.]

This article is republished from The Conversation under a Creative Commons license. Read the original article.

8 June 2020
Is Bite-Sized Therapy A Good Option For Kids?

Clinicians test the effectiveness of single, 30-minute sessions to treat kids suffering from depression and anxiety.

Despite the fact that more and more young people are struggling with depression, anxiety and other psychological obstacles, help is still hard to come by for some.

According to Vox, it’s estimated that about one-quarter of those under age 18 have struggled with such a problem and only about one-third receive help.

But Jessica Schleider is hoping to change that.

Teaching Kids Coping Skills Through Cognitive Behavioral Therapy

Schleider is in charge of the Lab for Scalable Mental Health at Stony Brook University in New York and is an advocate of psychotherapy, which is similar to therapy but “much, much shorter.”

Psychotherapy is also known as talk-based therapy. Traditionally, patients have hour-long sessions over the timeframe of weeks or months.

But Schleider’s approach differs. Her sessions are about 30 minutes and are rooted in the idea of cognitive behavioral therapy. Three such sessions are available online for free so that young patients can try them and then assist in evaluating them.

While Schleider is still working to determine the effectiveness of the sessions, a pilot study with 96 participants in 2018 showed encouraging results, finding that one 30-minute session decreased depression and anxiety in comparison to a control group.

Schleider says her hope is that these sessions can provide kids with coping skills.

“I don’t think what we’re doing will replace anything already out there,” Schleider says. “But there needs to be other options.”

Short, Online Modules on Mental Health

Because of the shortage in mental health care, Schleider says one way her sessions could be used is when a child is waiting for a one-on-one appointment with a therapist. Or, she adds, they could be used by pediatricians when a child is showing signs of depression.

One of the sessions available online confronts depression by teaching children that the feelings they are experiencing are temporary. Another of the sessions delves into self-hatred and being kind to oneself, while the third deals with mood management.

Schleider says the content in the modules are “all little pieces of what you might get in a full treatment package.”

“But nobody’s ever bothered to test whether every aspect of those full treatment packages need to happen in order for someone to make a change,” she added.

As such, Schleider plans to continue collecting data on whether her programs are effective.

“Right now we have four or five different programs we’re evaluating,” she said. “We want to get an excellent grasp of what they do, and how they do it, and for whom they can be supportive and helpful before getting to the point of saying ‘everyone should now do this thing.’”

“Too many kids have gone without care for too long, and that’s why I’m doing this,” she added.

View the original article at thefix.com

25 September 2019
What Is Evidence-Based Addiction Treatment?

12-step programs are an incomplete approach and do not meet the requirements for evidence-based treatment because they lack biomedical and psychological components, and they use a one-size-fits-all approach.

When looking for treatment for addiction, there is a lot of information out there and countless opinions. Friends, family, doctors, researchers, and people in recovery all have their own beliefs about what you need to do to get well. Unlike in other areas of healthcare, addiction treatment is often deemed “effective” based on anecdotal reports. In fact, most people who seek or are forced into treatment do not receive health care that is aligned with evidence-based practice.

A frequently-cited definition comes from a 1996 article in the BMJ Medical Journal: evidence-based “means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” Other definitions also include the patient’s individual circumstances, preferences, expectations, and values.

These variables are not necessarily constant, and there is no one-size-fits-all solution; any list of evidence-based treatments is going to include a wide variety of approaches.

What is Addiction?

In the United States, addiction is still treated more as a crime than as a chronic illness or disorder. Until that perspective changes, treatments will not meet their full potential and will not be as effective as they could be. Addiction, or substance use disorder (SUD), is a chronic medical condition that has remissions, relapses, and genetic components.

Are Relapses Normal?

A relapse is not a failure but a symptom. The brain of a person with SUD has gone through neurobiological changes that increase the risk of relapse because the damaged reward pathways stick around much longer than the substances stay in the body. Stressful events and other painful life experiences can trigger that maladaptive coping mechanism and cause a relapse.

For other chronic illnesses we would consider a relapse to be an unfortunate symptom of the disease, and we might call it a recurrence instead of a relapse. When successfully managed, the condition is considered to be in remission. Remission is a term that is relatively new in addition treatment; substance use disorder was not always believed to be a disease but rather a moral failing and a problem of willpower. We now understand that addiction is a chronic medical condition and that remission is the goal of treatment. Remission, as defined by the American Society of Addiction Medicine, is “a state of wellness where there is an abatement of signs and symptoms that characterize active addiction.”

What Is Successful Addiction Treatment?

Let’s take a look at what it means to have an effective treatment outcome in terms of addiction. The primary goal is usually abstinence or at least a “clinically meaningful reduction in substance use.” To measure effectiveness, we must look at how and if treatment improves the quality of life for the patient. Improving quality of life is the aim when treating all chronic conditions that have no cure.

Evidence-based therapies do not support the notion of “hitting bottom.” As with any chronic disease, early intervention is going to provide the best outcomes. Even more effective than early intervention is prevention because SUDs are both preventable and treatable.

Pharmacotherapies to Treat Substance Use Disorders

Addiction is an overstimulation of the brain’s reward pathways, and as the condition progresses, the brain becomes less sensitive to the rewarding effects of a drug and requires more of the substance to get the same effect. This overstimulation can play tricks on memory recall, turning experiences that were not good into ones that seem better than they actually were. It creates false memories to encourage re-indulging in the addictive substance or behavior.

From a medical standpoint, this disparity needs to be interrupted and corrected. Akikur Mohammad, the author of The Anatomy of Addiction, argues that successful treatment of addiction “must first address the biological component and correct the brain’s chemical imbalance in the process.”

Pharmacotherapy is used in medication-assisted treatment and recovery. Depending on the patient’s individual drug history, different medications may be used to mitigate the brain’s compulsive race to stimulate the reward loop.

Therapy for Substance Use Disorders

Most research on therapy for substance use disorders has been done on cognitive behavioral therapy (CBT)—a form of typically short-term psychotherapy that combines talk therapy with behavioral therapy. Patients are taught how to adjust their negative thought patterns into positive thoughts. There is clinical evidence that CBT can be as effective as medications for many types of depression and anxiety. For treating SUD, CBT has been shown to have a “small but statistically significant treatment effect” but doesn’t necessarily have a long-lasting effect. As it’s a chronic illness, it stands to reason that SUD requires further maintenance beyond any short-term treatment.

Are 12-Step Programs Evidence Based?

Alcoholics Anonymous and other 12-step programs use a social model of recovery. They are built on the basic notion of peer support in a safe environment. There is research on the efficacy of 12-step programs, which shows it works for some people and that there are benefits to this social model of recovery. The steps, or rather the principles of the steps, must be internalized into a person’s psyche in order for the person to achieve lasting abstinence. 12-step programs are an incomplete approach and do not meet the requirements for the classification of evidence-based treatment because they lack biomedical and psychological components, and they use a one-size-fits-all approach.

One central tenet of the 12-step solution requires turning one’s will over to the care of a higher power. Certainly, letting go of the notion that force of will can change the trajectory of addiction is necessary for any treatment. It’s a disease, and willpower will no sooner cure addiction than it will cure diabetes or heart disease. An evidence-based approach could mean that a doctor recommends a patient attend a 12-step program, or other support group, as part of a maintenance regime.

The addiction treatment world is overrun with rehabs that primarily utilize 12-step programs, which are touted as the only treatment for addiction. That simply isn’t true. Addiction researchers have found that individually, cognitive and behavioral therapies, including social supports like 12-step programs, are incomplete treatment for a chronic disease that is both physiological and genetic in origin. From a treatment perspective that is grounded in evidence-based practice, involvement in a support group would be merely one piece of the puzzle.

Holistic Care

In evidence-based practice, the treatment process individualizes care and uses a holistic perspective to see what combination of resources will work best for a particular patient. The combination of treatment tools depends on a clinician’s specialized knowledge, the patient’s values and preferences, and the best research evidence. We need more specially trained addiction clinicians who can help people with SUDs make informed treatment decisions.

Are you in recovery from addiction? What worked for you? Tell us in the comments!

View the original article at thefix.com

2 April 2019
How Does AA Work? A Review of the Evidence

AA is cloaked in misconceptions and mysticism: a society of “former drunks” who tout spirituality as a means to cure the chronic, genetic, and life-threatening disease of alcoholism.

Alcoholics Anonymous (AA), as an organization, “neither endorses nor opposes any causes.” But AA, as a societal symbol, is very controversial. People have strong opinions about its benefits and its dangers. It’s an organization cloaked in misconceptions and mysticism: an anonymous society of “former drunks” who tout spirituality as a means to cure the chronic, genetic, and life-threatening disease of alcohol use disorder (AUD). There is no denying that many have found support and achieved recovery through involvement in 12-step programs. That has left researchers with the question: what mechanisms are at work behind the scenes?

Peer Support Groups like AA Increase Oxytocin

Participation in mutual help programs may increase levels of oxytocin, the feel-good hormone. Nicknamed the “love hormone,” it is released when people bond socially or physically. A neurobiological view of addiction recovery might look at how oxytocin plays on the brains of people in a treatment program. Oxytocin increases when bonding socially with others in AA and there are other neuroplasticity rewards that come from 12-step program participation. Interactions with other members improve the connectivity between the part of the brain that makes decisions and the “craving behavior” part of the brain.

The oxytocin system is created before age four and its development can be affected by variables such as genetic differences within the receptor itself, or environmental causes like stress or trauma. An underdeveloped oxytocin system is a risk factor for drug addiction. Healthy levels of “oxytocin can reduce the pleasure of drugs and feeling of stress.” Creating opportunities for healthy oxytocin production could benefit people in recovery from addiction.

Oxytocin also boosts feelings of spirituality, according to Duke University research. The study defined spirituality as “the belief in a meaningful life imbued with a sense of connection to a Higher Power, the world, or both.” Study participants who received a dose of oxytocin prior to meditation reported higher levels of positive emotions and feelings of spirituality. The effects lasted until at least one week after the initial experience.

Do AA Prayers Reduce Cravings?

Researchers at the NYU Langone Medical Center used brain imaging to see what, if any, effect praying has on the brains of AA members. They were able to see increased activity in the areas of the brain associated with attention and emotion during prayer which correlated with a reduced craving for alcohol. When exposed to triggers such as passing a bar or experiencing an emotional upset, people who were abstinent from alcohol but not members of AA were significantly less likely to experience the benefits of “abstinence-promoting prayers.” This brain activity seems to also be associated with a “spiritual awakening.”

A spiritual awakening is not necessarily about the divine; rather, it’s an awareness of needing resources that are beyond the reach of a person’s individual ego. This awareness causes a shift that alters one’s perspective about drinking. There are also physiologic changes that seem to occur with increased spiritual awakening/awareness. In previous research, those who were directed to pray daily for four weeks drank half as much as the study participants who were directed to not pray.

Research published in the last five years has tried to find ways to measure effectiveness in 12-step programs, in a way that is unbiased and scientific. One such study published in 2014 discovered that spiritual (rather than behavioral) 12-step work was important for later abstinence.

Spirituality Is Not for Everyone

Not everyone who enters AA experiences a spiritual awakening. According to a review of 25 years of research, it seems that only a minority of people with severe addiction experience this spiritual Aha! moment. While a sense of spirituality creates changes in the brain that can be measured on an MRI machine, there are other aspects of AA — social, mental, and emotional — that aid recovery for the majority of participants.

Twelve-step programs can help addiction recovery because of their ability to propagate therapeutic mechanisms similar to the coping tools and behavioral strategies that are utilized in formal treatments. AA has a lot of parallels with cognitive behavioral therapy (CBT). CBT is an evidence-based form of psychotherapy that is effective over just a short period of time. In CBT, patients learn new habits through increasing self-awareness, overcoming fears, taking personal responsibility, and developing shifts in perspective. These are the same underpinnings as the 12 steps.

Clinical interventions that encourage 12-step participation are more successful than clinical interventions that do not encourage attendance. Meeting attendance, sponsorship, and active involvement have come up in multiple studies as being positively correlated with continued abstinence, highlighting the critical nature of connection to others as part of an effective plan for managing addiction long term.

12-Step Programs as a Useful Management Tool

Addiction is a chronic illness with no cure, according to AA literature as well as the medical community, and chronic illnesses require lifelong management. AA can be a good ally in the quest to maintain a healthy lifestyle free of active addiction.

The International Journal of Nursing Education published a study that sought to learn about the quality of life for those attending AA as opposed to those who are not attending AA. They found a significant difference, with those who attend AA reporting a better quality of life than non-attendees.

When looking at meeting attendance over long periods of time, abstinence patterns can be predicted. For people who went through inpatient treatment, the pattern shows that meeting attendance is highest during treatment and reduces at a steady pace afterwards. With reduction in attendance there is also a reduction in abstinence from using drugs or alcohol. Findings from many long-term studies suggest that meeting attendance is important in early recovery and for successful long-term recovery. The reasons for this echo other research findings: community matters.

Dangers Inherent to 12-Step Groups

The nature of AA and other 12-step programs leaves them to be individually organized and without a central governance. There is no oversight and no quality controls. Abuse, inappropriate behavior, bad advice, and social ostracizing can happen.

Perhaps most dangerous is when a single solution is pushed on someone for whom a different angle would work better. Individual satisfaction with treatment plays a major role in “subsequent psychiatric severity,” which means that recovery rates are lower for people who are unsatisfied with the addiction treatment they receive. The World Health Organization suggests that to improve treatment outcomes and engagement with treatment, patient satisfaction ought to be a focus when caring for people with substance use disorders.

AA provides a range of pathways to recovery, but it is not the one-size-fits-all approach it claims to be. It’s particularly challenging for people who also have a diagnosis of (or just struggle with) social anxiety. It’s common for AUD to exist alongside social anxiety. The fear of being negatively appraised can impede progress in recovery. Long-term participation in mutual aid groups such as AA may reduce social anxiety but overcoming that hump in early recovery may require clinical interventions or alternative treatments.

Did you find recovery in 12-step programs or did you have a negative experience? Let us know in the comments.

View the original article at thefix.com

4 March 2019
Can Internet-Based Therapy Effectively Treat Depression?

Scientists investigated whether internet-based platforms that offer treatment for depression were actually effective.

Technology may soon have a larger role in treating severe depression, as new research has determined that cognitive behavioral therapy sessions via an app can be effective.

Cognitive behavioral therapy, according to Medical News Today, is a type of therapy that works to change people’s thought patterns over time. When delivered via an app, it is referred to as internet-based CBT or iCBT.

In the past, it has been deemed effective for depression, anxiety and panic disorder, bipolar, substance use disorders and various other mental health disorders.

However, until recently, it was unknown whether iCBT was effective for severe depression or for those struggling with both depression and anxiety/alcohol use disorder.

According to Lorenzo Lorenzo-Luaces, a clinical professor in the Department of Psychological and Brain Sciences at Indiana University in Bloomington and lead study author, iCBT is effective in such cases.

Lorenzo-Luaces says the criteria for major depressive disorder is met by about one in four people.

“If you include people with minor depression or who have been depressed for a week or a month with a few symptoms, the number grows, exceeding the number of psychologists who can serve them,” he told Medical News Today.

In the study, Lorenzo-Luaces and his team analyzed 21 existing studies and determined that iCBT apps were, in fact, effective for treating mild, moderate and severe levels of depression.

Many of the existing studies compared iCBT apps to “sham apps,” or apps that are meant to make weaker recommendations to their users. In these cases, the iCBT apps were far more effective for users.

“Before this study, I thought past studies were probably focused on people with very mild depression, those who did not have other mental health problems and were at low risk for suicide,” Lorenzo-Luaces said.  

“To my surprise, that was not the case,” he added. “The science suggests that these apps and platforms can help a large number of people.”

Even so, Lorenzo-Luaces says it’s important that people don’t interpret this evidence as a reason to stop taking a medication and rely solely on iCBT.

In conclusion, Lorenzo-Luaces and his team note that iCBT is on par with other treatment methods for severe depression.

“A conservative interpretation of our findings is that the patient population sampled in the literature on self-guided iCBT is relatively comparable with that of studies of antidepressants or face-to-face psychotherapy.”

View the original article at thefix.com

19 December 2018