Category: Mental Health

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Chris Tuell Ed.D., LPCC-S, LICDC-CS
Clinical Director of Addiction Services Lindner Center of HOPE
Assistant Professor, Department of Psychiatry & Behavioral Neuroscience University of Cincinnati College of Medicine

In 1987, Francine Shapiro went for a walk. While on her walk, Francine was contemplating some very upsetting personal events that were occurring in her life at the time. But as she began to focus on this upsetting information, she noticed that her eyes began to flicker from side to side. More importantly, she noticed that the once upsetting information was no longer as upsetting. Shapiro felt that she had stumbled on some aspect of how the mind processes information. Eye Movement Desensitization and Reprocessing, better known as EMDR, was born.

For the past 30 years EMDR has become one of the most effective therapeutic approaches in the treatment of trauma. EMDR is not only approved by the American Psychiatric and Psychological Associations, but also by the United States Department of Defense and the Veterans Administration, as an effective therapy in the treatment of post traumatic stress disorder (PTSD). Dr. Shapiro believes that one of the major theories behind EMDR is the bilateral stimulation of both hemispheres of the brain. When we sleep at night, our brain continues to process information. This occurs during rapid eye movement sleep or better known as REM sleep.

The brain processes the events of the day, keeping what is important (e.g. family, work, school, friends), and purging what is unimportant (e.g., What I had for dinner last Tuesday). How many times have we have been faced with a tough decision and resorted to, “I’ll just sleep on it,” only to awake the next morning with a better idea of what to do? But when a traumatic event occurs, the processing of this information becomes disrupted. The brain becomes unable to process and clear the event or information, resulting in the trauma experience continuing to occur as if it is happening all over again. In this playing-out, the right hemisphere of the brain, the part of our brain that experiences emotions such as fear and anxiety, continues to be activated by the unresolved trauma. The patient experiences this activation through intrusive thoughts, flashbacks, and disturbing dreams, the basic elements of PTSD.

EMDR involves the bilateral stimulation of both hemispheres of the brain while targeting the upsetting aspects of the trauma. In therapy, the therapist recreates what happens naturally during REM sleep, with the movement of the eyes as they follow the therapist’s hand, stimulating both hemispheres of the brain. Over the years, additional bilateral stimulation methods have been found to be effective (i.e., tactile, audio). This targeting involves, not only activating the image of the event, but also identifying the negative thoughts, emotions and sensations experienced by the patient from the trauma. During the reprocessing of the trauma experience, the logical, rational part of the brain, the left hemisphere, is integrated with the right emotional hemisphere. This results in the patient having a more adaptive response to the trauma. The patient may still have memory of the event, but the emotional aspects of fear and anxiety have dissipated. During EMDR, the left hemisphere of the brain, the rational, logical part, is integrated with the emotional right hemisphere of the brain, resulting in the patient feeling and knowing that, “The trauma is no longer happening to me now; The trauma is in the past; I am safe now.”

EMDR is not a wonder cure nor is it a quick fix. EMDR involves hard work by the patient and it takes a good amount of clinical skills in order to implement. This is not about touching the person’s forehead and he or she is better. The patient and therapist have to be responsible and work at this process, but it does appear to go much more rapidly than traditional types of therapy. If a trauma can occur within a few moments, why do we automatically accept that it has to take years to undo it?

More than 20,000 practitioners have been trained to use EMDR since its discovery. The use of EMDR has been found to be beneficial in other areas of mental health besides, PTSD. Areas such as panic disorders, anxiety disorders, grief, pain, stress, addiction, and abuse, have shown to be responsive to this unique therapy. One aspect of EMDR that I have found to be valuable is the fact that it is unnecessary for me, as the clinician, to know all the details and specifics of a patient’s trauma in order for EMDR to be helpful. Many individuals who have experienced trauma stay clear of therapy for fear of reliving the memories and feelings. The EMDR protocol allows for such traumatic episodes to be addressed and reprocessed without describing the details of the trauma. As a practitioner, I have found EMDR to be a valuable therapeutic tool in assisting patients in moving past one’s past.

For more information about EMDR: https://www.emdria.org

 

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By Marcy Marklay, LPCC, Adolescent Therapist,
Lindner Center of HOPE

Technology has changed the way people bully each other. Cyberbullying via text messages and use of social media, as well as the more traditional forms of bullying,can occur in childhood, adolescence and into adulthood, even in college and in the workplace. Bullying is far from uncommon and needs to be addressed.

Reasons For Bullying
Bullying can occur due to someone being different. Elevating one’s social status can be a common motivating factor for bullying. Some bullies are motivated by obtaining power and control of others through fear. Some groups can gang up on someone, or another group, because of different beliefs, for example, being bullied for being lesbian, gay, bisexual, or transgender (LGBT).

How It Appears
Bullying can be subtle or overt, occur once or be persistent and chronic in nature. Bullies can use rumors or gossip and berate a victim and turn others against them in a deliberate attempt to sabotage their reputation. Chronic bullying takes a greater toll on the bullied individual, and can lead to mental, emotional, physical and social harm.

Addressing Bullying
Best practices in addressing bullying will include providing education about bullying as well as providing treatment interventions to those individuals affected or targeted by bullying. Education needs to include what to look for or ways to identify bullying, why bullying is harmful and unacceptable, and how to go about reporting it. It is generally a bully’s goal to disempower the victim. Teaching assertiveness skills are not the only interested in touring method to teach the target of bullying. More recently, utilizing bystander intervention has become increasingly helpful in combating bullying because it addresses the problem from a systems or group perspective. Bystander intervention involves enlisting the help of others in the school or community to assist in addressing and reducing the problem behaviors, by using a social norming campaign to teach students about appropriate behaviors. By adopting a community responsibility standard, bullying can be reduced in an environment where it is not acceptable. The number of individuals willing to confront bullying , whether cyberbullying , assault, threats, verbal abuse, or offensive behavior that can be humiliating, intimidating or threatening can be reduced more significantly in this way.

It is important to thoroughly listen to the victim of bullying’s story without quickly jumping to conclusions, and to explore possible options, such as what a treatment professional can provide, a victim can do for themselves, what a school or the police can do to help the victim. Narrative therapy is helpful in letting the victim tell their story. It can help them look at what is in and out of their control. It can externalize the negative experience of being bullied from the victim. In some cases a threat assessment is indicated to assess for the potential escalation of violence by the bully and retaliation from the person being bullied. Suicide prevention is also a concern, as some who are bullied may become suicidal and need crisis intervention. Victims can experience a wide range of symptoms due to being bullied, which are not limited to anxiety, depression, somatic complaints, falling grades, family stress, isolation. Victims often blame themselves. It is critical to focus on finding a sense of safety, addressing mental health concerns, and connecting the victim to a support system. Work on self-esteem and coping skills is helpful, and working to restore lost confidence is a goal. Victims may suffer from depression, anxiety, panic attacks, PTSD, acute stress disorder and even suicide. The victim’s primary relationships may suffer as a result of the bullying.

Help for victims
Helping those who have been bullied includes exploring ways to heal, examining realistic solutions to the problems, and prioritizing health. Encourage self-care and social support. Provide psychoeducation. Assist victims with finding resources. Keep a focus on the present and near future; focusing too much on the past does not give the goal-directed and strengths based approach these individuals need. Role playing and practicing and rehearsing coping skills in a safe space can be empowering. There is immense power in the act of listening to a victim of bullying. Parents are important in supporting the young person and can also benefit from internet and online safety training, and social media training along with their children. Many parents fear the internet and require their children avoid technology, which may help in the short term, but is not a realistic long term solution, as the internet is used for homework, employment and socialization. Teaching internet and online safety skills to both youth and parents is most effective. Parents then can become good role models for youth in using technology, enhance communication and develop a greater bond; this can result in personal empowerment for both youth and their parents.

Source
Cyberbullying: What Counselors Need to Know by Dr. Sheri Bauman; published in 2011

 

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Amanda Porter, MSN, APRN, PMHNP-BC

Psychiatric Nurse Practitioner, Lindner Center of HOPE Board-Certified in Internal Medicine, Psychiatry/Mental Health, and Addictions

 

The question of “What causes mental health disorders?” is the eternal question on the field of psychiatry. The most widely accepted theory as to the cause of depression thus far has been the neurotransmitter theory; however even with correct diagnosis and appropriate treatment “between 40% and 70% do no respond to treatment, or only partially, while roughly half of patients who do achieve full remission following txt for severe depressed mood relapse within 2 years even when continuing on antidepressants.” (Greenblatt & Brogan, 2016; Keitner & Mansfield, 2012). Even when we place patients on medications meant to boost their neurotransmitters, often remission of mood disorder symptoms is elusive. Therefore, it behooves us as clinicians to seek out complementary and integrative methods (CIM) for treating for mood disorders that can augment or sometimes replace traditional medical treatments.

One method of CIM includes Mindfulness and Meditation. Broadly, this is described as cultivation of awareness, relaxation, focused attention and stillness. This is a methodology pioneered by Jon Kabat-Zinn. Release of serotonin, GABA, dopamine and melatonin occurs during meditation (Newberg, 2010). Since 2009, roughly 10 studies have examined the efficacy of mindfulness practices with patients who were unresponsive to antidepressant therapy. Three-quarters of these studies showed statistically significant reduction in Ham-D scores (Jain, 2015). Mindfulness has been suggested to have the ability modulate the immune system itself as demonstrated in HIV-infected adults who show increased in circulation of CD4+ T lymphocyte counts (Cresswell, 2009).

Another method of CIM includes Spirituality/Prayer. Many of my patients experience depression surrounding some pretty heady questions such as “What is my purpose in life? What was I created for? What happens after I die?” Becoming involved in a faith community, and engaging in spiritual practices associated with that community increase a sense of belonging and self-worth in a person, which leads to overall improved mental health. “In a systematic review of 850 studies of religion and mental health, religion was associated with greater overall well-being in 79% of these studies, lower suicidality in 84%, lower depression 66% and lower anxiety in 51%.” (Koenig, 2001).  Also, it’s postulated that while a sense of well-being and purpose provides greater benefit in preventing depression, a positive relationship with God provides greater benefit after onset of depression.

Another method of CIM includes Yoga and Movement therapies. Yoga and other movement therapies such as Tai Chi or Qi Gong have been found to be helpful for depression, ADHD, anxiety and chronic pain and are especially helpful in vulnerable populations such as pregnancy, adolescents or the elderly. When combined with meditation, this is an incredibly effective therapy, and the beauty of Yoga practice is that even 15 minutes a day can be helpful, so it’s not time-consuming. Yoga practitioners downregulate their HPA axis and modulate their cortisol levels (Sieverdes, et al 2014). Yoga and Tai Chi also have excellent indication for sleep duration with less arousal time. The mechanisms that are involved in the effects of yoga on stress response include the following: positive affect, self-compassion, and inhibition of the posterior hypothalamus and salivary cortisol (Riley, 2015).

Another method of CIM includes Exercise. With depression, often the patient becomes isolated, withdrawn, with poor motivation. This leads to increase in sedentary behaviors. Therefore, it’s important to increase activity in the form of exercise. The higher the dose, the lower the risk of relapse rates in patients with MDD, with 10 days being sufficient to begin seeing an improvement in mood (Knubben, et al, 2007). Exercise increases rate of neurogenesis, production of BDNF, increases serotonin by increasing tryptophan, increases norepinephrine, increases phenylethylamine, decreased cortisol, increase endorphins, and increases dopamine (Greenblatt & Brogan, 2016). It’s hypothesized that exercise helps the brain deal more efficiently with stress by enhancing the body’s ability to respond to stress, and coordinating the sympathetic nervous system response (McWilliams, 2001).

Another method of CIM includes appropriate Nutrition. There is an ongoing discussion about the gut-brain connection and the impact that our nutritional choices have on our mental health. The typical Western Diet consist of high fructose foods or beverages, transaturated fats, with large amounts of carbohydrates in the form of bread products. Sugar and gluten are both incredibly inflammatory, and alter the microbiome of the gut. Factors like alcohol, antibiotic use, NSAIDS, cytokine production, and psychological stress increase also intestinal permeability (Greenblatt and Brogan, 2016). So our dietary choices do have great impact on our mental health. Gluten attacks an enzyme involved in the production of GABA (Kramer & Bressnan, 2016). Patients with schizophrenia and autism are at higher risk for intolerance to gluten, and respond very positively to gluten-free and casein-free diets. Higher dietary fiber content was associated with lower odds of depression; increased consumption of vegetables and nonjuice fruit was associated with lower odds for depression; added sugars, but not total sugars or total carbohydrates, to be strongly associated with depression incidence (Gangswisch, 2015). It’s important to remember that sugar is not the enemy here, but excess sugar is. As with most things in life, balance is key.

Further methods of CIM used to treat mood disorders include: Creative Arts including painting, drawing, music, dance, and writing/narrative medicine; Nature therapy; Pet therapy; Water therapy/Floating; Life coaching/Financial planning; Massage therapy; Acupuncture; Micronutrient therapy; Essential oils; Light therapy; Media fasts; Psychotherapy; and TMS/ECT.

At Lindner Center of HOPE, an Integrative Mental Health consult service incorporates the above treatment modalities, aimed at addressing mental health disorders as holistically as possible. The goal is to strive for recovery with the whole person in mind.

 

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By Danielle J. Johnson, MD, FAPA
Lindner Center of HOPE, Chief of Adult Psychiatry

May is Maternal Mental Health Awareness Month.  One in five women will develop a maternal mental health disorder.  They are also referred to as perinatal mood and anxiety disorders (PMADs) to emphasize that women experience more than postpartum depression during pregnancy and after birth.  Women who have symptoms of PMADs might not seek help because of guilt, shame, or embarrassment for feeling something different than the expected norms of motherhood.  Awareness and education are important to reduce stigma so mothers and babies get the help they need.

PMADs can occur during pregnancy or up to one year after giving birth. The most common PMAD is the “baby blues”, affecting up to 80% of new mothers.  Symptoms include sudden mood swings, loneliness, sadness, crying spells, loss of appetite, problems sleeping, irritability, restlessness, and anxiety.  These symptoms are a normal adjustment to changes in hormones and resolve without treatment in two to three weeks.

About 10% of women experience depression during pregnancy and about 15% during the first year postpartum.  Feeling sad, hopeless, helpless, or worthless; fatigue, difficulty sleeping or sleeping too much, appetite changes, difficulty concentrating, crying, loss of interest or pleasure; lack of interest in, difficulty bonding with, or excessive anxiety about the baby; feelings of being a bad mother, and fear of harming the baby or self are symptoms of peripartum depression.  Risk factors include poverty, being a teen mother, advanced maternal age; personal or family history of depression, anxiety, or postpartum depression; premenstrual dysphoric disorder, inadequate support, financial stress, relationship stress; complications in pregnancy, birth or breastfeeding; a history of abuse or trauma, a major recent life event, birth of multiples, babies in neonatal intensive care, infertility treatments, thyroid imbalance, and diabetes.

Anxiety can occur alone, or with depression, in 10% of new mothers.  Symptoms include constant worry, racing thoughts, inability to sit still, changes in sleep or appetite, feeling that something bad is going to happen; and physical symptoms like dizziness, hot flashes, and nausea.  Some mothers may also have panic attacks with shortness of breath, chest pain, dizziness, a feeling of losing control, and numbness and tingling.  Risk factors are a personal or family history of anxiety, previous perinatal depression or anxiety, and thyroid imbalance.

Post-traumatic stress disorder (PTSD) can occur in up to 6% of mothers following a traumatic childbirth.  Possible traumas are prolapsed cord, unplanned C-section, use of vacuum extractor or forceps to deliver the baby, baby going to NICU; and feelings of powerlessness, poor communication and/or lack of support and reassurance during the delivery.  Women who have experienced a previous sexual trauma are also at a higher risk for developing postpartum PTSD.  Intrusive re-experiencing of the traumatic event, flashbacks or nightmares; avoidance of stimuli associated with the event; increased arousal (irritability, difficulty sleeping, hypervigilance, exaggerated startle response); anxiety and panic attacks, and feeling a sense of unreality and detachment are symptoms of PTSD.

Obsessive-compulsive disorder (OCD) can occur in 3% to 5% of new mothers.  Obsessions are persistent, repetitive thoughts or mental images, often related to the baby. Obsessions can be so bizarre or disturbing that they can be mistaken as psychosis.  Compulsions are repetitive acts performed to reduce obsessions.   Mothers are distressed by the obsessions which can lead to a fear of being left alone with the baby or hypervigilance in protecting the baby.  Mothers with postpartum OCD know that their thoughts are out of the ordinary and are unlikely to ever act on them.

Postpartum psychosis is the most severe of the PMADs.  It is often associated with an episode of bipolar disorder. It is rare, occurring in 1 to 2 per 1000 women.  The onset is abrupt, within 48 to 72 hours and up to two weeks after delivery. This is a psychiatric emergency, requiring immediate treatment.  Mothers may experience hallucinations (hearing voices or seeing things) and/or delusions (believing things that aren’t true.)  If psychosis occurs as part of a bipolar manic episode, there might be additional symptoms such as irritability, hyperactivity, decreased need for or inability to sleep, paranoia and suspiciousness, rapid mood swings, difficulty communicating, and confusion or memory loss. Risk factors are a personal or family history of bipolar disorder or a psychotic disorder.  Most women with postpartum psychosis do not have violent delusions but there is an up to 5% rate of infanticide or suicide due to acting on delusions or having irrational judgement.

PMADs are the most common complication of pregnancy and childbirth.  They are treatable with psychotherapy and/or medication and early intervention provides relief for the mother and ensures the baby’s wellbeing.

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Amanda Porter, MSN, APRN, PMHNP-BC

Psychiatric Nurse Practitioner, Lindner Center of HOPE Board-Certified in Internal Medicine, Psychiatry/Mental Health, and Addictions

 

Depression is a serious and costly health problem facing our country. Depression is the most common form of mental illness, and is a leading cause of disability, and affects more than a quarter of the US population (CDC, 2017). To date the most prevalent theory as to the etiology of depression is the neurotransmitter theory, however not everyone responds to medications which boost neurotransmitters. Only about half of patients respond to antidepressants, and those who do respond will likely experience relapse of depression within two years (Greenblatt and Brogan, 2016). Thus, we need to consider other influences which might be causing depression.

The field of Integrative Mental Health considers other reasons for depression, such as an altered microbiome, chronic inflammation, hormones, mitochondrial dysfunction, dietary sensitivities, genetic mutations, and the role of neurogenesis.

Integrative Mental Health focuses on the whole person in order to promote recovery as holistically as possible from a mental health diagnosis. Integrative Medicine is synonymous with functional medicine and complementary and alternative medicine. Integrative Mental Health Medicine is an area of medicine that is evolving through the work of its pioneer, Dr. Andrew Weil.

It’s important to understand that integrative therapies are not necessarily a replacement for mental health medications. Rather, integrative therapies can supplement your current mental health treatment plan, or at times reduce the quantity of medications a person takes.

At the Lindner Center of HOPE Integrative Mental Health programming includes genotyping that enables the detection of the MTHFR genetic mutation, and treat accordingly. Micronutrient, thyroid, and metabolic testing is also offered with appropriate recommendations on diet and lifestyle changes. As Hippocrates famously said, “Let food be thy medicine.” Through the UC Center of Integrative Health and Wellness, treatment modalities such as massage, yoga, and acupuncture are available.

After an initial consult with an Integrative Mental Health practitioner, an Integrative Mental Health treatment plan will be developed. The treatment plan is also based off the patient’s individual mental health needs. This treatment plan incorporates lifestyle changes such as diet and exercise, nutrient therapy consisting of beneficial dietary supplements, and also considerations for services such as acupuncture, massage therapy, mindfulness, meditation, and hypnosis. The program appeals to patients who are seeking to treat their mental health diagnosis with as few prescription medications as possible. Integrative Mental Health consultations and follow-up visits are covered under many insurance plans.

Sources

Greenblatt, J. M. & Brogan, K. (2016). Integrative therapies for depression. Boca Raton, FL: CRC Press

Mental Health Basics. (2013). Retrieved from https://www.cdc.gov/mentalhealth/basics.htm

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Free Community Education Series Offered the Third Wednesday of Every Other Month

The second session of a free education series to help community members increase awareness of mental health, substance use disorders, treatment and strategies for coping is April 18, 2018. Stacey Spencer, EdD, Lindner Center of HOPE staff psychologist, will present ADHD Through the Lifespan.

Lindner Center of HOPE with the support of Manor House in Mason, Ohio is once again offering a Free Community Education Series to increase awareness of mental health issues and substance use. The series offers expert discussion of Mental Health, Substance Use Disorders, Treatment and Strategies for Coping for community members seeking information.

The series is held at Manor House, 7440 Mason-Montgomery Rd., Mason at 6 p.m. the third Wednesday of every other month.

Register by calling Pricila Gran at 513-536-0318. Learn more by visiting lindnercenterofhope.org/education.

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By Michael O’Hearn, MSW, LISW-S

The drum is one of the oldest musical instruments. An interesting paradox of medical and cognitive neuroscience is how a range of intra- and inter-personal stress mediation, self-regulation, and mind-body continuity interventions are accomplished through ancient
traditions of meditation (mental training) (Davidson & McEwen, 2012; Khalsa, Rudrauf, Davidson, & Tranel, 2015), and drumming (Bittman, Berk, Fleton, Westenguard, Pappas, & Ninehouser, 2001; Bittman, Berk, Shannon, Sharaf, Westenguard, Guegler, & Ruff, 20015; Bittman, Croft, Brinker, van Laar, Vernalis, & Elisworth, 2013).
This paper outlines a drumming technology that naturally integrates with Shamatha (Object) meditation (Ponlop, 2006). Drumming technology is a source of practically limitless transverse, bi-lateral, fine, and gross motor algorithms for individuals, couples, or groups. The targeted and individualized interventions (algorithms) serve as the object of Shamatha meditation. The psychoneuromuscular (PNM) practice not only conditions self-regulation, mind-body continuity, and stress mediation; the acquired abilities are eventually habituated in procedural or working memory (Sacks, 2007; Sapolsky, 2017) in
client systems.
The proposed drumming technology is central to a theoretical paper on music-based learning culture in former totalitarian undergraduate, graduate, and post-graduate education. It is expected to be published by Summer, 2018. Michael Radin, Ph.D., a classically trained pianist and Mathematics Professor at the Rochester Institute of Technology and Riga Technical University, and Liga Engele, Head of the Music Therapy
Center at Leipaja University, Latvia are lead and co-authors.

A Drumming Technology
The following is a description of drumming technology components and processes, some dyadic tables, and a low complexity algorithm. Table 1 and 1a outline phalange/hand, and foot sources for drumming algorithms:

 

 

 

 

 

 

 

Time Signatures. Time signatures are expressed as fractions; Table 2 illustrates a 4/4-time signature. The denominator represents the total number of beats per measure; the numerator represents the number of beats played per measure. Any source combinations can fit with practically any desired time signature.
Additional time signatures are not limited to 3/3, 3/4, 2/4, and 6/8.

Basic Rhythms. The following are basic rhythmic patterns ubiquitous in drumming and dance choreography. Again, any combination of  sources can fit these basic rhythms.

 

 

 

Accents. Downbeat and syncopation are two examples of various  accents to basic rhythms. Table 2 also illustrates the downbeat accent in 4/4 time.

 

 

Syncopated rhythms have accents that are not necessarily patterned or predictable; the accent often “anticipates,” or is played on the half-beat in Latin rhythms, Jazz, and progressive rock music. As syncopated  rhythms require additional effort and resources to capture and integrate, they are indicated to enhance integration in trauma recovery (van der Kolk, 2009; 2014) patients.

Medium. Drum kit, hand drum, finger drum, homemade drum, lap,  belly, table, or other are examples of medium – the instrument selected for a drumming algorithm.

Tuplet. Tuplet is the number of strokes attributed to each beat (the numerator) in any time signature; typically, single, double, or triple.

Tempo. A metronome is a meter that measures tempo in beats per minute/second (bpm/s), and provides an auditory “click track.” The  practitioner plays at a precise tempo, in sync or “on meter” with the  metronome. There are advantages to fast and slow tempo. Drumming  algorithms can emphasize one, the other, or include both.

Duration. Duration is the length of time of practice session, or the number of repetitions a drumming algorithm is played.

Examples of Dyadic Tables and a Drumming Algorithm.
The following are samples of fine and gross motor, transverse and bi-lateral dyadic tables for drumming algorithms. It is followed by an  illustration of a low complexity drummingalgorithm.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUMMARY
Meditative drumming is a psychoneuromuscular (PNM) intervention for individuals, couples, and groups that facilitates self-regulation, mind-body continuity, and stress reduction.
Individualized drumming algorithms are designed to engage one or a combination of: autonomic/vagal, cognitive, emotional, language,  visual-spatial, fine/gross motor, and memory along transverse and/or  bi-lateral pathways. Acquired abilities from meditative drumming algorithms are eventually habituated in procedural or working memory (Sacks, 2007; Sapolsky, 2017).

Its value for generating nonlinear efficacy in all settings (including all levels of care continuums), is matched only by its portability and cost efficiency.

REFERENCES
Davidson, R. & McEwen, B. (2012). Social influences on neural plasticity: Stress and interventions to promote well-being.
Nature Neuroscience, 689-695.
Khalsa, Rudrauf, Davidson, & Tranel. (2015). The effect of meditation on regulation of internal body states. Frontiers in Psychology, 1-15.
Bittman, B., Berk, L., Felten, D., Westenguard, J., Pappas, J., Ninehouser, M. (2001). Composite effects of group drumming music therapy on modulation of neuroendocrine-immune parameters in normal subjects, Alternative Therapies In Health and Medicine, Jan: 7(1), 38-47.
Bittman, B., Berk, L., Shannon, M., Sharaf, M., Westenguard, J.,
Guegler, K., Ruff, D. (2005). Recreational music-making
modulates the human stress response: a preliminary
individualized gene expression strategy, Medical Science
Monitor, 11, BR31-40.
Bittman, B., Croft, D., Brinker, J., van Laar, R., Vernalis, M., & Elisworth,
D. (2013 Recreational music-making alters gene expression pathways in patients with coronary artery disease, Medical Science Monitor,19, 139-147.
Ponlop, D. (2006). Mind beyond death. Ithaca, NY: Snowlion.
Sacks, O. (2007). Musicophilia. NY: Vintage.
Sapolsky, R. (2017). Behave: The biology of humans at our best and worst. NY: Penguin.
van der Kolk, B. (2009). Presentation of Trauma and Recovery, to the Milton H. Erikson Foundation Evolution of Psychotherapy Conference, Sacramento, CA.
van der Kolk, B. (2014). Trauma Recovery presentation to the 2014 International Trauma Conference, Boston, MA.

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By Nicole Mori, RN, MSN, APRN-BC, Research Advanced Practice Nurse

Medical mobile phone apps are changing the doctor-patient relationship by promising patients greater control over their care, lower costs, improved safety and convenience.  Patient demand for apps is increasing with an estimated 50% of smartphone users having a medical app by the end of 2017.  Acceptance among clinicians is increasing, with as many as 1/3 of doctors recommending health and wellness apps to their patients.  In mental health, mobile apps have great potential as platforms for psychoeducation, self-management and enhanced patient-provider communication, in addition to increasing access and improving care for patients in rural and underserved areas.

Even though mental health apps could be useful, the market is still dominated by low-quality products that may not follow best clinical practice guidelines.   There is little published research and reliable information to guide patients and clinicians while app store and user-generated ratings do not correlate with quality of content.  This is a rapidly-evolving market, with new products and updates arriving on a weekly basis, therefore, clinicians need a framework to evaluate products, weigh risks versus benefits and offer guidance.

A review of recent literature, including 2016 published review of commercially-available mental health apps reveals significant concerns1:

Quality, functionality and reliability:  Mobile health apps are often developed without the input of clinicians and without validation by research or reference to best practice guidelines.  Information is often generic, incomplete and in some cases, inaccurate.  Few apps cited their sources of information.  Less than 50% of mental health apps used validated symptom scales, and when these were used, developers failed to properly credit the sources.

Patient Safety:  Symptom-monitoring apps may not issue safety alerts instructing patients with high illness severity scores (such as severe suicidal ideation) to seek prompt medical evaluation.  Few apps are designed to respond to indicators of deteriorating condition.

Burden on clinicians:  Apps may generate large amounts of data that may not be clinically-relevant or useful.  There is no framework for reimbursing patients for the costs of downloads or physicians for the time spent reviewing the data.

Absent regulatory oversight:  Laws and regulations have failed to address privacy and cybersecurity risks associated with health apps.  The majority of apps marketed to patients are exempt from regulations, with only a small number subject to FDA oversight.  Security and disclosure standards are left to the discretion of developers who often lack the expertise and resources to manage protected health information.

Privacy and confidentiality:  Health app developers are generally exempt from HIPAA regulations.  Products storing sensitive patient information pose significant privacy and security risks but many still lack mechanisms to safeguard patient information such as passwords and encryption.  There are no laws against the sale of patient information to data aggregators, who may in turn sell it to third parties such as credit card and insurance companies. Few products have comprehensive privacy policies, disclosing how personal information would be stored, used and protected.   Patients assume that information entered into mobile apps is private, when this is often not the case3.

In view of these quality concerns, more research and development of evidence-based mobile apps driven by clinicians is needed in addition to legal protections to safeguard the privacy and security of patient data.  At the present time, clinicians should be aware of the uneven level of quality in the app market and be familiar with a few reliable websites patients can visit for health education and be able to offer some guidance to patients using apps that store personal health information.

Discussion should address potential security risks and unauthorized disclosure of personal data, whether the product is evidence-based and in agreement with best practice guidelines and consider risks and potential benefits.

Note:  The American Psychiatric Association has developed an App Evaluation Model to help clinicians evaluate health apps.  The guidelines provide a list of issues that must be considered in order to make an informed decision about an app 2.

Sources
1         Nicholas, J., Larsen, M. E., Proudfoot, J., & Christensen, H. (2015). Mobile Apps for Bipolar Disorder: A Systematic Review of Features and Content Quality. Journal of Medical Internet Research, 17(8), e198. http://doi.org/10.2196/jmir.4581
2         APA (Ed.). (n.d.). App Evaluation Model. Retrieved November 16, 2017, from https://www.psychiatry.org/psychiatrists/practice/mental-health-apps/app-evaluation-model
3         Sarah R. Blenner, Melanie Köllmer, Adam J. Rouse, Nadia Daneshvar, Curry Williams, Lori B. Andrews. Privacy Policies of Android Diabetes Apps and Sharing of Health Information. JAMA. 2016;315(10):1051–1052. doi:10.1001/jama.2015.19426

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By Anna I. Guerdjikova, PhD, LISW, CCRC

Director of Administrative Services, Harold C. Schott Foundation Eating Disorders Program

University of Cincinnati, Department of Psychiatry, Research Assistant Professor

We spend about one third of our lives sleeping, yet more than one third of Americans do not get enough sleep. Adults, ages 18-60, are recommended to get between seven to nine hours of sleep each night. The need for sleep varies in children and teenagers, with 13-17 years olds needing eight to ten hours per night for optimal wellness. Getting adequate sleep each night is mandatory for maintaining one’s overall mental and physical health and insufficient sleep is associated with a number of chronic diseases and conditions including diabetes, cardiovascular disease, decreased sex drive, obesity, depression and even increased thoughts of suicide and death. While its exact biological purpose remains unclear, sleep is found to be crucial for proper nerve cell communication and possibly plays a housekeeping role in removing toxins that build up in the brain when awake.

Insomnia is a sleep disorder that can make it hard to fall or to stay asleep, or causes early awakenings and inability to get back to sleep. Insomnia is common (6-10% of population struggles regularly with at least a few insomnia symptoms) but it remains under recognized and under treated. According to recently published guidelines from the American Academy of Sleep Medicine (1), psychological and behavioral interventions are effective and recommended in the treatment of chronic primary and comorbid (secondary) insomnia and should be utilized as an initial inter­vention when appropriate and when conditions permit. Cognitive behavioral therapy for insomnia (CBT-I), for example, is a structured program and an effective, non-medication treatment for chronic sleep problems. CBT-I teaches identification of thoughts and behaviors that cause or worsen sleep problems and encourages habits that promote healthy sleep. Some basic techniques used in CBT-I reinforce good sleep hygiene that can be easily implemented if one struggles with poor sleep are described below:

  • “Yes” to fixed bedtime and an awakening time through the week- establishing a consistent sleep routine and allowing for no more than 30min variation, including on weekends, will reteach the body to “get used” to falling asleep at a certain time.
  • “Yes” to sleep rituals -from relaxing stretches or breathing exercises, reading something light, meditating, or taking a hot bath to sitting calmly with a cup of caffeine-free tea, pre-sleep rituals can vary, but are needed to break the connection between all the intensive daily activities and bedtime. The sleep rituals might be equally important for enhancing healthy sleeping in both children and adults.
  • “Yes” to using a sleep diary. Tracking amount and quality of sleep can be a very helpful tool in establishing realistic goals and following progress when working on improving sleep.
  • “Yes” to comfortable bedding, moderate room temperature, limited excess noise and a well ventilated room.
  • “No” to naps: avoiding activities/ taking naps because of tiredness or poor sleep the previous night perpetuates the insomnia issues. If a nap is needed, limiting it to no longer than 30 minutes, before 3pm, is recommended.
  • “No” to caffeine 4-6 hours before bedtime, including caffeinated beverages like tea, many sodas and chocolate. Avoid heavy, spicy, or sugary foods 4-6 hours before bedtime.
  • “No” to exercise before bed. Regular exercise no less than 3h before bedtime promotes better sleep, but exercising shortly before going to bed can increase insomnia issues.
  • “No” to clock-watching and no electronics in the bedroom. Using a cell phone at night can increase depression and lower self-esteem, especially in teenagers.

On note, various smart phone apps that promote sleep hygiene via calming music (ex. Pzizz app), enhance circadian rhythm regulation (ex. Sleep Cycle app), teach meditation (ex. Long deep breathing” app), help with tracking sleep and can be used as a sleep diary (Sleep diary pro app) or even deliver mobile CBT-I support (ex. CBT-i Coach App.) can be helpful in insomnia management.

It takes up to one month before the body will naturally respond to some of the behavioral changes consistent with healthy sleep, thus patience and persistence while “relearning” sound sleep related habits are the key factors in psychological management of insomnia. Occasional restlessness at night can be normal, however if you have tried and failed to improve your sleep using some of the above mentioned strategies, you may like to consider professional help. Besides psychological interventions, an armamentarium of medications approved for insomnia is available and timely diagnosis and proper management of insomnia can significantly improve everyday wellness. Overall quality of life and life satisfaction should not be postponed, especially if symptoms are affecting daily functioning.

 

  1. http://www.aasmnet.org/Resources/ClinicalGuidelines/040515.pdf

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By Jennifer L. Shoenfelt, MD
Board Certified Child, Adolescent, and Adult Psychiatrist, Lindner Center of HOPE
Assistant Professor, University of Cincinnati, College of Medicine, Department of Psychiatry and Behavioral Neuroscience
Assistant Professor, Wright State University, Boonshoft School of Medicine, Department of Psychiatry

There are several levels of psychiatric care for children and adolescents. These are separated by the acuity of the clinical scenario, past care, and the goals of treatment. The least restrictive type of care is the outpatient setting.  Higher levels of care include intensive outpatient, partial hospitalization, inpatient hospitalization, and residential treatment centers. Residential care exists in different settings or types of environments. Residential care is often considered when a child has “failed” other less restrictive interventions, such as having repeated inpatient stays in a short span of time. Residential care is also considered when the adolescent‘s family feels unable to assure the teen’s safety or the safety of other family members in any other environment. The following outlines advantages to pursuing or choosing residential treatment options.

  1. Residential treatment programs are longer in duration than most other levels of care. These programs range from 10-14 days for a diagnostic program to 3 months or longer for long term therapeutic interventions. In residential settings, the patient is away from home, living at the facility. Often, this means that the adolescent is a significant distance away from their family. They are removed from their daily stressors and the environment that is likely contributing to their current mental, physical and behavioral state.
  2. Residential treatment affords diagnostic clarification which includes in-depth testing, observational analysis, formalized testing, concentrated, in –depth, historical information gathering, and observation of family dynamics and social interaction. Professionals in multiple areas of expertise interact with the patient and then collectively formulate a differential diagnosis over time. Most programs are staffed with physicians, psychologists, social workers, teachers, chemical dependency counselors, nurses, family therapists, dieticians, and other specialty area professionals.
  3. Residential programs offer a vast array of therapies and approaches that are not commonly available in other treatment programs. Utilizing a combination of therapies or approaches may be what the adolescent needs to achieve success they could not find in other limited programming. For instance, a partial hospitalization program may be able to offer, dialectical behavioral therapy, group therapy, and recreational therapy among their regimen of daily activities. However, a residential program may be able to combine this with family systems therapy, cognitive behavioral therapy, acceptance and commitment therapy, eye movement desensitization and reprocessing, yoga, equine therapy, holistic approaches, martial arts, community service, academic planning and testing, etc. Of course, these do not come without a significant price.
  4. Residential programming allows the adolescent time to practice and strengthen skills they are learning. Many programs are based on the adolescent achieving certain levels of competency and progressing step-wise through a customized program that encourages improved self-esteem, acknowledgement of accomplishments, recognition of effort and gentle re-integration to their family dynamic.
  5. Educational planning if often another advantage to residential treatment. Adolescents can undergo detailed educational and neuropsychological testing. While in treatment, a plan can be devised and implemented to address any deficits or challenges the teen is facing. The educational team can make recommendations for placement and interventions for post discharge.
  6. Residential treatment comes in many different settings. There are programs focused on wilderness, arts, education, addictions and many others. While the teen is being treated in these novel environments, family members at home can be focusing on improving the home setting and engaging in their own specific therapies to prepare for re-integration of the child. This break for the family has its own healing effect and enables other family members to focus on their issues and concerns while their family member is away. Likewise, the adolescent may find new interests and strengths to build upon after discharge.
  7. Although residential treatment is costly and sometimes not covered by commercial insurance, in the long-term it can be cost effective by saving the family from multiple hospitalizations, partial hospitalization or expensive intensive outpatient care.
  8. Lastly, residential treatment is often more successful in addressing or treating co-occurring disorders. The comprehensive nature of residential and the duration of treatment allow the team to focus on all aspects of the clinical picture and to thoroughly attack each facet of the adolescent’s needs.

Overall, there are many advantages to residential care, though it is often the least used avenue in adolescent psychiatry. The drawbacks of cost and availability often preclude the neediest of adolescents from obtaining the comprehensive treatment benefits that could help them most.