Category: Mood Disorder

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By Danielle Johnson, MD, FAPA
Chief Medical Officer, Lindner Center of Hope

Mood disorders have distinct disturbances in emotions. Low moods are called depression and high moods are called hypomania or mania. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) categorizes mood disorders into bipolar disorders and depressive disorders. Mood disorders include major depressive disorder, bipolar I and bipolar II disorder, disruptive mood dysregulation disorder, premenstrual dysphoric disorder, persistent depressive disorder, and cyclothymic disorder. In the U.S., almost 1 in 10 (9.7%) adults experienced any mood disorder in the past year, with past year prevalence of any mood disorder being higher for females (11.6%) than for males (7.7%). More than 1 in 5 (21.4%) U.S. adults will experience any mood disorder in their lifetime. Mood disorders are common in children and adolescents with an estimated 15% having any mood disorder. Major depressive disorder and bipolar disorder are the most common mood disorders with 8.3% of all U.S. adults experiencing at least one major depressive episode in the past year and 2.8% of U.S. adults having bipolar disorder in the past year.

When people experience symptoms of a mood disorder that do not look like major depression or bipolar disorder this can lead to a delay in diagnosis and treatment as they might have difficulty articulating their symptoms and healthcare professionals might not ask questions about other disorders. Although other mood disorders are less common and less severe, they still impact quality of life and functioning.

Persistent depressive disorder (dysthymia) was added to DSM-5 in 2013, combining some criteria of dysthymic disorder and chronic major depressive disorder. With PDD, depressed mood occurs for most of the day, for more days than not, for at least two years (one year for children and adolescents). During a two-year period (one year for children or adolescents), a person has never been without symptoms for more than two months at a time. A major depressive episode can occur before PDD, or people can experience “double depression” when major depressive episodes occur during PDD.

Symptoms can include poor appetite or overeating; insomnia or hypersomnia; low energy or fatigue; low self-esteem; poor concentration or difficulty making decisions; or feelings of hopelessness. PDD is associated with greater childhood adversity and maltreatment, childhood loss of a parent, earlier onset of depression, and higher rates of chronic depression in relatives. People with PDD also experience a higher number of traumatic events during their lifetime. The 12-month prevalence ranges from 0.5% to 1.5%.

Cyclothymic disorder consists of episodes of hypomanic and depressive symptoms that do not meet the full criteria for bipolar or major depressive disorder. The lifetime prevalence is approximately 0.4%-1%. Symptoms last two years, for more days than not with stability of mood for no longer than two consecutive months. Symptoms of depression can include depressed mood, irritability, hopelessness, helplessness, insomnia, fatigue, anhedonia, avolition, negativity of affect, and suicidal ideation. Hypomanic symptoms can include impulsivity, grandiosity, racing thoughts, increased sociability, excess physical activity, and increased speech production.

People with cyclothymia may experience emotional lability, hypersensitivity, recurrent interpersonal altercations, incidents of self-harming, episodes of excessive gambling, reckless sexual activity, multiple divorces, legal or financial problems, and recurrent job loss. The chronic and pervasive nature of cyclothymic disorder can lead to misdiagnosis with cluster B personality disorders.

There are no FDA-approved medications for PDD or cyclothymic disorder. Your psychiatrist or psychiatric nurse practitioner will take a thorough history including past medical history, previous medical trials, and other psychiatric diagnoses and work with you to develop a treatment plan and choose appropriate medications and psychotherapy to treat depressive and/or hypomanic symptoms.

Sekhon S, Gupta V. Mood Disorder. [Updated 2023 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558911/

https://www.nimh.nih.gov/health/statistics/any-mood-disorder

https://www.nimh.nih.gov/health/statistics/major-depression

https://www.nimh.nih.gov/health/statistics/bipolar-disorder

Patel RK, Aslam SP, Rose GM. Persistent Depressive Disorder. [Updated 2024 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK541052/

Patel RK, Aslam SP, Rose GM. Persistent Depressive Disorder. [Updated 2024 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK541052/

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Kaila Busken, Lindner Center of HOPE, Licensed Independent Social Worker

One moment you are bursting at the seams with overwhelming joy. Every fiber of your being is filled with love for this tiny human being in your arms. Looking in your baby’s eyes, you feel like you have found your life’s purpose. And still, motherhood is really hard. New motherhood is sitting in the messy middle of seemingly opposite feelings. You can feel a mixed bag of emotions: sad and happy, overwhelmed, and peaceful, grief and joy, lost and found.

The transition to motherhood and its ambivalence has its own name: matrescence (pronounced like adolescence). The term was first developed by medical anthropologist Dana Raphael in 1973. This term is used to describe the bio-psycho-social- spiritual change that occurs when a woman makes the transition to motherhood. Like in adolescence, matrescence is a physical, hormonal, and emotional change all happening at the same time. Matrescence recognizes the large shift in identity that occurs when a woman becomes a mother and helps to normalize what it feels like to be in the middle of a whirlwind of emotions. Motherhood is a magical metamorphosis, because once you have a baby, nothing will ever be the same. And that is both beautiful and sad.

Around 15-20% of women who birth a child will experience postpartum mood disorders such as depression and anxiety. But matrescence is a normal part of motherhood and it is normal to feel ambivalence in this season of life.

Here are some helpful tips for coping in this new season of life:

1. Let go of expectations.
From the time a woman decides she is going to have children she hears an influx of information about what it means to be a mom and how to care for her baby. One of the biggest things a mom may hear is “you don’t have time for yourself anymore.” An important thing to remember is that you are a person worth caring for. You deserve to eat. You deserve a hot shower. You deserve to hydrate yourself. And you deserve love. You may even have a “Pinterest” perfect image in your head of what motherhood would be like. You may have pictured a blissful bubble in which you only feel complete happiness, but it is important to allow yourself to embrace the messiness and imperfection that is motherhood.

2.  Build your support system.
Just as a baby was born, you as a mother were born too. It is okay to ask for help and it is important to find a group of people who will help care for you. Look for people who will help support you emotionally while you adapt to your new role. Also look for people who will provide practical support like doing that pile of dirty dishes in your sink or the endless pile of laundry that babies create. Babies are tiny but they certainly require a village.

3.  Practice self-compassion.
Being a new mother is difficult. Suddenly this new little life is depending on you day and night and it can be exhausting.  It can be easy in this new vulnerable state to be harsh and self-critical. During this time, it is especially important to practice self-compassion and remind ourselves of our own worth. It can be easy to believe that you are a “bad” mother and that you are not providing what your baby needs. An important self-compassionate reminder is that “you are the best mother for your baby”. The goal is not for you to be a perfect mother but rather to be a “good enough” mother and embrace all the imperfection that comes with raising a baby. Perfection in motherhood is not possible and practicing self-compassion can help in remaining resilient in the face of this new role.

4.  Embrace the ambivalence.
Motherhood is embracing so much of the messy middle between seemingly opposing emotions. It can be uncomfortable to be in this place, where you want to spend every moment with your precious newborn and to crave the independence and space you had prior to having a baby. Motherhood is about the “both/and”, knowing that good and bad can exist in the same place. It is possible for you to embrace them both at the same time. You can love your baby with every fiber of your being and miss a time when you were able to sleep through the night or drink a hot cup of coffee.

5.  Allow yourself to grieve.
It is okay to grieve in this new phase of life. We tend to believe that grief is only reserved for death, but we can grieve many things in this new phase of motherhood. You may grieve your old life, previous relationship dynamics, your body and how it may have worked before, your time, your envisioned birth plan, your envisioned feeding plan, or your expectation of what you thought motherhood would be like. Allowing yourself to feel the sadness in some of these losses will help you to move on and embrace your new role as a mother.

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By Peter White, M.A., LPCC, LICDC, Lindner Center of HOPE Outpatient Therapist

The problem during Bipolar Mood Disorders is a pattern of swings of the essential elements of mood between the two poles, like the North Pole and South Pole, of Mania and Depression. These swings are not moodiness, which are swings of mood throughout a day. A Bipolar swing is a distinct period of at least one week when the full spectrum of mood elements exhibits depressive and/or manic elements.

Although thought of as a subjective experience, mood deeply influences three areas. First is metabolism – sleep, appetite, libido and energy levels. Second, mood influences both motivation as well as the ability to experience pleasure and/or a sense of accomplishment. Thirdly, mood deeply influences interpretations within thoughts from positive to neutral to negative.

So, we can think of this first spectrum of mood disorder along an axis of depression to neutral to manic. Therefore, a depressed mood will depress metabolism. A person will have difficulty with sleep through either excessive or inadequate or disrupted sleep, loss of appetite or excessive eating despite disrupted appetite, loss of libido as well as loss of energy. Depression will hinder motivation making it difficult to experience the drive to initiate activities as well as hinder pleasure or the reward of activity. This is a very difficult cycle when it is hard to get active in the day compounded by not finding any pleasure or reward in the day’s activities. Lastly, depression will darken the flow of thoughts adding many themes of hopelessness, helplessness, worthlessness and guilt into our thought process.

Conversely, mania will elevate the same essentials. It will increase energy levels often in the face of declining sleep hours. It will increase libido, increase excessive and/or absence of appetite. It will increase motivation often leading to excessive engagement of plans or activities and will create a compounding loop of all activity feeling especially pleasurable or rewarding. Again, conversely is will paint thinking with elevated judgements of specialness, invulnerability, and inevitable positive outcomes.

The second spectrum of mood disorders, like most other behavioral health problems, is along the spectrum of severity – mild to moderate to severe. If you combine this spectrum of severity along with the first spectrum of depressive to manic, we see how varied and individualized any person’s experience with Bipolar Mood disorders can be.  Most people can relate to some degree of depression during periods of their life with perhaps a few weeks or month of low energy, noticing that they are not getting the same rewards in their regular activity as well as perhaps noticing they are thinking unusually negatively about themselves and their outlook on life. We might call this a mild, brief depressive episode. But the reality is that depression is one of the most disruptive and costly of all health conditions as recognized by the World Health Organization. This mean that depression is often moderate or severe to very severe and can disrupt functioning on every level for weeks to months if not years. A severe depression can make it difficult to get out or bed for days on end both from collapsed energy and motivation. It can destroy the pleasure and rewards of living so that all activity feels like a painful chore at best. Finally, it can turn thoughts dangerously dark with so much hopelessness, helplessness and worthless that suicidal thinking emerges nearly with a sense of relief.

Again conversely, though experienced less often by most people, Manic Episodes can present with mild, moderate, severe and very severe intensity. During a sever episode, a person with manic symptoms is often sleeping little but maintaining very high levels of energy. They are often talking very quickly and sometimes laughing excessively and outside the context of humorous things. Given the very high levels of motivation and the reinforcement of pleasure in all activities, they often initiate an excessive number of activities – starting multiple projects with little awareness of the ability to balance or complete them. They frequently initiate conversations or relationship in an open or disinhibited style very unusual for to their character. With elevated thought patterns, they might believe they have a unique or special purpose, and they are convinced that all their activities will be successful and rewarding. Give the excessive energy, motivation, pleasure and elevated sense of self and success, people in manic states will often engage in behavior patterns much riskier than typical – spending money well beyond their mean, unusually disinhibited sexual decision, reckless driving, shop lifting.

I hope it’s useful to review the way mood symptoms fluctuate along these two spectrums, because like all health care conditions, we are best off when we accurately identify what these behaviors are – symptoms. Mood symptoms are not moral challenges, personality traits or unconsciously desired behaviors. Mood symptoms are symptoms, and fortunately, there are many very effective treatments for all symptoms along both spectrums. Please know if you or a loved one or a client is experiencing any degree of Bipolar mood problems, there will be many ways to help and cope, and experience the satisfaction of effectively treating a behavioral health care condition.

 

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Danielle Johnson, MD, FAPA
Lindner Center of HOPE/Chief Medical Officer
University of Cincinnati College of Medicine Adjunct Assistant Professor of Psychiatry

Medications are undoubtedly an important tool in the treatment of mental illnesses. Expert application of psychopharmacology is a game changer in improving symptoms of mental illness and helping individuals achieve a manageable baseline. Complex co-morbidities and severe mental illness make prescribing even more complex.

Psychiatric medications can stabilize symptoms and prevent relapse. They work by affecting neurotransmitters in the brain. Serotonin is involved in mood, appetite, sensory perception, and pain pathways. Norepinephrine is part of the fight-or-flight response and regulates blood pressure and calmness. Dopamine produces feelings of pleasure when released by the brain reward system.

One in ten Americans takes an antidepressant, including almost one in four women in their 40s and 50s. Women are twice as likely to develop depression as men.

Selective Serotonin Reuptake Inhibitors (SSRIs) Side Effects

Selective serotonin reuptake inhibitors (SSRIs) increase levels of serotonin. Fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro) treat depression, anxiety disorders, premenstrual dysphoric disorder, eating disorders, and hot flashes. Potential side effects include jitteriness, nausea, diarrhea, insomnia, sedation, headaches, weight gain, and sexual dysfunction.

Zoloft Side Effects in Women

Zoloft, also known by its generic name sertraline, is an antidepressant medication that can cause a range of side effects in women. Some of the common side effects of Zoloft include nausea, diarrhea, headache, dizziness, dry mouth, drowsiness, and difficulty sleeping. Women may also experience sexual side effects such as decreased libido, difficulty reaching orgasm, and erectile dysfunction. In some cases, Zoloft may cause weight gain or weight loss, and it can also affect blood pressure and heart rate. Rare but serious side effects of Zoloft in women may include seizures, serotonin syndrome, and suicidal thoughts or behavior.

Prozac Side Effects in Women

Prozac, also known by its generic name fluoxetine, is an antidepressant medication that can cause a range of side effects in women. Some of the common side effects of Prozac include nausea, diarrhea, headache, dizziness, dry mouth, drowsiness, and difficulty sleeping. Women may also experience sexual side effects such as decreased libido and difficulty reaching orgasm. Prozac may also cause weight gain or weight loss, and it can affect blood pressure and heart rate. Rare but serious side effects of Prozac in women may include serotonin syndrome, suicidal thoughts or behavior, and seizures.

Lexapro Side Effects in Women

Lexapro, also known by its generic name escitalopram, is an antidepressant medication that can cause a range of side effects in women. Some of the common side effects of Lexapro include nausea, diarrhea, headache, dizziness, dry mouth, drowsiness, and difficulty sleeping. Women may also experience sexual side effects such as decreased libido and difficulty reaching orgasm. Lexapro may also cause weight gain or weight loss, and it can affect blood pressure and heart rate. Rare but serious side effects of Lexapro in women may include serotonin syndrome, suicidal thoughts or behavior, and seizures.

Serotonin-norepinephrine Reuptake Inhibitors (SNRIs) Side Effects

Serotonin-norepinephrine reuptake inhibitors (SNRIs) increase levels of serotonin and norepinephrine. Venlafaxine (Effexor), duloxetine (Cymbalta), and desvenlafaxine (Pristiq) are used to treat depression, anxiety disorders, diabetic neuropathy, chronic pain, and fibromyalgia. Potential side effects include nausea, dry mouth, sweating, headache, decreased appetite, insomnia, increased blood pressure, and sexual dysfunction.

Tricyclic Antidepressants Side Effects

Tricyclic antidepressants (TCAs) also increase serotonin and norepinephrine. Amitriptyline (Elavil), clomipramine (Anafranil), desipramine (Norpramin), nortriptyline (Pamelor), doxepin (Sinequan), trimipramine (Surmontil), protriptyline (Vivactil), and imipramine (Tofranil) are used to treat depression, anxiety disorders, chronic pain, irritable bowel syndrome, migraines, and insomnia. Possible side effects include sedation, forgetfulness, dry mouth, dry skin, constipation, blurred vision, difficulty urinating, dizziness, weight gain, sexual dysfunction, increased seizure risk, and cardiac complications.

Other Antidepressants Side Effects

Wellbutrin Side Effects in Women

Bupropion (Wellbutrin) increases levels of dopamine and norepinephrine. It treats depression, seasonal affective disorder, ADHD, and can be used for smoking cessation. It can also augment other antidepressants. Potential side effects include anxiety, dry mouth, insomnia, and tremor. It can lower the seizure threshold. There are minimal to no sexual side effects or weight gain.

Trazodone (Desyrel, Oleptro) affects serotonin and mirtazapine (Remeron) affects serotonin and norepinephrine. They are both used for depression and sleep. Mirtazapine has minimal sexual side effects.

Monoamine oxidase inhibitors (MAOIs) increase serotonin, norepinephrine, and dopamine. Isocarboxazid (Marplan), phenelzine (Nardil), selegiline (Emsam), tranylcypromine (Parnate), and moclobemide are associated with more serious side effects than other antidepressants. There are dietary restrictions and numerous drug interactions. MAOIs are often used after other antidepressant classes have been tried. Other antidepressants need to be discontinued for a period of time prior to starting an MAOI.

Newer antidepressants include Viibryd (vilazodone) which affects serotonin, Fetzima (levomilnacipran) which affects serotonin and norepinephrine, and Brintellix (vortioxetine) which affects serotonin. Brintellix and Viibryd have mechanisms of action that make them unique from SSRIs. Viibryd is less likely to cause sexual side effects.

Excess serotonin can accumulate when antidepressants are used with other medications that effect serotonin (other antidepressants, triptans for migraines, certain muscle relaxers, certain pain medications, certain antinausea medications, dextromethorphan, St. John’s Wort, tryptophan, stimulants, LSD, cocaine, ecstasy, etc.) Symptoms of serotonin syndrome include anxiety, agitation, restlessness, easy startling, delirium, increased heart rate, increased blood pressure, increased temperature, profuse sweating, shivering, vomiting, diarrhea, tremor, and muscle rigidity or twitching. Life threatening symptoms include high fever, seizures, irregular heartbeat, and unconsciousness.

Estrogen Levels With Antidepressants in Females

Varying estrogen levels during the menstrual cycle, pregnancy, postpartum, perimenopause, and menopause raise issues with antidepressants and depression that are unique to women. Estrogen increases serotonin, so a decrease in estrogen at certain times in a woman’s reproductive life cycle can reduce serotonin levels and lead to symptoms of depression. Hormonal contraception and hormone replacement therapy can reduce or increase depressive symptoms; an increase in symptoms may be more likely in women who already had major depressive disorder. During pregnancy, antidepressants have a potential risk to the developing baby but there are also risks of untreated depression on the baby’s development. With breastfeeding, some antidepressants pass minimally into breast milk and may not affect the baby. The benefits of breastfeeding may outweigh the risks of taking these medications.   Antidepressant sexual side effects in women are vaginal dryness, decreased genital sensations, decreased libido, and difficulty achieving orgasm. Women should communicate with their psychiatrist and/or OB/GYN to discuss the risks and benefits of medication use vs. untreated illness during pregnancy and breastfeeding; the use of hormonal treatments to regulate symptoms associated with menses and menopause; and the treatment of sexual dysfunction caused by antidepressants.

It has been observed that some antidepressants can affect estrogen levels in women. The exact mechanisms behind these effects are not fully understood, but it is thought to be related to the interactions between the medication and the hypothalamic-pituitary-gonadal (HPG) axis, which is responsible for regulating estrogen production. It is important for women to discuss any potential effects of antidepressants on estrogen levels with their healthcare provider, especially if they have a history of hormonal imbalances or are taking hormonal therapies.

It is important for women to discuss any potential side effects with their healthcare provider before starting any depression medication.

Lindner Center of HOPE’s Approach

Lindner Center of HOPE’s residential services employ full-time psychiatrists with expertise in psychopharmacology. These prescribing physicians are designated members of each residential client’s treatment team. Medication management within Lindner Center of HOPE’s residential programs is also supported by 24/7 psychiatry and nursing staff, onsite pharmacy and an innovative Research Institute.

In some cases, patients over the course of treatment for mental illnesses accumulate many prescriptions. In cases like this, Lindner Center of HOPE’s residential units can offer a safe environment for medication assessment and adjustment. While the client participates in appropriate evaluation and treatment, their psychiatrist can also work with them on reaching rational polypharmacy — in other words, medication optimization.

For patients with more severe, treatment-resistant mental illness, Lindner Center’s psychiatrists can implement the most complicated, and often hard to use, treatments, in a safe environment, while under their observation.

If medication adjustments result in decompensation on the residential units, a patient can be temporarily stepped up to an acute inpatient unit on the same campus.

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By Danielle Beltz, MSN, PMHNP-BC, Psychiatric Nurse Practitioner, Lindner Center of HOPE

Pregnancy and childbirth can be one of the most rewarding and fulfilling things a woman can do in her
lifetime but can hand in hand be one of most challenging and emotionally taxing times.
A female goes through not only physical changes throughout pregnancy but also hormonal, emotional,
and psychological changes. In addition, a pregnancy can bring stress and emotional hardship to their
interpersonal dynamics.

A lot of new moms experience postpartum “baby blues” after giving birth which differentiates from
postpartum depression. Symptoms usually include sadness, irritability, moodiness, crying spells, and
decreased concentration. Baby blues usually begin within 2 to 35 days after childbirth and can persist up
to 2 weeks. When these symptoms last longer than 2 weeks this is when the mother should consider talking
to a healthcare provider.

About one in seven women develop postpartum depression. It most commonly occurs 6 weeks after delivery but can begin prior to
delivery as well. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) a major depressive episode with the onset
of pregnancy or within 4 weeks of delivery is considered postpartum depression. Five of the nine symptoms must be present nearly every
day for at least two weeks and constitute a change from previous functioning to be diagnosed. Depression or loss of interest in addition
to the following symptoms must be present:

• Depressed mood (subjective or observed) most of the day
• Diminished interest or pleasure in all or most activities
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Feelings of worthlessness or guilt
• Loss of energy or fatigue
• Recurrent suicidal ideation, thoughts of death or attempts
• Diminished concentration or indecisiveness
• Change in weight or appetite (5% weight change over 1 month)

Fifty percent of postpartum major depressive episodes begin before
delivery so collectively these episodes are described as peripartum
episodes. Mothers with peripartum major depressive episodes commonly have severe anxiety and panic attacks.

The exact etiology of postpartum depression is unknown. Several factors have been reported to contribute to the development of
postpartum depression. The physical and hormonal fluctuations resulting from pregnancy influence postpartum women to develop
depression when stressful and emotional events coincide with childbirth. Some of these factors include the stress of motherhood, difficult
labor, poor financial and family support, and harmful health outcomes of childbirth. Lower socioeconomic demographic, personal or
family history of depression, anxiety, or postpartum depression, PMDD, complications in pregnancy and birth, and mothers who have
gone through infertility treatments have also all been suggested to be strong contributors.

Postpartum depression not only affects the mother’s health but also the relationship the mother has with her infant and that child’s
development. Studies have shown that children are at a greater probability of developing behavioral, cognitive, and interpersonal problems
whose mothers have postpartum depression. It can also lead to inability to breastfeed and marital conflict.

Postpartum psychosis is another severe kind of depression but is not the same thing as postpartum depression. Around 1 in 500 or 1 in
1,000 women has postpartum psychosis after delivering a baby. It commonly starts the first 2 weeks after giving birth. Women who are
also diagnosed with bipolar disorder or schizoaffective disorder are more prone to have postpartum psychosis than women who are not
diagnosed with other mental health conditions.

Postpartum psychosis is considered a psychiatric emergency with a capacity of suicide and infanticidal threat. Some symptoms include
delusions, hallucinations, unusual behavior, paranoia, and sleep disturbances. If postpartum psychosis is suspected help should be sought
immediately.

Psychotherapy and antidepressant medications are the first line treatments for postpartum depression. Psychotherapy is considered first
line for women with mild to moderate depression or if they have concerns of starting a medication while breastfeeding. For moderate to
severe depression therapy and antidepressant medications are recommended. The most common medication for postpartum depression is
an SSRI or selective serotonin reuptake inhibitor. Once an efficacious dose is reached, treatment should persist for 6-12 months to prevent
relapse of symptoms. Risk versus benefits of treated versus untreated depression while breastfeeding or pregnant should be discussed.
Transcranial Magnetic Stimulation (TMS) is an alternate therapy that can be used for women who have concerns about their child being
exposed to a medication. Although, the risk of taking an SSRI while breastfeeding is relatively low. ECT is another option for women with
severe postpartum depression who do not respond to traditional treatment. It can be particularly helpful with psychotic depression.

Zurzuvae (zuranolone) is the first oral medication approved by the FDA specifically for the treatment of postpartum depression in adults.
Until August 2023, treatment for PPD was only available as an IV (Brexanolone) and was only available at certified healthcare facilities.

People with depression especially new mothers and postpartum mothers may not identify or accept that they’re depressed. They also
may be unaware of the signs and symptoms of depression. If you are questioning whether a friend or family member has postpartum
depression or is developing signs of postpartum psychosis, assist them in pursuing medical treatment and recognize that help is accessible.
References:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Commissioner, O. of the. (n.d.). FDA approves first oral treatment for postpartum depression. U.S. Food and Drug Administration. https://www.fda.
gov/news-events/press-announcements/fda-approves-first-oral-treatment-postpartum-depression#:~:text=Today%2C%20the%20U.S.%20Food%20
and,the%20later%20stages%20of%20pregnancy
Guo, L. , Zhang, J. , Mu, L. & Ye, Z. (2020). Preventing Postpartum Depression With Mindful Self-Compassion Intervention. The Journal of Nervous and
Mental Disease, 208 (2), 101-107. doi: 10.1097/NMD.0000000000001096.
Mayo Foundation for Medical Education and Research. (2023, April 14). “I’m happy to be a new mom. but why am I feeling
so sad?” Mayo Clinic. https://mcpress.mayoclinic.org/mental-health/im-happy-to-be-a-new-mom-but-why-am-i-feeling-sosad/?
mc_id=global&utm_source=webpage&utm_medium=l&utm_content=epsmentalhealth&utm_
campaign=mayoclinic&geo=global&placementsite=enterprise&invsrc=other&cauid=177193
Miller, L. J. (2002). Postpartum depression. JAMA : The Journal of the American Medical Association, 287(6), 762-765. https://doi.org/10.1001/jama.287.6.762
Mughal S, Azhar Y, Siddiqui W. Postpartum Depression. [Updated 2022 Oct 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023
Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519070/
Postpartum depression. March of Dimes. (n.d.). https://www.marchofdimes.org/find-support/topics/postpartum/postpartum-depression?gad_
source=1&gclid=EAIaIQobChMIqKLemfTfggMVq0VyCh3ouwGDEAAYBCAAEgKxjPD_BwE
Silverman, M. E., Reichenberg, A., Savitz, D. A., Cnattingius, S., Lichtenstein, P., Hultman, C. M., Larsson, H., & Sandin, S. (2017). The risk factors for postpartum
depression: A population-based study. Depression and Anxiety, 34(2), 178–187. https://doi-org.uc.idm.oclc.org/10.1002/da.22597
Stewart, D. E., & Vigod, S. (2016). Postpartum depression. The New England Journal of Medicine, 375(22), 2177-2186. https://doi.org/10.1056/NEJMcp1607649

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People often wonder what “psychological evaluation” is, what it is used for, and how it can help.

This blog post is written by Jennifer L. Farley, PsyD, Lindner Center of HOPE, Staff Psychologist. We’ll dive into the varying answers to those questions, learn more about referral questions, testing settings and why psychological evaluation is important.

What is psychological assessment?

Psychological assessment is the process of evaluating an individual’s mental health and behavioral functioning through the use of standardized tests, observations, and other methods. It is typically conducted by a mental health professional, such as a psychologist or psychiatric nurse practitioner, and is used to diagnose mental health conditions, determine appropriate treatment options, and measure progress in treatment.

Most broadly, psychological evaluation involves an objective manner in which one’s “psychological functioning” is assessed. An “objective” way of testing involves comparing one’s responses to standardized measures (in which every respondent is given the same measure or responds to tests that are administered in the same way) to normative group (usually based on the person’s age) to see how well they are functioning compared to their age peers. (Think of the standardized testing that students complete in school or with college preparatory examinations such as the ACT or SAT.) “Psychological functioning” is also a broad label, since many different abilities are assumed within this. More specifically, when people refer to “psychological functioning,” it helps to understand if they are referring to intellectual abilities and some other cognitive skills (such as attention), emotional functioning, and/or personality characteristics.

Types of psychological evaluation and what is included in testing?

There are different types of evaluations that can be pursued, depending on the purpose of the testing.

Psychoeducational evaluation

First, a psychoeducational evaluation is one in which the patient typically undergoes testing for a learning-based disorder. Often, this testing centers around intellectual testing and academic achievement measures (such as tasks involving math, reading, and written language). Comparisons are then made between one’s intellectual abilities and his or her academic skills; if there is a large discrepancy between one’s intellectual skills and academic skills in any particular area (in which the academic ability is significantly lower than what would be expected for the patient’s intellectual abilities), this helps form the basis of diagnosing a specific learning disorder.

Psychoeducational evaluations are often performed within schools when there is a concern about a child having a cognitive or learning-based disorder that is interfering with their learning. These types of evaluations are also often done “privately,” meaning that individuals pursue these evaluations in a clinical (i.e., not academic) setting with a licensed psychologist. Often, other measures (such as classroom observations or parent and teacher questionnaires of observations of behaviors or emotional functioning) may be included in these types of evaluations. Though school psychologists cannot diagnose specific disorders (such as Attention Deficit/Hyperactivity Disorder), what matters most is that regardless of the testing setting, the findings help guide interventions and/or accommodations that can be implemented into a 504 Plan or into a more formal, Individualized Education Plan (IEP).

Emotional and/or personality functioning evaluation

Some may seek evaluations to help understand a patient’s emotional and/or personality functioning, especially because the testing helps learn about the individual in a more comprehensive way in a shorter amount of time (instead of over several therapy sessions). Results from these measures can help with recommendations for mental health treatment, such as with use of medications and/or for therapy (such as which strategies can be most helpful to teach the patient). Findings can also help guide other referrals, such as to other specialists (such as a psychiatrist or a neurologist). Depending on the age of the patient, these measures may include questionnaires that are only completed by the patient themselves (this is particularly the case among adult patients).

Assessments in children

When assessing a child, parents often complete questionnaires that ask about what they observe (behaviorally and emotionally) in their child. When the patient is an adolescent, it is more common that a combination of emotional and personality questionnaires are included that involve the adolescent responding to self-report measures and the parent(s) or primary caregiver(s) responding to their own measures involving observations of the child. Parent or caregiver responses are particularly helpful (and often necessary) when assessing children and adolescents, as most children and many adolescents lack enough insight or awareness into their difficulties, and often parents are the ones to observe problems or concerns first. These evaluations are conducted in clinical settings such as outpatient practices and sometimes inpatient hospitals in which obtaining such information is necessary to guide a clinician’s diagnostic impressions and treatment recommendations.

Neuropsychological evaluation

Another type of psychological assessment is a neuropsychological evaluation that helps measure more detailed aspects of cognitive functioning, such as executive functioning abilities (i.e., one’s ability to plan, organize, and inhibit cognitive, emotional, and behavioral responses), attention, learning, memory, and even motor coordination and/or strength. Individuals who specialize in these types of assessments are required to have completed more thorough post-doctoral training. Often times, referrals may come from physicians or therapists who are concerned about a patient’s functioning in these areas, whether it be related to a neurological condition (such as a seizure disorder, a head injury, or dementia) or to a psychiatric disorder (in which it is common for mood states or anxiety to negatively affect one’s cognitive functioning). Neuropsychological assessments are most often conducted in medical-based settings. Yet, they can also be conducted when a more comprehensive evaluation is sought after (such as in psychiatric residential settings). When this is the case, a neuropsychological assessment battery can capture one’s functioning more globally with measures of intelligence, academic achievement, neurocognitive abilities, and personality and emotional functioning.

Why is psychological testing important?

There are several reasons why psychological testing is important:

  • Psychological assessment is important because it can help identify mental health conditions and other issues that may be impacting an individual’s thoughts, feelings, and behaviors.
  • It can provide a more complete understanding of an individual’s strengths and weaknesses, which can be useful in making decisions about treatment and support.
  • Psychological assessment can help diagnose conditions such as depression, anxiety, bipolar disorder, and attention deficit hyperactivity disorder (ADHD), among others.
  • It can also be used to assess an individual’s cognitive abilities, such as memory, problem-solving skills, and intellectual functioning.
  • Psychological assessment can help identify the underlying causes of an individual’s symptoms and provide a basis for developing a treatment plan that is tailored to their needs.
  • It can also be used to monitor an individual’s progress in treatment and make any necessary adjustments.
  • Psychological assessment can help individuals and their families better understand the nature of their struggles and the options available for addressing them.

A final consideration for any kind of psychological assessment is this: while testing is often sought after to diagnose a condition or to understand one’s possible difficulties in any area of functioning, it is also important to learn what someone’s strengths are. Everyone has strengths and weaknesses relative to their own abilities; it is helpful to inform individuals from testing of what their strengths are and how to use these to compensate for any documented weaknesses they may have. Information helps empower people to develop and grow, and results obtained from psychological assessment can help people be more informed as to how to proceed with utilizing their cognitive and/or emotional strengths to help improve their mental health overall.

There is HOPE. For help, call 1-888-537-4229.

If you or a loved one is suffering from mental illness or addiction, contact us for information on our residential treatment programs for mental health in adults.

Read more about Lindner Center of HOPE’s assessment programs.

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Radically Open Dialectical Behavioral Therapy (RO DBT) is a treatment developed by Thomas Lynch for those who develop disorders associated with an overcontrolled (OC) personality.  OC individuals are often described as reserved and cautious, not very expressive with their emotions, and great at delaying gratification. OC individuals tend to be strong rule followers and feel a high sense of obligation in their lives (i.e., go to a birthday party because they feel they have to rather than wanting to do so). However, at times, they may experience “emotional leakage,” or emotionally breaking down once they are in private after holding it all together all day in public. An OC personality can be really helpful in some ways. These are the people that get their work done no matter what, show up to work on time every day, work through all the nitty, gritty details of a project, and follow through on their word. They can be very organized and methodical, and they are great at planning for long-term gains (i.e., saving to buy a house). However, they can be rigid and inflexible at time (i.e., get very upset if a restaurant lost a dinner reservation and struggle with figuring out where else to go to eat) and may have difficulty receiving feedback. Patients that may benefit from this treatment include those with chronic depression and anxiety, autism spectrum disorders, Obsessive-Compulsive Personality Disorder, and Anorexia Nervosa.

Radically Open Dialectical Behavior Therapy for Overcontrolled Personality

The biosocial theory behind RO DBT explains that OC individuals have brains that zoom in on the negative or threatening aspects of a situation before seeing the positives. This predisposition interacts with being raised in an environment that encourages or praises high levels of self-control in one’s life (i.e., doing homework without one’s parents needing to remind them to do so), performing at a high level (i.e., getting good grades, doing well in sports, receiving accolades), and avoiding making errors. These individuals end up avoiding uncertain situations, hold back their emotions out of fear that others may see them as being out of control, and become guarded in social situations, appearing to others as withdrawn.  Their lack of vulnerability and difficulty expressing what they are really feeling leads others to struggle to relate to them, so they end up feeling lonely and isolated.  Thus, RO DBT operates under the assumption that increasing connectedness to others can improve psychological functioning, thus targeting emotional expression. Additionally, RO DBT encourages being open to hearing other points of view so that one can learn as well as learning to be flexible in responding to varying situations.

Thomas Lynch describes that the five main behavioral targets of RO DBT include 1) being socially distant or reserved, 2) inflexible, rule-governed behaviors, 3) focusing on the details rather than the big picture of a situation and being overly cautious, 4) demonstrating emotional expressions that are inconsistent with how one is really feeling, and 5) comparing oneself to others, leading to resentment and envy. In RO DBT, patients work with their therapists on identifying personal goals consistent with these behavioral targets, connecting these goals to the problems that brought them into treatment. For instance, a patient may bring up that he/she would like to deepen relationships with others, be more flexible when things don’t go according to plan, or let go of past grudges to help fight depression and anxiety.

Radically Open DBT vs DBT

Many incorrectly assume that RO DBT and Dialectical Behavior Therapy (DBT) are the same thing. While RO DBT has some similarities with DBT, these are two very different treatments. DBT primarily benefits those who have an undercontrolled (UC) personality. UC traits include being impulsive, sensation-seeking, wearing one’s heart on one’s sleeve, and acting in the here and now.  Thus, DBT can be helpful for those that have impulsive control problems, such as those with borderline personality disorder, bulimia nervosa, binge eating disorder, and substance abuse disorders. Both RO DBT and DBT combine individual therapy with skills training classes, involve tracking emotions and behaviors via diary cards, allow for telephone consultation with the individual therapist, and involve consultation teams for the group and individual therapists. However, DBT has a stronger focus on self-regulation to target emotion dysregulation whereas RO DBT is much more focused on helping individuals address social signaling and connectedness with others.

For more information see our Comprehensive Guide to RO-DBT.

References:

Lynch, T. R. (2018). Radically Open Dialectical Behavior Therapy. New Harbinger Publications.

Lynch, T. R. (2018). The Skills Training Manual for Radically Open Dialectical Behavior Therapy. New Harbinger Publications.

Elizabeth Mariutto, PsyD

Lindner Center of HOPE, Psychologist and Clinical Director of Partial Hospitalization/Intensive Outpatient Adult Eating Disorder Services

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By: Jessica Kraft, APRN, PMHNP-BC
Lindner Center of HOPE, Psychiatric Nurse Practitioner

Seasonal affective disorder (SAD) is a type of depression that is more isolated to the changing of the seasons. It can happen in the spring and summer but occurs most commonly in the fall and winter months. We know that everyone is going to have a bad day from time to time, and it’s not uncommon for some to face more challenges in the winter months when the weather is colder and the days are shorter. But when does this become a problem that requires intervention?

What are some of the common symptoms of SAD? 

  • Feeling down or depressed for most of the day, almost every day
  • Less interest in hobbies, social activities, or things that have brought you joy in the past
  • Decreased concentration at home and at work
  • Fatigue, sluggishness, or low energy
  • Sleeping too much or too little
  • Changes in appetite (increased craving for carbohydrates) or changes in weight
  • A general feeling of hopelessness
  • Low self-esteem
  • Thoughts of self-harm or suicide

It is hard to estimate the number of people who have SAD, as many do not know they have it. It’s also thought that the number in recent years has been higher due to the COVID-19 pandemic. Women can be at higher risk for developing SAD as well as those who live further north. SAD most commonly develops in young adulthood, it often runs in families, and can often be co-morbid with other mental health conditions including depression, bipolar, anxiety, ADHD, and eating disorders.

It is not entirely understood what causes SAD, but research indicates that people with SAD may have reduced activity of serotonin, too much melatonin production, or even vitamin D deficiency. Changes in these areas may impact the body’s daily rhythm that is tied to the seasonal night-day cycle. Negative thoughts and feelings about the winter and its associated limitations and stresses are common among people with SAD, as well as others. It is unclear whether these are “causes” or “effects” of the mood disorder, but they can be a useful focus of treatment especially when seeking therapy.

If the above symptoms start to interfere with day-to-day life, it may be beneficial to seek out care for SAD. For some it may be ideal to start with their primary care provider in order to rule out other medical conditions that could be responsible for symptoms of SAD including alterations in thyroid hormones, low blood sugar, anemia, or viral infections like mono. If there is not an identifiable medical cause, seeking psychiatric help may be beneficial.

What are some of the common symptoms of SAD?

  • Light therapy – a common approach to SAD since the 1980s. The thought is that exposure of bright light every day can supplement the lack of natural sunlight/sun exposure in the winter months. Sitting in front of a light box of 10,000 lux daily during the winter months in the morning can be a helpful intervention.
  • Talk therapy – the most common type of talk therapy for SAD is cognitive behavioral therapy (CBT).
  • Vitamin D supplementation – there is mixed research on how helpful supplementation of Vitamin D is for SAD but some find it helpful and a good option to try prior to trying a psychiatric medication.
  • Psychiatric medication – for those who haven’t seen much improvement with light therapy or CBT, psychiatric medication can be an option including SSRIs (Prozac, Zoloft, Lexapro, etc.) or Wellbutrin. It is important to keep in mind that treatment with one of these medications may take several weeks in order to be efficacious, for some up to 6-8 weeks.
  • When doing research on this topic I came across many anecdotal stories from those struggling with SAD and what interventions they tried and found helpful. Some examples included going outside more often, taking a trip, caring for something like a plant or a pet, finding a new hobby or interest, staying social, creating new rituals, consistent exercise, quality nutrition, good sleep, and maintaining a consistent schedule.

What are some of the common symptoms of SAD?

One of the helpful things about treating SAD is the predictability of when symptoms set in compared to other sub-types of depression that are much more variable. Unfortunately there is little research answering the question of whether or not this can be prevented or if there is a significant benefit to starting treatment early. Of the limited data available the medication Wellbutrin was found to be the most helpful intervention to start early.

Sources:

https://www.nimh.nih.gov/health/publications/seasonal-affective-disorder/index.shtml 

https://www.psychiatry.org/patients-families/depression/seasonal-affective-disorder 

https://www.yalemedicine.org/news/covid-19-seasonal-affective-disorder-sad 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7302868/ 

https://www.sciencedirect.com/science/article/pii/S2215036620303072 

https://forge.medium.com/advice-for-coping-with-seasonal-depression-from-9-people-who-have-it-a5c04fdfe996

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By Angela Couch, RN, MSN, PMHNP-BC

Psychiatric Nurse Practitioner, Lindner Center of HOPE

Anxiety is a common symptom. Anxiety is a part of everyone’s lives, we have all experienced it to one degree or another. Believe it not, anxiety serves some useful purposes. Anxiety can help give you the drive to make a change, or complete task on time.Anxiety can activate the fight or flight instinct, in a “potentially” dangerous situation, giving you the drive to get out of there, or do something to prevent harm. Anxiety can occur when you are enduring multiple stressors, or there is uncertainty, and it’s not entirely unexpected.

For instance, say you hear layoffs are coming in the company, and you’re not sure if your department will be affected. You may experience physical symptoms of anxiety (which could include racing heart, nervous stomach, sweating, tremor, nausea, shortness of breath, and more), and you might also experience worry. COVID-19…yup, that can cause some anxiety, or worry, too! Situational anxiety is a part of life, and often can be managed by rational self-talk, problem-solving, and various positive self-care strategies. (For more on that, see some of our other recent blog articles, for lots of helpful ideas!) So how do we know when the anxiety is more than just “normal” or to be expected, and when to seek help?

According to the National Comorbidity Study Replication, about 19.1% of U.S. adults will have had an anxiety disorder in the past year, and 31.1% experience an anxiety disorder in their lifetime. In other words, it’s pretty common! There are various types of anxiety disorders, and most have an underlying common thread– difficulty in accepting uncertainty in some form. So how do you know if you may need to seek further assessment or help for anxiety, if it’s really so common? If everyone gets it, is it really a problem that requires treatment? The answer is yes, it might. Some symptoms that may indicate problematic anxiety include:

* Feeling “paralyzed” by fear.

* Anxiety is causing you to avoid things you used to be able to do without anxiety, or things that are important to you (this could include social activities, leaving your house, going to your job, driving, engaging in spiritual activities, etc.).

* You have difficulty staying present “in the moment”, which may repeatedly distract you from attending to conversations, being able to complete work or school tasks because of lack of focus.

* You are having difficulty with sleep or eating due to excessive worry or anxiety.

Anxiety is causing significant physical symptoms.

* You cannot determine a cause for the anxiety and the symptoms are persistent or very bothersome.

* You worry about “everything” or “all the time”.

* The anxiety/worry you are experiencing about situations seem excessive.

* You need to engage in compulsive or repetitive behaviors, or do things in a certain way, in order to avoid significant anxiety/worry.

* Anxiety is causing you to turn to self-medication with alcohol or substances.

So you’ve determined you should seek help, now what? Psychotherapy can be helpful for anxiety, and is a very important component of treatment. Psychotherapy may include several modalities such as cognitive behavioral therapy, addressing faulty beliefs contributing to anxiety, psychoeducation about anxiety and worry, problem-solving, exercise and wellness activities/lifestyle changes, addressing sleep hygiene, skills for time management and stress reduction, or exposure therapy, just to name a few.

How do you know if psychotherapy is enough to manage the symptoms? Medication can be a helpful component in treatment of anxiety, particularly if symptoms are not improving with other psychotherapeutic interventions mentioned above. Medications alone are rarely enough to treat anxiety disorders adequately. Medication can often make it easier to engage in meaningful psychotherapy, to make those helpful lifestyle changes, or try new ways of coping with the anxiety/worry. If you are experiencing suicidal thinking or significant depression, medication should be a consideration. If the anxiety symptoms are preventing you from being able to work or do other essential tasks, medication may be indicated. If your therapist suggests a medication consultation, you should consider it.

The important things to remember are, everyone has some anxiety, not all anxiety is bad, and when anxiety does become problematic or excessive, there are evidence-based treatments to help, so don’t be afraid to reach out for help!

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Tuning into the news can be a stressful and anxiety provoking experience, even in the best of times. During a pandemic, it can be downright frightening. If all of this negativity is wreaking havoc on your emotions, maybe it’s time to put your energy into building a Gratitude Practice.

Gratitude is the conscious decision to focus attention on the positive aspects of a situation and to notice feelings of joy, appreciation and thankfulness.  It is a mindset that celebrates all of the wonderful, special, and unique gifts that life has to offer every day, no matter how simple.

When the world pressures us to pay attention to things that are hurtful, dangerous or missing in our lives, it can be especially challenging to maintain a mindset of gratitude and appreciation. This year especially has brought many unforeseen challenges to us all. Cultivating a mindset of gratitude can be accomplished even in these difficult times.

Why Gratitude?

Over the last several decades there have been numerous studies that have shown countless positive effects of practicing gratitude on our emotional, social and physical health. Practicing gratitude has been shown to improve mood, and help reduce depression, anxiety and irritability. Regular practitioners of gratitude are likely to feel happier, more peaceful and do kinder things for others.

Those who practice gratitude may have stronger social relationships. Couples who regularly express gratitude to each other feel their partners are more responsive to their needs and are overall more satisfied with their relationship. This extends to the workplace as well. When gratitude is expressed at work, employees improve their felt sense of self-worth and confidence, leading to an increase in trust between colleagues and more initiative to help one another out.

Physically, people who practice gratitude regularly have a host of positive effects including improved sleep, stronger immune systems, more consistent exercise habits, fewer physical symptoms and better progress towards achieving personal goals. This is especially important in the current climate.

The act of being grateful creates a chain reaction: the more positive things you notice and give thanks for, the better you feel. As you feel better, you are likely to seek out more positive experiences for which to be thankful.

Building a Gratitude Practice

There are many ways that you can begin to incorporate more gratitude into your life. Remember that when making any change in behavior, it is best to start small and gradually build over time.

If you are just starting out, try choosing one or two times per day that you devote to being grateful. You might consider as you are falling asleep each night to think of three things that happened during that day that you are thankful for. You could also try to think of the one thing you are most grateful for. Try to be as specific as possible. Instead of saying to yourself “I am grateful for my family” think …“I am grateful my husband cleaned up the kitchen after dinner.” Or “I am grateful that my son gave me a hug before bed.”

Once you have practiced that, you might want to upgrade to a Gratitude Journal. You can spend 5-10 minutes each night or first thing in the morning, reflecting on all of the things in your life you appreciate. The act of writing it down helps to solidify in your mind the memories and experiences.

Consider incorporating your family into the practice. When sitting down to meals, ask your family members one thing that happened today that they each feel grateful for. We tend to do this before Thanksgiving dinner, but we can also do this as we sit down with our take-out pizza. Before falling asleep, tell your partner something about him or her that you value and appreciate.

Lastly, find opportunities in your day to express your appreciation for others. Consider sending an email to a colleague when you overhear a positive comment or compliment about them. A text with a thank you or heart emoji only takes five seconds but can brighten someone’s morning.

Remember that gratitude is not the same as denial or wearing rose colored glasses. It does not dismiss or deny the very real things that are not ‘ok’ in our society. Instead, gratitude helps us to collectively notice and appreciate the beauty, the kindness, the love that surrounds us every day. Sharing our gratitude allows us to work together to find solutions and to maintain hope in the face of adversity.

Practicing a grateful mindset can be challenging at first, especially when there are so many messages of negativity around us. Over time and with intention, building your gratitude practice can bring just a little more peace and joy to your world.

 

By Laurie Little, PsyD, Director of Therapeutic Services, Residential, Lindner Center of HOPE