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

The use of dietary supplements or vitamins for the treatment of depressive symptoms is increasingly common among patients. Factors driving this trend include unsatisfactory response with standard treatments, adverse drug events, skepticism about psychiatric medications and the perception of dietary supplements as “natural” and safe.

Although evidence increasingly supports the relationship between quality of diet and mood, more research is needed to clarify the role of dietary supplements in the management of depression. Consumers often take supplements based on inconclusive data from small, methodologically-flawed studies. Unlike FDA-approved drugs, supplements do not have to demonstrate unequivocal evidence for efficacy or safety. Adulteration, contamination, variations in potency, and product instability are not uncommon. When treating depressed patients, it is important to ask about use of dietary supplements and to be ready to offer guidance regarding the evidence for potential benefits, possible risks and drug-supplement interactions. The following are commonly-used supplements with a potential effect on depressive symptoms.

Omega 3 polyunsaturated fatty acids: Eicosapentanoic acid (EPA) and Docosahexaenoic acid (DHA)

Omega 3 fatty acids are long chain lipids found in oily fish. High dietary intake has been associated with low rates of depression. Omega 3 fatty acids enhance neurotransmission, neurogenesis and reduce inflammation. There is support for supplementation in Major depression with several meta-analyses showing efficacy. There is some evidence for efficacy of omega 3 fatty acids for bipolar depression. Over the counter products vary greatly in composition and EPA/DHA ratio. Evidence supports the use of EPA-dominant formulations. Adverse events and drug interactions are uncommon, but risk for excessive bleeding must be considered. Dose 1-2g of EPA/day.

Folic acid and Methylfolate

Involved in dopamine, serotonin and norepinephrine synthesis. Folate deficiency has been associated with increased risk for depression. Evidence supports adjunctive use of methylfolate with antidepressants for the reduction of Major depression symptoms. An FDA approved formulation of l-methylfolate available by prescription has shown efficacy at the 15mg/d dose level. Evidence for the efficacy of folic acid and Depression is mixed and there is no evidence supporting the use of either folate or methylfolate in Bipolar depression. Methylfolate is usually well-tolerated, although there are concerns about use masking B12 deficiency and historical concerns about cancer. Routine folate supplementation >1g/d is not recommended. l-methylfolate dosage is 7.5-30mg/day, maximum 1g/day (folate).

S-adenosylmethionine (SAMe)

An endogenous aminoacid involved in neurotransmitter synthesis. Decreased serum and CSF levels are associated with depression. A few studies support efficacy for supplementation in Major depression but more research is needed.  There is no data to support use of SAMe in bipolar depression. Adverse events include nausea and anxiety. May interact with serotonergic antidepressants and increase risk for manic and hypomanic episodes in Bipolar disorder. Dose 200-800 twice/day.

Vitamin D

Low serum concentrations have been associated with depression. Vitamin D acts as a receptor ligand in the prefrontal cortex and hypothalamus. Some evidence supports supplementation for reducing symptoms in clinically-depressed patients but further research is needed. Evidence does not support supplementation as a therapy for bipolar depression.  Caution regarding risk for hypercalcemia and toxicity with excessive intake. Dosing varies.

N-acetylcysteine (NAC)

Available as a nutritional supplement and as prescription medication for treating acetaminophen overdose. NAC has antioxidant and anti-inflammatory properties and modulates the glutamate pathway.  Some evidence for reduction in bipolar depression symptoms. Not effective in Major depression. Gastrointestinal upset may occur. Dosing 1-1.5g twice/day.

St. John’s Wort

A perennial herb containing active compound hypericin, which inhibits reuptake of dopamine, norepinephrine and serotonin. Some support for short-term efficacy in depressive symptoms, but more long term and safety data is needed. Significant risk for drug interactions due to interaction with serotonergic drugs (serotonin syndrome) and interference in the metabolism of hundreds of drugs by induction of Cytochrome P450 enzymes make this an undesirable adjunctive option. Dosing varies due to variability in potency.

Probiotics

Alterations in intestinal flora have been implicated in mood disorders, although the mechanism is unclear. Probiotic supplements are thought to impart a health benefit by optimizing intestinal flora and are used to manage gastrointestinal symptoms. Animal studies show blunting in inflammatory response and improvement in mood symptoms with supplementation, but few clinical trials yielded positive results. Products on the market vary in terms of bacterial strain content, stability and bioavailability. Adverse events are rare, except for opportunistic infection immunocompromised individuals. Dosing varies.

There isn’t a one size fits all or best supplement for depression. There are some benefits to adding in supplements for depression symptoms and in other areas more research is needed. Be sure to work with a medical professional and consider the potential benefits, possible risks and any drug-supplement interactions for medications you may already be taking.

If you are seeking help for your depressive symptoms, contact us at the Lindner Center of HOPE. There is HOPE.

 

References

Sarris J, Murphy J, Mischoulon D, et al. Adjunctive Nutraceuticals for Depression: A Systematic Review and Meta-Analyses. Am J Psychiatry. 2016;173(6):575-87. Nahas, R., & Sheikh, O. (2011).

Complementary and alternative medicine for the treatment of major depressive disorder. Canadian Family Physician, 57(6), 659–663.

Sarris J. Clinical use of nutraceuticals in the adjunctive treatment of depression in mood disorders. Australas Psychiatry. 2017;:1039856216689533.

Rakofsky JJ, Dunlop BW. Review of nutritional supplements for the treatment of bipolar depression. Depress Anxiety. 2014;31(5):379-90.

 

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By Nicole Bosse, PsyD, Lindner Center of HOPE, Staff Psychologist

Kyle has been happily married to his wife Joanne for 5 years. One night while watching a movie together, he notices the thought in his mind, “Gee, that Matt Damon is a good looking guy!” He then is suddenly flooded with a wave of panic and fear that perhaps the presence of this thought means he is gay and his whole marriage is a sham.  Although this scenario is fictional, it is an all-too common manifestation of a form of obsessive compulsive disorder.  Referred to as sexual orientation- obsessive compulsive disorder (SO-OCD).  SO-OCD is characterized by recurrent distress-producing doubts about whether one is gay or straight, fears of becoming homosexual (or becoming straight if their sexual orientation is homosexual), or fears that others might perceive the individual having the undesired sexual orientation.  (Williams, 2008). A person may have only one of these concerns or some combination. SO-OCD is very different from ordinary doubts and anxieties that are experienced by individuals attempting to discern their sexual orientation. For example, an individual coming to understand that they are gay may feel anxious about coming out or about the potential changes this will bring to their lifestyle. As clinicians, it is important to thoroughly assess if their client’s intrusive thoughts are ego-dystonic. In SO-OCD, ego-dystonic intrusive thoughts are cognitions that are inconsistent with the individual’s fundamental desires, wants, and sexual history.

Individuals with SO-OCD typically experience confusion and shame, which may unfortunately deter them from seeking appropriate treatment. Another factor that might impact entering appropriate treatment is that many of the individuals who struggle with this type of OCD have very few observable compulsions, which can prevent it from being recognized and properly diagnosed. Many of the compulsions typically take the form of cognitive compulsions, specifically mental reviewing to check the presence or absence of feelings of attractiveness or arousal, reassurance seeking, self-observation to see if one “looks”, talks, walks, or gestures like someone who is gay or straight, and avoidance of situations that might trigger fears.

Treatment for SO-OCD is very similar to treatment for other categories of OCD, specifically exposure and response prevention (ERP) is the gold standard treatment. It is important to emphasize in treatment that it is impossible to control thoughts and that typically trying to control thoughts or push thoughts away significantly increases them. Next it is key to explain ERP and to help them understand the reason why they are leaning into the anxiety. It can be particularly helpful to have them identify what in their life would be different once their OCD is no longer in the picture. Once the client is on board with and understands the importance of exposures, the client and clinician work collaboratively to create a hierarchy of exposures. It is important to begin with low distress exposures at first, and then gradually work up the hierarchy once they habituate to the low level exposures.

As with any form of OCD, exposures for SO-OCD can take various forms, depending on the client’s core fear. For example, one client’s core fear may be that they need to be 100% certain that they are attracted to individuals of the gender of their preferred sexual orientation, while another client’s core fear may be that they do not want to hurt the person they are with if they one day discover they are attracted to a different gender. In short, it is very important to first identify what their core fear is before creating the exposure hierarchy. Some common exposures for clients with whom I have worked whose obsessions focus on fears of being gay include identifying attractive individuals of the same sex, watching movies involving homosexual characters, attending pride events, writing sentences stating “I am homosexual,” or writing imaginal scripts about coming out to loved ones or sitting with uncertainty that they will never know 100% if they are in the correct relationship. It is also important to emphasize the second component of exposure and response prevention, namely response or ritual prevention. For instance, it would be necessary for the patient to not give in to reassurance seeking or mentally assess arousal before, during or after exposures.

Treatment length can vary depending on severity of symptoms. It is important to work with someone who specializes in OCD. Typically, therapy occurs once per week with the idea that once exposure work is started the client will be completing exposures each day between sessions.

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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.

 

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Integrative mental health (IMH) combines conventional biological psychiatry and psychological interventions with traditional and complementary alternative medicine (CAM) to provide holistic patient-centered care. Using non-hierarchical interdisciplinary teamwork, the patient and practitioner are able to explore psychological paradigms involving biological, cultural and spiritual dimensions of health and illness. Kindness, avoidance of harm and informed consent are core ethical principles of practice. As well as addressing immediate mental health problems, the patient is encouraged to become actively involved in their own prevention of mental illness and maintenance of mental health.

Mental health is a key determinant of wellness, and has been shown to be strongly influenced by lifestyle factors such as chronic stress, sedentary life style, poor nutrition, obesity, substance abuse, and social isolation. Use of complementary alternative medicine in mental health conditions has been driven by the high cost of conventional care, and the growing list of medication safety concerns reported by the FDA, but due caution must be used with all Interested in touring therapies, conventional or complementary.

The fundamental goal of an integrative approach to mental health is to find the most appropriate treatments (conventional and complementary) that safely and effectively address the symptoms
of the individual, while taking into account personal preferences, cultural beliefs and financial constraints, an approach endorsed by the American Psychiatric Association.

Integrative mental health is an evolving, whole-systems approach to wellness of mind, body, and spirit. It considers that symptoms are associated with multiple causes and that multiple approaches to assessment and treatment may be necessary so that each individual may attain an optimal state of health and well-being. Therefore, the integrative mental health professional is knowledgeable about complementary and alternative medicine and trained in the art of collaboration so that they can discuss patient care with medical doctors, as well. The goal is to understand as much as possible about the whole person and to be aware of what treatments are occurring simultaneously. Approximately half of the individuals diagnosed with mood or anxiety disorders are using a combination of therapies and conventional strategies to alleviate symptoms. For this reason, it is important for health care professionals to ask the right questions and to collaborate in seeking answers when treating individuals who come seeking help.

Today, these individuals may first seek counsel from a medical doctor, a psychotherapist, a chiropractor, an acupuncturist. Therefore, it is important that patients disclose all of their treatments to all of their health care professionals. Mental health professionals trained in integrative approaches frequently serve as the historians of each patient’s care, especially since they are the ones who spend the most time with each patient during the course of treatment.

Recent years have witnessed growing openness to nonconventional therapies among conventionally trained clinicians and researchers. At the same time people who utilize Western biomedicine as currently practiced are turning increasingly to integrating non-conventional therapies for the treatment of both medical and mental health problems. Approximately 72 million U.S. adults used a non-conventional treatment in representing about one in three adults. If prayer is included in this analysis almost two thirds of adults use non-conventional therapies. Anyone diagnosed with a psychiatric disorder is significantly more likely to use nonconventional therapies compared to the general population.

Integrative health care is based on the philosophy that health is influenced by a variety of interrelated factors such as life choices, environment, genetic makeup, intimate relationships, and the
meaning and purpose in life. As a model it is collaborative and multidisciplinary. It is open to and recognizes the importance of conventional medicine, complementary and alternative medicine, mental health care, and mind-body approaches (such as meditation, yoga, hypnotherapy, Reiki, and therapeutic massage). There is a respect for each individual’s journey and for the stories that make up the history of their lives. There is a belief that these individual journeys influence the biology that manifests in illness or in health. Integrative health care supports all of the important
aspects of life, including creativity, cultural expression and the celebration of community. To have “health” means that the whole person is in balance – physically, emotionally, psychologically, and spiritually. Is health really health without mental health?

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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

Depression is on the rise in American teens and young adults. Adolescent girls, in particular, seem to be the most vulnerable youth, according to recent research published online in the Journal of Pediatrics.  Data collected between 2005 and 2014, analyzed by the Johns Hopkins University School of Public Health, concluded that “the 12 month prevalence of major depressive episodes in adolescents increased from 8.7% in 2005 to 11.3% by 2014”.  This number rose from 4.5% to 5.7% in boys and 13.1% to 17.3% in girls. The reasons for this increase remain under discussion. However, cyber bullying has been hypothesized as one trigger, particularly for girls.

How does a parent know when and where to seek help? How can parents support their child or adolescent suffering from depression? Here are some general guidelines for getting started.

  1. Observe your child’s behavior for idiosyncrasies or changes. Children with depression may demonstrate low mood, irritability, anger, fear or anxiety, mood swings, disruptive or risk-taking behavior, disobedience/defiance/ illegal behavior, isolation, lack of self-care/hygiene, decreased interest in previously enjoyable activities, decreased energy, increased or decreased sleep, increased or decreased appetite, and changes in friendships or family relationships. Some children turn to drugs or alcohol. Others turn to the internet for support or socialization. School performance may deteriorate, or attendance may decrease due to physical complaints or blatant truancy. Some children engage in self-harming behaviors or talk of death and dying.
  2. Engage your child in daily conversation or other one- on -one activity to open lines of communication.  Gently ask questions about your child’s change in mood, daily life and issues or how he or she is getting along with others. Find novel ways, if necessary, for your child to communicate his or her feelings. This may include sharing a journal that you pass back and forth or quantifying your child’s mood with a “mood scale” (0= severe depression and suicidal thinking versus 5 = happy mood/doing well) or even sharing “emojis” reflecting how the child is feeling that day. If your child expresses suicidal thoughts, such as not wanting to live or wishing he or she were dead, talks about ending his or her life, or engages in writing suicide notes – please take them directly to the local emergency room for further psychiatric evaluation.
  3. Talk to your pediatrician or family doctor about your child’s mood or changes in behavior. Consult with your child’s teachers or school counselor. Talk to your minister, priest, or rabbi. Arrange timely assistance for your child, perhaps through your Employee Assistance Program or through your health insurance. These professionals can assist you in finding a qualified mental health professional to provide evaluation and counseling.
  4. Monitor and limit phone, computer and electronics time. Know with whom your child is communicating. Watch internet history, cellphone texting, and social media communications. Kids looking for support often look in the wrong places and meet the wrong people while there.
  5. Encourage a healthy and consistent sleep schedule.  Children and teens need about 8-10 hours of sleep per night. A regular pre-sleep routine that does not include electronics and enhances relaxation along with a scheduled bedtime and wake-up time are all tenets of a healthy sleep habit.
  6. Encourage healthy eating habits. Limit sodas, caffeine, sugar- laden foods and snacks. If your child is not eating regular meals or portions, encourage smaller, more frequent meals of healthy foods throughout the day. Observe aberrant behaviors at meals, such as restricting caloric intake, leaving the table immediately after eating to go to the restroom and diverting food by hiding it or throwing it away. Observe striking weight loss, excessive exercising, or obsessive concerns with body image that may indicate concern for an eating disorder.
  7. Be consistent and firm with limit setting. Some parents feel badly for their child with depression and feel they should relax limits or house rules to decrease perceived stress on the child with depression. They fear being too strict or harsh. Maintain the same or even slightly more stringent rules with your child to maintain structure and avoid singling out the child with depression. Treat all children in the family equally. Be aware of your child’s whereabouts and safety at all times.
  8. Safety- proof your home. Lock up all medications, even over- the -counter medications, and seemingly harmless remedies. Secure anything in the home that could be used as a weapon, particularly firearms. Remove firearms from the home entirely. Secure alcohol or remove it from the home entirely.
  9. Ensure that you are taking care of your own well-being and mental health. Depression can run in families. If you, as the parent, are struggling with your own mental health, it will be difficult to remain objective and supportive toward your child, who is also struggling. It may also make identifying your child’s depression more difficult or impossible. Resist the urge to tell your child that you know how they must feel or that you were once depressed or are currently depressed. Avoid trying to give advice or sharing how you have battled your own depression.

Practice listening attentively and reassuring your child that you will get them whatever help is needed for them to feel better and return to a healthy, happy life. Be sure to get help for yourself, such as therapy or medication or both. This will assist you in being the best possible support for your child and family.

Identifying child and adolescent depression and dealing with it can be overwhelming. The key is to reach out for assistance and allow others to provide their support and expertise, so that a team approach can be utilized to its fullest. Organizations such as the American Academy of Child and Adolescent Psychiatry, National Alliance on Mental Illness (NAMI) and the American Psychiatric Association are all excellent sources of information and support.

References:
Mojtabai R, Olfson M, Han B. National trends in the prevalence and treatment of depression in adolescents and young girls. Pediatrics. 2016; doi: 10. 1542/peds.2016-1878.
Glowinski AL, D’Amelio G. Depression is a deadly growing threat to our youth: time to rally. Pediatrics. 2016; doi:10.1542/peds.2016-2869.
American Academy of Child and Adolescent Psychiatry. Your Adolescent. 1999. 301-304.

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Charles F. Brady, PhD, ABPP, Lindner Center of HOPE, Clinical Director of Outpatient Services and Staff Psychologist, OCD/CBT Psychotherapist, Associate Professor, University of Cincinnati’s Department of Psychiatry

In today’s culture the terms “obsessive” and “compulsive” have been adopted to refer to excessively repetitive thoughts and hard to resist behaviors.  In clinical situations this overly broad definition leads to substantial confusion when discussing obsessive compulsive disorder (OCD) and substance use disorders (SUDS).  Individuals who report they are always thinking about using addictive substances and “cannot stop” acting on their urges to use, are often erroneously referred to as obsessing about using or compulsively using.  Most often, someone who is struggling with a SUD does not have OCD and vice versa. However, both research and clinical practice reveal that these two conditions co-occur frequently.  Mancebo et al, 2009 documented that in their sample of OCD treatment seeking patients, twenty- seven percent were found to have SUDS.  To address the inevitable chicken and egg question, they delved further to uncover that seventy percent of the patients with co-occurring OCD and SUDS reported that their OCD symptoms preceded the onset of their SUD by at least one year.   They also found that in their sample, the participants who reported childhood onset of OCD symptoms were at higher risk for subsequently developing a SUD.  In this article, the similarities and differences between OCD and SUDS will be explained and the pertinent issues regarding the approach to treatment when a person suffers from both OCD and a SUD will be detailed.

Psychologically, the difference between a person struggling with OCD and a person with a SUD lies in what fuels the behavioral urge.   For the person with a SUD, the behavior is positively reinforced. By this we mean that the mind anticipates pleasure from completing the action (i.e., using a substance).  For the OCD sufferer, negative reinforcement describes the mechanism of striving to reduce distress as the key for driving the behavioral urge behind the compulsion.   An additional difference is that thinking about substance use initiates a pleasure experience, whereas the intrusive thought the person with OCD experiences initiates a distress response (e.g., What if I touch a door knob and die?).  There are occasions in which the person with a SUD will express that they use their addictive substance even though they do not want to.  Typically, such an individual continues to experience pleasure and pleasurable anticipation of the use of the substance, but over time they develop an aversion to the negative consequences that use of the substance has brought into their life (e.g., loss of job, legal problems., relationship damage, shame, etc…  ).

Biologically, it appears that the orbitofrontal cortex (OFC) plays an important role for both SUDS and OCD.  The OFC is a part of the brain that helps to reign in emotional reactions.  For individuals with OCD, the OFC tends to be over activated, even in neutral situations. For individuals with SUDs, the OFC becomes over active in the presence of triggers. For instance, when a person with an alcohol addiction hears or sees a beer can being opened.  When the OFC is over activated, the individual experiences an intense drive to act and is overwhelmed by their desire to act.   This is why sufferers of both SUDS and OCD struggle to resist their urges to perform a compulsion or to engage in their addictive behavior.

For the individual with OCD and a SUD, the relationship between the two may vary.  Some individuals develop addictions as an attempt to soothe and self-medicate the distress caused by their OCD. Yet others may find that their use of addictive substances follows OCD-like rules.  For example, the person who must drink 7 ounces of alcohol per night due to the obsession that if they do not, something bad may happen to a loved one.  If the use of the substance is nested within a compulsion, exposure and response prevention (ERP)targeting the compulsion may need to be started.

At times if the addiction greatly interferes with treatment for the OCD symptoms then treatment must include aggressive treatment of the SUDS early in the treatment process. There are several ways in which substance abuse disorders, if untreated can impede effective treatment of OCD. First, many substances, including barbiturates, alcohol and benzodiazepines that are involved in SUDs are depressants.  They either cause or exacerbate depressed mood. If a person’s mood is depressed, the motivation and drive necessary to engage in ERP treatment for their OCD symptoms may be severely impacted.  Also, the essential component of successful ERP treatment involves learning. The person with OCD learns that the obsessive thoughts they experienced are not as dangerous or as intolerable as they previously believed.  This learning allows them to free themselves from compulsions and helps them resist relapse. Many individuals develop SUDS in an attempt to self-medicate and soothe the distress caused by their OCD by using drugs like alcohol, benzodiazepines (e.g., valium, Xanax, Ativan,  etc…), and marijuana. Unfortunately, these substances impede learning. The patients who are unable or unwilling to reduce or cease their abuse or dependency of these substances while they engage in ERP are going to have a more difficult time accomplishing the learning needed for recovery from their OCD symptoms.

When treating a patient with a co-occurring SUD and OCD, the clinician also must consider how willing and motivated is the person to tackle both the addictive behaviors and the OCD behaviors.  It is not uncommon for a person with a co-occurring SUD and OCD to be more hesitant and resistant to let go of their addictive behaviors as they derive some pleasure from them, yet they may be very motivated to rid themselves of their time consuming compulsions and the anxiety triggered by their obsessions.  In such instances, the clinician may need to start where the motivation allows, but continue to educate and explore with the patient about how the addiction may impede their OCD recovery and how it also may be negatively impacting their health and well-being.

In conclusion, for clinicians who treat individuals with OCD or SUDs, it is of primary importance to assess for symptoms of both disorders.  The person who presents with complaints of a SUD, may be ashamed of the absurdity of their obsessions and compulsions and may not volunteer them.  Likewise, the person with OCD may also feel hesitant to report their use of substances.  When the clinician discovers that a person may have co-occurring OCD and SUDS, the patient will benefit most from a thoughtfully and collaboratively developed treatment plan to address both conditions.

References:

Mancebo et al.,  J Anxiety Disord. 2009 May; 23(4): 429–435

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FOR IMMEDIATE RELEASE                                                                                                                                     

CONTACT:
Jennifer Pierson
Lindner Center of HOPE
(513) 536 -0316
[email protected]

Free Community Education Series to Address Substance Use Disorders, Behavioral Addictions, Treatment and Strategies for Coping

March session to explore Stress and Family Functioning

Lindner Center of HOPE with the support of Manor House in Mason, Ohio is offering a Free Community Education Series in 2017 on topics related to addiction. The series will offer expert discussion of Substance Use Disorders, Behavioral Addictions, Treatment and Strategies for Coping for community members seeking information.

The series will be held at Manor House, 7440 Mason-Montgomery Rd., Mason the third Wednesday of the month at 6 p.m. starting January 18, 2017 for one year (though sessions will not be offered in May 2017 or December 2017. On May 7, 2017 Lindner Center of HOPE will offer their second Education Day, a ½ day workshop about mental illness and addiction.)

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

The third session is March 15, 2017. Michael K. O’Hearn, MSW, LISW-S, Clinical Director of the Lindner Center of HOPE’s Stress Related Disorders program and staff provider, will present Stress and Family Functioning.

Lindner Center of HOPE in Mason is a comprehensive mental health center providing excellent, patient-centered, scientifically-advanced care for individuals suffering with mental illness. A state-of-the-science, mental health center and charter member of the National Network of Depression Centers, the Center provides psychiatric hospitalization and partial hospitalization for individuals age 12-years-old and older, outpatient services for all ages, diagnostic and short-term residential services for adults and adolescents, outpatient services for substance abuse through HOPE Center North location and co-occurring disorders for adults and research. The Center is enhanced by its partnership with UC Health as its clinicians are ranked among the best providers locally, nationally and internationally. Together Lindner Center of HOPE and UC Health offer a true system of mental health care in the Greater Cincinnati area and across the country. The Center is also affiliated with the University of Cincinnati (UC) College of Medicine.