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COUNSELOR'S CORNER 
Wednesday, October 03 2012

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State cracks down on pill abuse

Task force aims to halt Rx deaths

Vivian Sade
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Michelle Davies | The Journal Gazette

Allen County Health Commissioner Dr. Deborah McMahan and Attorney General Greg Zoeller unveil new state billboards.

Rx drug dangers
•Every day, an average of 2,500 teens use prescription drugs to get high; 1 in 7 admit to abusing prescription drugs to get high in the past year; 60 percent of those teens were younger than 15.

•Seven million people abuse or misuse prescription drugs every month.

•Every day in 2009, over 6,000 people abused prescription drugs for the first time.

•More people died last year from prescription drug overdoses than from illegal street drugs.

•Two out of every five teens think prescription drugs are “safer” than illegal drugs, and 3 in 10 believe that narcotic pain relievers are not addictive.

•Drug distribution through the pharmaceutical supply chain was the equivalent of 96 milligrams of morphine per person in 1997 and about 700 mg per person in 2007, an increase of 600 percent. That 700 mg of morphine is enough for everyone in the U.S. to take a typical 5 mg dose of Vicodin (hydrocodone) every four hours for three weeks.

Source: Centers for Disease Control and Prevention,

Fort Wayne-Allen County Department of Health

Last year in Allen County, 29 people died of drug overdoses, and 25 of those deaths involved prescription drugs.

That was one of the statistics given by Dr. Deborah McMahan, Allen County health commissioner, during Tuesday’s launch of a public awareness campaign headed up by Indiana Attorney General Greg Zoeller.

The new Prescription Drug Abuse Task Force organized by Zoeller’s office hopes to combat what is now the nation’s fastest-growing drug problem – prescription drug abuse.

A new billboard on U.S. 30 is part of the project and proclaims another startling fact: “Every 25 minutes, someone dies from RX drug overdose.”

“In 2009 and 2010, 1,350 Hoosiers died from drug overdoses,” Zoeller said. “In the state and in the nation, this is a real epidemic.”

The epidemic has been driven by increased use of antidepressants and pain killers.

The task force met for the first time last month and plans to make recommendations for new rules, regulations and state statutes regarding prescription medications, Zoeller said.

“This is a wake-up call to all of Indiana,” Zoeller said.

The group is made up of state legislators, law enforcement, health officials, pharmaceutical representatives, state and local agencies and local educators, he said. Five subcommittees will focus on education and public awareness, treatment and recovery, prescription drug monitoring, disposal and enforcement.

Through stricter state statues, Zoeller said he hopes to crack down on pain medication clinics known as “pill mills” where prescriptions are doled out indiscriminately.

McMahan, a member of the task force, thanked Zoeller for initiating the campaign, noting that Allen County is not immune.

McMahan described parties known as “Skittles or pharming parties” where teens take whatever prescription medications they can find at home, mix all the pills together and then eat a handful at a time.

“There are multiple complications of prescription drug abuse, including overdoses, addiction and dependence, social and family dysfunction, criminal consequences and heightened HIV and hepatitis C risks,” McMahan said.

Pat Weicker, director of administrative services at Orthopedics Northeast, works closely with local medical professionals to promote responsible prescribing of narcotics, and sits on two committees for the Prescription Drug Abuse Task Force. Those committees will develop a protocol for primary care physicians and pain physicians for assessing pain.

“We are interested in developing best practices, seeing what other doctors’ practices are doing and then combining those tools to create a better system of prescribing narcotics,” Weicker said.

It’s important that practices that have a high population of pain patients get a clear diagnosis, assess the pain and understand clearly what the problem is before prescribing pain medication, she said.

“Sometimes there are other modalities to consider, including physical therapy, magnetic resonance imaging or injections,” Weicker said.

There’s no doubt that assessing the patient is key to curbing the problem, McMahan said. “We want to make sure people are pain free, but we need to control that pain without hurting others.

“Of 500 patients who are screened and assessed properly before given pain medication, only one will become addicted,” McMahon said. “But of those not screened, one in 30 will become addicted.

“That is astounding.”

vsade@jg.net

© Copyright 2012 The Journal Gazette. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


Posted by: Dr. Dan L. Boen AT 10:46 am   |  Permalink   |  Email
Wednesday, October 03 2012

Psychotherapy for Late-Life Depression: What Works, What Doesn’t, and Practical Tips

As the US population ages, mental health professionals find their patients aging as well. Over the past 3 decades, there has been a substantial increase in the number of clinical trials that have looked at the effects of psychosocial interventions on late-life depression. The literature has been broadly supportive of psychotherapy as a first-line treatment for late-life depression (MDD in persons aged 65 and older).

Cognitive-behavioral therapy (CBT), problem-solving treatment (PST), and interpersonal therapy (IPT) have the strongest evidence base for treating patients with late-life depression.1 Although these therapies are helpful in making treatment decisions in general, there is little to inform mental health clinicians about the conditions under which one treatment may be better than another and how to accommodate age-related challenges for effective delivery of psychotherapy.

Research on the effectiveness of psychotherapy in late-life depression is relatively sparse, although there has been considerable growth in the database in the past 15 years. Most studies that are large enough to determine a stable effect of treatment have focused on ambulatory, middle- to high-income older adults. Only a handful of studies have looked at the effects of psychotherapy on older adults who are medically ill or disabled or who have mild cognitive complaints.

Not all psychotherapies have been studied; for instance, large clinical trials on psychodynamic therapy, behavioral activation, or mindfulness-based therapies do not exist. Research on other interventions, such as reminiscence therapy and supportive therapy, have only been explored as comparisons with other treatments, and although these therapies appear to have very positive effects on depression and function, they tend not to have as strong an effect as CBT, PST, and IPT do.2

CASE VIGNETTE

Mrs S, an older woman, was referred by her daughter for a differential diagnosis and treatment recommendation. The patient had been forgetting important appointments and was beginning to isolate herself from her family. The patient’s husband had died 5 months earlier, and during her interview, she indicated that although she missed her husband, she had already processed her grief.

In an interview with her daughter, it was discovered that the patient had lost her son to suicide 15 years earlier, and that after the funeral, the patient’s husband had told her that she was not to talk about her son ever again. She had that day to mourn him, but after that he did not want to see or hear her cry. The patient complied dutifully.

Treating older adults

CBT was compared with expressive psychotherapy in older caregivers for dementia patients. Long-term caregivers responded better to CBT, while those who were newer to caregiving responded better to expres-sive psychotherapy.3 Theoretically, recent caregivers were focused on mourning the loss of their spouse’s or parents’ cognitive skills, whereas longer-term caregivers had already processed this loss and instead were focused on practical issues related to caregiving.

Clearly, there were several interpersonal and grief-related issues driving this patient’s depression. IPT was recommended, because of its success in treating complicated grief.

Studies of the effects of gender and advanced age found that these factors do not influence treatment effects. With healthy older adults, clinicians can use their judgment and patient preferences to select among 3 very effective interventions.

Older adults with medical illnesses

There have been few psychotherapy trials with older adults with specific medical illnesses. CBT is an effective intervention for managing both depression and anxiety symptoms in patients with chronic obstructive pulmonary disease.4 However, evidence to support the use of CBT for depression in patients with cardiovascular disease and heart failure is insufficient.5 Trials are under way to study the effects of CBT in patients with type 2 diabetes mellitus.6

PST has been studied broadly as a depression intervention in older medical patients and has been found to be effective; however, PST studies for specific disease entities have yet to be conducted.7-9 Research findings for IPT in medically ill older adults are similar to those for PST; as an intervention in primary care medicine, IPT is an acceptable and effective depression treatment.10 However, there are no large-scale studies of IPT for specific medical illnesses.

Clinicians are faced with having to decide among 3 effective treatments with very little information about their impact on depression in patients with specific medical conditions. As of this writing, PST and IPT are good choices for general medical patients; they can be easily delivered in a primary care setting.

The traditional therapeutic time frame can be a barrier to the delivery of psychotherapy in the medically ill. Weekly appointments and 50-minute sessions may be hard for many medically ill patients, particularly for those who may have numerous medical appointments, have days when they feel particularly fatigued and ill, and who need help getting to their appointments. PST and CBT are effective even if the interval between sessions is 2 weeks. If a clinician and patient agree that longer between-session intervals are appropriate, then it is helpful to provide the patient with support materials to use between sessions.

Enlisting family members to assist with therapeutic activities between sessions can also be helpful. If fatigue is an issue, psychotherapies geared toward shorter sessions (eg, PST) or in-home therapies (eg, self-guided CBT) may be appropriate.11 Patients with chronic pain may need to adjust positions during therapy; thus, frequent breaks during the session may be needed. Telephone therapy is another option for addressing pain concerns.

Cognitive complaints/impairment

Normal age-related changes in cognition do not usually interfere with psychotherapy.12 However, minor impairments may complicate treatment. There are few studies of psychotherapy for late-life depression in older adults with cognitive complaints, with the exception of older adults with mild to moderate executive dysfunction—a common cognitive complaint in most people with depression and a noted risk factor for poor response to antidepressants.1,12

Only PST has been rigorously studied and found to be effective in depressed older adults with mild executive dysfunction.13,14 There have been no large-scale studies of IPT for depression in older adults with mild memory complaints.15 CBT has been researched as an intervention for depression in older adults with moderate dementia, but the results have not been positive.16 A recent systematic review found that the most effective interventions for persons who have dementia and neuropsychiatric symptoms are behavioral interventions that include assessment of the causes of the symptoms and plans to reduce or prevent symptoms from occurring.17

The success of learning-based therapies—CBT and PST—is most affected by a patient’s memory impairment and cognitive slowing. To address problems associated with cognitive slowing when providing PST or CBT, present therapeutic material at a slower pace and over a longer period. Frequent demonstrations of the therapeutic technique with a generic example and regular in-session practice also help older patients learn new coping skills. By going slowly, you can gauge how well the patient understands the new skill.

TABLE


Recommended psychotherapies for depression in older adults

Life review, a technique commonly used in reminiscence therapies, is an excellent tool for linking new material to past experiences.18

Finally, memory aids—such as notebooks to record information or the engagement of family members to help remind patients about between-session activities—may be useful.

Patients with disabilities

There has been considerable recent interest in psychotherapy for older adults who are homebound and disabled. PST can reduce depression and improve physical functioning in homebound and visually impaired older adults.19,20 IPT has not been rigorously studied as a depression intervention for disabled patients.

When working with disabled patients, it is important to provide information about available medical and social services. The therapeutic process may benefit from close, ongoing collaboration with other health care professionals, particularly in working with frail elderly patients with multiple medical problems. Some practical tips include:

• Offer visually impaired patients audiotaped sessions for at-home review

• Provide written information or forms in large print and with larger writing spaces to accommodate changes in fine motor skill

• Sit closer to the patient and speak slowly and in low tones to help those with hearing loss (microphones connected to headphones that amplify the clinicians voice can also be worn by patients)

Using older adults’ strengths and resources

Older patients have a vast wealth of knowledge and experience that can be used to move them forward in their recovery. Although cognitive functions may be less efficient than those of younger adults, older adults’ stores of experience can be used in learning new coping techniques and in developing effective strategies. Even past failures can be used to guide a different course of action for the future. The older adult’s store of life experience coupled with psychotherapy for late-life depression can lead to highly effective treatment outcomes and a positive therapeutic experience for both the patient and the clinician. (The Table can be used as a guide for selecting the best psychotherapy for older patients.)

Conclusions

Although research on psychotherapy for older depressed patients has grown substantially, there are still unanswered questions. First, there have been no studies on the effects of psychotherapy for treating late-life depression with psychosis. Thus, it is not possible to recommend specific psychotherapies for this presentation of late-life depression.

Second, results from studies that have compared antidepressant medications with psychotherapy and from studies of combined treatments for late-life depression have been mixed. Antidepressants appear to be better than IPT for chronic, recurrent, late-life depression, but CBT appears to be as effective as antidepressants.21,22 Moreover, there has not been enough research to determine when antidepressants should be used in combination with or instead of psychotherapy. Patient preference is an important consideration when selecting treatments.

Third, although there is evidence that psychotherapy reduces depression symptoms overall, there has been no analysis of whether psychotherapy reduces specific symptoms.

Finally, there have been no studies of family-based therapies in late-life depression.

References

1. Kiosses DN, Leon AC, Areán PA. Psychosocial interventions for late-life major depression: evidence-based treatments, predictors of treatment outcomes, and moderators of treatment effects. Psychiatr Clin North Am. 2011;34:377-401, viii.

2. Areán PA, Cook BL. Psychotherapy and combined psychotherapy/pharmacotherapy for late life depression. Biol Psychiatry. 2002;52:293-303.

3. Gallagher-Thompson D, Steffen AM. Comparative effects of cognitive-behavioral and brief psychodynamic psychotherapies for depressed family caregivers. J Consult Clin Psychol. 1994;62:543-549.

Click here for full reference list

Psychiatric TimesThis article originally appeared on:

APA Reference
Martin, L. (2012). Psychotherapy for Late-Life Depression: What Works, What Doesn’t, and Practical Tips. Psych Central.Retrieved on October 3, 2012, from http://pro.psychcentral.com/2012/psychotherapy-for-late-life-depression-what-works-what-doesnt-and-practical-tips/001026.html


Last reviewed: By John M. Grohol, Psy.D. on 4 Sep 2012


Posted by: Dr. Dan L. Boen AT 10:39 am   |  Permalink   |  Email
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