This Month’s Expert: Michael Posternak, M.D., on Choosing Antidepressants
By Michael Posternak, M.D.
TCR: Dr. Posternak, thank you for agreeing to speak with us and I also want to thank you for having collaborated on a series of research articles that have been extremely useful to clinicians. I’d like to start with your article about factors that we use when we are selecting antidepressants (Zimmerman, Posternak, et. al., Am J Psychiatry 161:1285-1289, July 2004). How did that study come about?
Dr. Posternak: Most psychiatrists pretty much agree that all antidepressants are more or less equally effective. So if you start with that premise and you have 10-15 antidepressants out there, why are you picking one versus another? And what algorithm are we all using? Dr. Zimmerman developed a questionnaire for psychiatrists to fill out immediately after they wrote antidepressant prescriptions. We asked, “What influenced you to choose that medication?”
TCR: And what were your findings?
Dr. Posternak: We found that there were three compelling factors: The first was avoiding specific side effects, the second was the presence of comorbid psychiatric disorders, and the third was the presence of specific clinical symptoms. For example, many people wanted to avoid sexual side effects or weight gain and would choose meds based on this. And if a patient had depression plus panic disorder, for example, we would lean toward the SSRIs. And if someone’s clinical profile included both insomnia and poor appetite, we might choose Remeron (mirtazapine). As you can see, there was nothing terribly earth shattering about any of these findings, but they give us insight into what factors people are actually considering when they prescribe an antidepressant.
TCR: Do you find that there is much research support for the validity of these factors?
Dr. Posternak: No, because there isn’t much research to begin with. For example, if you look for papers on antidepressant efficacy for patients with comorbidity (and comorbidity is the norm rather than the exception) there is almost nothing out there. Most treatment trials assessing depression exclude patients with comorbid disorders or do not assess for them. A prototypical example would be the common practice of avoiding bupropion in patients with depression and significant anxiety. And yet John Rush and colleagues have published three papers showing no difference between Wellbutrin and sertaline in efficacy for anxiety in depressed patients (see, for example, J Clin Psychiatry 2001; 62:776-781).
TCR: You and Dr. Zimmerman have also written about the concept of “remission,” which has become the gold standard for antidepressant trials lately. How do you suggest we decide when a patient has responded well enough to an antidepressant?
Dr. Posternak: I think that is a terrific question. Even from a research standpoint, there is something problematic about using “remission” as the endpoint of a study. The problem is that, both in clinical trials and in our practices, patients start off with different degrees of depression. So let’s say you define your endpoint as a HAM-D score of 7 or less. A patient who starts at a HAM-D of 26 and has a 50% improvement will not meet criteria for remission, but will nonetheless feel much better than when they started the medication. Many patients may not reach the formally-defined point of remission, and may have residual symptoms and yet you and your patient may decide that you are satisfied with that response and you don’t want to keep pushing the dose or switching medications.
TCR: What research instruments would you suggest for use in our practices?
Dr. Posternak: Over the years, I have come to conclude that the CGI (Clinical Global Impression) is a pretty good judge. I ask patients, “Do you think your depression is partially improved or much improved since starting medication?” Usually if they are “much improved,” this corresponds with a greater than 50 percent improvement on the HAM-D, and most of us are not going to switch medications at that point. You might still try to tweak the regimen to help them sleep or improve their energy, but generally we would say that we have found something that seems to be worth sticking to.
TCR: And what are your favorite medication manipulations for tweaking the regiment to enhance response?
Dr. Posternak: The two that I use the most, and that I think are the simplest and most effective are: 1) Ensuring that patients get adequate sleep, and 2) Enhancing energy.
TCR: Tell me a bit about sleep. Why is this so important in resolving depression?
Dr. Posternak: When people don’t sleep it affects many other things like energy, concentration and mood, often leading to irritability. So one of the simplest interventions that I can do for my patients is to help them get a good night’s sleep. Some people are reluctant to take a sleep medicine and if so, I say to them, “This is important for your depressive illness, because if you don’t sleep well the research studies have demonstrated that you are going to be at higher risk for relapse.”
TCR: What are your “go-to” agents for insomnia?
Dr. Posternak: Well I often start with trazodone, because it is safe, it generally doesn’t lead to tolerance, and people like the fact that it has no addictive potential. I usually start at 25 mg because I don’t want them to get turned off from being groggy in the morning. If it doesn’t work at that dose, I will titrate the dose fairly aggressively until they are either sleeping well or they have limiting side effects. You can safely go up to 600 mg, which is an antidepressant dosage.
TCR: What do you do if trazodone doesn’t work?
Dr. Posternak: I like Remeron, but very often this is not an option because people are concerned about weight gain, so then I will move to benzodiazepines.
TCR: What about the non-benzo’s, like Ambien or Sonata?
Dr. Posternak: I rarely go to these next for a very simple reason, which is cost. I generally stick with the generics. I think that they are at least as effective and they are a fraction of the cost. My sense is that the non-benzos are marketed based on their lower risk of dependence or addiction, and yet I find in my clinical practice that people do not get addicted to sleeping pills. It just doesn’t happen, so why should we spend so much money on these other medications? I explain that to patients.
TCR: What benzos do you usually use?
Dr. Posternak: I simply use Valium (diazepam), 5-10 mg.
TCR: Why Valium and not Ativan (lorazepam) or Restoril (temazepam), or the others?
Dr. Posternak: Lorazepam is short-acting, so I find it less effective. Xanax (alprazolam) is the same thing; it is a very short-acting medication. It may help them fall asleep. It may even help the first few nights, but I find if I am treating more long-term insomnia that tolerance builds up. Restoril should be as effective as Valium in theory based on half-life, but in clinical practice I haven’t found that to be the case.
TCR: What about Klonopin?
Dr. Posternak: Klonopin I find is less sedating, which is useful for a daytime anxiolytic but I find that it is just not as effective as a hypnotic.
TCR: You also mentioned enhancing energy?
Dr. Posternak: Yes, and what I use for this, and what I feel is underutilized, is psychostimulants. A lot of times people are depressed, are not as happy as they would like, because they are not as focused or their energy isn’t as good. Like sleeping pills, stimulants have an immediate effect, which is nice and it is quite dramatic.
TCR: And then which specific medication do you like to use?
Dr. Posternak: Well, being boring and simple, I start with plain old generic Ritalin (methylphenidate) and I dose it 5 to 10 mg twice a day, early morning and early afternoon.
TCR: And what do you tell patients when you give it to them about potential side effects?
Dr. Posternak: I tell them that it is very well-tolerated, that its purpose is to increase their energy and help their concentration, and that we can increase the dose if it doesn’t work. As far as side effects, I’ll say, “You might get a tremor, it could increase your anxiety, it could cause insomnia, it could increase your heart rate, but in general people tolerate it very well.”
TCR: Do you see problems with stimulant abuse?
Dr. Posternak: A small minority of my patients report that they tended to get euphoric on stimulants and then crash afterwards. But this is rare.
TCR: How do you deal with prescribing stimulants long term?
Dr. Posternak: Once they are stable and I want to see them every three months I give them two post-dated prescriptions.
TCR: Is there anything else that you have been doing lately for antidepressant augmentation?
Dr. Posternak: Yes, we just completed a randomized trial of T3 (triidothyronine, trade name “Cytomel”) augmentation, and we found that it accelerated antidepressant response in comparison to placebo augmentation.
TCR: What dose did you use?
Dr. Posternak: 25 mcg QD.
TCR: Many psychiatrists are tempted to use Cytomel but are concerned about causing medical problems by adding thyroid hormone to our patients’ systems. What are your thoughts about that?
Dr. Posternak: I don’t think that they have to be concerned about that. If someone has an arrhythmia, I wouldn’t use it, but otherwise 25 mcg. is a very low dose; it is quite safe and you really don’t have to be concerned about that from a clinical standpoint.
TCR: And before you start, do you recommend that we get any particular labs?
Dr. Posternak: No, it is not necessary. If you use T3 and it works, then you will want to get a TSH at some point just to make sure you are not affecting the thyroid gland. But if it doesn’t work, you’ll just stop the medication and you’ll save your patient a blood draw.
This article originally appeared in: Click on the image to learn more or subscribe today!
This article was published in print 1/2006 in Volume:Issue 4:1.
APA Reference The Carlat Psychiatry Report. (2013). This Month’s Expert: Michael Posternak, M.D., on Choosing Antidepressants. Psych Central. Retrieved on August 7, 2013, from http://pro.psychcentral.com/2013/this-months-expert-michael-posternak-m-d-on-choosing-antidepressants/002640.html
Last reviewed: By John M. Grohol, Psy.D. on 30 Jul 2013
Posted by: Dr. Dan L. Boen AT 08:39 am
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Communities that pull together in a crisis are happier.
What has happened to people's happiness all around the world as they've faced the economic crisis? How have they coped with job losses, less money coming in, the sense of despair and lack of control over a nightmare that seems to have no end?
That's the question that Helliwell et al. (2013) ask in a new paper in the Journal of Happiness Studies.
They guessed that one answer is one of the oldest in human civilisation: by pulling together.
Pulling together, though, has a new fancy name: social capital. Here are the kinds of things which tell you whether a group of people have 'social capital':
How many people do volunteer work in the community?
How many people have done a favour for a neighbour in the last month?
How many people have given a little money to charity (about $25)?
How many people regularly have meals together as a family?
These go on and on, but you get the general idea. It's essentially doing nice things for other people around you; they don't have to be that dramatic like donating a liver, just little boyscout-type activities count.
They then looked at a huge amount of data on both social capital and happiness across 255 metropolitan areas in the US and drew this conclusion:
"...communities with greater social engagement are happier than otherwise equivalent communities and that life evaluations fell by less, in response to unemployment increases, in those communities with high levels of a broad measure of social engagement."
So social capital has a protective effect: by pulling together through doing little things for each other, people helped keep their spirits up during the economic crisis.
Happy countries
Helliwell et al. (2013) also found the same when they compared between countries, not just between US metropolitan areas. They divided countries into those which had become happier since the crisis, those which remained about the same and those that had become less happy.
In the group of countries with falling levels of happiness (which includes the US but not the UK):
"We saw that average happiness drops were far greater than could be explained by their lower levels of GDP per capita, suggesting that social capital and other key supports for happiness were damaged during the crisis and its aftermath."
In contrast, South Korea is a country whose average levels of happiness have rocketed up since the economic crisis. This is partly because the economy has recovered remarkably well, but maybe also because of policies that have encouraged social capital. Here's the President of South Korea explaining:
"Korea has already proposed a new way forward from the global crisis. [...] We decided to share the burden. Employees chose to sacrifice a cut in their own salaries and companies accepted to take cuts in their own profits because they wanted to save their employees and co-workers from losing their jobs."
More than social: pro-social
The explanation for these effects is that humans are fundamentally pro-social so:
"...they get happiness not just from doing things with others, but from doing things both with and for others. Despite a wealth of findings that those who do things for others gain a bigger happiness boost than do the recipients of generosity, people underestimate the happiness gains from unselfish acts done with and for others"
→ This site is written by psychologist and author, Jeremy Dean. It is completely free. Please help it continue by spreading the word. Thank you.
Making Habits, Breaking Habits
In his new book, Jeremy Dean--psychologist and author of PsyBlog--looks at how habits work, why they are so hard to change, and how to break bad old cycles and develop new healthy, creative, happy habits.
Can belief in God predict how someone responds to mental health treatment? A recent study suggests it might.
Researchers at McLean Hospital in Belmont, Mass., enrolled 159 men and women in a cognitive behavioral therapy program that involved, on average, 10 daylong sessions of group therapy, individual counseling and, in some cases, medications. About 60 percent of the participants were being treated for depression, while others had bipolar disorder, anxiety or other diagnoses.
All were asked to rate their spirituality by answering a single question: “To what extent do you believe in God?”
The results, published in The Journal of Affective Disorders, revealed that about 80 percent of participants reported some belief in God. Strength of belief was unrelated to the severity of initial symptoms. Over all, those who rated their spiritual belief as most important to them appeared to be less depressed after treatment than those with little or no belief. They also appeared less likely to engage in self-harming behaviors.
“Patients who had higher levels of belief in God demonstrated more effects of treatment,” said the study’s lead author, David H. Rosmarin, a psychologist at McLean Hospital and director of the Center for Anxiety in New York. “They seemed to get more bang for their buck, so to speak.”
One possible reason for this, he said, is that “patients who had more faith in God also had more faith in treatment. They were more likely to believe that the treatment would help them, and they were more likely to see it as credible and real.”
Of the 56 people who expressed the strongest belief in God, 27 also had very high expectations for the treatment, while nine had very low expectations. In contrast, of the 30 patients who said they had no belief in God or a higher power, only two had high expectations for the treatment.
“It’s one of the first studies I’ve read that actually looks at perhaps a mechanism” for “why we see some correlation between the strength of religious commitment or the strength of spiritual commitment and better outcomes,” said Dr. Marilyn Baetz, a psychiatrist at the University of Saskatchewan who studies the effects of religion and spirituality on mental health. An earlier yearlong study by Dr. Baetz and her colleagues found that people with panic disorder who rated religion as “very important” to them responded better to cognitive behavioral therapy, showing less stress and anxiety, than those who rated religion as less important.
Assessing how religious practices affect health is difficult, in part because researchers can’t randomly assign people to embrace religion or not, the way they might assign participants in a drug test to take a new medication or a placebo. Most studies of this relationship are observational, and people who are more or less religious may differ in other important ways, making it difficult to know whether religious faith is actually causing the effect or if it is a result of to some other factor.
But teasing out the effects of faith on treatment outcomes may be an important goal. Most Americans believe in God — 92 percent, according to a 2011 Gallup poll, though the percentage among mental health professionals may be considerably lower. One study from 2003 found that 65 percent of psychiatrists said they believed in God, compared with 77 percent of other physicians.
Previous research has associated church attendance with increased life expectancy and, in some studies, a reduced risk of depression. But this study looked not at how often the participants went to church or at their religious affiliation but at their belief in a higher power.
“I think it’s a scientifically sound way of measuring things that have to do with people’s experience of spirituality,” said Torrey Creed, a psychologist at the Beck Institute for Cognitive Behavior Therapy, near Philadelphia. “I think about this as a study of cognitive styles, that there’s a pattern of thinking that helps people get better in treatment. And two examples of this pattern of thinking are ‘I believe in treatment’ and ‘I believe in God.’”
Randi McCabe, director of the Anxiety Treatment and Research Center at St. Joseph’s Healthcare in Ontario, said, “People’s belief that something is going to work will make it work for a significant proportion of people,” similar to the placebo effect.
“Your belief that you’re going to get better, your attitude, does influence how you feel,” Dr. McCabe continued. “And really, in cognitive behavior therapy, that is really what we’re trying to change: people’s beliefs, how they’re seeing their world, their perspective.”
Dr. Rosmarin offered further explanation for why religious faith might aid psychiatric treatment. “There’s a vulnerability associated with physicality,” he said. “I think people, psychiatric patients in particular, might recognize that vulnerability and recognize that things can’t be counted on.
“Sometimes medications don’t work, and sometimes psychotherapy doesn’t work,” he continued. “But if someone believes in something that is metaphysical, if someone believes in something spiritual, which would ostensibly be eternal, permanent, unwavering, omnipotent, then that could be an important resource to them, particularly in times of emotional distress.”
Posted by: Dr. Dan L. Boen AT 01:10 pm
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As a girl, Father's Day underscored the other 364 days of the year, bringing a blaring reminder there was no father around to celebrate. The absence of that single, critical male relationship didn't just make me feel lonely and left out, it impacted my understanding of the world and my place in it. .
After reflecting on how my father's absence has impacted me as a girl and now woman, wife and mother in my memoir, The Artist's Daughter, others have shared with me similar stories of abandonment and struggle. Our collective stories confirm what statistics scream: that the bond from father to child is essential. Whether our dads were good, bad, or not there at all, this relationship shapes our understanding of our very identities.
Yet, we live in a country where too many of us have broken relationships with Dad. In America, 1 in 3 kids live apart from their biological fathers. A recent Washington Post article addressed the dad dilemma with the eye-catching title: The new F-Word – Father. In it, Kathleen Parker addresses a question being asked as we discuss the latest stats on America's female breadwinners: In the evolving 21st-century economy, "what are men good for?"
Parker concludes:
Women have become more self-sufficient (a good thing) and, given that they still do the lion's share of housework and child rearing, why, really, should they invite a man to the clutter? Because, simply, children need a father… . Deep in the marrow of every human child burbles a question far more profound than those currently occupying coffee klatches: Who is my daddy? And sadly these days, where is he?
While single mothers may have enough grit, love, and know-how to raise us, the absence of Dad will still have its effect. Study after study shows that a children with absent fathers are more likely to live in poverty, drop out of high school, have a failing marriage, even be incarcerated than those whose fathers are involved in their lives. The data confirms how much a father matters to a child's physical and emotional wellbeing and development. Fatherhood, it turns out, is a social justice issue.
But that's unfortunately where the church often ends the conversation. We lament the shift in the family structure, express outrage at the latest statistics. We bring absent fathers into the culture wars, wrapping them up with changing definitions of marriage and family. As we preach and debate, Father's Days go by and millions of children remain without the single, most influential male relationship that will continue to shape their identity throughout their lives.
If we take James' words seriously and see true religion as caring for orphans and widows (James 1:27), we must see strong parenting, orphan prevention, as part of the call. How do we practically support the idea of children maintaining relationships with their fathers, if the ultimate responsibility lies on the father himself?
We can—without fanfare—support the fathers we know, including those that live with their children and those that do not. As Christians, we can offer dads opportunities to connect with their kids. That doesn't mean plan another church carnival or father-daughter dance, though those are nice events.
Instead, as Christian families and communities, we should help foster organic relationships between fathers and children. Though relationships can be redeemed at any stage, the earlier the father-child bond is cultivated the larger the benefit is to the child. We can invite a dad and his kids into our lives, the things we are already doing, so they can experience life together. We support fathers as we ask a family over for dinner, ask them to go camping with us or signing up for T-ball together. Putting on the father-daughter dance is easier to execute because at the end of the night it's over, while organic relationships are open-ended. It's this side-by-side kind of journey that presents father and child the opportunity to be together.
We support mom and dad's relationship, despite the cultural shifts around marriage. Many couples choose to have kids before deciding if they will marry; the latest figures show 48 percent of all first births are to single women. While plenty of single or remarried dads remain committed to their children despite not being in a relationship with their mother, that arrangement becomes more difficult and more complicated. Quite simply, a father is more likely to be involved a child's life if he and the child's mother are together.
So, as Christians who care about fatherhood, we need to affirm the importance of the relationship between mom and dad, even if they aren't married. For some of us this is uncomfortable territory, to support relationships that may not look like we'd like. We can practically support these couples so they don't feel isolated. When we offer to babysit for friends to go to counseling or out to dinner, we are we are helping build healthier relationships—both between parenting partners and between parent and child. When we pray with and for couples who are struggling, when we openly discuss our own struggles in marriage we are modeling sticking it out in the difficult and that in turn supports fathers who are present.
Sadly, we must acknowledge that not every father is a safe person, and a severed relationship is in the child and mother's best interests. However, in the cases where connection and reconciliation is possible, we can extend our support.
We do it all clothed in love. Our goal is not to fight a culture war, but to love God with our whole hearts and to love others as we want to be loved. Our goal is to care for orphans and widows, to foster loving earthly families that reflect the love of our Divine Father. To do this, we as Christians must act clothed in love for parents and kids. Supporting fatherhood does not require a project or political campaign, but something much more meaningful: actual relationships with people in our midst. We should acknowledge and be grateful for the responsible, caring fathers we know. We should be patient and helpful with men working towards being better fathers. We should encourage reunion and reconciliation for fathers who live away from their children or who have grown distant over time.
God refers to himself as "Father" on purpose. The title embodies trust, provision and security. Let us help one another move closer to that holy representation, knowing we will always be stumbling and always fall short, but it is a critical relationship worth nurturing.
Alexandra Kuykendall is Mom and Leader Content Editor at MOPS International (Mothers of Preschoolers) a ministry to moms of young kids. Her memoir, The Artist's Daughter, explores her own journey of identity development and significance from childhood to marriage and motherhood. Connect with her at AlexandraKuykendall.com
Posted by: Dr. Dan L. Boen AT 10:27 am
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Meditation That Eases Anxiety? Brain Scans Show Us How
Rick Nauert PhD
By Rick Nauert PhDSenior News Editor Reviewed by John M. Grohol, Psy.D. on June 5, 2013
Research and technology have advanced to the point where scientists can observe the way in which meditation affects the brain to reduce anxiety.
Using special imaging technology, researchers from Wake Forest Baptist Medical Center report that they have determined the way in which meditation affects or acts upon certain brain mechanisms.
“Although we’ve known that meditation can reduce anxiety, we hadn’t identified the specific brain mechanisms involved in relieving anxiety in healthy individuals,” said Fadel Zeidan, Ph.D., the lead author of the study.
“In this study, we were able to see which areas of the brain were activated and which were deactivated during meditation-related anxiety relief.”
In the study, published in the journal Social Cognitive and Affective Neuroscience, researchers followed 15 healthy volunteers with normal levels of everyday anxiety. Participants did not have previous meditation experience or diagnosed anxiety disorders.
All subjects participated in four 20-minute classes to learn a technique known as mindfulness meditation.
In this form of meditation, people are taught to focus on breath and body sensations and to non-judgmentally evaluate distracting thoughts and emotions.
Both before and after meditation training, the study participants’ brain activity was examined using a special type of imaging — arterial spin labeling magnetic resonance imaging — that is very effective at imaging brain processes, such as meditation.
In addition, anxiety reports were measured before and after brain scanning.
The majority of study participants reported decreases in anxiety. Researchers found that meditation reduced anxiety ratings by as much as 39 percent.
“This showed that just a few minutes of mindfulness meditation can help reduce normal everyday anxiety,” Zeidan said.
Researchers discovered that meditation-related anxiety relief is associated with activation of the areas of the brain involved with executive-level function (the anterior cingulate cortex and ventromedial prefrontal cortex).
During meditation, there was more activity in the ventromedial prefrontal cortex, the area of the brain that controls worrying.
In addition, when activity increased in the anterior cingulate cortex – the area that governs thinking and emotion – anxiety decreased.
“Mindfulness is premised on sustaining attention in the present moment and controlling the way we react to daily thoughts and feelings,” Zeidan said.
“Interestingly, the present findings reveal that the brain regions associated with meditation-related anxiety relief are remarkably consistent with the principles of being mindful.”
While meditation is becoming generally accepted as a method to significantly reduce anxiety in patients with generalized anxiety and depression disorder, the current study (using sophisticated neuroimaging experiment technology) is the first to show the brain mechanisms associated with meditation-related anxiety relief in healthy people.
APA Reference Nauert PhD, R. (2013). Meditation That Eases Anxiety? Brain Scans Show Us How. Psych Central. Retrieved on June 6, 2013, from http://psychcentral.com/news/2013/06/05/meditation-that-eases-anxiety-brain-scans-show-us-how/55617.html
More than one-third of American marriages today get their start online — and those marriages are more satisfying and are less likely to end in divorce, according to a new study.
The research, which was funded by the online-dating site eHarmony, was published in the Proceedings of the National Academy of Sciences.
“Meeting online is no longer an anomaly, and the prospects are good,” says lead author John Cacioppo, a professor of social psychology at the University of Chicago. “That was surprising to me. I didn’t expect that.”
The research involved a Harris Poll of nearly 20,000 Americans who got married between 2005 and 2012. It found that 35% of people met online. But while 8% of those who met off-line got separated or divorced, the percentage for those who met online was just 6%. Although these differences narrowed after controlling for factors that affect divorce rates such as income, education and number of years married, they remained significant, Cacioppo says.
Income, however, was a big factor: According to the study, just 3% of people making less than $15,000 annually met online, while a whopping 41% of those making $100,000 or more met partners online. Since greater income is linked with happier marriages and less divorce, controlling for income reduced the differences seen between those who met online and off.
The study also found increased marital satisfaction among people meeting online, compared with off-line venues like at college or in bars.
Eli Finkel, a professor of social psychology at Northwestern University who has published research critical of the online-dating industry, said in e-mail to several journalists that the research is “impressive” with a “large sample” and “fascinating findings.” However, Finkel thinks that the conclusion that online marriages are better is premature.
“The study is a good one,” he says. “It suggests that one can meet a serious romantic partner online. That’s a big deal. But any conclusions that online meeting is better than off-line meeting overstep the evidence.” Finkel explains that the differences between the two venues overall are not large enough to support this claim.
The study does not suggest that meeting online in and of itself actually improves matchmaking or somehow causes marriages to be better. In fact, both online and off, different types of meeting places were linked with different marital prospects.
Not surprisingly, for example, growing up together or meeting at school, through friends or through a religious group were linked with more satisfying marriages than meeting at a bar or club or on a blind date. Oddly, however, meeting at work was just as bad as finding a spouse at a bar or nightclub.
In terms of online venues, marriages begun in chat rooms or online communities were less satisfying than those initiated via online-dating sites, although dating sites themselves varied in terms of the marital satisfaction reported.
“In chat rooms and off-line, you meet only the people who are around and not large numbers of people,” Cacioppo says as a possible explanation for this finding. “If you do online dating, all of sudden, there’s a world of possibilities.”
Another potential explanation for differences between online and off-line marital success has to do with personality. “If you have good impulse control, you may be more likely to meet your spouse [deliberately] online rather than impulsively at a bar,” he says.
Of dating sites, eHarmony fared particularly well — a finding that may raise suspicion because of the funding source. However, the study could not determine whether or not this has anything to do with how it matches people or anything else specific to the site. Because it advertises itself to those who are seeking a spouse, eHarmony may simply attract more people who are ready to settle down. A marriage-focused website, Cacioppo says, “is not appealing if you are just looking for a hookup.”
Cacioppo notes one additional reason why the online world might be conducive to matchmaking — an explanation that might surprise many online daters who have met people whose bodies didn’t exactly match their pictures. “There is some experimental work going back more than 30 years now, which [shows that] meeting [via computer or text] leads people on average to be a little more honest and self-disclosing,” he says.
“When you are face to face, there is face-saving,” he explains. “When you don’t [see each other], you can be more comfortable being yourself.” Being more open, the same studies found, led people to like each other more — something that could obviously influence romantic connections.
When it comes to playing Cupid, it’s still not clear whether online dating ultimately makes better matches. But given the large number of people who meet their mates this way, the good news is that at least it doesn’t seem to make matters any worse.
Future Criminals Can Be Identified as Early as Age 6
Fran Lowry
Mar 22, 2013
Conduct problems and hurtful and uncaring behavior in children as young as 6 years are accurate predictors of violent and nonviolent criminal convictions in young adulthood, new research shows.
Investigators from the Université de Montréal in Canada found that negative behavior at age 6, such as fighting, disobedience, and a lack of empathy, predicted criminal convictions by age 24.
"Most nonviolent and violent crimes are committed by a small group of males and females who display conduct problems that onset in childhood and remain stable across the lifespan," study author Sheilagh Hodgins, PhD, told Medscape Medical News.
"If their conduct problems could be identified and reduced early in life, this would potentially allow these children to alter their developmental trajectories, live healthy and happy lives, and to make positive rather than negative contributions to our society."
The study is published in the March issue of the Canadian Journal of Psychiatry.
Need for Early Intervention
The aim for the study was to further the understanding of how to prevent crime and thereby reduce the human and economic costs associated with criminal activity, she said.
The researchers examined teacher assessments of conduct problems such as fighting, disobedience, school absenteeism, destruction of property, theft, lying, bullying, blaming others, and a lack of empathy among students at age 6 years.
The 1593 boys and 1423 girls were recruited when they were in kindergarten at French-speaking public schools in the province of Quebec from 1986 to 1987.
The same groups of boys and girls were assessed again at age 10 years. They were also assessed for aggressive behavior at age 12.
The researchers later obtained juvenile and adult criminal records and found that teacher ratings of pupils' behaviors at ages 6 and 10 were associated with criminal convictions between the ages of 12 and 24.
Specifically, they found that boys aged 6 who were rated by their teachers as having the highest degree of conduct behavior problems and hurtful and uncaring behaviors were 4 times more likely to be convicted of violent crimes and 5 times more likely to be convicted of nonviolent crimes than boys with lower ratings.
Similarly, girls aged 6 with high ratings for conduct problems and hurtful and uncaring behaviors were 5 times more likely than girls with lower ratings to have a conviction for nonviolent crimes by age 24.
Boys who had high ratings for uncaring and hurtful behaviors but who did not have conduct behavior problems also had an elevated risk for violent and nonviolent crime convictions, and girls with high ratings for uncaring and hurtful behaviors but no conduct behavior problems had a high risk for nonviolent crime convictions.
Such students, Dr. Hodgins added, require "interventions to reduce these behaviors at an early age, which, in turn, will promote better relations with family, peers, and teachers, better academic performance, and the development of prosocial skills."
Pediatricians may be able to identify children who exhibit these behaviors by observing and talking to the children and their parents, she added.
"When these problems are thought to be present, families could be referred to child psychiatric services or other agencies that provide parent training and other interventions aimed at reducing these problems," she said.
Reservations
Commenting on the study for Medscape Medical News, Michael Brody, MD, a child psychiatrist in private practice in Potomac, Maryland, said he has reservations about the study.
Dr. Brody, who was not involved in the research, said he was concerned about "putting a label on a child as young as 6. If you label the child as likely to become a criminal, it could have problems down the road."
Nevertheless, if labeling a child would result in some guarantee of treatment or intervention, it might be worthwhile, Dr. Brody said.
"Often, it does not. In fact, this is a major problem with all of these studies that call for intervention. In our country, there just are no facilities to deal with these children. Even when the kid does something really terrible, who is going to see the child? All the services are overwhelmed. The resources to deal with these problems are nonexistent. Therefore, I have problems about the practicality of this research," he said.
Finally, Dr. Brody questioned the ability of teachers to accurately predict criminality.
"I think teachers are great. What they do is unbelievable, especially in the younger grades, to sit in the classroom for 6 or 7 hours with the kids, but I just wonder about their ability to accurately evaluate them. [The researchers] based their predictions on observations that the child was bullying or hitting or biting and so forth, but I question the reliability of their observations."
The study was supported by the Groupe de Recherche sur L'Inadaptation Psychosociale and the Centre de Recherche at the Institut Philippe Pinel de Montreal. Dr. Hodgins and Dr. Brody report no relevant financial relationships.
Why we're more down than ever—and the crucial role churches play in healing.
Dan G. Blazer [ posted 3/06/2009 ]
The church is God's hospital. It has always been full of people on the mend. Jesus himself made a point of inviting the lame, the blind, and the possessed to be healed and to accompany him in his ministry, an invitation often spurned by those who thought they were fine as is. We should not be surprised, then, that the depressed populate not only secular hospitals and clinics, but our churches as well. Yet depression remains both familiar and mysterious to pastors and lay church leaders, not to mention to those who share a pew with depressed persons.
Virtually everyone has experienced a "down" day, often for no clear reason. We might say we "woke up on the wrong side of the bed," are "out of sorts," or just "in a funk." Such polite references are commonplace in America. Yet as familiar as melancholic periods are to us, the depths of a severe depression remain a mystery. We may grasp in part the distress of King David: "Be merciful to me, O Lord, for I am in distress; my eyes grow weak with sorrow, my soul and my body with grief. My life is consumed by anguish and my years by groaning; my strength fails because of my affliction, and my bones grow weak" (Ps. 31:9-10). But most of us have no idea what David meant when he further lamented, "I am forgotten by them as though I were dead" (v.12). Severe depression is often beyond description. And when such deep and painful feelings cannot be explained, they cut to the heart of one's spiritual being.
Humans are intricately complex creatures. When things go wrong in us, they do so in myriad and nuanced ways. If churches want to effectively minister to the whole of fallen humanity, they must reckon with this complexity. Depression indicates that something is amiss. But what? And what should churches be doing about it?
What is depression?
First we need to clarify what we are talking about. In order to distinguish severe or "major depression" from everyday blues, the American Psychiatric Association offers the following diagnostic criteria:
Major depression is diagnosed when an adult exhibits one or both of two core symptoms (depressed mood and lack of interest), along with four or more of the following symptoms, for at least two weeks: feelings of worthlessness or inappropriate guilt; diminished ability to concentrate or make decisions; fatigue; psychomotor agitation (cannot sit still) or retardation (just sitting around); insomnia or hypersomnia (sleeping too much); significant decrease or increase in weight or appetite; and recurrent thoughts of death or suicidal ideation.
This clinical definition is sterile, however, and fails to capture the unique quality of the severely depressed person's suffering.
Deep depression is embodied emotional suffering. It is not simply a state of mind or a negative view of life but something that affects our physical being as well. Signs of a severe episode of depression include unfounded negative evaluations of friends, family, and oneself, emotional "pain," physical problems such as lethargy, difficulty getting one's thoughts together, and virtually no interest in one's surroundings. Though most of us know at least an acquaintance who has committed suicide, this tragic act baffles us perhaps as much as it pains us. "I just don't understand," we say. The irony is that survivors of serious suicide attempts frequently reflect on those attempts with a similar attitude: "I have no idea what came over me." The pain and mental dysfunction of major depression are that deep.
How big is the problem?
However we choose to define depression, both its frequency and its disruption of normal life are staggering. The World Health Organization named depression the second most common cause of disability worldwide after cardiovascular disease, and it is expected to become number one in the next ten years. In the United States, 5 to 10 percent of adults currently experience the symptoms of major depression (as previously defined), and up to 25 percent meet the diagnostic criteria during their lifetime, making it one of the most common conditions treated by primary care physicians. At any given time, around 15 percent of American adults are taking antidepressant medications.
Studies of religious groups, from Orthodox Jews to evangelical Christians, reveal no evidence that the frequency of depression varies across religious groups or between those who attend religious services and those who do not. So in a typical congregation of 200 adults, 50 attendees will experience depression at some point, and at least 30 are currently taking antidepressants.
How do we explain these numbers? In part, they result from a two-pronged shift in cultural attitudes about depression. Groups such as the National Alliance on Mental Illness and pharmaceutical companies have aggressively promoted the view that depression is not a character flaw but a biological problem (a disease) in need of a biological solution (a drug). The efforts to medicalize depression have helped to remove the stigma attached to it and convince the public that it's not something to hide. Consequently, depression has come out of the closet.
Some critics argue that along with the disease view of depression comes a lowered diagnostic threshold. Professors Allan Horwitz and Jerome Wakefield argue in The Loss of Sadness (Oxford, 2007) that psychiatrists no longer provide room for their clients' sadness or life's usual ups and downs, labeling even normal mood fluctuations "depression." (Everyday conversation reflects this assumption. When asked how we are doing, we commonly answer "great" or at least "good." If we reveal that we're "fine"—or worse, just "okay"—people tend to assume something is wrong and begin probing.)
Critics like Horwitz and Wakefield are half right. It is true that the mental health community has lowered the threshold for recognizing depression. Yet when we trace depression in the United States over the past 20 years using fixed criteria—the very research I do—we still see a significant increase in frequency. So although the numbers may be inflated, and this bump unquestionably serves the profit margins of pharmaceutical companies, we nevertheless have a substantial, documented increase to try to explain.
Our society has reaped considerable benefit from casting a wide net and assuming that everything caught is a disease. We now are more attuned to depression's burden of emotional suffering, better understand biological factors, and have medications that address those factors. We should be thankful for these significant gains.
Shrunken humanity
Yet redefining depression broadly as a disease has some untoward consequences. This model rightly acknowledges the biological aspect of human nature and how it can become disordered. But it fails to consider other dimensions at play. For example, the disease model ignores social environments as possible contributors to depression, viewing depressed persons as isolated individuals with a strong boundary between their bodies and everything outside. Depressed persons are reduced to broken bodies and brains that need fixing.
Browse any major psychiatric journal and you will read that our genes are the first cause of depression. Given certain environmental challenges, depression emerges. This is true, but it does not go far enough. Most have heard that depression can be caused by a chemical imbalance (such as a deficit in serotonin). Though the biological aspect of depression is more complex than a simple chemical imbalance, depression is nonetheless associated with poor regulation of the chemical messengers in our brains. This is why certain medications can relieve symptoms of moderate to severe depression. But this is not a new biological development; our bodies have not changed significantly over the past 100 years.
We also know that distorted thoughts contribute to depression. Those who are depressed do not evaluate themselves accurately (i.e., I am not as good as others). They fear that their selves are disintegrating (i.e., I am falling apart). They depreciate their value to others (i.e., I am of very little benefit to my family). And they believe they do not have control over their bodies (i.e., I just cannot make myself eat). Aaron Beck, the father of the most popular psychotherapy today, cognitive behavioral therapy (CBT), proposes that depression derives in large part from these cognitive distortions. Depression is relieved by bringing the distorted views more in line with reality. Evidence supports Beck's contention, though not in all cases.
But cognitive behavioral therapies have been criticized for focusing on the person as such and ignoring the context of the person within society. Psychotherapist Robert Fancher believes the CBT approach "devalues those attributes of mind most likely both to create culture and to take us beyond the status quo—imagination, passion, and the courageous, painful process of bringing new ways of thinking and living to birth. It amounts to an endorsement of the middlebrow life under the authority of 'good mental health.' " To put it more simply, cognitive therapy tends to reinforce the social norm, focusing almost exclusively on assisting the individual to adapt to the environment.
We now know much more about the neuroscience and cognitive patterns associated with depression, and have found fairly effective biological and therapeutic treatments. But we still do not have an answer to the pressing question behind this virtual epidemic: Why now? In order to get at this question, we must look beyond biological and psychological factors.
Things fall apart
"Life's tough," said one of my professors of medicine, and I knew what he meant. A young intern, I was seeking empathy after surviving a night on call without a wink of sleep. I had forgotten to look up a reference he had recommended the day before. He wanted the reference, not an excuse. But life was busy, chaotic, and demanding, and I was having trouble holding everything together.
Everyday life in 21st-century American society can be tough. The constant pressure of negotiating increasingly complex and sometimes harsh social realities takes a toll. Depression is in part a withdrawal by the weary into an inner world, an attempt to create a protective cocoon against real-world demands. Whatever personal factors contribute to an individual's depression, the broader epidemic suggests that living in disordered social conditions makes things worse.
But when compared with preceding generations of Americans, we are, on the whole, healthier, safer, better off financially, and more educated. So where is the disorder?
The truth is, these barometers don't tell the whole story. In the workplace, many of us sit in comfortable surroundings compared with those of our ancestors, who fought cold, wind, and rain. Yet we feel as much uncertainty as they did and much less control over our work. Our jobs are not secure, and due to specialization, many of us do not have the flexibility to move easily and quickly from one job to another. We work long hours, often with a sense of being "behind," and do not recognize boundaries between work and non-work. (Is the office Christmas party work or recreation?) We compare ourselves with other colleagues when comparisons are fruitless, or find ourselves being compared unfairly. When we come up short, we feel the burden of unrealistic expectations we have placed on ourselves or have received from others. We are given responsibilities with little authority and even fewer resources, and feel we have no control over job expectations or even how we use our work time. Many of us are subject to sometimes dehumanizing corporate or economic systems not of our own making and seemingly beyond our influence. We feel small, insignificant, and expendable.
Some Americans find their everyday reality so tough that they try to escape it via substance abuse, sexual promiscuity, petty theft, or embezzlement. Consider substance abuse. Nearly 15 percent of Americans will struggle with alcoholism in their lifetimes, and over 10 million Americans are actively using illicit substances. Among those who are dependent on opiates such as heroin or prescription pain relievers, depression rates may be as high as 50 percent. Though depression can lead to increased substance use, the much more common path is for substance use, often begun as an escape from the pressures of life, to lead to serious episodes of depression. At that point a vicious cycle ensues, as depression leads to increased substance use, and substance use to worsening depression.
While most of us have daily contact with many people, our generation is nevertheless a lonely crowd. In his classic Bowling Alone, sociologist Robert Putman suggests that America's stock of "social capital"—networks among individuals and the reciprocity and trustworthiness that arise from them—has declined substantially over the past few decades. We are less likely to vote, give blood, play cards, join in league bowling, or have friends or neighbors over for dinner. Perhaps some of these opportunities to build social networks have been replaced with others, such as soccer games or Facebook. Yet we are increasingly disconnected from family, neighbors, and friends.
And the nature of the relationships we do have is changing. Many have become what British sociologist Anthony Giddens labels "pure relationships"—"pure" in that they are detached from any social context, external structure, or security. There is no covenant, community, or being to orient the relationship or provide ongoing assurance, direction, and support. All of this must be generated by the relationship itself, which exacts a heavy burden. We can never relax in pure relationships because there is no pledge of fidelity or constancy on which to rest. We must "maintain" these relationships ourselves. Over time, constant vigilance and sustained insecurity often lead to frustration, anxiety, and weariness. These relationships are just too hard to keep up.
Complex societies built on interdependence require trust, yet this precious public resource continues to decline as society becomes even more complex. "Who can you believe these days?" has become a familiar refrain. Reality, we are told, has become little more than the shared worldview of small communities. In response, some encourage us to accept all views, but this leaves us disoriented. Others suggest we cling tenaciously to our views and mistrust anything new, leaving us isolated and alienated. From this double bind, the leap to a symptom of severe depression—paranoia—is not that far. The depressed lose confidence not only in themselves, but also in those around them.
Finally, no symptom is more central to depression than the loss of hope. And if last year's election cycle revealed anything, it was that hope is at a premium in American society. Fear of catastrophe—due to terrorists, financial collapse, or ecological disaster—haunts our times. Some busy themselves with survival strategies, withdrawing from communal concerns to personal preoccupations. Many more, uncertain about the future, anxiously gorge themselves on our culture's smorgasbord of instantly gratifying diversions.
Opportunity for the church
Uncertainty, insignificance, and powerlessness. Destructive, self-indulgent escape. Loneliness and isolation. Fear and distrust. Loss of hope. Retreat. Although hasty and incomplete, this sketch of the early-21st-century American cultural mood picks up dark details masked by indices of societal well-being. It also reminds us that to focus exclusively on the individual in our efforts to understand the depression epidemic is to miss the forest for the trees.
When used wisely, antidepressants and cognitive behavioral therapy can restore stability to individuals so that they can better negotiate everyday challenges. For those in the thick of paralyzing depression, the effects of medicine and CBT might even prompt gratitude for common grace. And they should give thanks. Yet neither of these approaches provides much help in understanding or addressing the more fundamental and intractable problems of which the depression epidemic is a symptom. These approaches provide needed relief, but not answers or prevention.
The medical models come up short because they can only go as far as their understanding of the subject of the problem will take them. And both slight their subject: human beings. Cultural institutions and authorities may sometimes treat human beings as if we are nothing but brains in bodies, but this does not make it so. For those with eyes to see, the depression epidemic is in part a witness to the complexity of human nature. In particular, it reminds us that we are social and spiritual (as well as physical) creatures, and that a fallen society's afflictions are often inscribed on the bodies of its members. We have misjudged humanity if we expect our bodies to be impervious to social travail. ("And being in anguish, he prayed more earnestly, and his sweat was like drops of blood falling to the ground," Luke 22:44.)
In fact, sometimes an episode of what looks like depression does not indicate that the human organism is malfunctioning, but is instead being true to her spiritual-social-physical nature. Embodied emotional pain can be an appropriate response to suffering in a world gone wrong. The author of Lamentations must have felt such pain as he gazed upon the destruction of Jerusalem around 588 B.C. "My eyes fail from weeping, I am in torment within, my heart is poured out on the ground because my people are destroyed, because children and infants faint in the streets of the city" (Lam. 2:11). Christians are called to weep with those who weep, and should welcome emotional pain that results from empathy and draws us alongside the afflicted. If we have grown numb to the pain and suffering around us, we have lost our humanity.
Christian teaching about sin and its reverberating effects frees the church from surprise about the disordered state of human affairs. We can acknowledge the effects of sin both within and without. We can look at wrecked reality squarely in the eye and call it what it is.
And thanks be to God, who raised the One who entered fully into our condition, breaking the power of sin, death, and hell, that we not only can name wrecked reality, but also lean into it on the promise that Christ is making all things new.
Those who bear the marks of despair on their bodies need a community that bears the world's only sure hope in its body. They need communities that rehearse this hope again and again and delight in their shared foretaste of God's promised world to come. They need to see that this great promise, secured by Christ's resurrection, compels us to work amidst the wreckage in hope. In so doing, the church provides her depressed members with a plausible hope and a tangible reminder of the message they most need to hear: This sin-riddled reality does not have the last word. Christ as embodied in his church is the last word.
Dan G. Blazer is J. P. Gibbons Professor of Psychiatry and Behavioral Sciences at Duke University Medical Center and author of The Age of Melancholy (Routledge, 2005). Download a companion Bible study for this article at ChristianBibleStudies.com.
To Be Happy in Jesus | Are evangelical Christians really happier than their neighbors? (March 8, 2006)
Good Question: Is Suicide Unforgivable? | Question: What is the biblical hope and comfort we can offer a suicide victim's family and friends? (July 10, 2000)
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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.
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.
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
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