Dr. Sarah Ravin - Psychologist | Eating Disorders |Body Image Issues | Depression | Anxiety | Obsessive-Compulsive Disorders | Self-Injury
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Dr. Sarah Ravin

Welcome to my professional blog. I am a Florida Licensed Psychologist and trained scientist-practitioner. In 2008, I received my Ph.D. in clinical psychology. A major component of my professional identity is staying informed about recent developments in the field so that I may provide my clients with scientifically sound information and evidence-based treatment. There is a plethora of information on the internet about Eating Disorders, Depression, Anxiety, Psychotherapy. Unfortunately, much of this information is unsubstantiated and some of it is patently false. It is my hope that by sharing my thoughts and opinions on psychological issues, with scientific research and clinical experience sprinkled in for good measure, I can help to bridge the gap between research and treatment.

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Depression Category

Sunday, June 11th, 2017

There’s an App for That!

 

Technology can be used in a variety of ways to enhance mental health and aid in recovery from psychological disorders.   For example, patients can use smart phone apps to help them track moods and symptoms, implement coping strategies, and reach out for help from clinicians and peers when needed.   Most evidence-based, behaviorally-oriented treatments for mental health problems – such as Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), and Mindfulness-Based Cognitive Therapy (MBCT) – require some degree of self-monitoring.  These types of treatments also strongly encourage daily practices to enhance well-being, such as journaling, identifying and challenging negative thoughts, diaphragmatic breathing, or mindfulness meditation.

Most of the teenagers and college students I work with are far beyond the old pen-and-paper logs and worksheets I was trained to use during graduate school.  It seems there’s an app for everything these days, and so many of these apps are relevant to mental health and wellness.  Today’s young people organize their lives on their smart phones anyway, so it is only natural that we would look to the smartphone to help them self-monitor their symptoms, complete their therapy assignments, and keep track of the strategies they use to help themselves.

There are literally hundreds, if not thousands, of apps that are useful to people with mental health conditions.  Here are a few of my favorites:

The Recovery Record app helps patients with eating disorders self-monitor their meals and snacks as well as thoughts, feelings, and urges that arise around food.

The Insight Timer app offers a meditation timer, thousands of free guided meditation tracks, groups for like-minded meditators, and the ability to track quantitative statistics such as how many minutes the user spends each day in meditation.

DBT Diary Card and Skills Coach is an electronic version of the Diary Card used in standard DBT practice, which helps the patient track target behaviors and utilize DBT skills from the modules of Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness.

The nOCD app helps patients with Obsessive Compulsive Disorder implement their exposure and response prevention treatment while compiling objective, real-time data on their experience.

I am a firm believer that what transpires in the therapist’s office is only a fraction of the treatment package.  Most of the healing process results from consistent changes that patients and their families make on a daily basis at home, at school, and in various social settings.   Thanks to modern technology, individuals who are committed to improving their well-being are now able to hold new tools, literally, in the palms of their hands.

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Tuesday, August 2nd, 2016

Fighting Stigma: The Gift of a New Generation

Somehow, sometime in the past several years, I crossed some invisible line from “young adult” to simply “adult.”  Polite strangers call me “ma’am” at least as often as they call me “miss.”  Shopping at Forever 21 now seems scandalously inappropriate.  And I can’t remember the last time I was still awake to watch Saturday Night Live.  Now that I seem to be old enough to complain about the younger generation (They think women’s empowerment is posting bikini-clad selfies!  They use social media excessively! Their pivotal relationship conversations take place over text message!), it seems only fair that I also recognize the strengths of this cohort.  And they do have tremendous strengths.

Teenagers and young adults these days, for the most part, have grown up in an era where it is socially acceptable, even encouraged, to speak openly about mental health issues.  Just about every high school and college student who walks into my office has at least a couple of friends with mental health diagnoses.   Most of my patients have one or more members of their extended family, if not their immediate family, who has dealt with a mental illness.   And they know this because they talk openly about it.

And that excessive use of social media I complained about a minute ago?  Well, social media has allowed famous people to speak candidly to a wide audience about their experiences with mental illness, seeking treatment, and ultimately recovering.   Actress Kristen Bell has struggled with depression.   Writer/producer/actress Lena Dunham has received treatment for OCD.  Singer Demi Lovato has spoken openly about her struggles with bipolar disorder and her recovery from an eating disorderJohn Green, author of The Fault in Our Stars, has chronic anxiety which he is able to control with therapy and medication.  Olympic swimmer Michael Phelps has a diagnosis of ADHD.  These individuals have been extremely successful in their professions and have had the courage to speak publicly about their psychiatric problems.

Even more courageous than these celebrities, though, are the regular people who attend school, play sports, hold down jobs, pay bills, raise families, volunteer in their communities, and maintain friendships while also dealing with mental illness.  These are the people who have a lot to lose from the stigma surrounding mental health issues.  These are also the people who have the most to gain from breaking down the stigma.

The younger generation is fighting this stigma.  Australia’s National Youth Mental Health foundation has created an organization called Headspace dedicated to supporting adolescents and young adults with mental illnesses as well as combating stigma surrounding these issues.  In the UK, Prince William, Princess Kate, and Prince Harry have created Heads Together, a charity dedicated to fighting stigma surrounding mental illness and improving the mental well-being of all citizens.  Here in the US, the National Alliance on Mental Illness (NAMI) is running a Stigma-Free campaign.

The message of these organizations is simple and straightforward: mental illness is common and treatable.  Mental health problems are as much a part of the human condition as any other health problem.  Untreated mental illness can have dire effects on the individual, on the family, on the community, and on society as a whole.  People who have psychiatric diagnoses can overcome them and live fulfilling, successful, meaningful lives.  Learn about it.  Talk about it.  Seek treatment when needed, and support others in doing so as well.  Silence and shame help no one.

I can’t recall ever hearing these messages as a teenager or young adult.  If these messages existed at all back in my day, they were eclipsed by the OJ Simpson trial, overshadowed by the Clinton/Lewinsky scandal, drowned out by the Spice Girls and ignored amidst episodes of Friends.  It is an honor and a privilege for me to treat the teens of this generation, who live their lives with more knowledge, understanding, and acceptance than the generation before them.

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Thursday, February 6th, 2014

Let’s Get Physical: Exercise in the Treatment of Mood and Anxiety Disorders

As the Olympic Winter Games are commencing tomorrow in Sochi, I feel inspired to write about the role of physical activity in mental health. This post will focus specifically on exercise in the treatment of mood and anxiety disorders.

Numerous studies have shown that regular exercise improves mood in people with mild to moderate depression. For those with severe depression or bipolar disorder, exercise alone is rarely sufficient, but exercise can play an adjunct role in helping patients recover and prevent relapse.

We know from Newton’s law of motion that an object at rest stays at rest unless a force acts upon it, and an object in motion stays in motion unless some force makes it stop. The same is true for human bodies. Paradoxically, sedentary people tend to have less energy and active people tend to have more.

Now, of course this begs the question of the chicken or the egg – it is likely that people become sedentary because they have little energy or stay active because they have a surplus. This is true. People seem to have “set points” for activity level just as they do for weight and mood. That being said, physical activity has an almost immediate effect on mood and energy level. Over time, consistent exercise helps to stabilize moods, improve sleep, reduce stress, and enhance motivation to continue moving.

For these reasons, I strongly encourage my patients who suffer from mood disorders or anxiety disorders to exercise regularly. In my opinion, exercise is every bit as important as therapy, medication, and sleep when it comes to mood and anxiety disorders.

As I have emphasized in previous posts, the mind is a series of conscious functions carried out by the brain, and the brain is part of the body. Physical health and mental health are one in the same. Despite what society, popular wisdom, and health insurance companies may tell us, there is no actual difference between a physical illness and a mental one. When you exercise your body, you are exercising your brain.

Unlike therapy or medication, exercise is cheap or even free. Unlike medication, which can have unpleasant or dangerous side effects, exercise is generally safe so long as you do it sensibly and moderately. Unlike therapy, which requires another person and an appointment, exercise can be done alone if you choose at a time that suits your schedule. Unlike therapy, which is typically one-on-one and indoors, exercise can be enjoyed inside or outside with your family, friends, classmates, or teammates.

Numerous times, I have been amazed at how much exercise improves my patients’ mental health. This is especially true for people who have historically been sedentary and embark on a new exercise routine as part of their treatment plan. For example, I am working with a 15-year-old girl whom I’ll call Elsa who suffered from severe depression and crippling anxiety. When I met Elsa last year, she hated exercise and barely had the energy to get out of bed. After months of encouraging her to try different enjoyable physical activities, she finally started biking with her mom and jogging with her neighbor. She is now in full remission from her depression, making excellent progress in tackling her anxiety, and training for her first 5K. She now wakes up at 7:00 am with plenty of energy and really enjoys exercising. I am so proud of her.

One of the more challenging aspects of incorporating exercise into a patient’s treatment plan is that sometimes the mental illness itself is part of the reason why the patient is inactive. Depressed people tend to lose interest in activities they once enjoyed. They feel unmotivated and chronically exhausted. Clearly, it is a challenge for them to do essential things like get dressed and go to school, let alone something “extra” and “optional” like exercise.

For these patients, I use a behavioral technique called behavioral activation. Here’s how it works: we agree upon a small, realistic exercise goal such as walking for 10 minutes three evenings a week. [Elsa’s initial idea was to do the Insanity DVDs she saw on an infomercial. Given that she hadn’t exercised in years, I told her that this idea was, frankly, insane, and I suggested something more moderate.] I have the patient choose an activity they enjoy (or at least one that they don’t hate) and a time of day when they’re likely to follow through (for example, not at 5:00 AM if they aren’t a morning person).

When possible and feasible, I encourage patients to exercise socially by attending a class, joining a sports team, taking lessons, or doing something active outdoors with their families. We make this activity part of their weekly schedule, writing it down (or, often, putting it in their smart phone) as if it were any other appointment or commitment. Most of the time, the patient achieves their initial goal because it is small, realistic, specific, and planned.

Achieving this initial exercise goal creates a feeling of success and personal satisfaction and enhances the person’s motivation to keep going. In addition, they experience a bit of a mood boost from the activity itself. Once the patient achieves the initial exercise goal, it is increased a little bit in frequency or duration.

Using the example above, the patient may walk for 20 minutes during the second week and 30 minutes during the third week. This gradual increase in frequency and duration continues for a number of weeks or months. Eventually, the patient has incorporated regular exercise into her lifestyle. The stress reduction, mood enhancement, and improvement in fitness level enhance her internal motivation to continue exercising.

Anxiety can also interfere with a patient’s plans to exercise. Many people who experience panic attacks are afraid of the physical sensations that result from exercise (rapid breathing, increased heartbeat, sweating), which closely resemble those of a panic attack.

Patients who have social anxiety may shy away from joining sports teams, taking dance classes, or going to gyms because they worry about being judged or making a fool of themselves. For example, Elsa had enjoyed dance classes and swimming in elementary school but later became socially anxious and self-conscious about wearing a leotard or swimsuit in front of her peers. For this reason, she chose to do biking and jogging which did not require such revealing attire. And now, for the record, Elsa does wear a swimsuit with only mild anxiety when she goes to the beach or the pool with her friends. Did I mention how proud of her I am?

For patients with eating disorders, exercise is altogether a different story. That will be the topic of my next blog post.

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Wednesday, December 11th, 2013

Sleep and Mood Disorders: Implications for Mental Health Care

Getting enough sleep is important for everyone. Well-rested bodies and brains are healthier, more resilient, and more energetic. For those with depression and other mood disorders, getting plenty of sleep must be a priority. In fact, research has demonstrated that people with insomnia are ten times more likely to develop depression than those who get sufficient sleep. Further, new research has shown that sleep disturbances can trigger psychiatric illnesses in those who are vulnerable.

Sleep is every bit as important as medication and therapy in the treatment of mood disorders. For this reason, I make a point of discussing and monitoring sleep patterns with my patients, and I integrate sleep hygiene into their treatment plans.

A recent study financed by the National Institute of Mental Health and published in The New York Times found that a psychological treatment called CBT-I (Cognitive-Behavioral Therapy for Insomnia) doubled the effectiveness of antidepressant medication in the treatment of depression.

This was not surprising to me. I was trained in CBT in graduate school and I have seen cognitive-behavioral techniques work wonders in many of my patients. But the implications of this study, and the fact that the results have made it into the popular media, are quite significant.

One of the most disturbing and unfortunate trends in mental health care in recent years has been the overuse of psychotropic medication and the corresponding underuse of behavioral and psychological interventions. This trend is especially bothersome to me because I am keenly aware – thanks to my training and experience as a psychologist – that certain evidence-based psychological treatments are as effective, if not more effective, than medication for treating certain illnesses.

Unfortunately, most people outside the field of psychology don’t know this. Americans are bombarded daily with advertisements for psychotropic medication on television, online, and in print. It’s only natural, then, that consumers who are suffering from depression or anxiety would request medications from their doctors, even when they have a problem that can be successfully treated by other means.

Don’t get me wrong – I am by no means anti-medication. I am thankful that we have effective, relatively safe medications on the market now that can help people effectively manage serious illnesses which were once disabling. Indeed, psychotropic medication can be extremely helpful – even life-saving – for many people. My concern is that psychotropic medications are prescribed too frequently to people who may not need them, often without the necessary monitoring, and often without the corresponding psychological and behavioral interventions that have been proven effective.

As a psychologist who practices said psychological and behavioral interventions, rather than a psychiatrist who prescribes said medications, am I biased? Well, obviously. I believe in what I do and I chose this profession for a reason. But still.

My hope is that, with articles such as this one, the general public will learn that evidence-based psychological treatments exist which can reduce their suffering and improve their quality of life. I would like people to be fully informed about their options when it comes to mental health treatment. I look forward to the day when people experiencing psychiatric symptoms routinely ask their primary care physicians for referrals to psychologists who practice evidence-based treatments, rather than, or in addition to, asking for prescriptions.

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Thursday, November 21st, 2013

Giving Thanks

In my work as a clinical psychologist, I am faced daily with stories of tragedy, trauma, illness, conflict, and loss. Each therapy session is a window into private suffering.

“Isn’t it hard?” people ask me. “Isn’t it awful to listen to people’s problems all day long? Doesn’t it make you depressed?” My answers to these questions are: “Yes,” “No,” and “Quite the opposite.” It is painful to witness people suffering, but it is endlessly rewarding to help them triumph.

Rather than letting other people’s pain drag me down, I feel honored that they have shared it with me and privileged that I am in a position to help them cope with it. I am intimately aware of the obstacles people face – and overcome – every single day. Being a clinical psychologist provides me with daily opportunities to participate in stories of healing, strength, opportunity, resolution, and empowerment.

As Thanksgiving approaches, many Americans begin to think about expressing gratitude for the things we take for granted the rest of the year. Consider these:

If you get out of bed next Thursday, give thanks.
There are those with depression who cannot do so without herculean effort.

If you are preparing to host relatives in your home, give thanks.
There are those with crippling social anxiety for whom a house full of guests would be unthinkable.

If you are planning to travel across several time zones to spend the holiday with relatives, give thanks.
There are those with mood disorders for whom jet lag can trigger an episode of mania or depression.

If you are looking forward to Thanksgiving dinner, give thanks.
There are those with anorexia nervosa for whom a holiday feast is an object of fear, loathing, and guilt.

If you set the table next Thursday in under five minutes, give thanks.
There are those with OCD who cannot relax unless every napkin, fork, and knife is lined up precisely.

If you sit on the couch after dinner to watch football with your uncles and cousins, give thanks.
There are those with bulimia nervosa who will be pacing around the house, waiting for an opportunity to purge unnoticed.

If you settle into bed with a good book later that evening, give thanks.
There are those who will be cutting their forearms with a razor to numb themselves from the intolerable emotions triggered by the day’s events.

If you go to bed Thanksgiving night satiated and content, give thanks.
There are those whose restless worry keeps them up until sunrise.

If you have never even considered feeling grateful for these ordinary things, give thanks.
Our mental health, and that of our family, should not be taken for granted.

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Monday, November 4th, 2013

Summary of Treatment Outcomes

My blog posts from June through November 2013 have been devoted to describing my patients’ treatment outcomes. I’ve been advised that my recent posts have been too data-heavy and too detailed, but hey – that’s how I roll. I like to be thorough, meticulous, and transparent. Prospective patients and their families deserve to have access to this information. But for those who prefer brevity, I’ve summarized my treatment outcomes below. Click on the headings in bold for details.

    Outcomes for Patients with Anorexia Nervosa


Fifty-seven percent of my former patients with Anorexia Nervosa (AN) completed treatment. Of the “treatment completers,” 94% reached full remission and the remaining 6% reached physical remission. Patients required, on average, 28 sessions over the course of 17 months to complete treatment.

Forty-three percent of my former patients with AN did not complete treatment with me. Of the “treatment non-completers,” 23% were referred to other treatment settings which could better meet their needs; 15% moved to other geographic locations during treatment and thus were referred for treatment near their new homes; and the remaining 62% dropped out of treatment prematurely.

    Outcomes for Patients with Bulimia Nervosa and Eating Disorder Not Otherwise Specified


Thirty-three percent of my former patients with Bulimia Nervosa (BN) and Eating Disorder Not Otherwise Specified (EDNOS) completed treatment. One-hundred percent of those who completed treatment reached full remission. On average, patients took 15 sessions over the course of 10 months to complete treatment. Amongst patients with BN, 44% made significant progress prior to discontinuing treatment prematurely. For patients with EDNOS, 17% made significant progress prior to discontinuing treatment prematurely.

    Outcomes for Patients with Mood Disorders


Twenty-nine percent of patients my former patients with primary diagnoses of mood disorders completed treatment. Of the patients who completed treatment, 83% achieved full remission and the remaining 17% made significant progress. On average, patients took approximately 23 sessions over the course of 11 months to complete treatment.

Thirty-eight percent of mood disorder patients quit treatment prematurely, 24% were referred to other treatment providers who could better meet their needs, and 9% moved to other geographic locations during their treatment and were referred for treatment near their new homes.

    Outcomes for Patients with Anxiety Disorders


All of my former patients with primary diagnoses of anxiety disorders who attended more than two sessions experienced substantial improvement in anxiety symptoms as well as significant improvement in functioning, even if they did not complete a full course of treatment. Patients with anxiety disorders attended an average of 10 sessions over the course of 6 months.

Amongst those who completed a full course of treatment, 75% achieved full remission and the remaining 25% made significant progress.

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Wednesday, September 18th, 2013

Correlates of Treatment Outcome for Patients With Mood Disorders

In my last blog post, I described end-of treatment outcomes for patients with mood disorders. Here, I will elaborate on factors that were correlated with treatment outcome for these patients. Please be advised that these results are specific to my practice and my patients, and should not necessarily be generalized to other clinicians or populations.

Diagnosis
Type of mood disorder diagnosis was strongly correlated with treatment outcome. Patients with Depressive Disorder NOS (DDNOS; n = 3) fared best. Two-thirds of these patients (n = 2) completed treatment and achieved full remission. The remaining one-third (n = 1) attended treatment for two months and made significant progress before quitting prematurely.

Patients with Mood Disorder NOS (MDNOS; n = 4) had varying outcomes. Half of them (n = 2) completed treatment; of these, one achieved full remission and the other made significant progress. Of the remaining MDNOS patients, one quit prematurely after making some progress and the other regressed and was referred to a higher level of care.

Both of the patients in this sample with Dysthymic Disorder also had a diagnosis of Major Depressive Disorder (MDD). For statistical purposes, I am subsuming these individuals under the category of MDD, as that is the more severe of the two diagnoses. Patients with Major Depressive Disorder (MDD; n = 11) had varying outcomes. Eighteen percent (n = 2) completed treatment and achieved full remission; 9% (n = 1) quit treatment after making significant progress; 45% (n = 5) either quit treatment or moved away after making some progress; and 27% (n = 3) were referred to other providers.

The presence of both dysthymic disorder and MDD (n = 2) did not have a consistent impact on treatment outcome – one of these individuals completed treatment and achieved full remission, while the other regressed and was referred to a higher level of care.

None of the patients with bipolar disorder (n = 3) completed treatment or achieved full remission. However, one of the patients with bipolar disorder remained in treatment for over a year and made significant progress, but was eventually referred to another treatment provider to address other treatment needs.

Comorbidity
Presence of a co-morbid diagnosis was a negative prognostic factor. Only 18% (n = 2) of the patients with comorbid disorders completed treatment, and only 9% (n = 1) achieved full remission, while the remaining 9% (n = 1) made significant progress. In contrast, 40% (n = 4) of patients without a comorbid diagnosis completed treatment, and all of these patients achieved full remission.

Medication
Patients who did not take psychiatric medication during treatment with me were more likely to make progress in treatment and more likely to achieve remission than those who took psychiatric medication. All of the patients who did not take medication (n = 8) made at least some progress in treatment. In contrast, 30% of those who took medication either made no progress (n = 2) or regressed (n = 2) during treatment. Half of the patients who did not take medication (n = 4) achieved remission by the end of treatment, compared to 8% (n = 1) of those who took medication.

My hypothesis is that patients who took medication had poorer outcomes not because their medication didn’t work or made them worse, but rather because taking medication is confounded with severity of mood disorder and with comorbidity. In other words, those with more severe mood disorders and/or comorbid conditions were more likely to require medication in order to function, whereas those with mild to moderate mood disorders were less likely to need medication.

Age and Family Involvement
Younger age was a significant predictor of treatment completion. Patients who completed treatment ranged in age from 16 – 29, with an average age of 19.7. Those who did not complete treatment ranged in age from 12 – 59, with an average age of 28.6.

Being under 18 years old was a protective factor. None of the adolescents under 18 quit treatment prematurely. Of the 6 adolescents in this sample, 50% (n = 3) completed treatment and attained full remission, 33% (n = 2) were referred to other treatment settings after a year or more of treatment with me due to other needs, and the remaining 16% (n = 1) engaged in treatment as a 17-year-old and made some progress, but quit shortly after his 18th birthday. I suspect that the high level of parental involvement that I require for adolescent patients is the primary reason why they are likely to remain in treatment and have positive outcomes. In addition, younger patients tend to have shorter duration of illness compared to adult patients, and early intervention is also predictive of positive outcome.

For patients over 18, family involvement often included spouses and significant others instead of parents, based on the patient’s living situation and relationship status. Sixty percent (n = 9) of the patients over 18 in this sample had no family involvement whatsoever, 27% (n = 4) had a low level of family involvement, and 13% (n = 2) had a moderate level of family involvement. None of the patients over 18 had a high level of family involvement.

Importantly, amongst the adults in this sample, family involvement was not necessary in order to make progress in treatment or attain remission. None of the adults who attained full remission (n = 2) had family members involved in their treatment. Likewise, 67% (n = 2) of the adults who made significant progress in treatment had a low level of family involvement and 33% (n = 1) had no family involvement at all.

None of the patients over age 30 (n = 5) completed treatment. I hypothesize that there are several reasons for this: 1.) Older patients had a longer duration of illness, which means that their illness was more entrenched and more difficult to treat; 2.) The majority of these patients (80%; n = 4) had no family support at all; 3.) All of these older patients paid reduced rates for my services, which indicates that they were of lower socio-economic status, and which may suggest that they value my services less than those who pay full price; 4.) I saw all of these patients during my post-doctoral year, when I was less experienced and not yet fully licensed. Therefore, it is reasonable to assume that the quality of my services was somewhat lower back then than it is now that I am fully licensed and more experienced; and 5.) I prefer working with child and adolescent patients and find that I tend to be more effective with them. For these reasons, particularly #5, I no longer treat adult patients beyond their mid-twenties.

Gender
Average duration of treatment was comparable for males and females (6.8 months vs 7.4 months, respectively). Rates of remission were similar between males and females. Twenty percent (n = 1) of males completed treatment and achieved remission, compared with 25% (n = 4) of females. However, amongst those who did not achieve remission, females were more likely to make significant progress than males. Twenty-five percent (n = 4) of females made significant progress, compared with none of the males.

Hospitalization
Hospitalization during treatment with me predicted regression in treatment. Of the patients who were hospitalized during treatment with me, 67% (n = 2) had regressed by the end of their treatment with me. In contrast, none of the patients who were not hospitalized during treatment had regressed as of their final session with me.

I hypothesize that patients who remained out of the hospital during treatment with me were responding well to treatment, which would explain why they were more likely to achieve remission or at least make significant progress. In contrast, being hospitalized during treatment may have been an indication that the patient was not responding well to treatment, which explains why they were likely regressed as of their last session with me.

Surprisingly, history of hospitalization before entering treatment with me was not related to outcome. Of the 8 patients who had been hospitalized previously, 25% (n = 2) achieved remission, 25% (n = 2) made significant progress, 38% (n = 3) made some progress, and only 12% (n = 1) regressed in treatment with me. These percentages are comparable to those of the 13 patients who had not been hospitalized before beginning treatment with me: 23% (n = 3) achieved remission, 15% (n = 2) made significant progress, 38% (n = 5) made some progress, 15% made no progress, and 8% (n = 1) regressed.

I would have suspected that history of hospitalization would be confounded with illness severity, and therefore would predict poor treatment outcome. However, it is possible that the individuals who had been hospitalized before entering treatment with me had not been given appropriate outpatient treatment, hence the escalation of illness need for hospitalization. Perhaps these patients were able to benefit from their treatment with me, and it is possible that, in some cases, hospitalization could have been avoided if they had received effective outpatient treatment sooner.

Attendance at Therapy Sessions
Attendance at therapy sessions was correlated with treatment retention as well as treatment outcome. Sixty-seven percent (n = 4) of those who completed treatment attended all of their appointments, while the remaining 33% (n = 2) had only one missed appointment. Eighty percent of patients who attained full remission (n = 4) had perfect attendance in therapy; the remaining 20% (n = 1) missed only one appointment. None of the patients who missed more than one appointment completed treatment or achieved full remission.

I suspect this relates to the old adage: “You get out of it what you put into it.” A patient who frequently misses appointments probably places little value on their mental health, which may explain why they tended to drop out of treatment prematurely. Those who were diligent about their treatment prioritized their mental health and worked hard in therapy. Those who were conscientious and responsible about attendance were, most likely, conscientious and responsible about completing therapy homework, taking their medication consistently, and making positive life choices in general. Thus, it is natural that these individuals had better treatment outcomes.

Fee for Services
Payment of full fee for services was a predictor of treatment completion and achieving full remission. Sixty-seven percent of patients (n = 2) who paid my full rate completed treatment, compared with only 22% of patients (n = 4) who paid a reduced rate. Given that so few patients in this sample paid my full rate (n = 3), it is difficult to draw any conclusions about how these individuals differ from those who pay a lower rate.

However, in my practice, the correlation between payment of full services and better treatment outcome has been consistent across diagnoses, regardless of the number of clients in the sample. As I have noted in recent posts, individuals who pay lower fees are, by definition, of lower socio-economic status (SES). These individuals may have more financial stressors than those of higher SES, and may have other life obstacles in general (limited access to healthcare, transportation difficulties, unemployment, single parent families) which interfered with their ability to progress in treatment.

In addition, those who pay reduced rates were much more likely than those who pay full rate to no-show for sessions or to cancel at the last minute. This finding suggests to me that, on average, individuals who paid reduced fees placed less personal value on their sessions, had less respect for my time, did not prioritize their recovery, and/or were generally irresponsible, compared with individuals who paid full rate.

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Wednesday, August 14th, 2013

End of Treatment Outcomes for Patients with Mood Disorders

Since opening my practice in 2009, I have evaluated 30 patients with mood disorders. Former patients who attended at least one treatment session with me following their evaluation were included in this sample. Patients who are currently in treatment with me were not included in this sample. As you read, please bear in mind that these data are specific to my practice and my patients, and should not be generalized to other therapists or other patient populations.

The 21 patients in this sample had a range of different mood disorder diagnoses. The most common diagnosis was Major Depressive Disorder (43%; n = 9). Other mood disorder diagnoses included Mood Disorder Not Otherwise Specified (19%; n = 4), Depressive Disorder Not Otherwise Specified (14%; n = 3), Bipolar Disorder (14%; n = 3), and Dysthymia (10%; n = 2). Approximately one quarter of the sample (24%) was male.

Patients ranged in age from 12 to 59, with a median age of 21. Most of these patients had been suffering from their mood disorder for years before beginning treatment with me, and most had received some sort of psychological or psychiatric treatment in the past. Duration of illness prior to intake ranged from 1 month to 35 years, with an average duration of 8.4 years. These figures reflect the length of time since symptoms began, which is usually substantially earlier than diagnosis.

Many mood disorders, such as Major Depressive Disorder and Bipolar Disorder, tend to be episodic, characterized by periods of remission and periods of relapse. Thus, the “duration of illness prior to treatment” figures reflect the total length of time from the onset of first symptoms to the initial session with me. Many patients had periods of mild or absent symptoms and good functioning in between mood disorder episodes.

Most of the patients in this sample had relatively severe forms of mood disorders. Thirty-eight percent of them (n = 8) had been hospitalized for a suicide attempt, suicidal gesture, or related psychiatric issue prior to beginning treatment with me, and many of these individuals had been hospitalized multiple times. Fourteen percent of patients (n = 3) had to be hospitalized during the course of their treatment with me.

This sample was ethnically diverse, comprised of 43% White Hispanic, 43% White Non-Hispanic, 10% multi-racial, and 4% Black Hispanic. The majority of patients in this sample (86%; n = 18) paid a reduced fee for my services; only 14% (n = 3) paid my full rate. Thus, most of these patients were of lower socio-economic status and/or were college students responsible for supporting themselves.

Approximately half of the sample (52%; n = 11) had a comorbid psychiatric disorder. The most common comorbid diagnoses were Anxiety Disorder Not Otherwise Specified (14%; n = 3) and Eating Disorder Not Otherwise Specified (14%; n = 3).

The patients in this sample received various types of treatment, depending on their age and symptoms. Nearly half of the patients in this sample (48%; n = 10) received Cognitive-Behavioral Therapy (CBT). Patients whose illnesses were characterized by impulsivity and self-harm received a Dialectical Behavior Therapy (DBT) skills-based approach (38%; n = 8). Patients with milder symptoms and social difficulties received supportive counseling focused on self-care and interpersonal relationships (14%; n = 3). Sixty-two percent of patients (n = 13) were also seeing a psychiatrist and taking psychotropic medication during their treatment with me.

The level of family involvement in a patient’s treatment varied based upon his or her age, symptoms, and preferences as well as logistics. In this sample, 43% (n = 9) of patients had no family involvement, 19% (n = 4) had a low level of family involvement, 19% (n = 4) had a moderate level of family involvement, and 19% (n = 4) had a high level of family involvement.

I require the parents of all patients under 18 to be fully informed and actively involved in their child’s treatment. Therefore, all patients under 18 in this sample had moderate to high degrees of family involvement in treatment. This means that the patient’s parents participated fully in the evaluation and treatment planning, and participated in a portion of most therapy sessions (e.g., the last 10 minutes of each session) for the purposes of providing feedback, setting goals, and evaluating progress. These parents also had regular access to me via phone and email for the purpose of sharing information about their child and asking questions. For patients over age 18, family members were involved as appropriate, as needed, and as requested by the patient. For example, many college-aged patients had parents involved in their treatment, particularly when it came to issues of psychiatric consultation and hospitalization.

Patients in this sample attended between 1 and 96 sessions, with a mean of 19 sessions. Duration of treatment ranged from 1 month and 39 months, with a mean duration of 7 months. In other words, the typical mood disorder patient attended 19 sessions over the course of 7 months.

Twenty-nine percent of patients (n = 6) completed treatment and 38% (n = 8) quit treatment prematurely. I referred twenty-four percent of patients (n = 5) to other treatment providers who could better meet their needs, and 9% of patients (n = 2) moved to other geographic locations during their treatment and were referred to other providers near their new homes.

Patients who completed treatment attended between 1 and 96 sessions, with an average of 23 sessions. Duration of treatment for those who completed treatment ranged from 1 to 39 months, with an average duration of 11 months. Thus, it typically took approximately 23 sessions over the course of 11 months to complete treatment.

Each patient was given an end-of-treatment rating which describes their state as of their final session with me, regardless of the reason why treatment ended.

• Patients were classified as being in “full remission” if they had not experienced any symptoms of their mood disorder within the past two weeks, and their social / occupational / academic functioning were good.

• Patients were classified as having made “significant progress” if their mood disorder symptoms over the past two weeks were substantially less severe, less frequent, and less intense than at intake, but were still occurring, and their social / occupational / academic functioning were relatively good.

• Patients were classified as having made “some progress” if their symptoms over the past two weeks were somewhat less severe and less frequent than at intake, and if their social / occupational / academic functioning were fair.

• Patients were classified as having made “no progress” if the frequency, intensity, and duration of symptoms had not improved since intake, and social / occupational / academic functioning had not improved since intake.

• Patients were classified as “regressed” if their symptoms over the past two weeks were more severe or more frequent than at intake and their social / occupational / academic functioning had declined since intake.

Of the patients who completed treatment, 83% (n = 5) achieved full remission from their mood disorder and 17% (n = 1) made significant progress. Of the patients who quit treatment prematurely, 25% (n = 2) had made significant progress by their last session with me, 63% (n = 5) had made some progress, and 12% (n = 1) had made no progress. Among the patients whom I referred to other providers, 40% (n = 2) regressed during their treatment with me, 20% (n = 1) made no progress (n = 1), 20% (n = 1) made some progress, and 20% (n = 1) made significant progress.

In my next post, I will discuss factors that are correlated with treatment completion and good outcome in these mood disorder patients.

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Sunday, June 30th, 2013

A Preview of My Treatment Outcome Data

As a scientist-practitioner, I am well aware that therapists aren’t always good at judging their patients’ outcomes. That’s why I love statistics. Numbers offer an objective, quantitative view. Numbers paint a clear picture that words cannot.

I believe strongly in evidence-based treatment. I also believe in therapist transparency – that is, that therapists should explain to patients and their families what interventions they are using, why they are using them, and what evidence is behind them.

For these reasons, I have chosen to collect data on my own patients and measure their response to treatment. I want prospective patients and their families to have access to these data to assist them in choosing a clinician. After four years in private practice, I have finally seen enough patients to collect treatment outcome data with a decent-sized sample. I am compiling these data for the purpose of improving the quality of my own practice. The results of my patients’ treatment outcomes are not intended to be used to generalize to other populations.

Since opening my practice in 2009, I have evaluated 138 patients. Eighty-nine percent (n = 123) of these patients were female and (n = 15) 11% were male. They ranged in age from 7-64, with a median age of 18 and a modal age of 15. The majority of patients were between the ages of 10 and 25.

The patients’ primary diagnoses were as follows:
• 54% (n = 75) had eating disorders, including anorexia nervosa, bulimia nervosa, and EDNOS
• 22% (n = 30) had mood disorders, such as major depressive disorder or bipolar disorder
• 10% (n = 14) had anxiety disorders, such as OCD or social anxiety disorder
• 8% (n = 11) did not meet criteria for any psychiatric disorder, but rather came to me for help with a specific problem, such as coping with parents’ divorce or stress management.
• 6% (n = 8) had an assortment of other primary diagnoses, including borderline personality disorder, adjustment disorder, or body dysmorphic disorder.

I work on a sliding scale based on the patient’s ability to pay. Sixty-three percent (n = 87) paid my full rate and 37% (N = 51) paid a reduced rate due to their financial circumstances (e.g., unemployment, low income, single parent supporting children alone, or college student paying for his/her own treatment). I saw 16% of these patients (n = 22) for evaluation and/or consultation only. The remaining 84% (n = 116) attended at least one treatment session with me.

All former patients who attended at least one treatment session with me are included in this sample. In addition, four patients who have completed their treatment but have opted to continue seeing me two or three times per year for “check-ups” were included as well. Patients who are currently in treatment with me were not included.

Over the next few weeks, I will be blogging about the end-of-treatment outcomes of my former patients, categorized by primary diagnosis. I am also in the process of conducting a follow-up study, and I hope to publish those data by the end of the summer. All data will be reported in aggregate form so that no individual patients will be identifiable.

Randomized controlled trials (RCTs) are the gold standard in treatment outcome research. However, other types of studies can be quite useful as well. My study tells a different story from the RCTs – the story of clinical practice in the “real world,” with all of the freedoms and confounds that come with it. While I do use evidence-based treatments such as Family-Based Treatment (FBT) and Cognitive Behavioral Therapy (CBT), I frequently make modifications to the manualized form of treatment based on the needs of the individual patient and family.

In addition, rather than fitting all patients into a 10-session or 20-session protocol, the length of treatment varied based on individual needs. Essentially, patients could stay in treatment until they were completely well. Insurance constraints were not an issue, as I don’t participate on insurance panels, and finances were not a deterrent from completing treatment, as I am very flexible with my sliding scale.

So what do treatment outcomes look like in the real world? You’ll have to keep reading my blog to find out!

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Sunday, March 25th, 2012

Show Me The Science

The debate over evidence-based practice (also known as empirically-supported treatment) in psychology is contentious and polarizing. Evidence-based practice, as defined by the APA, is “the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences.” The debate over evidence-based practice can be summarized as follows:

Proponents of evidence-based treatment argue that clinical psychologists are scientists, that psychotherapy is (or should be) based upon scientific theory, and therefore therapists must use the best available scientific evidence in their practice of psychotherapy. They argue that the public must be protected from therapies which are not evidence-based, as such therapies may be ineffective or harmful.

Opponents of the evidence-based practice movement argue that psychotherapy is an art rather than a science, and that the essence of what they do – the “human element” – cannot possibly be manualized or subjected to clinical trials. Opponents are typically therapists who practice relationship- or insight-oriented approaches. They see their work as diametrically opposed to the principals of evidence-based practice.

I understand and appreciate the arguments of the opponents, and I do believe they have some valid points. However, I have established my professional identity as a strong proponent of evidence-based treatment.

When you visit a physician for an illness and she prescribes a medication, you can safely assume that the medication has been FDA-approved for your particular illness, that it is likely to be effective, and that it is unlikely to seriously harm you.

Imagine the following scenario: Drug A was used to treat Illness X twenty years ago. Then, ten years ago, clinical studies showed that Drug B is significantly more effective than Drug A in treating illness X. A physician, Dr. Dolittle, continues to prescribe Drug A for Illness X because he really believes it works, and because he was taught that Drug A works well when he was a medical student 20 years ago. Dr. Dolittle does not inform his patients that Drug B exists, because he doesn’t believe it will work for them and he has no experience with it.

The scenario described above would not happen in medicine, would it? And if it did happen, Dr. Dolittle would be reprimanded by the medical board and may have his license revoked.

Believe it or not, this scenario happens in psychology all the time. Most people outside the field would be shocked to learn that the majority of psychological treatment out there is NOT evidence-based.

I have seen patients who underwent years of psychodynamic therapy for severe depression, without getting any better, without being told about cognitive-behavioral therapy (CBT) and without being referred to a psychiatrist for a medication evaluation. I have seen patients with anxiety disorders whose psychiatrists have prescribed multiple medications for them, never once referring them for psychological treatment, without ever mentioning that CBT at least as effective, if not more so, than medication for most anxiety disorders. I have seen patients who suffered from eating disorders for many years, who have seen many therapists, who have had multiple stints in residential treatment and have taken numerous medications, but were never restored to their ideal body weight and never provided with the support they needed to eat properly. And finally, a substantial portion of my case load is comprised of teenagers with eating disorders who have experienced months or years of ineffective, non-evidence-based treatment. The families of these teenagers were never informed about Family-Based Treatment (FBT), which is the only empirically-supported treatment for adolescents with eating disorders. Their parents discovered FBT on their own through desperate late-night internet searches.

These patients are pleasantly surprised to see how quickly and dramatically they improve with evidence-based treatment. They are also angry that they were not provided with, or at least informed about, effective treatment from the start. I believe that all patients and their families deserve to be fully informed about the range of different treatment options available to them, including evidence-based treatment. I do believe that there is a place for non-evidence based treatment, but patients and families should know from the outset what they are getting.

Evidence-based practice is not about using treatment manuals verbatim, or only relying upon randomized clinical trials. Treatment manuals are necessary for research and dissemination, but they are not intended to be followed verbatim with every patient in the real world. Manuals don’t treat patients – they merely provide a guide and a plan of action which may be revised and altered as needed for each unique patient. The basic principles and techniques of the treatment are the brick and mortar; the details of each room can and should be tailored to the individual.

Clinical psychology is a science, but it is not as precise as the so-called “hard sciences” like physics or mathematics. The brain is too intricate; human behavior too complex to be boiled down to immutable formulas. There is, and always will be, room for intuition, creativity, spontaneity, and that intangible “human element” that cannot be manualized or subjected to laboratory research. But the evidence base is there, so we owe it to our patients and to our profession to use it. Otherwise, we are no better than Dr. Dolittle.

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