Dr. Sarah Ravin - Psychologist | Eating Disorders |Body Image Issues | Depression | Anxiety | Obsessive-Compulsive Disorders | Self-Injury
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Coral Gables, FL 33146
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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.


Psychotropic Medication Category

Friday, November 1st, 2013

End of Treatment Outcomes for Patients with Anxiety Disorders

Since opening my practice in 2009, I have evaluated 14 patients who presented with a primary diagnosis of an anxiety disorder. All former patients who attended at least one treatment session with me following their evaluation were included in this sample (n = 9). Those who are currently still in treatment with me were not included in this sample. Please bear in mind that the results described below are specific to my practice and my patients, and should not be generalized to other therapists or other patient populations.

The sample described includes nine female patients who ranged in age from 10 to 42 years old (median age = 22). The patients’ primary diagnoses were Panic Disorder (n = 3), Anxiety Disorder Not Otherwise Specified (n = 2), Acute Stress Disorder (n = 2), Hypochondriasis (n = 1), and Generalized Anxiety Disorder (n = 1). One-third of the patients (n = 3) had a comorbid diagnosis: one had Social Anxiety Disorder, one had Major Depressive Disorder, and one had Depressive Disorder Not Otherwise Specified.

Duration of treatment ranged from one month to 11 months, with a mean duration of 5.6 months. Number of sessions attended ranged from 1 session to 18 sessions, with a mean of 10 sessions.

The primary treatment model used was individual Cognitive Behavioral Therapy (CBT). The children in this sample (n = 2) each had a high degree of family involvement, with a parent participating in part of each session. All of the college-aged patients in this sample (n = 3) were treated individually but had some degree of family involvement, with a parent participating in at least one session over the course of treatment. Amongst the adult patients in this sample (n = 4), half had no family involvement and half had some family involvement, with a loved one attending one session over the course of treatment.

None of the patients in this sample had a history of psychiatric hospitalizations before beginning treatment with me, and none of them needed to be hospitalized while in treatment with me. Forty-four percent (n = 4) of these patients took psychotropic medication during treatment. Approximately 56% of patients (n = 5) paid a reduced rate for my services based on their financial situation, and the remaining 44% (n = 4) paid my full rate.

For the purposes of this study, “full remission” was defined as complete absence of anxiety disorder symptoms in the past two weeks, along with good social, occupational, and academic functioning. “Significant progress” was defined having substantially less severe and less frequent anxiety symptoms compared to intake, along with significant improvement in social, occupational, and academic functioning. “Some progress” was defined as having somewhat less severe and frequent anxiety symptoms compared to intake, along with fair social, occupational, and academic functioning.

Forty-four percent (n = 4) of the patients in this sample completed treatment. The remaining 56% (n = 5) quit treatment prematurely. Seventy-five percent of the patients who completed treatment (n = 3) achieved full remission, and the remaining 25% (n = 1) made significant progress.

Patients who quit treatment prematurely attended an average of 12 sessions before quitting. Amongst patients who quit treatment prematurely, 80% (n = 4) had made significant progress at the time of the last session they attended, and the remaining 20% (n = 1) had made some progress. Importantly, the only individual who did not make significant progress quit treatment after attending only an evaluation and one treatment session.

In sum, patients with anxiety disorders responded very well to treatment in a relatively short period of time. All patients 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.

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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.

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.

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.

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.

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 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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Thursday, July 18th, 2013

A Comparison of Treatment Outcomes: AN, BN, and EDNOS

My previous posts described treatment outcomes and correlates of my patients with various eating disorder diagnoses, including Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorder Not Otherwise Specified (EDNOS). Some findings were similar across diagnostic groups:

• The vast majority of patients with any diagnosis who completed treatment achieved full remission.

• The attrition rate, overall, was high.

Family-Based Treatment (FBT) was associated with treatment retention, meaning that patients who participated in FBT were less likely to discontinue treatment prematurely than those receiving individual therapy.

• Patients who paid a reduced rate for services were much less likely to complete treatment and much less likely to achieve remission than those who paid full rate.

• Hospitalization during treatment with me was not related to treatment completion or treatment outcome, regardless of diagnosis.

• History of intensive eating disorder treatment (e.g., residential treatment, day treatment) was related to treatment non-completion and poorer outcome for patients across diagnoses.

Quite surprisingly, the differences among the diagnostic groups outnumbered the similarities:

• Patients with AN who completed treatment attended more sessions, over a longer period of time, than patients with BN or EDNOS. Completing treatment for AN involved an average of 28 sessions over 17 months, whereas completing treatment for BN or EDNOS involved an average of 15 sessions over 10 months.

• Type of treatment had a significant impact on outcome for patients with AN but not for patients with BN or EDNOS. All AN patients who achieved remission did so through FBT. However, patients with BN and EDNOS achieved remission through various means, including individual therapy with no family involvement, individual therapy with family involvement, and FBT.

• Younger age at intake and shorter duration of illness predicted treatment completion and remission for patients with AN. However, neither age nor duration of illness affected treatment outcome for patients with BN or EDNOS.

• All “treatment non-completers” with AN (those who quit prematurely, moved away, or were referred to other treatment settings) discontinued treatment within the first six months. In contrast, a number of “treatment non-completers” with BN or EDNOS remained in treatment for more than a year.

• Among patients with AN, those who completed treatment attended significantly more sessions than those who did not (28 sessions vs. 8 sessions) and remained in treatment for a much longer time than those who did not (17 months vs. 3 months). In contrast, for patients with BN and EDNOS, treatment completers and non-completers both remained in treatment for an average of 10 months, and treatment non-completers actually averaged more sessions than treatment completers (20 sessions vs. 15 sessions). Thus, it appears that for BN and ENDOS, treatment completers did not remain in treatment longer, but rather reached remission more quickly.

• Caucasians with AN were slightly more likely than Hispanics with AN to complete treatment and achieve remission. In contrast, Hispanics with BN or EDNOS were significantly more likely than Caucasians with these diagnoses to complete treatment and achieve remission.

• The presence of a comborbid disorder was not related to treatment completion or treatment outcome for patients with AN. However, the presence of a comorbid disorder was a significant predictor of treatment dropout and poorer outcome for patients with BN and EDNOS.

• History of hospitalization for an eating disorder or related psychiatric issue was related to poorer outcome for patients with BN and EDNOS, but not for patients with AN.

• Taking psychotropic medication during treatment was related to treatment completion and positive outcome for patients with AN but not for patients with BN or EDNOS.

Please bear in mind that these findings are specific to my practice and my patients, and are not intended to be generalized to other treatment settings or other patients.

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Sunday, July 7th, 2013

Correlates of Treatment Outcome for Patients with Anorexia Nervosa

In my last blog post, I described the end-of-treatment outcomes of my former patients (N = 30) with Anorexia Nervosa (AN). In sum, 57% of patients completed treatment (n=17) and 43% of patients (n = 13) did not complete treatment. The former group is referred to as “treatment completers” and the latter as “treatment non-completers.”

As expected, end-of-treatment results differed dramatically between the two groups. By the end of treatment, 94% percent of treatment completers had achieved full remission and 6% (n = 1) had achieved physical remission. In contrast, none of the treatment non-completers achieved remission, although 46% of them made significant progress (n = 6).

Bear in mind that I set the bar very high for my patients in terms of defining remission. In most published studies of AN treatment outcome, the patients whom I categorized as having made significant progress would be categorized as “recovered” or “in remission.” If I used the (completely inadequate) definitions of remission that other studies have used, a full 77% of my sample would have completed treatment and made a full recovery. But I digress.

These data clearly demonstrate that my approach to treating AN is effective. Patients with AN who have completed treatment with me always achieved physical remission and almost always achieved psychological and behavioral remission as well.

The 43% attrition rate is disheartening, given that patients are likely to achieve remission if they remain in treatment long enough. Attrition is a major problem in AN treatment in general, and in AN treatment for adults in particular. The validity of most AN treatment outcome studies is compromised by the high rates of attrition. It is not surprising that many adults discontinue AN treatment prematurely, given that treatment is very difficult, anxiety provoking, and lengthy.

This raises the question of what is “long enough” in terms of AN treatment? In my opinion, “long enough” is as long as it takes to bring the patient to full remission, which varies considerably based on individual differences. Among the treatment completers, the length of time to full remission ranged from 2 months to 4 years, with a mean of 17 months. The number of sessions attended by treatment completers ranged from 3 – 82, with a mean of 28 sessions. There were a handful of the young patients who achieved full remission in 12 sessions or less, although this was not the norm.

The rates of treatment completion versus non-completion in my sample beg the question of how these two groups differed. What was it that made treatment completers stick it out until the end, while the treatment non-completers either quit or regressed to the point that they required more intensive treatment? Cause and effect cannot be determined from this type of study. However, a careful examination of the similarities and differences between treatment completers and non-completers may yield useful information and hypotheses which can be tested in future studies.

The patients who completed treatment and reached remission differed in several important ways from those who discontinued treatment prematurely.

Variables That Had a Significant Impact on Treatment Outcome:

1.) Type of Treatment

In my practice, all children and adolescents under age 18 with AN receive FBT (Family-Based Treatment, also known as the Maudsley Method). Some adolescents also receive individual therapy as an adjunct to FBT after weight restoration. Some children and adolescents transition to individual therapy with me after FBT is complete; this may be the case for those who have comorbid disorders or other ongoing issues. Patients over 18 with AN are strongly encouraged to do FBT whenever appropriate, although it is not always possible for logistical reasons, and some young adults are staunchly opposed to it. In my sample, 66.7% of patients (n = 20) received FBT alone, 16.7% (n = 5) received FBT plus individual therapy, and 16.7% (n = 5) received individual therapy alone.

In my sample, all of the patients who received individual therapy alone were 20 or older. Six of the 11 young adults in my sample (n = 55%) participated in FBT, either alone or in conjunction with individual therapy. All of the patients under age 18 received FBT, and two of these patients also received individual therapy.

One-hundred percent of treatment completers (n = 17) received FBT, either by itself (n = 15) or in conjunction with individual therapy (n = 2). In other words, all patients who achieved remission did so through FBT. One-hundred percent of the patients who did individual therapy alone (n = 5) ended treatment prematurely, either because they moved (n = 2), they quit (n = 2), or I referred them to a higher level of care (n = 1). In other words, individual therapy by itself never resulted in treatment completion or remission.

2.) Subtype of AN

This sample contained 5 patients with the Binge-Purge subtype of AN (AN – BP) and 25 patients with the Restricting subtype of AN (AN – R). One-hundred percent of treatment completers had a diagnosis of AN-R. None of the AN-BP patients completed treatment.

Among the AN-BP patients, 2 were referred to higher levels of care after regressing during treatment with me. One patient moved to another state after making some progress in treatment with me. Two patients quit treatment prematurely after making significant progress with me.

The patients in my sample with AN-BP were more likely to have a history of impulsivity, self-injury, and suicidal gestures compared to those with AN-R. I hypothesize that this cluster of symptoms made these patients more difficult for me to treat effectively as an outpatient solo practitioner, and more likely to benefit from a more structured, comprehensive treatment approach such as day treatment or residential treatment.

3.) Age

On average, those who completed treatment and achieved remission were significantly younger at intake than those who did not complete treatment (p <.01). Treatment completers ranged in age from 10 – 24 at intake, with a median age of 14. Treatment non-completers ranged in age from 10 – 37, with a median age of 20. However, it is important to note that there was a broad range of ages in both groups, with some young adults achieving full remission and some children and adolescents discontinuing treatment prematurely. 4.) Fee Paid for Services I believe that neither finances nor insurance issues should prevent people from accessing high-quality healthcare services. Therefore, I do not participate on any insurance panels. I am flexible with my fees and I work on a sliding scale based on a patient's ability to pay. If a family’s financial status changes during the course of treatment, I will change my fee for them accordingly. I work with many patients for very low hourly fees. Thus, I can only assume that the patients who discontinued treatment prematurely did not do so for financial reasons. Among the patients in this AN sample, 87% (n = 26) paid my full fee and 13% (n = 4) paid a reduced rate. The rate of reduced-pay patients in this sample is significantly lower than in my other diagnostic groups. I hypothesize that this may be due to the fact that the majority of patients in this sample received family-based treatment and had at least one parent who was a working professional, or who at least was employed full-time. In contrast, many of my patients with other diagnoses were college students supporting themselves, who were therefore eligible for a low fee. In this sample of AN patients, those who paid a reduced rate were significantly less likely to complete treatment compared to those who paid a full rate. Only 25% of reduced fee patients (n = 1) completed treatment, versus 62% of full fee patients (n = 16). It is unclear why reduced rate patients were less likely to complete treatment. However, the reduced rate patients differed from the full rate patients in several important ways. First, and most obviously, they had lower incomes, and likely dealt with the host of stressors that accompany being of lower socio-economic status. Second, they were all over the age of 18, which statistically reduces their likelihood of full recovery. Third, they were more likely to receive individual therapy than the full-rate patients. All of the low-rate patients received individual therapy, either alone (n = 2) or in combination with FBT (n = 2). Observing my patients with other diagnoses, I have noticed that those who pay full rate are much more likely to attend all of their sessions and to complete treatment, whereas those who pay lower rates are more likely to cancel sessions, no-show for sessions, and drop out prematurely. While I’m sure that the reasons for these differences are complex, I can’t help but wonder if people who pay more for something tend to value it more and take it more seriously. Variables That Had a Minor Impact on Treatment Outcome:

1.) Length of illness before intake.

Among treatment completers, length of illness before intake ranged from 3 months to 13 years (mean = 27 months). Amongst treatment non-completers, length of illness before intake ranged from 3 months to 21 years (mean = 67 months). However, this difference was not statistically significant (t = 1.63; p = 0.11).

2.) Use of Medication During Treatment

Individuals who took psychotropic medication during treatment with me were somewhat more likely to complete treatment and achieve remission. Fifty-nine percent of treatment completers (n = 10) took medication during treatment, compared with 38% of treatment non-completers (n = 5).

3.) Ethnicity

This sample of 30 patients was comprised of 60% White Non-Hispanic individuals (n = 18) and 40% White Hispanic Individuals (n = 12). These percentages are roughly similar to the ethnic makeup of Coral Gables, Florida, the Miami Suburb in which my office is located. The treatment completers group was comprised of 71% White Non-Hispanic individuals (n = 12) and 29% White Hispanic individuals (n = 5). The treatment non-completers group included 46% White Non-Hispanics (n = 6) and 54% White Hispanics (n = 7). Therefore, White Non-Hispanics were slightly more likely to complete treatment and achieve full recovery than White Hispanics.

4.) History of intensive eating disorder treatment.

History of residential, day treatment, or intensive outpatient treatment had a minor impact on treatment outcome. Twelve percent of treatment completers (n = 2) and 23% of treatment non-completers (n = 3) had a history of residential eating disorders treatment prior to beginning treatment with me. Twenty-four percent of treatment completers (n = 4) and 31% of treatment non-completers had a history of partial hospitalization, day treatment, or intensive outpatient eating disorder treatment.

Variables that Had No Impact on Treatment Outcome:

1.) Comorbid disorders

The presence of comorbid disorders did not differ significantly between the two groups. Fifty-three percent of treatment completers (n = 9) had a comorbid diagnosis, as did 46% of treatment non-completers.

2.) Gender.

Given that only 7% of the sample was male (n = 2), I cannot draw any conclusions about gender differences in treatment response. Incidentally, both of the males in my sample achieved full recovery.

3.) Hospitalization before treatment.

Being hospitalized for AN or a related psychiatric issue prior to beginning treatment with me did not have a significant impact on treatment outcome. Thirty-five percent of treatment completers (n = 6) had been hospitalized at least one prior to beginning treatment with me, as had 31% percent of treatment non-completers (n = 4).

4.) Hospitalization during treatment.

The need for hospitalization during the course of treatment with me did not have a significant impact on treatment outcome. Eighteen percent of treatment completers (n = 3) needed to be hospitalized during the course of their treatment, compared with 15% (n = 2) of treatment non-completers.

These data, taken together, suggest that a patient with AN-R who enters treatment with me and receives FBT is very likely to achieve full remission within 28 sessions over the course of 17 months, regardless of gender, comorbid diagnosis, or history of hospitalization. A patient under age 18 has a greater likelihood of achieving full remission, although a patient over 18 is also likely to achieve full remission, provided that he or she is treated with FBT.

Please bear in mind that these results are specific to my practice and my patients. These data are not intended to be generalized to other clinicians or other patient populations.

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Thursday, August 25th, 2011

Leaving the Nest: 10 Tips for Parents

It’s back to school time! A new crop of 18-year-olds are leaving home to begin pseudo-independent lives in college. This is the time of year when my inbox is flooded with emails from other clinicians who are using professional list-serves to assemble treatment teams for their patients who are going off to universities in other cities or states.

“Looking for psychologist and psychiatrist in Atlanta for student entering freshman year at Emory. Bipolar disorder diagnosed in February 2011; has been stable on new meds since suicide attempt in June. Patient is very insightful but needs close monitoring.”

“Need treatment team in Boston for incoming freshman at Boston University with 4 year history of bulimia and major depression. Weight is normal but patient engages in binge/purge symptoms 3-4 times per week. Patient has delightful personality but is very entrenched in ED symptoms.”

“20-year-old patient with anorexia nervosa, social anxiety, and OCD just released from our day treatment program needs multidisciplinary treatment team in Chicago as she returns for her junior year at Northwestern University. Patient was discharged at 90% of ideal body weight and is compliant with meal plan. Needs nutritionist, psychologist, psychiatrist, and internist familiar with EDs.”

“23-year-old patient with major depression and alcoholism is entering graduate school at UMass Amherst and needs treatment team. Has 2 months sobriety.”

As I read vignettes such as these, I can’t help but wonder whether it is in the best interest of these vulnerable young people to be away at college. Adjectives like “compliant” and “insightful” and “delightful” seem to be inserted to justify the decision to send the patient away to school and/or to entice clinicians to take on these challenging cases. Qualifiers like “2 months sober” and “90% of ideal body weight” do nothing to quell my apprehension. Frankly, they frighten me more.

Let me be frank: a psychiatric diagnosis is a game changer. Any artificial deadlines, such as an 18th birthday or the start of the school year, are irrelevant. Psychiatric disorders are serious, potentially disabling (think major depression, which is a leading cause of lost productivity in the workplace), even deadly (think anorexia nervosa, which carries a 20% mortality rate). Individuals with psychiatric diagnoses can and do recover and go on to lead productive, fulfilling lives, but this requires prompt, effective treatment and a supportive, low-stress environment for a sustained period of time.

The transition to college presents numerous challenges to even the healthiest and most well-adjusted young people: leaving their hometown, family, and friends; living independently in a different city or state; adjusting to dorm life; navigating new peer relationships and social pressures; managing one’s time and money; choosing a career path and taking academically rigorous courses; assuming full responsibility for nutritional intake, sleep schedule, physical activity, and medical care.

Let’s face it: the typical college lifestyle does not promote physical or mental health. Late nights spent studying or partying, daytime napping, chronic sleep deprivation, erratic eating habits consisting mostly of processed snacks and caffeinated beverages in lieu of balanced meals. Most college students drink alcohol socially, and many drink to excess multiple times a week. Widespread use of illicit drugs as well as rampant abuse of black market prescription drugs as study aids (e.g. Adderall) or sleep aids (e.g., Xanax) is a mainstay of university life. Casual sex with multiple partners, often unprotected and usually under the influence of alcohol, is the norm on most campuses.

Navigating these challenges successfully requires a certain level of mental and emotional stability. Maintaining good self-care in an environment where virtually everyone else practices unhealthy habits requires a maturity and strength of character that is beyond the reach of most 18, 19, and 20 year olds.

I have treated patients before, during, and after college, and have counseled their parents throughout this process. I worked at three different university counseling centers during my doctoral training. During that time I worked with dozens of students struggling with psychiatric illnesses and gained an intimate understanding of what universities do, and don’t do, to support students with mental health problems.

Now, as a psychologist in private practice near two large universities, I treat a number of college students as well as high-school students who hope to go away to college in the near future. I also have a few patients who had attempted to go away to college in the past, but experienced a worsening of symptoms, a full-blown relapse, or in some cases life-threatening complications which rendered them unable to live independently. These are young people who have returned home to the safety of their families and are now going through treatment to repair the damage with hopes of living independently in the future.

I have developed the following professional recommendations for parents of young people with psychiatric illnesses based on these clinical experiences as well as the latest scientific research:

1.) If your child is a junior or senior in high school and hopes to go away to college in the future, begin working with her and her treatment team now to establish criteria to assess her readiness for going away to college. I recommend collaboratively establishing a written plan which includes specific, measurable criteria which the child must meet before she is permitted to leave home.

2.) If your child has had life-threatening symptoms (suicide attempt, drug/alcohol abuse, eating disorder), ensure that her condition is in full remission for at least 6 months prior to letting her go away to college. For example:
– A child with bipolar disorder should have at least 6 months of mood stability without any manic or major depressive episodes.
– A child who has attempted suicide should have a minimum of 6 months without any suicidal behaviors, gestures, or urges.
– A child with a substance abuse problem should have at least 6 months of complete sobriety.
– A child with anorexia nervosa should have at least 6 months of eating independently without restriction while maintaining 100% full weight-restoration with regular menstrual periods.
– A child with bulimia nervosa should have at least 6 months of normalized eating with complete abstinence from all binge/purge behaviors.

3.) A young person going off to college should have, at most, minimal or mild mental/emotional symptoms. For example, a child with an anxiety disorder who has occasional panic attacks, or who feels somewhat anxious at parties around new people, may be able to function well at college, but a child who has panic attacks multiple times a week or who avoids most social situations is not yet ready to go away.

4.) Ensure that your child has effective tools to manage any symptoms that may arise. This may include CBT or DBT skills to manage feelings of depression or anxiety.

5.) Work with your child and her treatment team to develop a self-care plan that includes plenty of sleep, physical activity, time management, and balanced meals and snacks at regular intervals.

6.) Do not rely upon university services (student health center or student counseling center) to provide therapy, psychiatric, or medical services for your child. University counseling centers are not equipped to manage the needs of students with major mental health issues. Most student counseling centers are over-worked, under-staffed, and underfunded. By necessity, most have limits on the number of sessions each student can attend, and most will not support parental involvement in treatment decisions or even communicate with parents at all.

7.) Prior to your child’s departure for college, establish a treatment team off-campus.
– Interview the clinicians over the phone and schedule a family meeting in person with the clinician before the school year starts, during the time you are helping your child move into the dorms. If the clinician is reluctant to talk with you over the phone or refuses to meet with you in person, this is a red flag.
– I recommend selecting a clinician who welcomes individualized, appropriate parental involvement in college students’ mental healthcare. This means working collaboratively with parents based upon the individual patient’s needs in light of her diagnosis, history, and developmental stage, irrespective of her chronological age.
– Ensure that your child signs releases of information allowing you to communicate with the clinician regarding your child’s care (law requires that persons over 18 must provide written permission for a mental health professional to release information to anyone, including parents).
– Use the initial family meeting to provide the clinician with any relevant history about your child’s condition. Written psychological evaluations or discharge summaries from previous treatment providers are very helpful in this regard.
– Work collaboratively with the new clinician and your child to establish frequency of contact, and nature of communication, between you and the new clinician. For instance, I often work out a plan wherein I call parents every two weeks, or once a month, with a general progress report on the patient, without revealing the specific content of sessions (e.g., “Mary is adjusting well to dorm life. She’s had some mild anxiety but she seems to be managing it well.” Or “Annie has been struggling with an increase in depressive symptoms over the past week. I will keep you posted and notify you right away if there is any indication of suicidality or deterioration in functioning.”) Be very clear about the type of information that will be shared between clinician and parents. It is important for the patient to establish a trusting relationship with the clinician and to feel secure that, in general, “what happens in therapy stays in therapy.” It is equally important for the parents to be reassured that they will be notified promptly if the child’s condition deteriorates.

8.) Have a safety net in place. Decide exactly what extra supports will be provided, and under what circumstances, if the child should experience an increase in symptoms while away at college. For example: an increase in symptoms lasting longer than one week may result in the child coming home for the next weekend, or perhaps a parent would travel to stay with the child in a hotel for a week or two.

9.) Have a plan B.
– Work collaboratively with your child and her new treatment team to establish what conditions would warrant a more serious intervention.
– Some situations, in my opinion, warrant a medical leave and an immediate return to the safety of home. For example, a suicide attempt or gesture, an episode of alcohol poisoning, a weight loss of more than 5 pounds (in the case of anorexia nervosa) or a recurrence of binge/purge symptoms lasting longer than a couple of weeks (in the case of bulimia).

10.) Always remember, and reiterate to your child: whatever happens is feedback, not failure.
– A medical leave of absence is not the end of the world. Nor is it permanent. It is simply an indication that your child temporarily needs more support than can be provided in the college setting. It is no different from a young person taking a leave of absence for major surgery or cancer treatment (try getting that done in the student health center!).
– Many young adults recover more swiftly from a relapse compared to the first time they were ill – the benefit of maturity and the motivation of wanting to return to college and independent living can be very helpful in this regard. If your child does well at home and recovers from the relapse, she may be able to return to school away from home the following semester or the following year.
– Depending on the circumstances and the course of your child’s illness, it is possible that the best scenario for her would be to live at home and attend college locally, or transfer to a school in-state and come home each weekend. Again, this is not the end of the world. If her recovery is robust after college, she will still have the opportunity to go away to graduate school or start the career of her dreams somewhere else.

Attending college is a privilege and a gift, not an inalienable right. It is not something that one must automatically do right after graduating from college. Living away from home, apart from one’s primary support system, to attend a faraway school is a privilege unique to American culture, and is not a prerequisite for success in any way. In most other countries, young people who do attend college (and not everyone does) do so locally while living at home until they are married.

Take your child’s psychiatric diagnosis very seriously, and do the right thing for her health. As her parent, it is not only your right but your duty to make these decisions, and you should be supported by a treatment team that empowers you to do so.

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Thursday, June 24th, 2010

A False Dichotomy

One of the things that bothers me most about my field is the false dichotomy between biology and psychology. On the one hand, there are psychiatrists who over-diagnose and overmedicate without taking the time to get to know patients and truly understand their symptoms. They spend very little time with patients and try to solve everything with a pill, rather than providing psychotherapy or referring patients to a psychotherapist. These psychiatrists do not take into account the role of environmental stressors, lifestyle (nutrition, sleep, substance use), and learned patterns of thinking that can be successfully treated without medication.

On the other hand, there are therapists who over-pathologize and overanalyze. These therapists are married to unscientific, unsupported psychodynamic theories about the etiology of psychological problems which tend to attribute symptoms to supposed family dysfunction and internal conflicts. These therapists fail to take into account the powerful role of genetics and neurobiology in contributing to the patient’s symptoms. They ignore or discount the recent scientific advances in our field, and they do not employ empirically-supported treatments which have been demonstrated to be effective. They rely instead on their opinions and “clinical judgment.”

Neither side of this dichotomy serves its patients well, as both sides fail to appreciate the true complexity of the human experience. One side places all eggs in one very small proverbial basket (a pill), effectively abnegating the patient of any responsibility for behavioral, psychological, or environmental change. The other side places an unfair amount of blame on the patient and / or her family, searching for root causes that may not exist, traumas that may never have occurred, or dysfunction in normal thoughts and behaviors. Consequently, it is implied, if not blatantly asserted, that biologically-driven thoughts and behaviors are freely chosen and can be un-chosen just as freely with enough insight into said root causes, traumas, and dysfunction.

I am often disappointed by those mental health professionals who have so little scientific understanding of the interaction between genes and environment, between biology and psychology, between experience and neurodevelopment. They seem to forget that the mind is an abstraction of the brain, and the brain is part of the body. Their thinking is so dichotomous – disorder X was caused by either genes OR environment; treatment must be medication OR psychotherapy; it’s a neurobiological illness OR it is caused by environmental factors. They don’t seem to understand that, with mental illness, it’s rarely a question of “nature or nurture.” Rather, it is nature AND nurture, both of which come in many forms. Biology, psychology, and environment are constantly interacting, with each of these components profoundly impacting the other two.

I would like to see all mental health professionals develop a full understanding of and appreciation for biopsychosocial models of mental illness and evidence-based treatments. It is my hope that psychologists, psychiatrists, and mental health professionals from all disciplines will begin taking a more well-rounded approach to treating psychiatric disorders and helping people achieve mental health.

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Saturday, May 15th, 2010

How to Help Your Depressed Teenager: Tips for Parents

If your child is depressed, it is important to act now. Untreated depression causes tremendous suffering and can lead to serious medical and emotional problems, including suicide. Adolescents with untreated depression have difficulty learning and making and keeping friends. They are also more likely to abuse drugs and engage in self-injury. You must intervene now in order to help your teenager blossom into the wonderful person she was meant to be.

1. Educate yourself on depression in adolescents.

Learn the signs and symptoms of depression and know how to differentiate between normal sadness or “teen angst” and clinical depression. All teenagers are moody and irritable at times, and sadness is a natural and healthy response to a loss or disappointment. Depression is a serious but treatable mental illness which affects between 2-5% of adolescents at any point in time.

Depression involves a pervasively sad or irritable mood that lasts at least two weeks, but usually several months or more, and causes a noticeable change in functioning. Depressed adolescents also experience physiological symptoms such as changes in appetite and weight, lack of energy, insomnia or hypersomnia, and physical aches or pains. They tend to have poor self-esteem and irrationally negative thoughts, lose interest in activities and friends, isolate themselves, and feel guilty or worthless for no good reason. Many depressed teens feel hopeless and have recurrent thoughts of death or suicide.

2. Take your child to the pediatrician for a complete physical exam to rule out organic causes of depression.

In some cases, depression is the result of a general medical condition such as hypothyroidism or mononucleosis. Depression can also be a side effect of certain medications. Some teens may exhibit depression as a result of abusing alcohol, drugs, or prescription or over-the-counter medications. Finally, simple things like sleep deprivation, too much stress, and nutritional deficiencies can manifest as depression. It is important that your child receives a complete physical exam in order to rule out any of these potential causes.

3. Let go of guilt and blame.

Depression is no one’s fault. Your child did not choose it and you did not cause it. We know that depression is a heritable brain disorder which is often (though not always) triggered by stressful life events and brain changes during puberty. It is unhelpful, even counterproductive, to blame yourself or your child for her depression. While your child is depressed, her moods and behaviors are to some degree out of her control. She cannot “choose to be happy” or “snap out of it.”

4. Don’t be too quick to medicate.

Psychotropic medication has its place, and under certain circumstances, it may be a very helpful adjunct to psychological treatment for depression. Far too often, however, psychiatrists and other physicians use medication as the first line of defense against depression. This is especially dangerous for children and adolescents, whose brains are still developing and who are more likely to suffer from serious side effects.

In addition to the risk of side effects and the lack of evidence about the long-term effects of antidepressants on a developing brain, there are other dangers to using medicating as the first, or only, line of treatment.

First, there has been very little research on the effects of antidepressants in youth. Second, there is only one antidepressant medication (Prozac) which has been FDA-approved to treat depression in adolescents, but doctors regularly use other medications “off-label” to treat them. Third, psychotherapy is more effective than medication for most adolescents with mild-to-moderate depression. Fourth, a child who receives medication without psychotherapy will not learn the necessary skills or make the necessary life changes needed to sustain lasting improvement and prevent relapse. The effects of medication expire when the medication is stopped, whereas the effects of good psychotherapy are longer-lasting.

In order to protect your child from being prescribed unnecessary or harmful medication, I recommend first taking your child to a psychologist (Ph.D. or Psy.D.) rather than a psychiatrist (M.D.). Psychologists perform psychological assessments and conduct psychotherapy but do not prescribe medication. Most psychiatrists, on the other hand, prescribe medication to the vast majority of patients they see, while conducting little (if any) psychotherapy.

If it becomes evident later on that your child could benefit from medication as an adjunct to psychotherapy, you can always ask your child’s psychologist or pediatrician to refer you to a child psychiatrist with whom he/she has a working relationship.

5. Seek evidence-based psychological treatment.

All therapy is not created equal. Some psychological treatments have been shown to work, while others have not. Research supports the effectiveness of three different types of psychotherapy for depressed adolescents: individual cognitive-behavioral therapy (CBT), group CBT, and interpersonal psychotherapy for adolescents (IPT-A). All three of these treatments are relatively short-term, usually consisting of 12-16 weekly sessions over the course of 3-4 months.

CBT focuses on the relationships among thoughts, feelings, and behaviors. CBT directly targets the adolescent’s present symptoms, without much emphasis on the past. The CBT therapist helps the adolescent identify patterns of thinking and acting which are contributing to her depression and teaches her new ways of thinking and behaving that facilitate positive feelings. CBT be delivered individually, with your child meeting 1-on-1 with a therapist, or in a group consisting of one or two therapists and 6-12 other adolescents who are experiencing depression.

IPT-A focuses on the adolescent’s social functioning and her current relationships with important people in her life. Through IPT-A, the adolescent develops her social skills, learns more effective ways of communicating, identifies connections between certain relationship patterns and her depressive symptoms, and learns to cope effectively with life transitions.

Be conscientious and selective in your search for an appropriate therapist for your child. Try to find a psychologist who has experience in treating adolescent depression. Speak with the psychologist briefly over the phone before making an appointment. Ask her about her philosophy of treatment, and make sure she practices evidence-based treatment.

6. Insist upon being fully informed and actively involved in your child’s treatment.

There is quite a bit you can do to help your child recover from depression, so don’t let any professional tell you otherwise. Treatment works best when you are fully informed and actively involved. Your child will probably be meeting with the therapist individually during most sessions. However, you should be involved in the initial evaluation and treatment planning. You should expect the therapist to check in with you on a regular basis to provide updates on your child’s progress. The therapist should always return your calls in a timely fashion and should definitely tell you if your child is engaging in dangerous behavior.

At the start of treatment, have a frank conversation with the therapist about confidentiality and boundaries. You, the therapist, and your child should come to a clear agreement about what types of information will and will not be disclosed to you as the parent. It is important that your child forms a comfortable, trusting relationship with her therapist. It is even more important, however, that you are made aware of any harmful behaviors (e.g., drug or alcohol use, unprotected sex, eating disorders, cutting) and involved in the process of helping your child overcome these issues.

7. Be willing to consider antidepressant medication under certain circumstances.

Antidepressants are vastly over-prescribed. They should not typically be used as a first-line treatment and should not be prescribed unless the patient is also in psychotherapy. However, there are certain circumstances under which medication may be beneficial and even life-saving:
• If your child has been in evidence-based psychotherapy for two or three months but has not shown any improvement, consider adding an antidepressant to your child’s treatment plan as an adjunct to psychotherapy.
• Depression has a strong genetic component. If your child has a first-degree relative (mother, father, or sibling) who suffers from a mood disorder, this suggests that your child’s depression is likely to be genetic and biologically-based. In this situation, it is more likely that your child will benefit from antidepressants.
• Research has shown that severe depression responds best to a combination of psychotherapy and antidepressant medication. In contrast, mild- to moderate depression can typically be successfully treated with psychotherapy alone. Most cases of depression are mild or moderate, so check with your child’s psychologist to determine the severity of her illness. Adolescents with severe depression are often too ill to engage in psychotherapy without the added benefit of medication to normalize their brain chemistry.
• Your child’s medication should be prescribed and monitored by a board-certified child and adolescent psychiatrist, not by her pediatrician. While pediatricians are able to prescribe antidepressants, they do not have the expertise necessary to monitor your child’s progress and ensure that she is on the correct dose of the right medication.
• You and your child should meet with the psychiatrist for a thorough evaluation before any medication is prescribed. Be sure to ask the psychiatrist about any potential side effects or drug interactions of which you should be aware.
• Your child should be closely monitored by her psychiatrist while she is on the medication, especially during the first month and after a change in dosage. After that, the psychiatrist should follow up with your child at least monthly to monitor her progress and change her dosage if necessary.

8. Create a home environment conducive to overall physical health and mental wellbeing.

Basic self-care habits such as sleep, nutrition, exercise, and stress release are extremely important for someone suffering from depression. Teenagers are notorious for staying up late, eating lots of junk food, and guzzling soda at all hours of the day. While most teens can “get away with” these habits for a few years, teens recovering from depression cannot afford to take shortcuts with their health. Depressive symptoms can be caused or exacerbated by sleep deprivation, poor nutrition, inactivity, and chronic stress.

Prioritize health and well-being above all else. Establish regular bedtimes to ensure that your child gets a minimum of 8 hours of sleep every night. Many adolescents need 9-10 hours of sleep or even more in order to function optimally. Require your child to eat nutritious, balanced meals with the entire family. Supplement her diet with multivitamins and Omega-3 essential fatty acids, which have been shown to improve mood, memory, and general mental functioning. Encourage her to enjoy some physical activity every day. Minimize the stress and tension in your household. Help your child create a balance of study time, personal time, friend time, and family time.

9. Encourage healthy social relationships and fun activities.

Depression causes adolescents to withdraw from their friends and family and lose interest in activities they once enjoyed. Unfortunately, social isolation and inactivity only exacerbate depressive symptoms. Ensure that your child stays connected to the family by sharing meals with the family every day and involving her in a weekly family outing or game night. Encourage her to go out with her friends or invite them over to the house.

See to it that your child is involved in activities that create a sense of purpose, nurture her talents and burgeoning self-concept, and help her connect with other like-minded kids and adults. If your child is artistic, sign her up for art lessons or encourage her to audition for a play. If she is musical, encourage her to join the marching band or take dance classes. If she is athletic, encourage participation on a sports team. Many adolescents find a sense of meaning in volunteer work or involvement in religious activities.

Depressed adolescents often lose motivation and lack the interest and energy to initiate activities on their own. However, once they become involved and engaged in activities, they usually begin to feel a little bit better. Remind your child of this when she expressed reluctance to do something fun or social.

10. Provide your child with plenty of nurturing, comfort, and physical contact.

No parent wants their child to suffer. It will be very difficult to and heart-wrenching to watch your child struggle with depression. However, it is important that you remain calm, steady, compassionate, and optimistic.

Depressed adolescents often feel worthless and guilty for worrying their parents. Tell your child that you love her infinitely and unconditionally, regardless of whether she is happy or depressed. Ensure your child that she is not to blame for being depressed and that she has done nothing wrong. Let her know that you are concerned about her depression, that you are here to support her, and that you will take all the necessary steps to get her good treatment and help her recover.

Physical contact through affection, hugging, kissing can be very comforting to a distraught adolescent. If your child resists being touched, use a soothing voice and reassuring words to comfort her and let her know that you are always available for a hug whenever she needs one. Express empathy towards your child and be willing to listen to her thoughts and feelings. However, you must keep in mind that depressed adolescents may have many irrational thoughts and negative perceptions about themselves and others. For example, your child may be extremely self-critical, believe that no one likes her, tell you her life is a living hell, or fear that you are angry with her. You can gently explain to your child her depression is causing her to see things through a “negative filter” such that many of her perceptions are colored by the depression and are not necessarily accurate.

11. Be patient and realistic.

Recovery from depression takes time. Your child will not feel better right away, nor should you expect her to. It takes weeks for the effects of psychotherapy and medication to become evident. Your child may begin to feel hopeless and worry that she will be depressed forever. This hopelessness is a symptom of depression, rather than an accurate assessment of her situation. You must remain hopeful and optimistic regardless of your child’s attitude. Reassure your child that recovery takes time; that she will begin to feel better soon; that she must stick with treatment.

It is often helpful to lower your standards while your child is depressed. This is difficult for many parents to accept. However, it is important to recognize that depression is a very real and very disabling condition that will have a major impact on your child’s functioning, personality, and behavior. Depression in teens can manifest in a variety of ways. Some teens may suffer a decline in academic performance due to inability to concentrate. Many depressed teens will become quiet and withdrawn; others will become angry and volatile. Some depressed adolescents will act out, abuse drugs, cut themselves, or get into trouble at school. However your child’s depression manifests, be aware of one thing: your child will NOT seem like herself while she is depressed. Just be aware of this fact and accept it. This is not to say that you must tolerate blatant disrespect, delinquency, or dangerous behavior. Continue to maintain appropriate boundaries and limits to keep everyone safe. However, recognize that your child is suffering from a serious mental illness that impairs her ability to function. If her grades slip, or she doesn’t do her chores, or she mouths off to you more than usual, show compassion and empathy, and try to maintain perspective.

Some adolescents experience one episode of depression and that’s it. However, more than half of adolescents who experience major depression will go on to have more episodes in the future. This does not mean that treatment didn’t work, or that your child failed, or that you failed your child. This is simply the nature of major depressive disorder. The good news is that if your child has been successfully treated the first time, you know exactly what to do if she begins to develop symptoms again. With the knowledge, insight, skills, and professional contacts gained the first time around, relapse should be briefer and easier to manage.

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Monday, February 22nd, 2010

The Seven Habits of Highly Effective Therapists

What qualities make for an effective therapist? Good listening skills? Yes. Ability to connect and empathize with patients? Sure. A nice person who genuinely cares about you? Absolutely. These qualities may enhance the therapeutic relationship, which is important for healing, but the therapeutic relationship itself does not always translate into recovery, especially for persons with serious mental illnesses. A doctoral degree in psychology, a license to practice, and years of experience in the field indicate that a therapist is qualified, but these things do not guarantee effectiveness.

To put it succinctly, a highly effective therapist is one whose patients get better. Here are the qualities, in my opinion, that highly effective therapists possess.

1. A highly effective therapist conducts a thorough assessment at the start of treatment, including, but not limited to: diagnostic interviews with the patient and her parents (if she is <18), psychosocial / developmental history, family history, medical and psychiatric history, and consultations with the patient’s other treating professionals (e.g., primary care physician, psychiatrist). She synthesizes this information to arrive at an accurate diagnosis. She is cognizant of the multifaceted etiology of mental disorders, and takes into account genetics, biology, temperament, psychosocial issues, environmental factors, lifestyle and behaviors (e.g., stress, sleep, nutrition, exercise) when determining the cause(s) of the patient’s problems. 2. At the end of the initial assessment, a highly effective therapist has an in-depth discussion with the patient, and the parents of minor patients, in which diagnostic impressions are shared. The therapist provides the patient and her family with a scientifically-grounded explanation of her disorder(s) and explains the full range of treatment options available.

3. In collaboration with the patient, and parents of minor patients, the highly effective therapist develops a treatment plan. This treatment plan may consist of services delivered by other professionals (e.g., psychiatrist, pediatrician, dietician) and may consist of one or more modalities of treatment (e.g., individual therapy, family therapy, group therapy). Parental involvement is an integral part of the treatment plan for children and adolescents, except in rare cases when parental involvement may be contraindicated. For adult patients, family members are often included in the treatment plan to participate in family therapy or to play a support role. The highly effective therapist coordinates the patient’s treatment with the other professionals on her treatment team and maintains regular contact with all team members throughout the patient’s course of treatment.

4. A highly effective therapist has training and experience in empirically-supported treatments, such as CBT, DBT, ACT, Maudsley FBT, and IPT. She stays abreast of recent developments in the etiology and treatment of the disorders she treats so that she may better serve her patients. She uses empirically-supported treatments with her patients unless contraindicated.

5. A highly effective therapist is well-prepared and fully present, in body and in mind, with her patients. Therefore, the highly effective therapist is not over-scheduled or over-stressed. She has enough time in her schedule to meet with every patient as often as necessary, including last-minute emergency appointments when needed. She has adequate time to devote to preparing treatment interventions, adequate record keeping, maintaining regular contact with other professionals, and returning patients’ calls and emails in a timely fashion. The highly effective therapist demonstrates respect for her patients’ time by starting and ending appointments promptly and refraining from canceling or rescheduling sessions in the absence of a true emergency. She has sufficient flexibility in her schedule so that, if a patient must cancel a session, she can reschedule the patient within the week. The highly effective therapist devotes her full attention to her patient during sessions by turning off her phone, not responding to emails, and not allowing visitors to knock on the door.

6. A highly effective therapist knows when, and when not, to refer her patients to psychiatrists. She knows which symptoms and disorders usually require medication and which symptoms and disorders can be treated solely with behavioral or psychological interventions. She is conservative in her approach to psychotropic medication and views it as an adjunct to effective psychotherapy. She prefers for her patients to be on medication only when necessary, and on as little medication as necessary for optimal functioning. A psychiatric referral almost always results in medication prescribed. Thus, a highly effective therapist refers patients to psychiatrists only if there is evidence that psychological interventions alone will not be sufficient for recovery. When a psychiatric referral is indicated, a highly effective therapist obtains a signed release of information from the patient to communicate with the psychiatrist. Thereafter, the highly effective therapist maintains communication with the psychiatrist for the duration of the patient’s treatment and is closely involved with decisions to start, stop, and change dosage of the patient’s medications.

7. A highly effective therapist terminates treatment at the appropriate time and in the appropriate manner. Typically, therapy is over when the patient has reached maximum benefit. Sometimes treatment must be terminated because a patient is not progressing. At this point, the therapist assists the patient in formulating a plan for future care. When it is clear that a patient requires a higher level of care than the therapist can provide (e.g., residential or inpatient treatment), she makes the appropriate referrals and supports the patient in following through with these referrals. She does not allow the patient to settle for a lower level of care than she requires. Regardless of the reason treatment ends, the therapist provides the patient with the opportunity to create meaning out of her therapeutic experience. At the end of treatment, the therapist allows at least two sessions for the patient to reflect on her experience in therapy, the progress that she has made, and the therapeutic relationship.

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Monday, February 8th, 2010

Top 10 Mistakes in Mental Health Care

Very early in my blogging career, I wrote about The Top 10 Mistakes in Eating Disorders Treatment. Bad treatment, however, is not limited to eating disorders. Here are the most common mistakes I have observed in the treatment of other mental illnesses:

1. Failure to conduct a thorough assessment at the beginning of treatment. This contributes to missed diagnoses, incorrect diagnoses, and ultimately to ineffective or inappropriate treatment.

2. Failure to assess for behavioral, lifestyle, and environmental factors that may be contributing to the patient’s symptoms. This generally corresponds with the failure to recommend simple lifestyle changes which have a powerful impact on psychological wellbeing. Sleep deprivation, excess alcohol or caffeine intake, lack of exercise, poor nutrition, and increased stress at work, school, or home create symptoms that appear identical to those of depression and anxiety. For many people, these symptoms can be alleviated by making behavioral changes. For others, psychotherapy and medication may be necessary.

3. Lack of basic, scientifically-sound education for patients and their families regarding the patient’s disorder(s) and the efficacy of various treatment options. It never ceases to amaze me how many patients and families come to me, after months or years of therapy, without a basic science-based explanation of their mental illness, and without ever being informed that evidence-based treatment exists. Perhaps the most common example of this phenomenon is the patient whose four years of previous therapy focused on the “why” or the “root cause” of her mental disorder without providing any symptom relief. Insight is important, but insight itself does not cure mental illness. These patients are not provided with the simple (and in my mind, very liberating) explanation that mental illnesses are caused by certain biological and genetic vulnerabilities which are often expressed when certain environmental circumstances are present. They are not told that, regardless of the reasons why they developed their illness, they can learn skills to help them manage their symptoms and feel better.

4. Failure to use effective, evidence-based psychological treatments (EBT’s). For the majority of mental illnesses, there is research demonstrating which treatments are most effective. The problem is that the majority of therapists do not use EBT’s. There are several reasons for this: A.) Some therapists have not been trained in evidence-based treatments. This is the result of a three-pronged failure: on the part of the graduate programs which do not teach EBT’s, on the part of the therapists who do not take the initiative to keep up with the literature or seek out the proper continuing education courses, and on the part of the state licensing boards, which do not require that therapists learn about or practice EBTs. B.) Some therapists have been trained in EBT’s but choose not to use them because they value their own clinical judgment more than they value science. This is faulty logic, because research shows that statistical prediction consistently outperforms clinical judgment. Translation: therapists are far more effective when they select their interventions on the basis of scientific research (e.g., what works best for most people with this particular disorder) rather than using their own judgment to decide how to help a patient. C.) Some therapists protest: “But EBT’s don’t work for everyone.” Well, of course they don’t. Nothing works for everyone. But if research consistently shows that treatment A is effective for 80% of people with OCD, while treatment B is effective for 25% of people with OCD, and treatment C is based upon a psychological theory but has never been studied scientifically, it’s a no brainer. Use treatment A with OCD patients unless you have a specific, convincing reason not to. It makes no logical, mathematical, ethical, or scientific sense to do otherwise.

5. Insufficient amount or intensity of psychological treatment. Sessions may begin too late in the course of a mental illness; sessions may be held less frequently than needed; treatment may be terminated before the patient is fully recovered; patients may not receive the level of care (e.g., hospitalization, residential treatment, day treatment) that they need in order to recover. Financial issues and insurance limits are largely to blame for this problem. However, our attitudes about mental illness and personal autonomy play a major role as well. I don’t believe in the “least restrictive environment” criterion. I do not believe that a person should have to be imminently suicidal, homicidal, or floridly psychotic to warrant inpatient treatment. I do not believe that residential and day treatment programs should be reserved for those who have had multiple failed attempts at outpatient treatment. I believe that providing intensive, aggressive treatment at initial diagnosis (which often requires more than your typical weekly therapy sessions) would greatly reduce the severity and duration of mental illnesses.

6. Focusing on “underlying issues” rather than symptoms early in treatment. It makes no sense to do intensive psychotherapy with a drug addict while she is high or while she is actively using drugs. Her mental state is too compromised for her to do meaningful psychological work, and the psychological work detracts time and attention away from the most glaring, life-threatening problem: the drug use. This patient would need to go through detox and rehab before she could really benefit from psychotherapy. Similarly, if a person is severely depressed, severely anxious, or engaging in self-injurious behavior, it makes no sense to spend the therapy hour processing inner conflicts or exploring childhood memories. She cannot think rationally or process emotional information accurately while such acute symptoms are present. The first step must be to alleviate the symptoms. To do otherwise simply serves to delay her recovery and prolong her misery.

7. Failure to address underlying issues, if they exist, later in treatment. Once symptoms are under control, it is important to assess for and treat any underlying issues which could make the patient vulnerable to relapse. I do not mean to imply that every patient has deep, dark secrets of trauma or major internal conflicts. Many patients have simpler underlying problems, such as poor communication skills, unhelpful relationship patterns, low self-esteem, perfectionism, unhealthy core beliefs, or overly stressful jobs or home lives. Regardless of the nature of the patient’s issues, they must be treated if the patient is to heal fully and maintain a lasting recovery. Disclaimer: It is a huge mistake for therapists to presume that all patients have serious underlying issues that must be addressed in treatment. This assumption leads to endless exploration of the past, digging around for some buried treasure that often does not exist. This can be a waste of time and money, can lead to over-focus on the past at the exclusion of full engagement in the present, and can actually make patients feel worse. Sometimes a cigar is just a cigar.

8. Over-prescribing, or inappropriately prescribing, psychotropic medication. A lot of this has to do with insurance companies and financial issues: it is cheaper to medicate than to treat holistically with psychological therapy, at least in the short term. We know that for many mental illnesses, certain evidence-based psychological treatments are more effective than medications (i.e., DBT for borderline personality disorder, CBT, ACT, and exercise for mild to moderate depression, exposure and response prevention for OCD, behavior therapy for panic disorder, CBT-E for bulimia nervosa). And yet many patients are medicated for these illnesses without being offered psychological treatment, and without being informed that certain psychological treatments for certain conditions are actually superior to medication. Recent statistics show that 80% of prescriptions for psychotropic medications are written by general care physicians (internists and pediatricians). This appalls me. While GPs are allowed to prescribe psychotropic medication, they lack specialized training in the diagnosis and treatment of mental illness. The ideal situation is for a psychiatrist to prescribe the psychotropic medication, follow up with the patient regularly to monitor her response to the medication, and remain in close contact with the patient’s GP and therapist in order to ensure seamless coordination of care.

9. Failure to involve family members in a young patient’s treatment. Yes, the primary developmental task of adolescence is separation / individuation. But this developmental reality in no way precludes involving family members in an adolescent’s treatment. I believe that a child or adolescent’s treatment works best when family members are fully informed and actively involved. The patient may be with the therapist for 1 hour a week, but she is with her family for the other 167 hours. Therapists are most effective when they strengthen a family unit (rather than weakening it by pointing the finger of blame), communicate openly with parents (rather than hiding behind the cloak of confidentiality), and provide them with tools to help their children (rather than urging them to back off). Therapy is temporary; family is forever.

10. Blaming patients, either subtly or overtly, for their mental illnesses. This causes so much harm. Many therapists are of the opinion that if patients just tried a little harder, dug a little deeper, or stayed in therapy just a few months (or years) longer, they would get better. Patients are often held responsible for their own lack of therapeutic progress (Remember the old joke – “How many shrinks does it take to change a light bulb? Just one, but the light bulb has to WANT to change”). As a result, patients blame themselves when they do not recover. Guilt is paralyzing and depressing and disempowering. In what other illness would a patient be held responsible for her lack of improvement? Obviously, therapy is a collaborative process which requires tremendous courage and dedication from the patient. That said, the therapist is responsible for providing the patient with effective treatment and guiding her towards recovery.

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