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

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

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Tag: Suicide

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, 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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Friday, August 7th, 2009

Military Suicides

When American men and women make the courageous choice to join the armed forces, they realize that they may sacrifice their lives for their country. What they may not realize is that they are now more likely to commit suicide than they are to die in military combat.

The incidence of suicide in the military has increased steadily since the Iraq war began in 2003. There were 67 suicides in 2004, followed by 85 in 2005, 102 in 2006, and 115 in 2007. The 2008 statistic – 128 suicides – is the highest we’ve seen since record keeping began in 1980. Shockingly, military suicides outnumbered combat fatalities during the month of January 2009.

A recent APA Online article entitled Uncertainty about Military Suicides Frustrates Services describes the military’s attempt to understand this devastating suicide epidemic and how they plan to address it.

I am frustrated and saddened, though not surprised, to learn about the alarmingly high rate of military suicides. A combination of circumstances has created the perfect storm for suicides in the military. Consider the following:

• Service members are usually between the ages of 18-24. Neurological changes, developmental issues, and psychosocial stressors make individuals in this age group particularly vulnerable to mental illness.

• Service members are separated from their family, friends, and natural support systems for many months at a time. These extended absences contribute to homesickness, loneliness, depression, financial strain, marital problems, and infidelity.

• Service members are exposed to horrific violence on a daily basis. Their lives are constantly in jeopardy, and many are wounded in the line of duty. They witness their friends being shot, maimed, and killed.

• Service members are fighting a protracted, poorly managed, generally unpopular war with no clear end in sight.

• Military leaders and medical personnel are insufficiently trained in identification of psychological problems.

• There is a huge stigma associated with seeking mental health treatment amongst service members. The stigma often prevents service members from seeking the care they need.

• Service members are worried, often justifiably, that seeking mental health services may have a detrimental impact on their military career.

• Service members do not have sufficient access to adequate psychological services.

• Excessive drinking is deeply engrained in military culture.

• Service members have easy access to deadly weapons.

Given these conditions, it is not at all surprising that suicide is a problem in the military.

Lieutenant Justin D’Arienzo, Psy.D., a naval psychologist, described these systemic problems in a recent issue of the APA’s Monitor on Psychology. When D’Arienzo was serving on an aircraft carrier, he was solely responsible for the mental health of 8,000 people. He quickly discovered that he did not have time to see everyone who needed his services. In comparison, the ship carried 5 physicians, 4 dentists, and 40 medical assistants. To make matters worse, military psychologists are poorly compensated in comparison to other healthcare professionals in the service. The salary for a navy psychologist is about half that of a navy physician. This scenario sends the following not-so-subtle messages: psychologists are less valuable than physicians and dentists, psychologists are not needed as much as physicians and dentists, and service members’ physical health and dental health are more important than their psychological wellbeing. None of these messages are true.

The recent increase in military suicides is just one of many factors that points to the glaring need for improved mental health care for our service members. I have a few ideas as to how to improve this situation. Let me preface this by noting that, as an optimist and an idealist, I often have ideas that are less than practical. Nonetheless, here are my thoughts:

• The military hires more psychologists so that the number of military psychologists is commensurate to the number of military physicians. This will ensure that there are enough psychologists to meet the mental health needs of all service members.

• Military psychologists are paid the same salary as military physicians. Let’s face it: money talks. Higher salaries will increase the competition for these jobs and attract the best and brightest psychologists in the field. It also sends a clear message that soldiers’ mental health is valued as much as their physical health and dental hygiene.

• Every service member is required to attend weekly therapy sessions before, during, and after deployment. If all service members are required to attend therapy as a matter of course, this will eliminate the inner conflict troubled soldiers experience when considering whether to seek help, and it will remove the stigma of seeking mental health services. Further, mandatory weekly therapy is a preventative measure – soldiers can process their emotions and learn healthy coping skills before they reach the point of major depression or full-blown PTSD. Soldiers go through mandatory physical training to ensure that they are in top shape for combat. Mandatory therapy will help the troops stay psychologically fit for duty.

• More frequent therapy (e.g., 2-3 times per week) is available for those who are having great difficulty coping or who are beginning to show signs of mental illness.

• Confidentiality is maintained in the same manner as it is for civilian therapy clients.

• The length of deployment is shortened for all service members.

• Troops who develop major depression, PTSD, or other psychiatric problems are sent home to their families for more intense treatment with no adverse effect on their military career.

• Military leaders and military medical personnel are provided with more training on how to spot mental health issues in troops.

Regardless of my political beliefs and personal views on this war, I have tremendous respect for the brave men and women of our armed forces. The troops deserve high-quality, accessible mental health care. They have risked their lives serving and protecting our country. Isn’t it about time we serve and protect them?

1. Military Suicide Rate. Chicago Tribune, May 29, 2008.
2. Army says suicides among soldiers at highest level in decades. Paula Jelinek, Boston Globe, January 30, 2009.
3. Army Official: Suicides in January ‘Terrifying.” Barbara Starr & Mike Mount, CNN.com, February 5, 2009.
4. Uncertainty about military suicides frustrates services. APA Online. July 31, 2009.
5. Pentagon: Military’s Mental Health Care Needs Help. CNN.com. June 15, 2007.
6. The Military’s War on Stigma. Sadie F. Dingfelder. APA Monitor on Psychology. June 2009.
7. Stahre et al. (2009). Binge Drinking Among US Active-Duty Military Personnel. American Journal of Preventative Medicine, Volume 36, Issue 3.

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