Dr. Sarah Ravin - Psychologist | Eating Disorders |Body Image Issues | Depression | Anxiety | Obsessive-Compulsive Disorders | Self-Injury
Blog
1550 Madruga Ave Suite #225
Coral Gables, FL 33146
305-668-5755 (phone)
305-668-5756 (fax)
info@DrSarahRavin.com
Driving Directions
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.

space

Tag: therapy

Monday, November 6th, 2017

End of Treatment Outcomes for Patients with Mood Disorders (2009 – 2017)

 

Description of the Sample

This analysis includes all patients with a primary diagnosis of a mood disorder who participated in an evaluation followed by a minimum of one therapy session with me between the start of my practice in 2009 and spring 2017.  Given that this is an analysis of end of treatment outcomes, patients who are currently in treatment with me were not included in this sample.

The sample includes 34 individuals (29 females and 5 males) who ranged in age from 12 – 59 years old, with a median age of 20.  The majority of patients in this sample (65%) had a primary diagnosis of Major Depressive Disorder.   Other primary diagnoses included Unspecified Depressive Disorder, Bipolar Disorder, Mood Disorder Not Otherwise Specified, and Persistent Depressive Disorder (formerly known as Dysthymia).

More than half of these patients (56%) had a secondary diagnosis.  The most common secondary diagnoses were anxiety disorders. Other secondary diagnoses in this sample included ADHD, eating disorders, and PTSD.

Approximately 30% of the sample had a history of psychiatric hospitalization, most commonly for suicide attempts or suicidal ideation, prior to staring treatment with me.

Description of Treatment Received

The length of treatment varied dramatically, from one week to 3.7 years.  Number of sessions attended also varied dramatically, from 1 session to 135 sessions.  The broad range of treatment duration and sessions attended reflects the reality that some individuals decided not to proceed with treatment after one or two sessions, whereas other individuals attended sessions off and on, as needed, for the duration of their high school or college years.  The average duration of treatment was 11.9 months and the average number of sessions attended was 28.  So, a typical patient with a mood disorder attended approximately 28 sessions over the course of one year.

The type of treatment received was tailored to the individual patient, based on his or her presenting symptoms, circumstances, age, and preferences.  Forty-one percent of patients received Cognitive-Behavioral Therapy (CBT), 18% received a Dialectical Behavior Therapy (DBT) skills-based approach (NOT a comprehensive DBT program), 30% received integration of CBT and supportive counseling, and 11% interpersonal psychotherapy or supportive counseling.

Level of family involvement varied depending on the patient’s age, presenting symptoms, preferences, and living circumstances.  For the purposes of this assessment, high level of family involvement means that at least one family member attended all or most sessions with the patient.  Moderate level of family involvement means that family members attended some sessions and maintained ongoing communication with me throughout treatment.   Low level of family involvement means that at a family member was involved in the evaluation and/or at least one session, but most sessions were individual.  Among all patients in this sample, 18% had a high level of family involvement, 21% had a moderate level of family involvement, 18% had a low level of family involvement, and 44% had no family involvement.  Degree of family involvement was higher, in general, for adolescent patients than for adult patients, with all patients under age 18 having at least some family involvement in their treatment.  Fifty percent of adolescent patients (under age 18) had a high level of family involvement, while 42% had a moderate level of family involvement and the remaining 8% had a low level of family involvement.

Nearly ¾ of patients saw a psychiatrist and took psychotropic medications during treatment.  Nearly ¼ of patients were hospitalized during treatment, most commonly for suicidal ideation or suicidal gestures.

Treatment Completion and Recovery Rates

Of all patients who began treatment with me for a mood disorder, 15% achieved complete recovery, 24% made significant progress, 41% made some progress, 15% made no progress, and 6% regressed.  For a detailed description of what terms such as “complete recovery” and “significant progress” mean, please see this blog post from 2013.

Eighteen percent of patients completed a full course of treatment with me.  Completing a “full course of treatment” was defined as a mutual ending in which the patient, his/her family (in cases where family was involved) and I mutually agree that treatment goals have been met and treatment is no longer needed.  Of these “treatment completers,” 83% achieved full recovery and the remaining 17% made significant progress towards treatment goals.

The length of time required to complete a full course of treatment varied dramatically from person to person, depending on symptom severity and progress in treatment.  Time required to complete treatment ranged from 1 month to 3 years, with a mean of 16.6 months.  Likewise, number of sessions required to complete treatment varied dramatically between individuals.  Number of sessions attended for treatment completers ranged from 4 – 96 sessions, with an average of 23 sessions.  So, on average, individuals who were most successful in treatment (e.g., those who completed treatment and achieved full remission from their mood disorders) attended an average of 23 sessions over the course of 16 months.

Fifteen percent of patients moved to another geographic location during their treatment (either to attend college or to live elsewhere permanently), prior to completing a full course of treatment with me.  As of their last session with me, 60% of these “movers” had made significant progress in their treatment and the remaining 40% had made some progress.  These individuals were referred to other treatment providers in near their universities or new homes for continued treatment.

The dropout rate for patients with mood disorders was fairly high: 50% of patients discontinued treatment with me prematurely.  As of their last session with me, 18% of these “discontinuers” had made significant progress towards treatment goals, 59% had made some progress, and 24% had made no progress.   On average, individuals who discontinued treatment sooner made less progress, while those who remained in treatment longer made more progress towards their treatment goals.   Three quarters of the individuals who made no progress dropped out of treatment after just one or two sessions, and the remaining one quarter dropped out after 5 sessions.  In contrast, those who made significant progress prior to dropping out of treatment attended an average of 20 sessions.

I do not have data on what happens to patients after they discontinue treatment, so this is purely speculation, but I believe several factors contribute to the high dropout rate among patients with mood disorders.  First, depression frequently interferes with a person’s motivation and ability to carry out tasks, and tends to make people hopeless and pessimistic.  Individuals with these symptoms may have a more difficult time persisting towards a goal, such as scheduling appointments and continuing with treatment over a number of months, and they may feel less hopeful about having a positive outcome in treatment.  Second, some patients and families may be satisfied with “good enough,” and may drop out of treatment after making good progress but before achieving all treatment goals.  In contrast, I have high standards for my patients: I believe that full recovery is possible for most people, and when full recovery does not seem achievable, then a full and meaningful life with well-managed symptoms is an alternative good outcome.  I work diligently with patients and their families in pursuit of these goals.

Eighteen percent of patients with mood disorders were referred to other clinicians who could better meet their needs.  I made these referrals when a patient was not progressing in treatment, and when it did not appear likely that they would make progress in the near future.  As of their last session with me, 17% of referred patients had made significant progress, 33% had made some progress, 17% had made no progress, and 33% had regressed.

Predictors of Treatment Outcome

Not surprisingly, completion of a full course of treatment emerged as a strong predictor of positive treatment outcome.  83% of individuals who completed treatment achieved full recovery, while the remaining 17% made significant progress towards treatment goals.  None of the individuals who discontinued treatment prematurely achieved full recovery.

Another strong predictor of positive treatment outcome in this sample was referral source.  Eighty percent of individuals who achieved full recovery were self-referred (e.g., they found my practice through an online search), while the remaining 20% were referred by word of mouth (e.g., by a friend).    In contrast, none of the individuals who were referred to my practice by their psychiatrist, pediatrician, or another therapist completed a full course of treatment or achieved full recovery, although a number of them made significant progress.  My interpretation of this finding is that individuals who proactively sought my services of their own volition may be especially dedicated to improving their mental health, more invested in their treatment, and thus more likely to persevere through a full course of treatment and achieve recovery.   In the case of self-referred adolescents, their parents were the ones who actually brought their children to treatment.  These parents, on the whole, were particularly attuned to their child’s needs and struggles, researched their child’s symptoms and the variety of treatment approaches available, sought my services proactively, and were especially motivated to help their child recover.  Perhaps this parental conscientiousness, attunement, and empowerment helped facilitate recovery for their children.

Level of family involvement in treatment predicted treatment completion and full recovery for adolescent patients but not for adult patients.  All of the adolescents who completed treatment and recovered had moderate or high levels of family involvement.  In contrast, 75% of the adults who completed treatment and achieved full recovery had no family involvement in their treatment, while the remaining 25% had a low level of family involvement.

Individuals who took psychotropic medication were somewhat less likely to recover than those who did not: 40% of individuals who achieved full recovery were taking medication during treatment, whereas 76% of individuals who did not achieve full recovery were taking medication during treatment.  It is unlikely that taking psychotropic medication caused patients to have a worse outcome.  I believe the most likely explanation for this finding is that taking psychotropic medication is a marker of severity: individuals with more severe forms of mood disorders (e.g., Bipolar Disorder, Severe Recurrent Major Depressive Disorder) are more likely to need medication and are perhaps less likely to achieve complete remission of symptoms.

Hospitalization during treatment emerged as a predictor of less favorable outcome.  None of the individuals who were hospitalized during their treatment with me completed a full course of treatment or achieved full recovery.  It is unlikely that being hospitalized actually caused patients to quit treatment or caused them to make less progress in their treatment.  It is more likely that hospitalization, like taking psychotropic medication, is a marker of severity, and those individuals with more severe illnesses are less likely to experience complete remission of symptoms.

The following variables did NOT predict treatment outcome: age, gender, ethnicity, duration of illness, diagnosis, presence of co-morbid diagnoses, rate paid for services, type of treatment received, or history of hospitalization prior to starting treatment.

 

 

Tags: , , , , , , , , , , ,

Thursday, February 6th, 2014

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tags: , , , , , , , ,

Friday, August 14th, 2009

Maudsley Is As Maudsley Does

Those who know me professionally are well aware that I am an advocate of the Maudsley Method of Family-Based Treatment and that I use this approach to treat my adolescent patients with eating disorders. What they may not know is that Maudsley principles pervade my treatment philosophy for eating disorder patients of all ages, regardless of the treatment approach I employ with them. For example:

• I always externalize the eating disorder and teach my patients to do the same.
• I firmly believe that patients do not choose eating disorders and that parents do not cause them. I make this point explicitly to patients and their families at the start of treatment and as many times as necessary throughout the course of treatment.
• I explanation the etiology of eating disorders as follows: We don’t know definitively what causes eating disorders, and for the purposes of this treatment, the cause isn’t terribly important right now. The most recent scientific research suggests that eating disorders are biologically-based, genetically-transmitted mental illnesses which are triggered by an energy imbalance (for example, through dieting) and perpetuated by malnutrition, with emotional stress (e.g., anxiety, OCD, depression) as an aggravating factor. I mention all of the common myths about the causes of eating disorders (e.g., the media, fear of growing up, need for control, overbearing parents) and dispute each one of them.
• At the start of treatment, I provide patients with psycho-education about the central role of full nutrition, weight restoration, and cessation of binge/purge behaviors in recovery.
• Whenever possible, I involve family members (parents, siblings, spouses, girlfriends, boyfriends) in the patient’s treatment to some extent. In some cases, family involvement may be as simple as providing family members with psycho-education, literature, and internet resources on eating disorders. In other cases, family members may participate in the evaluation or attend some therapy sessions with the patient. Regardless of the patient’s age, I like to empower those who live with her (parents, spouses, significant others) to provide meal support and help stop other symptoms such as excessive exercise, bingeing, and purging.
• I view family members as essential members of the treatment team who can provide nutritional, practical, and emotional support to the patient as she recovers.
• I make physical health (including full nutrition, weight restoration, elimination of purging and other unhealthy behaviors) the most immediate priority in treatment.
• I help patients re-learn how to eat properly on their own once they are physically healthy and psychologically prepared to assume this responsibility.
• I treat patients’ other disorders (e.g., depression, OCD, anxiety) and address their developmental, familial, and interpersonal issues after physical health has been achieved.

In my view, these principles are equally applicable for children, adolescents, college students, and adults. They apply when I am doing individual therapy using a CBT, DBT, ACT, or IPT approach. They apply when I am doing couple’s therapy when one partner has an eating disorder. And, of course, they apply when I am doing Maudsley Family-Based Therapy.

These principles are a central part of my professional identity. I stand behind them when I am giving a lecture, doing a presentation, conversing with colleagues, speaking to potential clients, talking about work with family and friends, or even answering the questions of acquaintances who are interested in what I do.

To date, the Maudsley approach has only been empirically-supported for adolescents with anorexia nervosa and bulimia nervosa. However, preliminary data suggest that Maudsley may be equally effective for pre-adolescent children and young adults. Regardless of what the eventual published data may say about broader applications of Maudsley, I will hold fast to these principles. At least until science or experience convinces me otherwise.

Tags: , ,

Saturday, August 1st, 2009

Informed Consent

The American Psychological Association’s ethical guidelines require that psychologists obtain informed consent for treatment from all patients and parents of minor patients. But what does it mean for consent to be truly informed?

In standard practice, informed consent generally amounts to a frazzled patient or harried parent signing a consent form after a perfunctory glance. Patients and parents are often in crisis when they first present for treatment, and signing the form is just one more hoop to jump through before getting into therapy. Most therapists’ consent forms cover business procedures and confidentiality issues. This is important information, but does it amount to truly informed consent?

I don’t think so.

I believe that the APA’s ethical guidelines should be revised to require full disclosure in informed consent for psychological treatment. Specifically, therapists should be required to disclose 1.) The patient’s diagnoses and explanations of these diagnoses, 2.) What factors caused or contributed to the patient’s illness, as evidenced by the most recent empirical research and the clinician’s informed judgment, 3.) What treatment methods are available for treating the patient’s condition, 4.) Which of these methods are evidence-based, 5.) Which method(s) the therapist will use, 6.) Why the therapist has selected these methods, 7.) The anticipated course of treatment and prognosis, based upon recent empirical research, and 8.) Scientifically informed, practical resources (e.g., books, articles, websites) on the patient’s condition and the type of therapy that will be used. For patients under 18, all of the above should be explained to the parents and to the child, using language appropriate to the child’s age and developmental level. Finally, parents should be provided with guidance as to how they can help their child recover. I’m talking about specific recommendations, not just blanket statements like “be supportive.”

In my consent for therapy forms, which patients (and parents of minor patients) read and sign before meeting with me, I specify the types of treatment I use, all of which are evidence-based. After the evaluation, I provide patients(and parents of adolescent patients) with empirical research on their particular disorder, as well as information on the efficacy of various types of treatment and who recommends these treatments (e.g., APA, Society for Adolescent Medicine, etc.). I explain the type of treatment I recommend for them, why I have selected this type of treatment, how it works, and what to expect on the road to recovery. If there is a type of treatment that is likely to be effective for the patient but that I do not offer (e.g., psychiatric medication, residential treatment), I provide them with referrals to these types of treatments and explain why I think they would be beneficial. At this point, the patient has all of the information she needs to make an informed choice about treatment.

Most patients seeking therapy, and most parents seeking therapy for their children, are not aware that there are different types of psychological treatments with varying degrees of efficacy. I think most people outside of the field assume that therapy is therapy and that therapists are pretty much interchangeable, like dentists or surgeons. Many people assume that as long as you like your therapist and feel comfortable with her, that’s all that matters. While the therapeutic relationship is undoubtedly a critical aspect of treatment, there are other factors to consider in selecting a therapist. Often times, people want to see a psychologist with decades of experience. This is an understandable, albeit unreliable, method of seeking good treatment. The older, more experienced therapists were trained decades ago in theories that have since been discarded, in therapeutic methods with no scientific backing. Sometimes they become set in their ways of practicing, clinging to old theories like religious dogma in spite of evidence to the contrary. Granted, many experienced therapists have kept up with recent developments in the field and have educated themselves. Sadly, many have not.

Informed consent in therapy is complicated by the fact that different professionals have vastly different, and often contradictory, views on the causes of various mental disorders and how best to treat them. To make matters worse, the public has access to a tremendous amount of information on mental health issues through the internet, much of which is either unsubstantiated or patently false. Consequently, many patients arrive in our offices with deeply entrenched false beliefs about their illnesses. As professionals, it is our job to set the record straight.

I have had a number of patients come to me seeking therapy for the first time after being unsuccessfully treated for anxiety or depression by their primary care physician. I use the term “treated” very loosely here – their doctor spoke with them for a few minutes and wrote them a prescription for a low dose of antidepressants or sleeping pills, only to follow up with them a year later. They were not informed about evidence-based psychological treatments. They were not informed about behavioral methods of treating insomnia. And of course, they were not informed that their dose of Prozac is far too low to have any therapeutic benefit. Similarly, I have had patients come to me after years of therapy for depression or self-injury who have done endless amounts of exploration into the supposed causes of their supposed issues, without ever learning the skills they need to recover.

Parents of eating disordered children have come to me for Maudsley family-based therapy after months or years of unsuccessful therapy, after multiple hospitalizations and stints in residential treatment. These families were never informed about the Maudsley Method by any of their child’s previous treatment providers. These parents, desperate to help their children, did their own research on the internet late at night, sifting through the mounds of information to try to find the one thing that would save their child’s bright future. I’ve seen patients, who have been through years of eating disorder treatment with other professionals, who have never once been told that they have a biologically-based, genetically-transmitted mental illness which is neither their fault nor their choice.

Parents of eating disordered children have a right to be informed about the Maudsley Method at the time of diagnosis. The research is clear that Maudsley is the most effective treatment for adolescents with a short duration of illness who are still living at home with their families. For various reasons, Maudsley is not the best choice for every patient or family. Nonetheless, families have the right to know it exists and to decide for themselves whether they wish to pursue it. Patients with depression, anxiety disorders, and personality disorders have the right to be informed about evidence-based treatments such as CBT, DBT, and ACT. Many lives, many years of chronic illness, and many dollars spent on ineffective treatments could be saved if patients and parents were fully informed about evidence-based treatment options from the outset. If a patient has cancer, it is her physician’s duty to inform her of the various life-saving treatment options, some of which may be available in that physician’s office or the local hospital, and some of which are only available in the nearest major city. Why should psychology be any different?

Tags: , , , ,

http://www.drsarahravin.com/img/best-badge-eating-disorder.png
Top 10 Psychologists in Coral Gables 2015

Sarah Katherine Ravin's Practice is ranked in the top Coral Gables, FL Psychology practices.

Top 10 Psychologists in Coral Gables 2015