Advice to Junior Academics on How to Get Involved With Twitter

tweet imagesI’m not a good role model for junior academics whom I encourage to get involved with Twitter. I have been experimenting turning exchanges on Twitter or my Facebook wall into blog posts, which I increasingly turn into articles. When my articles are newly published, I promote them with the full range of social media. All this takes considerable commitment of time.

It is too early to evaluate whether this is really worth it, but so far I find it quite satisfying. Yet, most novices would consider it an unacceptable investment of their time to try to follow what I do. Many are concerned about social media consuming too much time with uncertain payoffs.

So, I turned to a more junior colleague to offer them advice. She has been quite successful getting involved in Twitter, obtaining its rewards, and not letting it consume the rest of her life. I gave her a series of questions to answer, and then invited her to provide some brief tips and tricks for junior people. Looking over her responses, I’m impressed how solid and useful the advice is.

gozdeGozde Ozakinci, PhD, is a lecturer in health psychology at the University of St Andrews, Scotland. She obtained her BA in Psychology at Bogazici University, Istanbul, her M.Sc in Health Psychology at the University College London, and her PhD at Rutgers-The State University of New Jersey, USA. Her main research interests are in emotional regulation and health behaviour change. She works with diverse group of clinical and non-clinical populations from cancer patients to medical students. She also teaches behavioural sciences to undergraduate medical students and health psychology topics to M.Sc health psychology students. When not on Twitter, she can be found doing DIY around the house, consuming coffee (preferably Turkish) and enjoying walks in Scotland (preferably not in rain). More information about her research can be found here. Twitter: @gozde786

So, how did you get past the idea that Twitter is a waste of time?

I was reluctant to get involved with Twitter, thinking it was the same as Facebook which I use mostly to keep in touch with family and friends. I thought I didn’t need another potential time-sucker social media outlet. But I quickly realized Twitter is very different – something I can get much out of professionally. I dip in and out during the day and each time I have a nugget of information that I find useful. I feel that with Twitter, my academic world expanded to include many colleagues I wouldn’t otherwise meet. I am now able to keep my finger on the academic pulse better. The information shared on Twitter is so much more current than you would find on journals or conferences.

thinker-twitterFor instance, academics I follow post their latest articles on Twitter that would otherwise probably take me months to learn about . I can then ask questions of the authors themselves and chat with them. I think we all love to talk about our work! The blog posts I find through Twitter make me feel connected to my colleagues, current issues that face us, and take part in conversations that matter to me from evaluating evidence to more general issues in higher education.

How did you take the plunge and get started on Twitter?

I got hooked on Twitter right away, when I realised that I could get access to information that I would have heard either too late or sometimes never. It was like suddenly my academic daily life became a lot bigger. I could interact with many more colleagues from all over the world on a daily basis, rather than just the people in the office or collaborators over email/meetings.

Importantly, I didn’t get discouraged when people didn’t follow me back. If I really wanted people who didn’t follow me back to comment or pay attention to something I wanted to have a conversation on, then I just added them to my tweet. The day that Clare Gerada, the past president of Royal College of General Practitioners followed me back and commented me that we had common research interests was a good day!

The other thing that helped me is that I have broad academic interests so I follow people from different backgrounds and tweet about various topics: cancer to politics. So, I’m not restricted to my own area at all. That means that many people can find something of interest in what I put out there. I think this is important.

Did you start with a clear goal?

I guess in the beginning, I didn’t have clear goals but they developed over time in a natural way:

  1. Wanting to be a part of a conversation on academic topics rather than watching people I admire from sidelines.
  2. Being a source of rigorous evidence on a variety of topics and encouraging discussion (not sure how much I manage the discussion part).
  3. Being a source of encouragement/support for early career scientists (I even got invited to a talk at another university on my health psychology career because of colleagues I met on Twitter!).

How did you get your initial selection of people to follow? 

I started checking out who followed who. Like I checked out your list! I was surprised to see how many people that I wanted to get to know academically were on Twitter. Some of them were leaders in their field. I also started following editors of journals, journals themselves, bloggers in science communication in general (Dean Burnett, Suzi Gage, etc..). I also found a wonderful group of women scientists who blogged and tweeted: Athene Donald, Dorothy Bishop and Uta Frith for instance. They became somewhat role models to me. They were good scientists who cared about women in science, not because we were women but because we did what we did well. That was very empowering to me. They also found the time to tweet and write blog posts, showing me what an important tool we have through the modern communication tools.

I also follow major source of news such as NY Times, National Public Radio and Slate that I feel many of my followers don’t follow. So if I tweet something from there, it attracts their attention as that’s a source they wouldn’t normally hear from.

Was there some trial and error for you? Moments of doubt whether it was worth it?

It was VERY slow the first 6 months to get followers and at times for no apparent reason that I could fathom, there would be periods of losing 4-5 followers in a row and stagnation. I still get that and I can’t figure out why.

I found that daily engagement with Twitter is necessary. It’s not difficult for me as it makes me feel connected to the wider academic world. But you can’t take a holiday from Twitter for a month and hope that people will still be interested in following you or you’ll find new followers upon your return.

You might ask ‘why should I care about having followers? Isn’t it all a bit vain?’. Well, I see it as having something to say and sharing it with others. I tried not to get obsessed about number of followers in the beginning (although it was hard!) as I soon realized that with daily tweets/conversations and retweets, people started to follow me anyway. But I guess, the message would be ‘don’t give up and keep tweeting and following people you’re interested in’.

Can you provide junior persons some tips and tricks for getting involved with Twitter?

Don’t just get a twitter account. USE IT! You have to engage with it before it starts to pay off. Don’t worry about how many people follow you. It takes time to establish a critical mass of followers and also a certain level of engagement with other people. Don’t give up. And don’t be shy. Think about Twitter as another dissemination tool. We are in science because we do something valuable and we need to share that knowledge.

You don’t know who to follow? Everybody knows someone on Twitter, so search for them. Once you found them start looking at their followers.

Start following those who interest you. And don’t be afraid of unfollowing them if you don’t find their tweets interesting. And don’t be discouraged if they don’t follow you back. I follow almost double the number of people I have as followers. This doesn’t bother me as I get fed by their tweets.

Initiate a conversation. If you think you have something interesting to say to the person you follow but they don’t follow you back, just tag their handle and you may get them engage in a conversation with you.

Keep in mind that social media has been rightfully called a great equalizer. So it doesn’t matter at what stage of your career you’re at. You can have a conversation with people you admire and also with people at the other end of the world whom you’ve never met.

TweetHashtagYou find something interesting that you want to share, make sure you use the hashtag associated with it. Add your own comment to the retweets.  I used to be shy to do that but it adds another dimension to the communication you want to initiate rather than just a simple retweet.

Tweet at conferences using the conference hashtag. It’s a great way of meeting people as they will pick up your tweets and you theirs. It brings an engagement with the conference that I found very refreshing.

Start reading the blogs of people who advertise theirs on Twitter. This is as good strategy for you to get to a researcher’s thinking at the time.

Personal versus professional use. I use Twitter mainly for keeping on top of my field but I also tweet about my personal interests (about 20% of the time). It’s a balance you have to find. But people usually don’t want to hear all your inane thoughts.twitter-follow-me-icon

Follow Gozde @gozde786 and Jim @CoyneoftheRealm on Twitter. Think about our differences in strategy. Check out differences in whom we follow and who follow us. Freely take suggestions for whom you should follow from our lists. Compare our tweets. What differences  are apparent in what we are trying to accomplish? What is best for you? Join in favoring or replying to our tweets. Feel free to leave comments about this blog and your experience with tweeter below.

Category: advice to junior researchers, Uncategorized | Tagged , | 14 Comments

Negative versus excessive feelings

A patient asked me a number of good questions today:

Mr. Y:  We all have feelings, including negative feelings. Having feelings, even negative feelings, is to some extent [said with a tentative tone of voice] a normal state. How do I know when my feelings are more than just “normal feelings”?

Dr. P: When it feels like your feelings [depression or anxiety or anger] are out of proportion to a stressor or when there is no stressor at all but powerful feelings are present for “no good reason” that is a good reason to seek the counsel of a specialist.

Mr. Y: When there is a stressor, is there a way of knowing if my emotional response is in fact “out of proportion”?

Dr. P: When your feelings, even if justified, run you down into the ground, chance is that they are “out of proportion”. Feeling overwhelmed by a feeling is a good rule of thumb. Have you ever felt feelings at that level of intensity?

Mr. Y: Yes. I had a very painful break-up years ago. It got the best out of me. To the point of having trouble getting out of bed, taking a shower, showing up for work every single day. It took time.

Dr. P: Did you stop going to work?

Mr. Y: No, but I was almost literally dragging my feet.

Dr. P: Did you stop caring for your loved ones?

Mr. Y: Still caring but I just wanted to be alone. Didn’t care to see anyone.

Dr. P:  When being overwhelmed gets to the point of affecting your ability to function across multiple area of your life (work, family, other relationship, leisure activities) most likely your feeling reached an “out of proportion” level. If you are still functioning, even though at a less than optimal level, and your reaction follows a significant stressor, it may be that things are not yet “out of proportion”.

Mr. Y: What is “significant”? Same situation: same people fall apart, some brace themselves and move on.

Dr. P: That is a good observation. Different individuals have different thresholds for falling apart.

Mr. Y: Some are strong and some are weak. Or lazy. Or look for excuses or the easy way out. Or is that mental illness?

Dr. P: You try to put yourself together but you cannot. It is not due to a lack of willingness or desire to do and feel well, but an inability to. When you try and fail and your best effort to get out of the situation only gets you to further sink down that is an indication that all might not be in order at the mental level.

Mr. Y: So that is an indication of mental dis-order? But then why was I able to deal successfully with similar situations at other times in my life?

Dr. P: As our mental “reserve” is not always the same. At times the reserve is plentiful, at times it runs dangerously low. To get “stressed-out” does not always require the same level of stress. If minimal stress stresses you out, your mental reserve is low, a potential indication of a mental dis-order, as were things to be in order, you would operate with optimal mental reserve, at a level that will protect you against stress. Do not compare yourself with others or even with your self-ability to hold it together at other times. If to the question “Am I falling apart?” at that specific moment in time you answer in the positive, that is a good reason to seek professional help.

Mr. Y: But I do have times when I feel like I am falling apart. Most times they are brief and I am then able to pull myself together. After how long of feeling “broken” should I call you?

Dr. P: Depends on how “broken” you are. So broken that you plan to get a gun and actually you start walking toward the gun store – call right away. Broken but able to bear it – wait till it becomes unbearable to the point of consistently affecting your ability to function in multiple areas of your life – remember our discussion about dysfunction. The wait period is dependent on the result of [level of dysfunction] x duration so to speak.

To summarize:

  1. The problem: excessive (rather than “negative”) feelings
  2. Intense feelings for no good reason are a reason of concern
  3. Intense feelings, while appropriate under certain circumstances, are a reason of concern if they result in consistent dysfunction across multiple areas/domains of life.
    1. Consistent dysfunction is a function of severity and duration

——————————————————————————————————————–

At the end of the day, while reviewing my notes, all of a sudden I was struck by the extent to which I relied on the patient’s feeling (as opposed to thinking) about his feelings in constructing a diagnosis. I was also struck by the frequent use of metaphorical speech (broken, out of proportion, falling apart), essentially a subjectively/value-loaded language, as the optimal way of conveying what should be to whatever extent possible, an objective understanding of the concept of mental disorder (in this specific context).

Interestingly, the criteria that emerged from our brief dialogue are to some extent consistent with Wakefield’s idea that “a mental disorder is a harmful mental dysfunction” – however in his definition Wakefield emphasizes the socio-cultural perspective on what is harmful – when in our dialogue the patient’s subjective perspective is the foundation of this value judgment (Wakefield 2007).

Further, the perspective that emerged from this dialogue where a patient was an equally invested partner in finding a mutually agreeable definition of the problem, is also fairly similar to the DSM dysfunction criteria for a “mental disorder”.

Was this also a therapeutic exchange?

Time will tell, but when it comes to mental disorders, somewhat paradoxically, it appears that there is a place for subjective feelings in constructing objective assessments.

How about making such collaborative exchanges a subject of empirical testing?

Category: Psychiatry, Uncategorized | Tagged , , | 2 Comments

Positive psychology in the schools: the UK Resilience Project

Why it could be predicted that the large scale school-based intervention would failcard_3_monkeys_see_no_evil_hear_no_evil_see-ra33d04ad8edf4f008e5230ac381ec8b0_xvuak_8byvr_512.

An important new study was greeted with a resounding silence  from the positive psychology community, and notably on the Friends of Positive Psychology listserv, but…

Results of the largest ever evaluation of a school-based positive psychology program, the UK resilience project are now available at Journal of Consulting and Clinical Psychology. The results are, uh, not impressive.

thrive_large_logoThe intervention, the 16-hour UK Resilience Programme (UKRP), was carefully based on the Penn Resiliency Program (PRP) for Children and Adolescents.  Jane E. Gillham, the corresponding author for the UK study was also one of the developers of the Penn program.

The study is behind a pay wall, but here’s an abstract. I’m sure that you can obtain a full copy from Dr. Gillham, E-mail: <jgillha1@swarthmore.edu>.

The study enrolled almost 3,000 students, with 1,000 students in the intervention group. The UK study is thus larger than the 17 previous studies combined. The largest past study had a total of only 697 students.

The authors reported that students receiving the intervention reported lower levels of depressive symptoms than students assigned to the control group, but the effect was small and did not persist to 1-year or 2-year follow-ups. There was no significant effect of the intervention on symptoms of anxiety or behavior at any point.

The authors concluded that the UKRP produced small, short-term effects on depressive symptoms and that

These findings suggest that interventions may produce reduced impacts when rolled out and taught by regular school staff.

In this blog post, I’m going to be arguing that

  • What the authors represent as weak findings may be even weaker than they portrayed.
  • There is nothing particularly new or positive psychology about the intervention package. It is a rehash of conventional (dare we say, bad old negative psychology?) treatment of depression applied to a student population in which the levels of depressive symptoms were low.
  • Under these circumstances, the intervention could not be expected to have an effect.
  • If we are truly committed to improving the well-being of students, we need to rethink the nature and focus of such interventions, and whether students should be required or coaxed to attend. As this intervention stands, it wastes staff and student time that could better be used for other ways of improving student well-being.

But first, some more details of the study:

Sample.

  • The 2,844 students were ages 11–12, 49% were female, 67% were white and they were drawn from 16 schools.
  • Students were not randomly assigned, but entire classes of students were arbitrarily enrolled in the intervention (UKRP) or control (usual school) conditions based on class timetables.
  • There were some baseline differences between the intervention and control groups and between schools. Some schools assigned students of above average academic achievement to the intervention groups, whereas other schools assigned students the intervention group because of concern about their emotional well-being or behavior.

Outcome measures.

Three standardized, normed self-report measures were used to evaluate the intervention:

Assessments were administered at baseline, immediately after the intervention, and at 1-year and 2-year follow-up.

The intervention package.resiliency

The article provides a web link to obtain more information about the intervention. When I went to the site, extensive information was requested that would be associated with me actually using the manual in a study. However, the description of the curriculum is available here.

The curriculum teaches cognitive-behavioral and social problem-solving skills and is based in part on cognitive-behavioral theories of depression by Aaron Beck, Albert Ellis, and Martin Seligman (Abramson, Seligman, & Teasdale, 1978; Beck, 1967, 1976; Ellis, 1962). Central to PRP is Ellis’ Adversity-Consequences-Beliefs (ABC) model, the notion that our beliefs about events mediate their impact on our emotions and behavior. Through this model, students learn to detect inaccurate thoughts, to evaluate the accuracy of those thoughts, and to challenge negative beliefs by considering alternative interpretations. PRP also teaches a variety of strategies that can be used for solving problems and coping with difficult situations and emotions. Students learn techniques for assertiveness, negotiation, decision-making, social problem-solving, and relaxation. The skills taught in the program can be applied to many contexts of life, including relationships with peers and family members as well as achievement in academics or other activities.

The control group.

The intervention received by the control group varied across the schools, but was generally Personal, Social and Health Education (PSHE) classes. In some of the schools, the control group was regular academic lessons.

Were effects of the intervention even weaker than presented?

Confirmation bias is common in presentation of results of test of interventions, especially when one of the developers of the intervention is among the authors or a consultant. To reduce the risk of bias, investigators are commonly required to preregister their design, including their plans for analysis of data. This commits investigators to a particular choice of outcomes and assessment points for evaluating the intervention. The alternative is that investigators can undertake a full range of analyses and report those that make the intervention looked strongest. This trial was apparently not preregistered.

Another check on risk of bias in reporting the results of a study are including all participants who were assigned to the intervention or control group in the primary analyses. The risk of not doing what is called an intent-to-treat analysis is a bias because selective retention on dropout of participants may affect results. In this particular study, results were quite weak and the appearance of significance could be influenced by even a small loss of participants from the analysis. If there is such a loss, a variety of techniques are available for adjusting.

Contrary to what the investigators say in the article analyses were not true intent to treat. Participants were excluded if they did not complete follow up assessments. Analyses indicate that students who came from special education classes or had initial high scores on depressive symptoms were less likely to complete subsequent assessments. The effect was bigger than the difference between intervention and control groups. No effort for compensating for loss of participants from follow up was reported. They were simply dropped.

For practical reasons, the study was not a true randomized trial, and the means of selecting participants resulted in differences in baseline characteristics. The investigators attempted to compensate these differences with statistical control. If there were any differences between the intervention and control groups, this could prove inadequate. Ideally, in such situations, investigators provide results without such corrections and then with them. If the two sets of results agree, it is more reassuring that apparent effects were not simply due to baseline differences between the intervention and control groups.

The article does not present simple differences in depressive symptoms, anxiety, and behavior problems at the end of the intervention. It is possible that already small differences between the intervention and control groups would disappear in a presentation of the simple analysis.

For their primary analysis, the investigators compared the intervention and control group and overall level of depressive symptoms. There were no significant differences. That would usually rule out continuing onto subgroup analyses examining the different time points. However, the investigators went on to look at depressive symptoms at each of the three post-assessment time points, and found a small difference at the first assessment that did not persist. This provided the basis for their bragging rights for having found a small, rather no effect, which is emphasized in their abstract and discussion.

Thus, by conventional standards, it could be concluded that  UKRP produced no significant effects, not merely small effects12359023-burst-balloons-white-background.

How is this intervention a positive psychology intervention?

In a Great Debate article, Howard Tennen and I complained  about proponents of positive psychology often drawing a false distinction between what is special about positive psychology versus the rest of conventional, “negative psychology” (Seligman, 2002).

Positive psychology articulates a role for hope, wisdom, courage, spirituality, responsibility, and perseverance in human adaptation in sharp contrast, proponents claim, to the negative biases of a conventional psychology that is too focused on distress and psychopathology to the exclusion of positive experiences.

Elsewhere in debates and on listserves and Facebook, I have argued that much is what effective about so-called positive psychology interventions is not new, and what is new about them is not effective.

This intervention is a warmed-over set of  “negative psychology”  interventions developed decades ago.

The UKRP intervention was carefully modeled after the Penn Resiliency Project and a key developer of the Penn project provided training and consultation and was the corresponding author for this article. Along with the Comprehensive Soldier Fitness Program, the Penn Resiliency intervention represents a premier positive psychology intervention package. But how does this intervention represent the distinctive ideas of positive psychology?

The article describes the intervention as

promoting resilience broadly and promoting adaptive thinking and coping.

Yet, key elements of the intervention come directly from Aaron T. Beck’s cognitive theory of depression and Albert Ellis’ Rational-Emotive Therapy (RET), or as Ellis later called it, his Adversity-Consequences-Beliefs (ABC) model. Both are conventional models of depression and its treatment that predate positive psychology by decades.

The primary outcome was a reduction in depressive symptoms, not any improvement in a characteristic positive psychology outcome, such as positive well-being or flourishing. As far as I can see, the only thing new about this intervention is that was taken out of its usual context of a treatment for  clinical depression and put into the schools where it was provided to all students, who happened, as a group, to be low in depressive symptoms. If any students actually showed high risk of clinical depression, they were evaluated and potential referred to conventional depression treatment.

So, does this important test of positive psychology in the schools merely examine whether conventional treatments for depression will produce lower levels of depressive symptoms subsequent to students receiving the intervention?

Why the intervention could not be expected to have an effect.

There was on average so little elevation in depressive symptoms, so the intervention could not be expected to have much of an effect. The investigators state:

  • At baseline, 60% of students in our sample scored 8 or below (average or below- average levels of symptoms), and 12% scored 0 or 1.
  • Only 6% scored above 19, indicating significant symptoms of depression.
  • Because of this, we encounter a strong floor effect: Students without many symptoms and with low risk of depression do not have much room for improvement.

For the time span covered by the intervention and the follow-up periods, depressive symptoms are relatively stable. Even students assigned to the control group are unlikely to face situations in which whatever is provided by the intervention would be of much use up to them, in terms of avoiding an increase in depressive symptoms.

First do no harm (Primum non nocere)

  • The study  required students to participate in a 16 hour intervention.
  • Most of the students who were present could not be expected to benefit from the intervention.

There is the possibility that post hoc (unplanned and after the fact) subgroup analyses would suggest that some subgroup had benefited. But given normative data suggesting that the intervention would be ineffectivewhy subject a large group of students to such intervention?

With only weak or probably no effects, the UK Resilience Programme cannot be presumed to be cost-effective. And in calculating the costs, we need to consider lost opportunities for the students enrolled in the program.

Arguably, students at risk for depressive symptoms would include those who had academic deficits which are readily identifiable. Why not devote the week and a half to remedying those deficits?

Is it ethical to require that students submit to a program that is unlikely to demonstrate benefits in the primary outcomes by which the program is evaluated?

The rollout continues…Roll_Out

As evidence of the practicality and sustainability of the intervention, there are now 85 schools teaching it in the United Kingdom, with over 800 teachers trained at 10 training courses. At least 250 of these teachers will have had their places funded entirely by the schools they work for, with the remainder being funded by some combination of school and LA [local area] funding. This demonstrates that schools and LAs are able and willing to provide the financial backing for the program.

 

 

Category: depression, positive psychology, Uncategorized | Tagged , | 5 Comments

What Dreams May Come: Treating the Nightmares of PTSD

David_Rijckaert_(III)_-_Man_Sleeping_-_WGA20590

David Rijckaert (III) [Public domain], via Wikimedia Commons

A standard part of any psychiatric evaluation involves inquiring about a patient’s sleep.  Hidden in the answers that follow the basic question of, “How are you sleeping?” are the clues that are needed to  diagnose what is ailing the patient seeking help from me.

For those with depression, they typically report early morning awakening (i.e. they wake 3-4 hours earlier than needed) and are not able to return to sleep. Those with anxiety disorders often complain of not being able to fall asleep (initial insomnia), they toss and turn for hours, their minds “racing” with anxious thoughts and worries. For those with mania they report that they can’t sleep at all for their energized and overcharged bodies simply have no need for sleep.

My patients with PTSD often report an amalgamation of all of the above in addition to a specific complaint–nightmares.

Nightmares–those threatening or scary dreams that leave you crying out in your sleep, thrashing around in your bed or waking up in a blind panic, soaked in sweat and with your heart pounding in your throat.

Nightmares–a very common complaint for those living with PTSD. Some studies reporting up to 80%, of those with PTSD, experience nightmares that have them reliving or re-experiencing the traumatic event for months or years after the actual event took place.

Nightmares are not only commonly experienced by those living with PTSD but they occur frequently too, sometimes several times a week so their impact on the lives of those living with PTSD can be profound.

The differences in sleep amongst those with PTSD related nightmares (compared with those who do not have PTSD) are tangible, they have:

-increased phasic R (REM) sleep activity

-decreased total sleep time

-increased number and duration of nocturnal awakenings

-decreased slow wave sleep (or deep sleep)

-increased periodic leg movements during both REM and NREM sleep

In short, their sleep is less efficient and associated with a higher incidence of other sleep related breathing disorders

Treating Nightmares

Clinically, this translates to the sad stories I hear all too often: People turn to alcohol or illicit drugs to “escape” the nightmares or their chronically poor sleep quality leads to other problems such as depression and anxiety. Others start to fear sleep or simply don’t function that well—they lose jobs, are irritable and short tempered with their loved ones, feel tired and lack energy. The nightmares and poor quality sleep chips away at their lives over weeks, months and years.

As a psychiatrist, there is a certain amount of dread associated with learning that your patient is experiencing nightmares for the very simple fact that nightmares related to PTSD can be very hard to treat.

The first approach is to treat the underlying condition i.e. the PTSD.  I offer the patient evidence based psychotherapies and, if necessary, medications that I know work for PTSD and hope that, with time, the frequency and intensity of the nightmares will start to decrease as the underlying PTSD is treated.

But often times, despite PTSD treatment, patients still complain of nightmares. What can I offer them then?

A Psychotherapeutic Option

Image Rehearsal Therapy (IRT) is one option:

-          IRT is a modified CBT technique that utilizes recalling the nightmare, writing it down and changing the theme. i.e. change the storyline to a more positive one

-          The patient rehearses the rewritten dream scenario so that they can displace the unwanted content when the dream recurs (they do this by practicing 10-20mins per day)

-          In controlled studies, IRT has been shown to inhibit the original nightmare by providing a cognitive shift that refutes the original premise of the nightmare

Though it is a well tolerated treatment, the issue remains that a patient has to be willing and able to commit to IRT for it to work.

This leaves a need for alternative options for patients who are unable to commit to this type of treatment.

A Medication for Nightmares

Recently, hope has been offered in new research published about the medication- Prazosin

Prazosin is an alpha adrenergic receptor antagonist (traditionally used as an antihypertensive agent). It acts to reduce the level of activating neurochemicals in the brain and, via this action, is thought to damp down neurological pathways which are overstimulated in people with PTSD.

Whilst clinically psychiatrists have been using prazosin for the treatment of PTSD related nightmares for years, the fact remains we still need more evidence, from controlled trials, to support its efficacy.  A small randomized controlled trial of prazosin for sleep and PTSD has, recently, made a much needed contribution to that evidence base.

In a 15 week trial involving 67 active duty soldiers with PTSD, the drug was titrated up based on the participant nightmare response over 6 weeks.  Prazosin was found to be effective in improving trauma related nightmares and sleep quality and, in turn, associated with reduced PTSD symptoms and an improvement in global functioning.

This is encouraging, and increases the enthusiasm with which I will recommend this treatment to my patients with PTSD.

Still, the profound effect nightmares have on the quality of life of those living with PTSD highlights that more needs to be done to expand the array of options available to clinicians, like me, to help these patients.

Category: mental health care, Psychiatry, PTSD, research | Tagged , , , , | 3 Comments

Repeated mental health screens in the schools

child depressionA Dr. Simon Williams calls for repeated screening for depression in the schools, not once but regularly from age seven onward. You can see the press release here, but BMJ has his article behind a pay wall, so you either have to have a subscription to BMJ, order the article through a University library website, or send an email to Dr. Williams (simonwilliams@northwestern.edu ) requesting it. But here’s an excerpt.

Dr. Simons asks

Why then, despite this mounting evidence, and in a time where other types of screening (including bowel, breast, cervical, and prostate screens) are becoming more common in the UK, do we not already have school based mental health checks?

Many mental health problems across the lifespan including depression first express themselves in childhood and adolescence. Mental health problems limit academic performance and social development. But most mental health problems in children go untreated or inadequately treated, with schools and families, as well as the children themselves, bearing the costs. So how could anyone oppose repeated mental health screens in the schools?

It was once thought that if problems are serious and common and a means existed for screening for them, we should screen. Now it’s recognized that there has to be evidence that screening improves the outcomes of the people who are screened if it is to be justified. Lots of previous recommendations are being dropped. And the burden of proof whether we should screen falls on those who propose it, not those who remain skeptical.

Choosing wisely

The World Health Organization dropped recommendation for screening for intimate partner violence. Not because it’s believed that intimate partner violence is not a public health problem, but because studies do not show that routine screening improves women’s health or prevents exposure to more violence. Certainly there are situations in which professionals should ask whether women are victims of violence, but that’s not routine universal screening.

choosing wiselyMedical organizations in a number of countries have collaborated in Choose Widely programs that are reconsidering the evidence for screening. Many forms of screening are now discouraged: for breast cancer among young women, prostate cancer, ovarian, and lung cancer, and dementia.

Screening for childhood depression

Even the best screening instruments for depression do not produce a diagnosis suitable for decision-making about treatment. Screening must involve two stages, the administration of a brief screening instrument, and follow-up of children who screen positive with interviews to determine whether they actually are clinically depressed.

Most children screen positive on mental health inventories are false positives—they would not be suitable for mental health treatment. But determining that requires interviewing them. And that consumes resources that could be applied to improving the treatment of children who are already known to have mental health problems.

A fragmented system of care for child depression

Unless mental health professionals are stationed in schools or other personnel are given special training, determining whether a child screening positive is clinically depressed requires referral to outside professionals. Without these follow-up interviews, children who screen positive could falsely be labeled as having a mental health problem.

Teachers and other professionals agree on the need to address mental health problems and the costs of them going unaddressed, but they disagree about the labeling of who should get treatment. Teachers prefer to label troubled or troublesome children as having emotional or behavioral problems. They also miss a lot of childhood depression. Teachers also tend to resist what they see as stigmatizing labels like depression. The problem is that many of the children causing teachers’ problems do not have treatable mental health problems. So, there’s a mismatch between the children who teachers believe need treatment and those for whom mental health professionals feel can be diagnosed and referred into evidence-based treatments.

Let’s think about the fate of children who screen positive for depression or other mental health problems. Many of them won’t get further evaluation, and are left with a stigmatizing label that is not accurate. Furthermore, many of them who are true positive still won’t get adequate treatment. Their problems will remain with additional problem of stigmatization.

In many health systems and particularly the UK, responsibility for determining whether children who screen positive actually have treatable problems fall upon physicians who generally lack training or interest in making such evaluations. There is the risk that physicians will proceed to prescribing medication without obtaining formal diagnosis. Medication is not first line of treatment for most depressed children.

Cognitive behavioral therapy has been shown to be effective for children and adolescents, but access it is difficult. There are long waiting lists in countries like the UK or the Netherlands where psychotherapy is free or low cost. A child identified as depressed during the school year might have to wait until the school year is over before getting a first session of therapy.

In the United States, Medicaid provides coverage for treatment of low income children, but most psychologists do not accept Medicaid because its reimbursement is too low.

A classic book on screening states

Screening must be delivered in a well functioning total system if it is to achieve the best chance of maximum benefit and minimum harm. The system needs to include everything from the identification of those to be invited right through to follow-up after intervention for those found to have a problem.

Schools may seem the ideal place to identify children with mental health problems, but they are not the ideal situation to treat these problems. Furthermore, even within medical systems that have the capacity to treat mental health problems, the quality of care is generally inadequate and simply poor, with an adequate follow up.

For screening to improve child outcomes, we would need a very different organization of care and better communication between the educational, social services, medical, and mental health systems. There are formidable challenges to that happening.

Dr. William cites a meta-analysis, a systematic integration of data from lots of studies, as demonstrating the value of preventive interventions for depression. However, he’s confused in equating the evaluation of specialized programs of treatment with the evaluation of screening. Most children who were screened for mental health problems in the schools couldn’t access such programs. Furthermore, when you look closely at the studies in the meta-analysis, many of them are pitifully small and of low quality.

It would not be appropriate to generalize from the studies anything could conceivably be integrated within routine care on a large scale.

Should we simply ignore mental health problems in children? Of course not, but it would be much better to use scarce resources to improve the care of children we already know have mental problems, rather than put more children into a fragmented system of care that is not working well.

Dr. Williams estimates that it would cost £18million to screen every 7 year old in the UK one time, but recommends repeatedly screening all school age children.

follow your heartRegular mental health screens for children would be ineffective, costly, and would probably have negative consequences.

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