Non-expert treatment shown to be more effective than primary care in soothing widespread anxiety

By Katherine Harmon

NEW YORK—One-size-fits-all treatments are particularly rare in the mental health world, where each patient's ailments can seem unique.

But a team of researchers seems to have found a therapeutic model to treat anxiety disorders as wide-ranging as post-traumatic stress disorder (PTSD), social phobia and panic disorder. Lead study author Dr. Peter Roy-Byrne, of the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine, presented the findings May 18 at a press briefing in New York convened by JAMA, Journal of the American Medical Association.

When taken together, anxiety disorders affect about 18 percent of the population (which is more than twice the rate of depression). Some three fourths of people with mental disorders are managed in primary care (which Roy-Byrne called "the de facto mental health system"), but getting those patients—especially those with anxiety disorders—to see mental health specialists is much harder than getting them to see a radiologist, Roy-Byrne noted.

He and his team devised a flexible, collaborative care system that lightened loads for both doctors and psychiatrists (or psychologists) while making it easier for patients to get the help they needed. By enlisting the skills of nurses or masters-level clinicians with some training in anxiety management and an online patient progress tracking system, the treatment plan could adapt to patients without sending them to an expensive psychiatrist or psychologist, which has been shown to be especially difficult in anxiety patients (and could also allow specialists more time to address patients who most need their care). And a controlled trial, published May 19 in JAMA, showed promising results.

The researchers randomized 1,004 patients with at least one anxiety disorder (with and without major depression) to either their treatment model (which offered a choice of drug-based therapy as prescribed by overseeing doctors, computer-assisted cognitive behavioral therapy or a combination of both) or standard care (any treatment by their primary physician, recommended counselor or medication).

Patients receiving medication in the experimental group were advised about type and dosage as well as given additional guidance about healthy lifestyle habits, such as sleep hygiene and behavioral tips. Those getting cognitive behavioral therapy met with a nurse or masters-level clinician to work through a computer-guided program, which provided questions, examples and videos to guide the sessions as well as tailor and reinforce concepts. Primary care physicians and psychiatrists or psychologists oversaw the progress of patients and administrators via an online tracking system that charted attendance, performance and wellbeing so that they could follow-up or intervene if necessary.

The trial itself was open to patients' changing needs, so if patients entered the trial on ineffective levels of medication but didn't want to switch, the docs allowed them to stay on their preferred regimen. And if an experimental-group patient was not improving on a current path (of cognitive behavior therapy or pharmacological treatment), doctors could immediately see that and recommend alternative courses of action.

After a series of blinded follow-ups with patients (at six, 12 and 18 months after the start of the trial), the researchers found that with just six to eight sessions, patients in the treatment group were "averaging really negligible symptoms," he said. Fifty-one percent of people in the flexible, monitored treatment group were in remission at 18 months, compared to 36 percent of the usual care group.

The results "showed how we could use technology" to treat a broad range of anxiety disorders, Roy-Byrne noted on Tuesday. And because the treatment model was effective for a broad range of disorders, it could help the many people who have more than one ailment, "which is the rule rather than the exception," he added.

By using clinician-administered, evidence-based strategy, he said, "you can get a lot of people better fast." And the social implications of the model were not lost on Roy-Byrne. He noted that the days of the well-to-do and well-insured seeking in-depth psychiatric help for every minor mental health issue might be numbered. "How can you more responsibly distribute the expertise?" he asked. With an evidence-based treatment protocol, he concluded, the psychiatric and psychological big guns could be reserved for those who really needed them.

We are the Evil In Man

A lecture by Carl G. Jung...

Mothers' Depression Can Go Well Beyond Child's Infancy

Mothers' Depression Can Go Well Beyond Child's Infancy
Many mothers continue to have depressive symptoms well into their child's youth, which can have lasting impacts on their children's development, but new research shows short therapy sessions can improve outlook.

By Katherine Harmon

Vast amounts of research on postpartum depression have focused on difficulties facing new mothers, and studies of adult depression have focused on individual struggles. Depression in mothers with children over the age of six months, however, is less discussed but exceedingly common. At least 12 percent of women in any given year—many of whom are mothers—and 20 percent of disadvantaged mothers have depressive symptoms.

New findings, presented May 1 at the Pediatric Academic Societies meeting in Vancouver, Canada, provide hope, showing that proper screening and brief cognitive behavior therapy can be a big help to both the mothers and their children.

"Anyone can be depressed," says Carol Weitzman, an associate professor of developmental-behavior pediatrics at Yale University School of Medicine and lead researcher on the study. But when an adult is caring for children, depression can have large and lasting effects on the kids, making maternal depression "a big public health problem for children," she notes. "The effects of depression on children are very profound. We can't look at children's health and function without looking at parents' functioning."

Depressed moms, weak bonds
Maternal depression is not an isolated event but part of "a continuum that actually starts prenatally," explains Janice Cooper, interim director of the National Center for Children in Poverty at Columbia University's Mailman School of Public Health. Regardless of a child's age, "moms with depression are less able to bond well with their children," she says.

Many mothers with depression are less likely to engage positively with their children, such as playing, reading or singing. They may even have trouble managing basic child well-being tasks, such as arranging doctor's checkups, childproofing a home or buckling children up in cars. Additionally, Cooper points out, depressed parents tend to be less consistent in their parenting. As symptoms wax and wane, discipline and engagement can fluctuate, leaving children in less-stable environments. All of these behaviors can influence cognitive, social and physical development, she says.

In many instances, maternal depression can initiate what Cooper calls a "vicious cycle." When depressed mothers do not respond well to their children, the children tend not to respond well to the mother, adding to the mother's concern, anxiety and general malaise. And these feelings are more likely to increase as the child gets older, a finding that surprised even Weitzman. These growing anxieties might stem from increased concern about difficulties children might face as they get older, she hypothesizes.

Exploring options
Given the high rates of maternal depression and its impact on the mother-child bond, Weitzman and her colleagues are seeking to understand how it can be better diagnosed and treated. "I think that we should be sitting up and really taking notice when we see numbers like that," Weitzman says. "For certain kinds of disorders, we would be all over that, but we still carry a lot of stigma for mental health."

The issue of maternal depression is outsized in disadvantaged families, and depressed mothers are less likely to be employed, probably increasing stress. A combination of other factors, such as less educated parents, also put children at higher risk for poor developmental outcomes even without a depressed parent.

In the new randomized study of 71 underserved mothers with depressive symptoms, Weitzman and her team examined how several short, on-site cognitive behavior therapy sessions compared with traditional referrals for improving both maternal symptoms and how mothers rated their children's behavior.

Conventionally, observant doctors might suggest specialists for women who seem to be depressed. For the study, Weitzman and her group gave women who were randomized into this control group substantial case management, in which they spoke with a social worker and were helped with referrals. In the cognitive behavior therapy group, the social workers "tried to help people make the link from their moods and behavior to how it affected their children." The six two-hour therapy sessions covered the relationship between thought, mood, behavior and physical feelings. It got the mothers to identify stigmas, practice relaxation techniques, reduce negative thinking, and explore the link between maternal mood and behavior and child mood and behavior.

Both groups showed improvement, but the cognitive behavioral therapy group "significantly reduced their ratings of problem behavior in their young children," Weitzman and her colleagues conclude in their abstract.

"These are great findings," says Cooper, who was not involved in the study. "We know that depression is highly treatable," she notes, adding that these data give credence to other work showing the importance of diagnosing and treating disadvantaged mothers with depression.

The follow-up period for Weitzman's study did not provide long-term assessments of mother and child behavior, and as Cooper notes, not all mothers can be helped by cognitive behavior therapy. In some cases, she says, the best solution is including some joint parent-child therapy: "For some families, they really do need help developing that parent-child relationship, rebonding, reconnecting with their children."

Incorporating treatment
But finding a way to integrate both screening and treatment into an already tenuous health care environment can be challenging. "We should be bringing this stuff right into pediatrics," Weitzman says. They have found that a simple screening, whether it is via a paper survey or simple questions from a pediatrician, is feasible to incorporate into a standard well-child visit. It will help, she notes, if pediatricians are aware of some of the red flags, such as infrequent (or overly frequent) doctor visits, negative description of young children or other behavioral signals. But once doctors recognize signs of depression, there are often few resources—especially for disadvantaged families—to recommend and even fewer on-site cognitive behavior therapy programs like the one in the study. And even in their study, Weitzman notes, there were high dropout rates, which emphasize the need for treatments that are easy for families.

Beyond the challenge of providing sessions and making sure those who need treatment get it, the cost of these programs can be prohibitive. Finding a way to establish screening and treatment protocols so they are not only convenient for families and practitioners but also integrated into the reimbursement structure is likely to be difficult. Because many programs address postpartum depression through six months, it can be hard to find reimbursable programs that will address maternal and parent-child bonding in treatment, Cooper notes.

As with other diseases, however, treating it is likely to pay off in the long run. Depressed adults often miss work or have trouble retaining consistent employment, resulting in lost productivity. "We know that depression is a huge cost to our society," Cooper says. And beyond the individual, improving parental state of mind pays long-term dividends for improved child development, she notes, adding that any booster to "foster those bonds and make sure those children have the most quality early childhood experience" is a solid investment. Citing a frequently used figure for cost-benefit analysis, Cooper notes that, "for every $1 invested in early childhood, we save $8.… If you think of it in terms of prevention, this is a huge benefit to society."

First, however, the concept surrounding maternal depression needs to change, Weitzman notes. "Depression is a chronic disorder—it waxes and it wanes," she says. "We just need to expand and broaden our thinking [from the idea] that there's this short time after the birth of a baby that someone can be depressed."

Understanding Dreams

Dreams about taking exam, being naked -- what they mean
By Elizabeth Landau, CNN

(CNN) -- You're in a classroom and the teacher puts an exam face down on your desk. You pick it up and can't really make out what's on it; it's blurry, or it's in another language, or it's in a subject you didn't study.

You feel like you're going to fail, even though it's been years since you've actually been in school.

People commonly relive this scenario in their dreams, even decades after their last graduation. While many high school, college and graduate school students are cramming for real exams this week, you may dream about it if you have anxiety about being judged, or if you're in a situation you don't know how to handle, experts say.

Dreams are "an extremely rich source of practical advice, and other alternatives about what we're doing in our lives," said Deirdre Barrett, Harvard psychologist and author of "The Committee of Sleep" and "Trauma and Dreams." "They're just coming from such a different part of ourselves that they're a very good supplement to our waking, rational thinking."

The dreaming brain

Scientists know about as much about the dreaming brain as they do the waking brain -- in other words, there's still a lot to learn about how the brain creates the dreaming consciousness and wakeful consciousness, said William Dement, leading sleep researcher at Stanford University.

Dreaming happens during the REM (rapid eye movement) stage of sleep. In a typical sleep cycle, there are 68 minutes of non-REM sleep and 22 minutes of REM sleep. An eight-hour night of sleep will include about six REM periods, during which multiple dreams can occur.

The body is temporarily paralyzed during REM sleep. But in a rare condition called REM behavior disorder, people act out what they are doing in their dreams, be it talking or running into a wall.

You are conscious in your dreams in basically the same way you are conscious in real life, but you don't remember dreams as well because memory processing is down, Dement said. The continuity of real life experiences helps you distinguish waking life from the dream world. For example, you don't magically reappear in a different setting in the real world, whereas it might appear that way in a single night of dreaming.

"In some ways, it's very good we don't remember our dreams very well," he said. "You'd constantly be saying, 'Did that happen, or was it a dream?' "

Inside your dreams

The symbols and events in dreams can mean many different things to different people, Barrett said. A dog might signal unconditional love to someone who has positive feelings toward canines; someone else with a fear of dogs might dream about them as a reflection of trauma.

But themes such as the "test you're not prepared for" do tend to have common meanings for people. A similar dream occurs for people who had experience in acting as a child: They dream that they forgot there was an audition that day, or that they get to an audition and it's in a garbled language, or they studied the wrong script -- they're being judged, or don't know what to do in this situation. People also commonly have dreams in which they are naked in public, associated with feeling exposed or ashamed. This could signal that the dreamer feels socially inadequate in some way, Barrett said

These are "psychological dreams" that are telling you that you should figure out where in life you are having a block, or how you should handle your difficult problem, said Dr. Judith Orloff, author of "Second Sight" and assistant clinical professor of psychiatry at the University of California, Los Angeles.

Nightmares can shed light into the dark areas of people's lives, Orloff said. They confront people with what they are most afraid of, and can be used to work through underlying problems.

Orloff had one patient who repeatedly dreamed she was being chased on a cliff by an "evil pursuer" who was going to hurt her. The patient and psychologist figured out that the pursuer represented the woman's abusive father. After working through it, the nightmare did not repeat.

Letting your dreams help you

If you want further insight into a difficult decision, consider asking a question before you go to bed, and then seeing what happens in your dream, Orloff said. Get a dream journal and write down the question at night; in the morning, without getting out of bed, write down everything you remember.

One patient of Orloff's had to make a difficult decision about whether to take a new job, and dreamed that she was in the new position but had a negative experience. This helped her realize that she did not get along with the boss, and she decided against the job, Orloff said.

Dement said he is somewhat skeptical about putting a lot of weight in dream interpretation. Dreams are often hard to remember, the associations in them can mean multiple things, and you shouldn't stress if you can't recall details, he said. It can be quite difficult to summon a memorable dream to answer a question in the way that Orloff recommends, he said.

But Dement agreed that dreams can help with major life events. He himself once had a life-changing dream: He had been trying to quit smoking, but simply could not, and dreamed that he had coughed up pink sputum indicative of cancer.

"I felt just utter complete despair -- I would never see my children grow up, I did it to myself because I didn't quit, I hadn't put enough aside to take care of my family," he said. "Then I woke up. I never smoked another cigarette."

Important discoveries have also emerged as a consequence of dreams. Otto Loewi, a German pharmacologist, is said to have dreamed about an experiment to show that the transmission of nerve impulses is chemical, not electrical. The experiment worked in real life, and Loewi went on to the Nobel Prize in medicine in 1936.

Some artists and musicians use their dreams for inspiration. The writer Robert Louis Stevenson drew on his dreams for "The Strange Case of Dr. Jekyll and Mr. Hyde."

The bottom line: Trust your waking, logical thinking, but don't ignore what your intuitive, feeling-based, visual side might have to say about difficult decisions through dreams, Barrett said.

"It can be very important to look to our dreams on anything that we're kind of stuck on in our waking lives, because the dream thoughts are likely to be so different, and they may really think outside the box and come up with an answer that we haven't awake," Barrett said.