Tag Archives: mental health

Clinical News You Can Use

Adult ADHD: Medication Plus Cognitive Behavioral Therapy, Latest Research

An article by Sanjay Gupta*, “Talk Therapy Alone for ADHD Doesn’t Cut It,” reviews a recent multi-site study of treatment for Adult Attention Deficit Hyperactivity Disorder [ADHD]. In sum, “talk” therapy does have a significant benefit, but it doesn’t benefit ADHD symptoms quite as much as medication or the combination of medication plus therapy.

Treating ADHD means BOTH

adhd11) improving symptoms of concentration, focus, and memory with medications AND

2) developing skills for organization, social behavior, following-through, remembering responsibilities, and anticipating consequences.

The research addressed mainly the symptom domain.

We have known since the 1980s that “psychosocial” therapy, such as individual psychotherapy, group therapy, or social skills training, does not significantly reduce the symptoms of most children with ADHD unless medication is also used. The most common medications for children with ADHD are formulations of one of four drugs,

1) methylphenidate (e.g., Concerta, Daytrona, Focalin, Metadate, Methylin, Ritalin),

2) dextroamphetamine (Adderall, Desoxyn, Vyvanse),

3) atomoxetine (Strattera), or

4) guanfacine (Intuniv, Tenex).

A child may do well on the first drug chosen. But often, one drug may have unwanted side-effects or weak benefits for that child. So then a different one of these drugs needs to be selected. Sometimes, the child benefits more from taking the drug twice per day. Depending upon other behavioral symptoms besides those of ADHD, some children receive a second medication, such as Clonidine (catapres), riperidone, or an anti-depressant.

Adult ADHD Outcomes

The recent German study published by Alexandra Philipsen, et al, in JAMA Psychiatry shows the same is true for adults with ADHD, adding medication produces more benefit than therapy alone. The researchers adhd2analyzed data from 419 patients who had been randomly assigned to one of these four conditions: methylphenidate, individual therapy, structured cognitive behavioral group therapy, or placebo. Simply stated, the methylphenidate group experienced larger reductions in symptoms than patients in the two therapy conditions. The main measure was the ADHD Index of the Conners Adult ADHD Rating Scale.

The implications of these findings are of special importance for mental health professionals and ADHD patients.

  1. A reduction of 20-25% in symptoms can be achieved by a combination of therapy and medication.
  2. Medication should be added to the treatment regime in order to boost the improvement.
  3. Realistic expectations are important. The state-of-the-art approaches lead only to modest gains in ADHD symptoms.

The study only measured the overall ADHD Index on the Conners. (CAARS) Note that in addition to measuring how closely the patient’s symptoms match DSM-IV symptoms for ADHD, the Conners also measures various adhd3other symptom domains as well.   We present these in order to clarify that a person with ADHD has both SYMPTOMS, as measured in the study, and IMPAIRMENTS, that is, areas of functioning which are limited by ADHD symptoms.

1) Inattention-Memory Problems – Since Working Memory deficits are thought to be central to ADHD, many patients have problems with concentration, short-term memory, forgetfulness, absent-mindedness, disorganization, and planning.

2) Hyperactivity/Restlessness – Many, but by no means all, patients feel or appear restless and have trouble sitting still.

3) Impulsivity/Emotional Lability – Many experience rapid shifts in mood (not to be confused with Bipolar Disorder), irritability, making snap choices without stopping to think about consequences.

4) Problems with Self-Concept – Lifelong difficulties with relationships, academic performance, and choices lead to a loss of self-esteem, a poor sense of competence.

The study did not determine if the treatments led to improvements in the adhd4range of domains and impairments. Nor did the study look at long-term skill improvements specifically. However, since Conners scores did not go down much in the study overall, we see that, without medication, patients lagged in the acquisition of new skills.

 

In recent years, an industry has arisen using coaching as an intervention with adults with ADHD. Motivated individuals can benefit from coaching or working with a psychotherapist to improve follow-through, completing important tasks, social interaction and relationships, and self-concept. The Philipsen study suggests that medication may enhance the ability to learn these crucial skills.

Lastly, ADHD is a lifelong condition. A person with ADHD learns

*to manage the symptoms

*to overcome the impairments,

*to acquire skills for effective performance in school, work, partnering, family life, and in the community

The study should not be read to mean that medication alone if the answer. Therapy or coaching is essential to helping many ADHD patients to manage the social, occupational, and educational effects of their primary ADHD symptoms.

*Click here to read the Sanja Gupta article.

Click here to read the abstract of the Philipsen article. 

The entire article reference is:

Philipsen A, et al (2015). “Effects of group psychotherapy, individual counseling, methylphenidate, and placebo in the treatment of adult ADHD. JAMA Psychiatry, 2146.

If you have more interest in the Conners Adult ADHD Rating Scale (CAARS), here are two sites which give examples of scoring for the CAARS and a breakdown of the symptom domains measured by the Scale, which include the major areas of difficulty in adult ADHD. The scale itself is only available to trained mental health professionals.

CAARS: Long Version (CAARS-S:L)

CAARS: Short Version (CAARS-S:S)

If you want to dig deeper into the professional literature on Cognitive Behavioral Therapy for ADHD, a good place to start is this review:

Knouse, L.A., & Safren, S. (2010). Current Status of Cognitive Behavioral Therapy for Adult Attention-Deficit Hyperactivity Disorder. Psychiatric Clinics of North America, 33 #3, 497-50

This link to the Knouse and Safren article on PubMed brings the reader to a number of other articles on this subject:

Current Status of Cognitive Behavioral Therapy for Adult Attention-Deficit Hyperactivity Disorder

 

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Introducing Shorehaven’s Referral Department

Most people who call Shorehaven for help will feel therapy has helped
them.  Whether the problem is with a child’s behavior, a couple problem,
anxiety, depression, substance abuse, or any number of other behavioral or
emotional problems, psychotherapy helps.

When you call Shorehaven to make your first appointment, your call will go
to our Referral Department.  Let’s introduce our Referral Coordinators:

Ryan Van Remmen
Leader In-Home Referral Coordinator

Laura Henning
In-Home Referral Coordinator

Antoinette Morrow
Outpatient Referral Coordinator

Cheronne Burks
Outpatient Referral Coordinator

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Antoinette (“Toni”) and Cheronne (“Ronnie”) set up appointments for clients who need psychotherapy, substance abuse treatment, or psychiatry.

Your Referral Coordinator will ask for all the information necessary to
start your treatment.  We will ask about your problem and your insurance.
We will check on your insurance coverage. Usually, we can make an
outpatient appointment for you while we have you on the phone.

Most clients who need help from a psychiatrist and who will be taking
medications also benefit from psychotherapy.  In order to make sure
psychiatry clients receive a thorough assessment, we will have one of our
mental health therapists do an initial assessment and recommend the best
services to help with your problems.

We hope to hear from you.  Call 414-540-2170 or write
referrals@shorehavenbhi.com.

Therapy Gem: Professionals’ Biases and Misconceptions With Substance Abuse Patients

Table of Contents: Biases and Misconceptions

Introduction and Fundamental Premises

The fundamental biases and their correlated misconceptions

I.      Substance users are not like me.

II.     Drug use always means addiction.

III.    Heavy drinking always means addiction.

IV.   All their problems are caused by their substance use.

V.    Treatment doesn’t work.

VI.   Drug users and heavy drinkers always need detox or intensive care.

VII.  Twelve-step programs are the way to go.

VIII. Any mental health professional should be able to treat such symptoms

Introduction and Fundamental Premises

subst abuse1I received a request to address staff at an HMO about substance abuse.  I was given this question: “What information about substance use and abuse will be most useful for nurse case managers?”

Thinking about that question, I knew the answer lay in one attitude that had troubled me more than any other.  Namely, too many colleagues in the mental health field believed that knowledge of substance use disorders (SUD) was outside their competence and, what’s more, they did not want to become knowledgeable about SUDs and their treatment.

Rather than learn the basics about treating substance use disorders – treatment which does work and which has applicability well beyond the treatment of SUDs — I heard many mental health professionals avoid knowledge of addictions and refer even mild cases to substance abuse professionals.  So the answer to the question “What information will be most useful?” is simply, “Before you can help change patients with substance use disorders, you first change yourself, your own attitudes, biases, and misunderstandings about substance use disorders.”

subst abuse2Over several weeks, I developed lists of such biases.  I also polled some of my colleagues who work in our Dual Disorders Department.  The result is a fairly comprehensive list of biases and misconceptions, each of which is juxtaposed with corrected information.

While I was organizing these biases by category, the list factored into what turned out to be eight domains.  A few crucial premises emerged from these ideas.  These premises summarize the main purpose and point of this presentation.

A.         The persistence of biases and misconceptions often leads to inappropriate, out-dated treatment recommendations and other potentially incorrect clinical decisions.  Accurate information AND attitudes lead to higher quality recommendations, treatments, and clinical decisions.

B.        Resolving our biases, we can connect with the substance using patient rather than distance from the patient or judge that person.  We can believe in and express hope – the foundation of motivation to change – rather than convey disapproval, judgment, or pessimism related to the patient’s lifestyle and distress.  Many of our biases derive from cultural beliefs and attitudes; therapists quite successfully overcome cultural beliefs about mental disorders, so they should easily overcome biases and misconceptions about SUDs and persons with addictions.

C.        If we judge addicts as weak and hopeless, will we do our best to help?  If we see them as people with strengths and abilities as well as with problems, we are more likely to see the best in them and do our best to help.

subst abuse3D.        Furthermore, a common fallacy is that we can cajole, guilt, criticize, admonish, confront, punish, or push a substance abuse patient into changing his or her outlook, attitudes, needs, burdens, pains, or behavior.  What we truly can change is our own outlook and attitudes. Rightly aligning ourselves, we can then better express empathy and help the other to see a hopeful vision of the changes he or she may be able to make.

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In the News- If Your Child Is Aggressive: Seven Major Steps for Parents

Many of the children in Shorehaven’s In-Home or Outpatient mental health and psychiatry programs display aggressive or hostile behaviors.  We work to change these behaviors, to replace them with more effective, appropriate behaviors.

In this essay, we are going to go over seven steps for parents to take when a child has persistent aggressive pic1aggressive behavior.  Such behaviors may be mostly verbal threats or negative remarks, such as “I hate you,” “You’re the worst parent,” “You’ll pay for this.”  The behaviors may be mostly physical abuses, such as throwing or breaking objects, holding kitchen knives while make threats, or hitting.  The behavior may be frequent or intermittent.  The behaviors may be in several environments such as home, school, and with peers, or only in one environment, such as at mother’s house, but not at father’s house.                      aggressive pic2

You may have tried everything you can think of to change the behavior on your own.  Or you may have sought treatment or medications without seeing the behavior change.  If this sounds familiar, then consider these steps.

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Clinical News You Can Use: New Medicaid Rules for Trainees

qtt pic1
Medicaid has paid for psychotherapy for over 30 years, long before mental health professionals were licensed in Wisconsin.  So Medicaid created a credential, Approved Provider, to identify those who could be providers of reimbursed services.  The purpose of the credential was to identify persons who had met a minimum level of presumed competence. That credential is the well-known “3000-hour letter” formerly called the “Dan Crossman letter,” then when he retired, the “Otis Woods letter,” and more recently the “Mark Hale letter.”

Psychologists have been licensed since around 1977 and approved for insurance payments since around 1978.

In the early 1990s, a law was passed creating certification of Marriage and Family Therapists, Social Workers and Clinical Social Workers, and Professional Counselors.  Certification only meant that no one could use those titles unless they met certain minimum requirements and were approved by the Department of Regulation and Licensing.

A law passed in 2001 upgraded certification to licensure.  That meant not only were the titles protected, but the very practice of psychotherapy was limited to those with one of these licenses.

All along, graduate students could practice under Medicaid and bill under a supervisor.

All this time, around 34 years, those who had graduated with a masters or doctorate, but who had not completed the Approved Provider credential or, after 1993, certification, could not practice under Medicaid – their services could not be billed to Medicaid.  This gap left new Masters level clinicians scrambling to get 3000 hours.

Finally, this week, Medicaid issued a bulletin, 2012-64, rectifying this long-standing problem.  From now on, masters-level clinicians who procure a training license and PhD/PsyD level clinicians who are on post-doctoral training will be able to credential as Medicaid providers.  They will be known as Qualified Treatment Trainees (QTT), a title defined under DHS35.03.  These provisions ONLY apply when the clinician works for a licensed mental health clinic.

This a major step to enable clinicians to train for licensure and to increase the capacity of the mental health community to serve Medicaid clientele.

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