Category: Mental Health History

What is Psychological First Aid?

Published on by Andrew Marshall2 Comments

Introduction

Psychological first aid (PFA) is a technique designed to reduce the occurrence of post-traumatic stress disorder. It was developed by the National Centre for Post Traumatic Stress Disorder (NC-PTSD), a section of the United States Department of Veterans Affairs, in 2006. It has been spread by the International Federation of Red Cross and Red Crescent Societies, Community Emergency Response Team (CERT), the American Psychological Association (APA) and many others. It was developed in a two-day intensive collaboration, involving more than 25 disaster mental health researchers, an online survey of the first cohort that used PFA and repeated reviews of the draft.

Refer to Crisis Intervention and Mental health First Aid.

Definition

According to the NC-PTSD, psychological first aid is an evidence-informed modular approach for assisting people in the immediate aftermath of disaster and terrorism to reduce initial distress and to foster short and long-term adaptive functioning. It was used by non-mental health experts, such as responders and volunteers. Other characteristics include non-intrusive pragmatic care and assessing needs. PFA does not necessarily involve discussion of the traumatic event. Just like physical first aid, psychological first aid focuses on providing effective initial support to individuals in distress.

Components

  • Protecting from further harm.
  • Opportunity to talk without pressure.
  • Active listening.
  • Compassion.
  • Addressing and acknowledging concerns.
  • Discussing coping strategies.
  • Social support.
  • Offer to return to talk.
  • Referral.

Steps

  • Contact and engagement.
  • Safety and comfort.
  • Stabilization.
  • Information gathering.
  • Practical assistance.
  • Connection with social supports.
  • Coping information.
  • Linkage with services.

Brief History

Before PFA, there was a procedure known as debriefing. It was intended to reduce the incidences of post traumatic stress disorder (PTSD) after a major disaster. PTSD is now widely known to be debilitating; sufferers experience avoidance, flashbacks, hyper-vigilance, and numbness. Debriefing procedures were made a requirement after a disaster, with a desire to prevent people from developing PTSD. The idea behind it was to promote emotional processing by encouraging recollection of the event. Debriefing has origins with the military, where sessions were intended to boost morale and reduce distress after a mission. Debriefing was done in a single session with seven stages: introduction, facts, thoughts and impressions, emotional reactions, normalisation, planning for future, and disengagement.

Debriefing was found to be at best, ineffective, and at worst, harmful. There are several theories as to why debriefing increased incidents of PTSD. First, those who were likely to develop PTSD were not helped by a single session. Second, being re-exposed too soon to the trauma could lead to retraumatisation. Exposure therapy in cognitive behavioural therapy (CBT) allows the person to adjust to the stimuli before slowly increasing severity. Debriefing did not allow for this. Also, normal distress was seen to be pathological after a debriefing and those who had been through a trauma thought they had a mental disorder because they were upset. Debriefing assumes that everyone reacts the same way to a trauma, and anyone who deviates from that path, is pathological. But there are many ways to cope with a trauma, especially so soon after it happens.

PFA seems to address many of the issues in debriefing. It is not compulsory and can be done in multiple sessions and links those who need more help to services. It deals with practical issues which are often more pressing and create stress. It also improves self efficacy by letting people cope their own way. PFA has attempted to be culturally sensitive, but whether it is or not has not been shown. However, a drawback is the lack of empirical evidence. While it is based on research, it is not proven by research. Like the debriefing method, it has become widely popular without testing.

Today, PFA has been widely used not just for crisis intervention for natural disasters, but also personal crises such as when individuals face traumatic losses of loved ones or pets, or when organisations go through critical incidents such as the suicide or death of a colleague.

Overview of Mental Health First Aid

Published on by Andrew Marshall3 Comments

Introduction

Mental health first aid is a training programme that teaches members of the public how to help a person developing a mental health problem (including a substance use problem), experiencing a worsening of an existing mental health problem or in a mental health crisis. Like traditional first aid, mental health first aid does not teach people to treat or diagnose mental health or substance use conditions. Instead, the training teaches people how to offer initial support until appropriate professional help is received or until the crisis resolves.

While first aid for physical health crises is a familiar notion in developed countries, conventional first aid training has not generally incorporated mental health problems.

Refer to Crisis Intervention and Psychological First Aid.

Rationale

Mental health problems are common in the community, so members of the public are likely to have close contact with people affected. However, many people are not well informed about how to recognise mental health problems, how to provide support and what are the best treatments and services available. Furthermore, many people developing mental disorders do not get professional help or delay getting professional help Someone in their social network who is informed about the options available for professional help can assist the person to get appropriate help. In mental health crises, such as a person feeling suicidal, deliberately harming themselves, having a panic attack or being acutely psychotic, someone with appropriate mental health first aid skills can reduce the risk of the person coming to harm.

There is also stigma and discrimination against people with mental health problems, which may be reduced by improving public understanding of their experiences.

Brief History

The Mental Health First Aid Programme was developed in Australia by Betty Kitchener and Anthony Jorm in 2000. Since 2003, this Mental Health First Aid Programme has spread to a number of other countries (Bermuda, Canada, Denmark, England, Finland, France, Germany, Hong Kong, India, Ireland, Japan, Malaysia, Malta, Netherlands, New Zealand, Northern Ireland, Saudi Arabia, Scotland, Sweden, Switzerland, United States, United Arab Emirates, Wales). By 2019, over 3 million people had been trained in mental health first aid worldwide.

Research on Mental Health First Aid Training

A number of studies have been carried out showing the people who are trained in mental health first aid showed improved knowledge, confidence, attitudes and helping behaviour. A meta-analysis of data from 15 evaluation studies concluded that mental health first aid training “increases participants’ knowledge regarding mental health, decreases their negative attitudes, and increases supportive behaviours toward individuals with mental health problems”.

There has been research to develop international guidelines on the best strategies for mental health first aid. Mental health first aid training has been included in the US Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-based Programmes and Practices.

By Country

Australia

In Australia, mental health first aid training is run by the not-for-profit charity Mental Health First Aid International (trading as Mental Health First Aid Australia). A range of training courses are offered:

  • Standard Mental Health First Aid is a 12-hour face-to-face course for adults to learn to assist other adults.
    • Culturally adapted versions of this course are available for Chinese and Vietnamese Australians.
    • eLearning and blended versions of the Standard course have been tailored for a range of professional groups, including pharmacists, the legal profession, financial counsellors, medical students and nursing students.
  • Youth Mental Health First Aid is a 14-hour face-to-face course for adults to learn to assist adolescents.
  • Aboriginal and Torres Strait Islander Mental Health First Aid is a 14-hour face-to-face culturally adapted course for adults to learn to assist Aboriginal and Torres Strait Islander adults.
    • It is run by Aboriginal or Torres Strait Islander instructors.
  • Teen Mental Health First Aid is a 3.5-hour classroom-based course that teaches high school students in years 10-12 how to provide mental health first aid to their friends.
  • Older Person Mental Health First Aid is a 12-hour face-to-face course for adults to learn to assist people aged 65 and over.

By 2015, Mental Health First Aid training had been received by over 350,000 people, which is more than 2% of the Australian adult population.

Mental health first aid training programmes in Australia have won a number of awards for excellence including:

  • Gold Achievement Award 2007 – winner of the Mental Health Promotion Mental Illness Prevention Programme or Project category at the MHS Conference.
  • Suicide Prevention Australia – 2005 Life Award.
  • Victorian Public Health Programmes Award for Innovation, 2006.
  • Enterprise and Resourcefulness Award – NSW Aboriginal Health Awards 2010.
  • Silver Achievement Award for Aboriginal and Torres Strait Islander Programme – Mental Health Promotion or Mental Illness Prevention Programme or Project category at the MHS Conference 2010.
  • Silver Achievement Award for Youth Mental Health First Aid Programme – TheMHS, Mental Health Promotion or Mental Illness Prevention Programme Category, 2014.
  • TheMHS Medal (the top award of the Mental Health Service Awards of Australia and New Zealand which “honours a unique and inspiring contribution to Mental Health by an individual or organisation”), 2017.

England

Mental health first aid (MHFA) came to England in 2007 and was developed and launched under the National Institute for Mental Health in England, part of the Department of Health, as part of a national approach to improving public mental health. Mental Health First Aid England was launched as a community interest company in 2009.

MHFA England offer a range of courses:

  • Standard MHFA, a two-day course which qualifies a participant to become a Mental Health First Aider
  • Youth MHFA, a two-day course which qualifies a participant to become a Youth Mental Health First Aider.
    • This course is designed for those who are working, living or interacting with young people.
    • It was first launched in England in 2010 and revised and re-launched in October 2013.
  • Youth MHFA Schools & Colleges, a one-day course which is based on Youth MHFA and designed to fit into school training timetables.
  • Armed Forces MHFA, a two-day course which qualifies participants to become an Armed Forces Mental Health First Aider.
    • This course was designed for the whole Armed Forces community, including veterans, serving personnel and their families.
    • It was launched 2013.
  • MHFA Lite, a three-hour introductory awareness course launched which is based on the Standard MHFA course.
    • MHFA Lite was launched in 2011.
    • There is also a Lite version of the Youth MHFA course.
  • MHFA Instructor Training, a seven-day course accredited by the Royal Society for Public Health to qualify as a Mental Health First Aid instructor who can deliver one or all of the two-day courses (Standard, Youth and Armed Forces).

Since 2007, more than 114,000 Mental Health First Aiders have been trained in England and more than 1,600 people have trained as Mental Health First Aid instructors. The Department of Health encouraged all employers in England to provide mental health first aid training as one of three steps in its 2012 “No Health Without Mental Health: Implementation Framework”. In 2016 Mental Health First Aid was recommended for all workplaces by the charity Business in the Community.

Scotland, Wales, and Northern Ireland have broadly similar courses to the above.

You can find further information on the various UK courses here.

Ireland

In May 2014 Saint John of God Hospital signed a Memorandum of Understanding with MHFA Australia to adapt the course for Ireland and in October 2014 Betty Kitchener came to Saint John of God Hospital to advise on the rollout of the MHFA Ireland Programme.

United States

In 2008, the National Council for Behavioural Health, in partnership with the Missouri Department of Mental Health, brought mental health first aid to the United States. Since 2008, more than 1.5 million people have been trained on the Mental Health First Aid USA course by an instructor base of more than 15,000. There are people trained in mental health first aid in all 50 states, Puerto Rico and Guam. The course is offered to a variety of audiences, including hospital staff, employers and business leaders, faith communities and law enforcement.

In 2012, youth mental health first aid was introduced in the United States to prepare trainees to help youth ages 12-18 that may be developing or experiencing a mental health challenge. Specialised versions of Mental Health First Aid USA including the Veterans, Public Safety, Higher Education, Rural and Older Adults modules and a Spanish version of the Youth and Adult curriculum are also available.

Mental Health First Aid USA was included in President Barack Obama’s plan to reduce gun violence and increase access to mental health services. In 2014, Congress appropriated $15 million to SAMHSA to train teachers and school personnel in youth mental health first aid. In 2015, an additional $15 million was appropriated to support other community organizations serving youth. The Mental Health First Aid Act of 2015 (S. 711/H.R. 1877) had broad bi-partisan support and would authorise $20 million annually for training the American public. Fifteen states have made Mental Health First Aid a priority by appropriating state funds, including Texas which allocated $5 million.

Canada

Mental health first aid debuted in Canada in 2007, and has operated under the leadership of the Mental Health Commission of Canada since early 2010.

MHFA Canada offers a range of courses, which, upon completion, certify a participant in mental health first aid:

  • MHFA Basic, a two-day 12 hour course.
  • MHFA for Adults who Interact with Youth, a two-day 14 hour course.
  • MHFA Seniors, a two-day 14 hour course.
  • MHFA Veteran Community, a two-day 13 hour course.
  • MHFA Northern Peoples, a three-day 18 hour course.
  • MHFA First Nations, a three-day 20 hour course.
  • MHFA Inuit, a three-day 24 hour course.
  • MHFA Police, an eight-hour course including 15-30 minutes online.
  • MHFA Instructor Training, a course which allows the participant to become a Mental Health First Aid instructor.

Different instructor courses are required to become a MHFA Basic, Youth, Seniors, Veteran Community, First Nations or Northern Peoples instructor. The duration of these courses vary from five to six days. First Nations & Northern People versions require two instructors/facilitators to deliver the course.

Since 2007, more than 400,000 Canadians have been trained in Mental Health First Aid, and more than 1,200 people have been trained as instructors.

United Arab Emirates

Mental health first aid debuted in the UAE in December 2017. MHFA UAE operates under the leadership of the Lighthouse Centre for Wellbeing, an out-patient mental health clinic in Dubai composed of more than 25 licensed psychologists. The Lighthouse is the only accredited provider of MHFA in the UAE.

MHFA UAE offers 3 courses:

  • Adult to Adult MHFA, a 12-hour training which qualifies a participant to become a Mental Health First Aider.
    • This course is designed for those who are working, living or interacting with other adults.
  • Adult to Adolescent MHFA, a 14-hour course which qualifies a participant to become a Youth Mental Health First Aider.
    • This course is designed for those who are working, living or interacting with young people.
  • Teen to Teen MHFA, a 4-hour course which qualifies teens to become Teen Mental Health First Aiders.

What is Crisis Intervention?

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Introduction

Crisis intervention is a time-limited intervention with a specific psychotherapeutic approach to immediately stabilise those in crisis.

Refer to Mental Health First Aid and Psychological First Aid.

Implementation

A crisis can have physical or psychological effects. Usually significant and more widespread, the latter lacks the former’s obvious signs, complicating diagnosis. Three factors define crisis: negative events, feelings of hopelessness, and unpredictable events. People who experience a crisis perceive it as a negative event that generate physical emotion, pain, or both. They also feel helpless, powerless, trapped, and a loss of control over their lives. Crisis events tend to occur suddenly and without warning, leaving little time to respond and resulting in trauma.

At a global level, when a mass trauma from an event like as a terrorist attack occurs, counsellors are trained to provide resources, coping skills, and support to clients to assist them through their crisis. Intervention often begins with an assessment. In countries such as the Czech Republic, crisis intervention is an individual therapy, usually lasting four to six weeks, and includes assistance with housing, food, and legal matters. Long waiting times for resident psychotherapists and in Germany, explicit exclusions of couples therapy and other therapies complicate implementation. In the United States, licensed professional counsellors (LPCs) provide mental health care to those in need. Licensed professional counsellors focus on psychoeducational techniques to prevent a crisis, consultation to individuals, and research effective therapeutic treatment to deal with stressful environments.

School-based

The primary goal of school-based crisis intervention is to help restore the crisis-exposed student’s basic problem-solving abilities and in doing so, to return the student to their pre-crisis levels of functioning. Crisis intervention services are indirect. People often find school psychologists working behind the scenes, ensuring that students, staff, and parents are well-positioned to realize their natural potential to overcome the crisis. School psychologists are trained professionals who meet continuing education requirements after receiving their degree. They help maintain a safe and supportive learning environment for students by working with other staff. such as school resource officers, law enforcement officers trained as informal counsellors and mentors.

At a school-based level, when a trauma occurs, like a student death, school psychologists are trained to prevent and respond to crisis through the PREPaRE Model of Crisis Response, developed by NASP. PREPaRE provides educational professionals training in roles based on their participation in school safety and crisis teams. PREPaRE is one of the first comprehensive nationally available training curriculums developed by school-based professionals with firsthand experience and formal training.

Misuse

When using crisis intervention methods for the disabled individual, every effort should first be made to first find other, preventative methods, such as giving adequate physical, occupational and speech therapy, and communication aides including sign language and Augmentative Communication systems, behaviour and other plans, to first help that individual to be able to express their needs and function better. Too often, crisis intervention methods including restraining holds are used without first giving the disabled more and better therapies or educational assistance. Often school districts, for example, may use crisis prevention holds and “interventions” against disabled children without first giving services and supports: at least 75% of cases of restraint and seclusion reported to the US Department of Education in the 2011-2012 school year involved disabled children. Also, school districts hide their disabled child’s restraint or seclusion from the parents, denying the child and their family the opportunity to recover.

The US Congress has proposed legislation, such as the “Keeping All Students Safe Act”, to curtail school district use of restraint and seclusion. Even with bipartisan support, the bill has repeatedly died in committee.

SAFER-R

The SAFER-R Model, with Roberts 7 Stage Crisis Intervention Model, is model of intervention much used by law enforcement. The model approaches crisis intervention as an instrument to help the client to achieve their baseline level of functioning from the state of crisis. This intervention model for responding to individuals in crisis consists of 5+1 stages. They are:

  • Stabilise.
  • Acknowledge.
  • Facilitate understanding.
  • Encourage adaptive coping.
  • Restore functioning or,
  • Refer.

Other models include Lerner and Shelton’s 10 step acute stress & trauma management protocol.

Critical Incident Debriefing

Critical incident debriefing is a widespread approach to counselling those in a state of crisis. This technique is done in a group setting 24-72 hours after the event occurred, and is typically a one-time meeting that lasts 3-4 hours, but can be done over numerous sessions if needed. Debriefing is a process by which facilitators describe various symptoms related PTSD and other anxiety disorders that individuals are likely to experience due to exposure to a trauma. As a group they process negative emotions surrounding the traumatic event. Each member is encouraged to continue participation in treatment so that symptoms do not worsen.

Commentators have criticised critical incident debriefing for its effectiveness on reducing harm in crisis situations. Some studies show that those exposed to debriefing are actually more likely to show symptoms of PTSD at a 13-month follow-up than those who were not exposed. Most recipients of debriefing reported that they found the intervention helpful. Based on symptoms found in those who received no treatment at all, some critics state that reported improvement is considered a misattribution, and that the progress would naturally occur without any treatment.

On This Day … 17 February

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People (Deaths)

  • 2012 – Ulric Neisser, German-American psychologist and academic (b. 1928).

Ulric Neisser

Ulric Richard Gustav Neisser (08 December 1928 to 17 February 2012) was a German-American psychologist and member of the US National Academy of Sciences. He has been referred to as the “father of cognitive psychology”.

Neisser researched and wrote about perception and memory. He posited that a person’s mental processes could be measured and subsequently analysed. In 1967, Neisser published Cognitive Psychology, which he later said was considered an attack on behaviourist psychological paradigms. Cognitive Psychology brought Neisser instant fame and recognition in the field of psychology. While Cognitive Psychology was considered unconventional, it was Neisser’s Cognition and Reality that contained some of his most controversial ideas. A main theme in Cognition and Reality is Neisser’s advocacy for experiments on perception occurring in natural (“ecologically valid”) settings. Neisser postulated that memory is, largely, reconstructed and not a snap shot of the moment. Neisser illustrated this during one of his highly publicized studies on people’s memories of the Challenger explosion.

In his later career, he summed up current research on human intelligence and edited the first major scholarly monograph on the Flynn effect. A Review of General Psychology survey, published in 2002, ranked Neisser as the 32nd most cited psychologist of the 20th century.

What is the Quality of Life in Depression Scale?

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Introduction

The Quality of Life In Depression Scale (QLDS), originally proposed by Sonja Hunt and Stephen McKenna, is a disease specific patient-reported outcome which assesses the impact that depression has on a patient’s quality of life. It is the most commonly used measure of quality of life in clinical trials and studies of depression. The QLDS was developed as a measure to be used in future clinical trials of anti-depressant therapy.

It is a 34 item self-rated questionnaire which consists of dichotomous response questions, with the response being either True/Not True. It is scored binomially (0-1) with higher scores on the QLDS indicating a lower quality of life. Several tests of construct validity and internal consistency have found the QLDS to be a good measure of quality of life.

Needs-based Model

The QLDS is built around the generally accepted assumption that one’s quality of life can only be assessed subjectively. Quality of life tends to be greatly influenced by factors such as depression, anxiety, tension or fatigue.

The QLDS is based around the needs-based model of quality of life. This is derived from the assumption that quality of life is dependent on a person’s ability to fulfil particular human needs. The QLDS questions centre around a number of needs that were considered crucial in order to suffice a high quality of life. These include but are not limited to; food, sleep, sex, safety, love, enjoyment, self-esteem and self-actualisation.

The QLDS uses a two-point response system with either True or Not True. The high number of items in the questionnaire allows the detection of moderately minor changes in quality of life.

Items on the QLDS are given a score of 1 when the question is applicable to the respondent and 0 when it is not applicable. The items are totalled to give a score ranging from 0-34. Low scores act as an indicator towards a high quality of life.

Development

The QLDS was developed by Galen Research in 1992 and was funded by Lilly Industries. It was developed in the United Kingdom in conjunction with the Netherlands. The QLDS was the first quality of life instrument to be developed in 2 languages simultaneously. The development of the QLDS coincided with a rising interest on the impact of illness and its treatment on the quality of life of the patient. McKenna and Hunt constructed the QLDS on the basis of providing a measure for this, as well as attempting to overcome contemporary studies concerning low correlations between patient self-assessment and nurse or therapist evaluations.

The items in the UK English QLDS were derived from statements made in qualitative interviews by 30 depressed or recently recovered patients based in the North West of England and Scotland. Interviews took a conversational approach and lasted between 30 minutes to 2 hours. Interviewees were between the age range of 19-64 years, with 22 females and 8 males. After a refinement process, based on categories of needs proposed by McKenna and Hunt, 426 relevant statements were derived from the interview transcripts. Upon further examination they produced 41 statements for an initial questionnaire.

A further 35 patients were asked to complete the draft questionnaire and review their experience with it. They were composed of 22 females and 13 males in the age range of 24-72 years. Interviewees expressed a great degree of approval with the questionnaire, although a few mentioned how the binomial system caused difficulty, as it required them to make complete choices.

Following this, the questionnaire was revised to 34 items and field tested to determine construct validity and reliability.

International Development

The first two languages the QLDS was available in were UK English and Dutch. These were shown to have good reliability, validity and responsiveness. In 1999, McKenna in collaboration with a team of international researchers developed and tested the QLDS in 9 new languages. This involved translation, followed by field testing for content validity and the new measure’s construct validity.

Across the majority of translations, no major difficulties arose excluding Morocco. Cultural differences between Morocco and the UK provided challenge, alongside a lack of literal equivalents between the two languages. An example of this is the absence of an equivalent for the verb ‘to enjoy’ in Arabic. Researchers also faced further difficulty due to the contemporarily high rate of illiteracy, as the test could not be self-administrative on as large a scale as anticipated. As a result, although the data demonstrated both reliability and construct validity, they were unable to place confidence in the Arabic adaptation’s equivalence to the other developed versions.

Reliability, Validity and Responsiveness

Testing the Anglo-Dutch Project

Following the collaborative Anglo-Dutch project, researchers had to compare the QLDS’ success with established measures of the same concept. No measure of quality of life in depression was available so both versions had to be matched to related measures. In the UK this was the General Well-Being Index (GWBI) whilst in the Netherlands the Sickness Impact Profile (PS-SIP) acted as a comparison.

Reliability and Internal Consistency

For use in a clinical trial, an instrument like the QLDS should have a test-retest reliability coefficient of minimum 0.85. Internal consistency also requires a minimum of 0.85 and is assessed using Cronbach’s alpha-coefficient.

In the UK, the test-retest correlation coefficient for patients with stable depression was 0.94 (n=37). The test-retest correlation coefficient in the Netherlands was 0.87 (n=33).

For internal consistency the UK recorded a value of 0.95 and the Netherlands a value of 0.92. These results suggested the QLDS produced a low degree of measurement error and high internal consistency.

Content and Construct Validity

No missing items applicable to participants were recognised. The relevancy and ease of completion indicated by field-test interviews suggested the high content validity of the QLDS.

The QLDS and GWBI had a correlation score of 0.79 in the UK (n=65). The Dutch adaptation had a correlation of 0.71 with the PS-SIP (n=77). These measurements were anticipated to be slightly lower due to the difference of purpose between measures.

Responsiveness

The QLDS’ responsiveness was analysed in a general practice population of 540 patients with major depression. Over a 6-month period, substantial progress in the level of depression was seen.

8 weeks into treatment the mean QLDS score rose by 68%, with patients who continued treatment for the full 6-months recording an increase of 78%. The QLDS was concluded by the researchers to be responsive to change in quality of life throughout successful pharmacological depression treatment.

International Use

Since its development, the QLDS has been adapted and validated in 17 languages other than UK English, including Norwegian, Spanish, Danish, French, German and Italian. This has allowed the QLDS to be used in research and clinical studies worldwide.

Studies utilising the QLDS include investigations into venlafaxine, duloxetine and bupropion.

Refer to Beck Depression Inventory, Beck Anxiety Inventory, Beck Hopelessness Scale, Major Depression Inventory.

What is the Major Depression Inventory?

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Introduction

The Major Depression Inventory (MDI) is a self-report mood questionnaire developed by the World Health Organisation. The instrument was constructed by a team led by Professor Per Bech, a psychiatrist based at Frederiksborg General Hospital in Denmark. The MDI differs from many other self-report inventories, such as the Beck Depression Inventory (BDI), because it is able to generate an ICD-10 or DSM-IV diagnosis of clinical depression in addition to an estimate of symptom severity.

Unlike many other similar instruments, the MDI is available free of charge and can be downloaded from the internet with a full manual and scoring instructions. This makes it an attractive option in epidemiological population surveys. It has also been translated into seven languages.

Scoring

To measure treatment outcome the sum of the ten items is used. A higher score signifies deeper depression.

When using the scale to diagnose depression according to ICD-10, there are the following possibilities:

  • Mild depression:
    • A score of 4 or 5 in two of the first three items.
    • Plus a score of at least 3 on two or three of the last seven items.
  • Moderate depression:
    • A score of 4 or 5 in two or three of the first three items.
    • Plus a score of at least 3 on four of the last seven items.
  • Severe depression:
    • A score of 4 or 5 in all of the first three items.
    • Plus a score of at least 3 on five or more of the last seven items.
  • Major depression:
    • The number of items is reduced to nine, as Item 4 is part of Item 5.
    • Include whichever of the two items has the highest score (item 4 or 5).
    • A score on at least five items is required, to be scored as follows:
      • The score on the first three items must be at least 4, and on the other items at least 3.
      • Either Item 1 or 2 must have a score of 4 or 5.

Refer to Beck Anxiety Inventory, Beck Depression Inventory, Beck Hopelessness Scale, and Quality of Life in Depression Scale.

What is the Beck Hopelessness Scale?

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Introduction

The Beck Hopelessness Scale (BHS) is a 20-item self-report inventory developed by Dr. Aaron T. Beck that was designed to measure three major aspects of hopelessness:

  • Feelings about the future;
  • Loss of motivation; and
  • Expectations.

The test is designed for adults, age 17-80. It measures the extent of the respondent’s negative attitudes, or pessimism, about the future. It may be used as an indicator of suicidal risk in depressed people who have made suicide attempts. The test is multiple choice. It is not designed for use as a measure of the hopelessness construct but has been used as such. Sufficient data about the use of the test with those younger than 17 has not been collected. It may be administered and scored by paraprofessionals, but must be used and interpreted only by clinically trained professionals, who can employ psychotherapeutic interventions. Norms are available for suicidal patients, depressed patients, and drug abusers.

Reliability and Validity

The BHS moderately correlates with the Beck Depression Inventory, although research shows that the BDI is better suited for predicting suicidal ideation behaviour. The internal reliability coefficients are reasonably high (Pearson r = 0.82 to 0.93 in seven norm groups), but the BHS test-retest reliability coefficients are modest (0.69 after one week and 0.66 after six weeks).

Dowd and Owen both positively reviewed the effectiveness of the instrument, with Dowd concluding that the BHS was “a well-constructed and validated instrument, with adequate reliability”.

DMCA Notice

In 2012 the scale became the subject of a much circulated DMCA notice that resulted in the temporary shutdown of 1.45 million education blogs due to the scale’s inclusion in a single blog several years prior to the incident, sparking widespread indignation.

Beck Hopelessness Scale is sold as a product by Pearson, along with the Beck Anxiety Inventory (BAI) and the Beck Depression Inventory II (BDI-II).

Questionnaire

The Beck Hopelessness Scale questionnaire consists of twenty true/false questions examining the respondent’s attitude for the past week, such as:

  • I might as well give up because there’s nothing I can do to make things better for me.
  • I happen to be particularly lucky and I expect to get more of the good things in life than the average person.
  • I never get what I want, so it’s foolish to want anything.
  • My past experiences have prepared me well for my future.

Refer to Beck Anxiety Inventory, Beck Depression Inventory, Major Depression Inventory, and Quality of Life in Depression Scale.

What is the Beck Anxiety Inventory?

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Introduction

The Beck Anxiety Inventory (BAI), created by Aaron T. Beck and other colleagues, is a 21-question multiple-choice self-report inventory that is used for measuring the severity of anxiety in children and adults. The questions used in this measure ask about common symptoms of anxiety that the subject has had during the past week (including the day you take it) (such as numbness and tingling, sweating not due to heat, and fear of the worst happening). It is designed for individuals who are of 17 years of age or older and takes 5 to 10 minutes to complete. Several studies have found the Beck Anxiety Inventory to be an accurate measure of anxiety symptoms in children and adults.

The BAI contains 21 questions, each answer being scored on a scale value of 0 (not at all) to 3 (severely). Higher total scores indicate more severe anxiety symptoms. The standardised cutoffs are:

  • 0-7: Minimal.
  • 8-15: Mild.
  • 16-25: Moderate.
  • 26-63: Severe.

The BAI has been criticised for its predominant focus on physical symptoms of anxiety (most akin to a panic response). As such, it is often paired with the Penn State Worry Questionnaire, which provides a more accurate assessment of the cognitive components of anxiety (i.e. worry, catastrophising, etc.) commonly seen in generalised anxiety disorder.

Two Factor Approach to Anxiety

Though anxiety can be thought of as having several components, including cognitive, somatic, affective, and behavioural components, Beck et al. included only two components in the BAI’s original proposal: cognitive and somatic. The cognitive subscale provides a measure of fearful thoughts and impaired cognitive functioning, and the somatic subscale measures the symptoms of physiological arousal.

Since the introduction of the BAI, other factor structures have been implemented, including a four factor structure used by Beck and Steer with anxious outpatients that included neurophysiological, autonomic symptoms, subjective, and panic components of anxiety. In 1993, Beck, Steer, and Beck used a three factor structure including subjective, somatic, and panic subscale scores to differentiate among a sample of clinically anxious outpatients.

Because the somatic subscale is emphasized on the BAI, with 15 out of 21 items measuring physiological symptoms, perhaps the cognitive, affective, and behavioural components of anxiety are being deemphasized. Therefore, the BAI functions more adequately in anxiety disorders with a high somatic component, such as panic disorder. On the other hand, the BAI will not function as adequately for disorders such as social phobia or obsessive-compulsive disorder, which have a stronger cognitive or behavioural component.

Clinical Use

The BAI was specifically designed as “an inventory for measuring clinical anxiety” that minimizes the overlap between depression and anxiety scales. While several studies have shown that anxiety measures, including the State-Trait Anxiety Inventory (STAI), are either highly correlated or indistinguishable from depression, the BAI is shown to be less contaminated by depressive content.

Since the BAI does only questions symptoms occurring over the last week, it is not a measure of trait anxiety or state anxiety. The BAI can be described as a measure of “prolonged state anxiety”, which, in a clinical setting, is an important assessment. A version of the BAI, the Beck Anxiety Inventory-Trait (BAIT), was developed in 2008 to assess trait anxiety rather than immediate or prolonged state anxiety, much like the STAI. However, unlike the STAI, the BAIT was developed to minimize the overlap between anxiety and depression.

A 1999 review found that the BAI was the third most used research measure of anxiety, behind the STAI and the Fear Survey Schedule, which provides quantitative information about how clients react to possible sources of maladaptive emotional reactions.

The BAI has been used in a variety of different patient groups, including adolescents. Though support exists for using the BAI with high-school students and psychiatric inpatient samples of ages 14 to 18 years, the recently developed diagnostic tool, Beck Youth Inventories, Second Edition, contains an anxiety inventory of 20 questions specifically designed for children and adolescents ages 7 to 18 years old.

Limitations

Though the BAI was developed to minimise its overlap with the depression scale as measured by the Beck Depression Inventory, a correlation of r=.66 (p<.01) between the BAI and BDI-II was seen among psychiatric outpatients, suggesting that the BAI and the BDI-II equally discriminate between anxiety and depression.

Another study indicates that, in primary care patients with different anxiety disorders including social phobia, panic disorder, panic disorder with or without agoraphobia, agoraphobia, or generalised anxiety disorder, the BAI seemed to measure the severity of depression. This suggests that perhaps the BAI cannot adequately differentiate between depression and anxiety in a primary care population.

In a study examining the BAI’s use on older adults with generalised anxiety disorder, no discriminant validity was seen between the BAI and measures of depression. This could perhaps be due to the increased difficulty in discriminating between anxiety and depression in older adults due to “de-differentiation” of the symptoms of anxiety with the aging process, as hypothesized by Krasucki et al.

Many questions of the Beck Anxiety Inventory include physiological symptoms, such as palpitations, indigestion, and trouble breathing. Because of this, it has been shown to elevate anxiety measures in those with physical illnesses like postural orthostatic tachycardia syndrome, when the Anxiety Sensitivity Index did not.

Finally, the mean and median reliability estimates of the BAI tend to be lower when given to a nonpsychiatric population, such as college students, than when given to a psychiatric population.

Refer to Beck Depression Inventory, Beck Hopelessness Scale, Major Depression Inventory, and Quality of Life in Depression Scale.

What is the Beck Depression Inventory?

Published on by Andrew Marshall11 Comments

Introduction

The Beck Depression Inventory (BDI, BDI-1A, BDI-II), created by Aaron T. Beck, is a 21-question multiple-choice self-report inventory, one of the most widely used psychometric tests for measuring the severity of depression. Its development marked a shift among mental health professionals, who had until then, viewed depression from a psychodynamic perspective, instead of it being rooted in the patient’s own thoughts.

In its current version, the BDI-II is designed for individuals aged 13 and over, and is composed of items relating to symptoms of depression such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight loss, and lack of interest in sex.

There are three versions of the BDI – the original BDI, first published in 1961 and later revised in 1978 as the BDI-1A, and the BDI-II, published in 1996. The BDI is widely used as an assessment tool by health care professionals and researchers in a variety of settings.

The BDI was used as a model for the development of the Children’s Depression Inventory (CDI), first published in 1979 by clinical psychologist Maria Kovacs.

Brief History

According to Beck’s publisher, ‘When Beck began studying depression in the 1950s, the prevailing psychoanalytic theory attributed the syndrome to inverted hostility against the self.’ By contrast, the BDI was developed in a novel way for its time; by collating patients’ verbatim descriptions of their symptoms and then using these to structure a scale which could reflect the intensity or severity of a given symptom.

Beck drew attention to the importance of “negative cognitions” described as sustained, inaccurate, and often intrusive negative thoughts about the self. In his view, it was the case that these cognitions caused depression, rather than being generated by depression.

Beck developed a triad of negative cognitions about the world, the future, and the self, which play a major role in depression. An example of the triad in action taken from Brown (1995) is the case of a student obtaining poor exam results:

  • The student has negative thoughts about the world, so he may come to believe he does not enjoy the class.
  • The student has negative thoughts about his future because he thinks he may not pass the class.
  • The student has negative thoughts about his self, as he may feel he does not deserve to be in college.

The development of the BDI reflects that in its structure, with items such as “I have lost all of my interest in other people” to reflect the world, “I feel discouraged about the future” to reflect the future, and “I blame myself for everything bad that happens” to reflect the self. The view of depression as sustained by intrusive negative cognitions has had particular application in cognitive behavioural therapy (CBT), which aims to challenge and neutralise them through techniques such as cognitive restructuring.

BDI

The original BDI, first published in 1961, consisted of twenty-one questions about how the subject has been feeling in the last week. Each question had a set of at least four possible responses, ranging in intensity. For example:

  • (0) I do not feel sad.
  • (1) I feel sad.
  • (2) I am sad all the time and I can’t snap out of it.
  • (3) I am so sad or unhappy that I can’t stand it.

When the test is scored, a value of 0 to 3 is assigned for each answer and then the total score is compared to a key to determine the depression’s severity. The standard cut-off scores were as follows:

  • 0-9: indicates minimal depression.
  • 10-18: indicates mild depression.
  • 19-29: indicates moderate depression.
  • 30-63: indicates severe depression.

Higher total scores indicate more severe depressive symptoms.

Some items on the original BDI had more than one statement marked with the same score. For instance, there are two responses under the Mood heading that score a 2:

  • (2a) “I am blue or sad all the time and I can’t snap out of it” and
  • (2b) “I am so sad or unhappy that it is very painful”.

BDI-IA

The BDI-IA was a revision of the original instrument developed by Beck during the 1970s, and copyrighted in 1978. To improve ease of use, the “a and b statements” described above were removed, and respondents were instructed to endorse how they had been feeling during the preceding two weeks. The internal consistency for the BDI-IA was good, with a Cronbach’s alpha coefficient of around 0.85, meaning that the items on the inventory are highly correlated with each other.

However, this version retained some flaws; the BDI-IA only addressed six out of the nine DSM-III criteria for depression. This and other criticisms were addressed in the BDI-II.

BDI-II

The BDI-II was a 1996 revision of the BDI, developed in response to the American Psychiatric Association’s publication of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, which changed many of the diagnostic criteria for Major Depressive Disorder.

Items involving changes in body image, hypochondriasis, and difficulty working were replaced. Also, sleep loss and appetite loss items were revised to assess both increases and decreases in sleep and appetite. All but three of the items were reworded; only the items dealing with feelings of being punished, thoughts about suicide, and interest in sex remained the same. Finally, participants were asked to rate how they have been feeling for the past two weeks, as opposed to the past week as in the original BDI.

Like the BDI, the BDI-II also contains 21 questions, each answer being scored on a scale value of 0 to 3. Higher total scores indicate more severe depressive symptoms. The standardized cutoffs used differ from the original:

  • 0-13: minimal depression.
  • 14-19: mild depression.
  • 20-28: moderate depression.
  • 29-63: severe depression.

One measure of an instrument’s usefulness is to see how closely it agrees with another similar instrument that has been validated against information from a clinical interview by a trained clinician. In this respect, the BDI-II is positively correlated with the Hamilton Depression Rating Scale with a Pearson r of 0.71, showing good agreement. The test was also shown to have a high one-week test–retest reliability (Pearson r =0.93), suggesting that it was not overly sensitive to daily variations in mood. The test also has high internal consistency (α=.91).

Impact

The development of the BDI was an important event in psychiatry and psychology; it represented a shift in health care professionals’ view of depression from a Freudian, psychodynamic perspective, to one guided by the patient’s own thoughts or “cognitions”. It also established the principle that instead of attempting to develop a psychometric tool based on a possibly invalid theory, self-report questionnaires when analysed using techniques such as factor analysis can suggest theoretical constructs.

The BDI was originally developed to provide a quantitative assessment of the intensity of depression. Because it is designed to reflect the depth of depression, it can monitor changes over time and provide an objective measure for judging improvement and the effectiveness or otherwise of treatment methods. The instrument remains widely used in research; in 1998, it had been used in over 2000 empirical studies. It has been translated into multiple European languages as well as Arabic, Chinese, Japanese, Persian, and Xhosa.

Limitations

The BDI suffers from the same problems as other self-report inventories, in that scores can be easily exaggerated or minimized by the person completing them. Like all questionnaires, the way the instrument is administered can have an effect on the final score. If a patient is asked to fill out the form in front of other people in a clinical environment, for instance, social expectations have been shown to elicit a different response compared to administration via a postal survey.

In participants with concomitant physical illness the BDI’s reliance on physical symptoms such as fatigue may artificially inflate scores due to symptoms of the illness, rather than of depression. In an effort to deal with this concern Beck and his colleagues developed the “Beck Depression Inventory for Primary Care” (BDI-PC), a short screening scale consisting of seven items from the BDI-II considered to be independent of physical function. Unlike the standard BDI, the BDI-PC produces only a binary outcome of “not depressed” or “depressed” for patients above a cutoff score of 4.

Although designed as a screening device rather than a diagnostic tool, the BDI is sometimes used by health care providers to reach a quick diagnosis.

The BDI is copyrighted; a fee must be paid for each copy used. There is no evidence that the BDI-II is more valid or reliable than other depression scales, and public domain scales such as the Patient Health Questionnaire – Nine Item (PHQ-9) have been studied as a useful tool.

Refer to Beck Anxiety Inventory, Beck Hopelessness Scale, Major Depression Inventory, and Quality of Life in Depression Scale.

What is Antidepressant Discontinuation Syndrome?

Published on by Andrew Marshall4 Comments

Introduction

Antidepressant discontinuation syndrome, also known as antidepressant withdrawal syndrome, is a condition that can occur following the interruption, reduction, or discontinuation of antidepressant medication that was taken continuously for at least one month. The symptoms may include flu-like symptoms, trouble sleeping, nausea, poor balance, sensory changes, anxiety, and depression. The problem usually begins within three days and may last for several months. Rarely psychosis may occur.

A discontinuation syndrome can occur after stopping any antidepressant including selective serotonin re-uptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs). The risk is greater among those who have taken the medication for longer and when the medication in question has a short half-life. The underlying reason for its occurrence is unclear. The diagnosis is based on the symptoms.

Methods of prevention include gradually decreasing the dose among those who wish to stop, though it is possible for symptoms to occur with tapering. Treatment may include restarting the medication and slowly decreasing the dose. People may also be switched to the long acting antidepressant fluoxetine which can then be gradually decreased.

Approximately 20-50% of people who suddenly stop an antidepressant develop an antidepressant discontinuation syndrome. The condition is generally not serious, though about half of people with symptoms describe them as severe. Some restart antidepressants due to the severity of the symptoms.

Signs and Symptoms

People with antidepressant discontinuation syndrome have been on an antidepressant for at least four weeks and have recently stopped taking the medication, whether abruptly, after a fast taper, or each time the medication is reduced on a slow taper. Commonly reported symptoms include flu-like symptoms (nausea, vomiting, diarrhoea, headaches, sweating) and sleep disturbances (insomnia, nightmares, constant sleepiness). Sensory and movement disturbances have also been reported, including imbalance, tremors, vertigo, dizziness, and electric-shock-like experiences in the brain, often described by people who have them as “brain zaps”. These “brain zaps” are often described as feeling like an unsettling shiver or shock sensation that starts in the head and moves quickly through the entire body. Mood disturbances such as dysphoria, anxiety, or agitation are also reported, as are cognitive disturbances such as confusion and hyperarousal.

In cases associated with sudden discontinuation of MAO inhibitors, acute psychosis has been observed. Over fifty symptoms have been reported.

A 2009 Advisory Committee to the FDA found that online anecdotal reports of discontinuation syndrome related to duloxetine included severe symptoms and exceeded prevalence of both paroxetine and venlafaxine reports by over 250% (although acknowledged this may have been influenced by duloxetine being a much newer drug). It also found that the safety information provided by the manufacturer not only neglected important information about managing discontinuation syndrome, but also explicitly advised against opening capsules, a practice required to gradually taper dosage.

Duration

Most cases of discontinuation syndrome may last between one and four weeks and resolve on their own. Occasionally symptoms can last up to one year. They typically resolve within a day of restoring the medication. Paroxetine and venlafaxine seem to be particularly difficult to discontinue, and prolonged withdrawal syndrome (post-acute-withdrawal syndrome, or PAWS) lasting over 18 months has been reported with paroxetine.

Mechanism

The underlying reason for its occurrence is unclear, though the syndrome appears similar to withdrawal from other psychotropic drugs such as benzodiazepines.

Prevention and Treatment

In some cases, withdrawal symptoms may be prevented by taking medication as directed, and when discontinuing, doing so gradually, although symptoms may appear while tapering. When discontinuing an antidepressant with a short half-life, switching to a drug with a longer half-life (e.g. fluoxetine or citalopram) and then tapering, and eventually discontinuing, from that drug can decrease the severity of symptoms in some cases.

Treatment is dependent on the severity of the discontinuation reaction and whether or not further antidepressant treatment is warranted. In cases where further antidepressant treatment is prescribed, then the only option suggested may be restarting the antidepressant. If antidepressants are no longer required, treatment depends on symptom severity. If symptoms of discontinuation are severe, or do not respond to symptom management, the antidepressant can be reinstated and then withdrawn more cautiously, or by switching to a drug with a longer half life, (such as Prozac), and then tapering and discontinuing that drug. In severe cases, hospitalisation may be required.

Pregnancy and Newborns

Antidepressants, including SSRIs, can cross the placenta and have the potential to affect the foetus and newborn, including an increased chance of miscarriage, presenting a dilemma for pregnant women to decide whether to continue to take antidepressants at all, or if they do, considering if tapering and discontinuing during pregnancy could have a protective effect for the newborn.

Postnatal adaptation syndrome (PNAS) (originally called “neonatal behavioural syndrome”, “poor neonatal adaptation syndrome”, or “neonatal withdrawal syndrome”) was first noticed in 1973 in newborns of mothers taking antidepressants; symptoms in the infant include irritability, rapid breathing, hypothermia, and blood sugar problems. The symptoms usually develop from birth to days after delivery and usually resolve within days or weeks of delivery.

Culture and History

Antidepressant discontinuation symptoms were first reported with imipramine, the first tricyclic antidepressant (TCA), in the late 1950s, and each new class of antidepressants has brought reports of similar conditions, including monoamine oxidase inhibitors (MAOIs), SSRIs, and SNRIs. As of 2001, at least 21 different antidepressants, covering all the major classes, were known to cause discontinuation syndromes. The problem has been poorly studied, and most of the literature has been case reports or small clinical studies; incidence is hard to determine and controversial.

With the explosion of use and interest in SSRIs in the late 1980s and early 1990s, focused especially on Prozac, interest grew as well in discontinuation syndromes. Some of the symptoms emerged from discussion boards where people with depression discussed their experiences with the disease and their medications; “brain zaps” or “brain shivers” was one symptom that emerged via these websites.

Heightened media attention and continuing public concerns led to the formation of an expert group on the safety of selective serotonin reuptake inhibitors in England, to evaluate all the research available prior to 2004. The group determined that the incidence of discontinuation symptoms are between 5% and 49%, depending on the particular SSRI, the length of time on the medicine and abrupt versus gradual cessation.

With the lack of a definition based on consensus criteria for the syndrome, a panel met in Phoenix, Arizona in 1997 to form a draft definition, which other groups continued to refine.

In the late 1990s, some investigators thought that the fact that symptoms emerged when antidepressants were discontinued might mean that antidepressants were causing addiction, and some used the term “withdrawal syndrome” to describe the symptoms. While people taking antidepressants do not commonly exhibit drug-seeking behaviour, stopping antidepressants leads to similar symptoms as found in drug withdrawal from benzodiazapines, and other psychotropic drugs. As such, some researchers advocate the term withdrawal over discontinuation, to communicate the similar physiological dependence and negative outcomes. Due to pressure from pharmaceutical companies who make anti-depressants, the term “withdrawal syndrome” is no longer used by drug makers, and thus, most doctors, due to concerns that they may be compared to other drugs more commonly associated with withdrawal.

2013 Class Action Lawsuit

In 2013, a proposed class action lawsuit, Jennifer L Saavedra v. Eli Lilly and Company, was brought against Eli Lilly claiming that the Cymbalta label omitted important information about “brain zaps” and other symptoms upon cessation. Eli Lilly moved for dismissal per the “learned intermediary doctrine” as the doctors prescribing the drug were warned of the potential problems and are an intermediary medical judgment between Lilly and patients; in December 2013 Lilly’s motion to dismiss was denied.

Research

The mechanisms of antidepressant withdrawal syndrome have not yet been conclusively identified. The leading hypothesis is that after the antidepressant is discontinued, there is a temporary, but in some cases, long-lasting, deficiency in the brain of one or more essential neurotransmitters that regulate mood, such as serotonin, dopamine, norepinephrine, and gamma-aminobutyric acid, and since neurotransmitters are an interrelated system, dysregulation of one affects the others.