Category: Mental Health

What is an Intrusive Thought?

Published on by Andrew Marshall1 Comment

Introduction

An intrusive thought is an unwelcome, involuntary thought, image, or unpleasant idea that may become an obsession, is upsetting or distressing, and can feel difficult to manage or eliminate.

When such thoughts are associated with obsessive-compulsive disorder (OCD), depression, body dysmorphic disorder (BDD), and sometimes attention-deficit hyperactivity disorder (ADHD), the thoughts may become paralysing, anxiety-provoking, or persistent. Intrusive thoughts may also be associated with episodic memory, unwanted worries or memories from OCD, post-traumatic stress disorder, other anxiety disorders, eating disorders, or psychosis. Intrusive thoughts, urges, and images are of inappropriate things at inappropriate times, and generally have aggressive, sexual, or blasphemous themes.

Description

General

Many people experience the type of bad or unwanted thoughts that people with more troubling intrusive thoughts have, but most people can dismiss these thoughts. For most people, intrusive thoughts are a “fleeting annoyance”. Psychologist Stanley Rachman presented a questionnaire to healthy college students and found that virtually all said they had these thoughts from time to time, including thoughts of sexual violence, sexual punishment, “unnatural” sex acts, painful sexual practices, blasphemous or obscene images, thoughts of harming elderly people or someone close to them, violence against animals or towards children, and impulsive or abusive outbursts or utterances. Such thoughts are universal among humans, and have “almost certainly always been a part of the human condition”.

When intrusive thoughts occur with OCD, patients are less able to ignore the unpleasant thoughts and may pay undue attention to them, causing the thoughts to become more frequent and distressing. The suppression of intrusive thoughts often cause these thoughts to become more intense and persistent. The thoughts may become obsessions that are paralysing, severe, and constantly present, these might involve topics such as violence, sex, or religious blasphemy, among others. Distinguishing them from normal intrusive thoughts experienced by many people, the intrusive thoughts associated with OCD may be anxiety provoking, irrepressible, and persistent.

How people react to intrusive thoughts may determine whether these thoughts will become severe, turn into obsessions, or require treatment. Intrusive thoughts can occur with or without compulsions. Carrying out the compulsion reduces the anxiety, but makes the urge to perform the compulsion stronger each time it recurs, reinforcing the intrusive thoughts. According to Lee Baer, suppressing the thoughts only makes them stronger, and recognising that bad thoughts do not signify that one is truly evil is one of the steps to overcoming them. There is evidence of the benefit of acceptance as an alternative to the suppression of intrusive thoughts. In one particular study, those instructed to suppress intrusive thoughts experienced more distress after suppression, while patients instructed to accept the bad thoughts experienced decreased discomfort. These results may be related to underlying cognitive processes involved in OCD. However, accepting the thoughts can be more difficult for persons with OCD.

The possibility that most patients with intrusive thoughts will ever act on those thoughts is low. Patients who are experiencing intense guilt, anxiety, shame, and are upset over these thoughts are very different from those who actually act on them. The fact that someone is tormented by intrusive thoughts and has never acted on them before is considered an excellent predictor that they will not act upon the thoughts. Patients who are not troubled or shamed by their thoughts, do not find them distasteful, or who have actually taken action, might need to have more serious conditions such as psychosis or potentially criminal behaviours ruled out. According to Lee Baer, a patient should be concerned that intrusive thoughts are dangerous if the person does not feel upset by the thoughts, or rather finds them pleasurable; has ever acted on violent or sexual thoughts or urges; hears voices or sees things that others do not see; or feels uncontrollable irresistible anger.

Aggressive Thoughts

Intrusive thoughts may involve violent obsessions about hurting others or themselves. They can be related to primarily obsessional obsessive compulsive disorder. These thoughts can include harming a child; jumping from a bridge, mountain, or the top of a tall building; urges to jump in front of a train or automobile; and urges to push another in front of a train or automobile. Rachman’s survey of healthy college students found that virtually all of them had intrusive thoughts from time to time, including:

  • Causing harm to elderly people.
  • Imagining or wishing harm upon someone close to oneself.
  • Impulses to violently attack, hit, harm or kill a person, small child, or animal.
  • Impulses to shout at or abuse someone, or attack and violently punish someone, or say something rude, inappropriate, nasty, or violent to someone.

These thoughts are part of being human, and need not ruin the quality of life. Treatment is available when the thoughts are associated with OCD and become persistent, severe, or distressing.

A variant of aggressive intrusive thoughts is L’appel du vide, or the call of the void. Those with L’appel du vide generally describe the condition as manifesting in certain situations, normally as a wish or brief desire to jump from a high location.

Sexual Thoughts

Sexual obsession involves intrusive thoughts or images of “kissing, touching, fondling, oral sex, anal sex, intercourse, and rape” with “strangers, acquaintances, parents, children, family members, friends, co-workers, animals and religious figures”, involving “heterosexual or homosexual content” with persons of any age.

Common sexual themes for intrusive thoughts for men involve:

  • Having sex in a public place;
  • People I come in contact with being naked; and
  • Engaging in a sexual act with someone who is unacceptable to me because they have authority over me.

Common sexual intrusive thoughts for women are:

  • Having sex in a public place;
  • Engaging in a sexual act with someone who is unacceptable to me because they have authority over me; and
  • Being sexually victimised.

Like other unwanted intrusive thoughts or images, most people have some inappropriate sexual thoughts at times, but people with OCD may attach significance to the unwanted sexual thoughts, generating anxiety and distress. The doubt that accompanies OCD leads to uncertainty regarding whether one might act on the intrusive thoughts, resulting in self-criticism or loathing.

One of the more common sexual intrusive thoughts occurs when an obsessive person doubts their sexual identity. As in the case of most sexual obsessions, individuals may feel shame and live in isolation, finding it hard to discuss their fears, doubts, and concerns about their sexual identity.

A person experiencing sexual intrusive thoughts may feel shame, “embarrassment, guilt, distress, torment, fear of acting on the thought or perceived impulse, and doubt about whether they have already acted in such a way.” Depression may be a result of the self-loathing that can occur, depending on how much the OCD interferes with daily functioning or causes distress. Their concern over these thoughts may cause them to scrutinize their bodies to determine if the thoughts result in feelings of arousal. However, focusing their attention on any part of the body can result in feelings in that body part, hence doing so may decrease confidence and increase fear about acting on the urges. Part of the treatment of sexual intrusive thoughts involves therapy to help them accept intrusive thoughts and stop trying to reassure themselves by checking their bodies. This arousal within the body parts is due to conditioned physiological responses in the brain, which do not respond to the subject of the sexual intrusive thought but rather to the fact that a sexual thought is occurring at all and thus engage an automatic response (research indicates that the correlation between what the genitalia regard as “sexually relevant” and what the brain regards as “sexually appealing” only correlates 50% of the time in men and 10% of the time in women). This means that an arousal response does not necessarily indicate that the person desires what they are thinking about. However, rational thinking processes attempt to explain this reaction and OCD causes people to attribute false meaning and importance to these physiological reactions in an attempt to make sense of them. People can also experience heightened anxiety caused by forbidden images or simply by discussing the matter which can then also cause physiological arousal, such as sweating, increased heart rate and some degree of tumescence or lubrication. This is often misinterpreted by the individual as an indication of desire or intent, when it is in fact not.

Religious Thoughts

Blasphemous thoughts are a common component of OCD, documented throughout history; notable religious figures such as Martin Luther and Ignatius of Loyola were known to be tormented by intrusive, blasphemous or religious thoughts and urges. Martin Luther had urges to curse God and Jesus, and was obsessed with images of “the Devil’s behind.” St. Ignatius had numerous obsessions, including the fear of stepping on pieces of straw forming a cross, fearing that it showed disrespect to Christ. A study of 50 patients with a primary diagnosis of OCD found that 40% had religious and blasphemous thoughts and doubts – a higher, but not statistically significantly different number than the 38% who had the obsessional thoughts related to dirt and contamination more commonly associated with OCD. One study suggests that the content of intrusive thoughts may vary depending on culture, and that blasphemous thoughts may be more common in men than in women.

According to Fred Penzel, a New York psychologist, some common religious obsessions and intrusive thoughts are:

  • Sexual thoughts about God, saints, and religious figures.
  • Bad thoughts or images during prayer or meditation.
  • Thoughts of being possessed.
  • Fears of sinning or breaking a religious law or performing a ritual incorrectly.
  • Fears of omitting prayers or reciting them incorrectly.
  • Repetitive and intrusive blasphemous thoughts.
  • Urges or impulses to say blasphemous words or commit blasphemous acts during religious services.

Suffering can be greater and treatment complicated when intrusive thoughts involve religious implications; patients may believe the thoughts are inspired by Satan, and may fear punishment from God or have magnified shame because they perceive themselves as sinful. Symptoms can be more distressing for individuals with strong religious convictions or beliefs.

Baer believes that blasphemous thoughts are more common in Catholics and evangelical Protestants than in other religions, whereas Jews or Muslims tend to have obsessions related more to complying with the laws and rituals of their faith, and performing the rituals perfectly. He hypothesizes that this is because what is considered inappropriate varies among cultures and religions, and intrusive thoughts torment their sufferers with whatever is considered most inappropriate in the surrounding culture.

Age Factors

Adults under the age of 40 seem to be the most affected by intrusive thoughts. Individuals in this age range tend to be less experienced at coping with these thoughts, and the stress and negative affect induced by them. Younger adults also tend to have stressors specific to that period of life that can be particularly challenging especially in the face of intrusive thoughts. Although, when introduced with an intrusive thought, both age groups immediately look for ways to reduce the recurrence of the thoughts.

Those in middle adulthood (40-60) have the highest prevalence of OCD and therefore seem to be the most susceptible to the anxiety and negative emotions associated with intrusive thought. Middle adults are in a unique position because they have to struggle with both the stressors of early and late adulthood. They may be more vulnerable to intrusive thought because they have more topics to relate to. Even with this being the case, middle adults are still better at coping with intrusive thoughts than early adults, although it takes them longer at first to process an intrusive thought. Older adults tend to see the intrusive thought more as a cognitive failure rather than a moral failure in opposition to young adults. They have a harder time suppressing the intrusive thoughts than young adults causing them to experience higher stress levels when dealing with these thoughts.

Intrusive thoughts appear to occur at the same rate across the lifespan, however, older adults seem to be less negatively affected than younger adults. Older adults have more experience in ignoring or suppressing strong negative reactions to stress.

Associated Conditions

Intrusive thoughts are associated with OCD or OCPD, but may also occur with other conditions such as:

  • Post-traumatic stress disorder (PTSD).
  • Clinical depression.
  • Postpartum depression.
  • Generalised anxiety disorder and anxiety.

One of these conditions is almost always present in people whose intrusive thoughts reach a clinical level of severity. A large study published in 2005 found that aggressive, sexual, and religious obsessions were broadly associated with comorbid anxiety disorders and depression. The intrusive thoughts that occur in a schizophrenic episode differ from the obsessional thoughts that occur with OCD or depression in that the intrusive thoughts of people with schizophrenia are false or delusional beliefs (i.e. held by the schizophrenic individual to be real and not doubted, as is typically the case with intrusive thoughts) .

Post-Traumatic Stress Disorder

The key difference between OCD and post-traumatic stress disorder (PTSD) is that the intrusive thoughts of people with PTSD are of content relating to traumatic events that actually happened to them, whereas people with OCD have thoughts of imagined catastrophes. PTSD patients with intrusive thoughts have to sort out violent, sexual, or blasphemous thoughts from memories of traumatic experiences.[48] When patients with intrusive thoughts do not respond to treatment, physicians may suspect past physical, emotional, or sexual abuse. If a person who has experienced trauma practices looks for the positive outcomes, it is suggested they will experience less depression and higher self well-being. While a person may experience less depression for benefit finding, they may also experience an increased amount of intrusive and/or avoidant thoughts.

One study looking at women with PTSD found that intrusive thoughts were more persistent when the individual tried to cope by using avoidance-based thought regulation strategies. Their findings further support that not all coping strategies are helpful in diminishing the frequency of intrusive thoughts.

Depression

People who are clinically depressed may experience intrusive thoughts more intensely, and view them as evidence that they are worthless or sinful people. The suicidal thoughts that are common in depression must be distinguished from intrusive thoughts, because suicidal thoughts – unlike harmless sexual, aggressive, or religious thoughts – can be dangerous.

Non-depressed individuals have been shown to have a higher activation in the dorsolateral prefrontal cortex, which is the area of the brain that primarily functions in cognition, working memory, and planning, while attempting to suppress intrusive thoughts. This activation decreases in people at risk of or currently diagnosed with depression. When the intrusive thoughts re-emerge, non depressed individuals also show higher activation levels in the anterior cingulate cortices, which functions in error detection, motivation, and emotional regulation, than their depressed counterparts.

Roughly 60% of depressed individuals report experiencing bodily, visual, or auditory perceptions along with their intrusive thoughts. There is a correlation with experiencing those sensations with intrusive thoughts and more intense depressive symptoms as well as the need for heavier treatment.

Postpartum Depression and OCD

Unwanted thoughts by mothers about harming infants are common in postpartum depression. A 1999 study of 65 women with postpartum major depression by Katherine Wisner et al. found the most frequent aggressive thought for women with postpartum depression was causing harm to their newborn infants. A study of 85 new parents found that 89% experienced intrusive images, for example, of the baby suffocating, having an accident, being harmed, or being kidnapped.

Some women may develop symptoms of OCD during pregnancy or the postpartum period. Postpartum OCD occurs mainly in women who may already have OCD, perhaps in a mild or undiagnosed form. Postpartum depression and OCD may be comorbid (often occurring together). And though physicians may focus more on the depressive symptoms, one study found that obsessive thoughts did accompany postpartum depression in 57% of new mothers.

Wisner found common obsessions about harming babies in mothers experiencing postpartum depression include images of the baby lying dead in a casket or being eaten by sharks; stabbing the baby; throwing the baby down the stairs; or drowning or burning the baby (as by submerging it in the bathtub in the former case or throwing it in the fire or putting it in the microwave in the latter). Baer estimates that up to 200,000 new mothers with postpartum depression each year may develop these obsessional thoughts about their babies; and because they may be reluctant to share these thoughts with a physician or family member, or suffer in silence out of fear they could be “crazy”, their depression can worsen.

Intrusive fears of harming immediate children can last longer than the postpartum period. A study of 100 clinically depressed women found that 41% had obsessive fears that they might harm their child, and some were afraid to care for their children. Among non-depressed mothers, the study found 7% had thoughts of harming their child – a rate that yields an additional 280,000 non-depressed mothers in the United States with intrusive thoughts about harming their children.

Treatment

Treatment for intrusive thoughts is similar to treatment for OCD. Exposure and response prevention therapy – also referred to as habituation or desensitisation – is useful in treating intrusive thoughts. Mild cases can also be treated with cognitive behavioural therapy, which helps patients identify and manage the unwanted thoughts.

Exposure Therapy

Exposure therapy is the treatment of choice for intrusive thoughts. According to Deborah Osgood-Hynes, Psy.D. Director of Psychological Services and Training at the MGH/McLean OCD Institute, “In order to reduce a fear, you have to face a fear. This is true of all types of anxiety and fear reactions, not just OCD.” Because it is uncomfortable to experience bad thoughts and urges, shame, doubt or fear, the initial reaction is usually to do something to make the feelings diminish. By engaging in a ritual or compulsion to diminish the anxiety or bad feeling, the action is strengthened via a process called negative reinforcement – the mind learns that the way to avoid the bad feeling is by engaging in a ritual or compulsions. When OCD becomes severe, this leads to more interference in life and continues the frequency and severity of the thoughts the person sought to avoid.

Exposure therapy (or exposure and response prevention) is the practice of staying in an anxiety-provoking or feared situation until the distress or anxiety diminishes. The goal is to reduce the fear reaction, learning to not react to the bad thoughts. This is the most effective way to reduce the frequency and severity of the intrusive thoughts. The goal is to be able to “expose yourself to the thing that most triggers your fear or discomfort for one to two hours at a time, without leaving the situation, or doing anything else to distract or comfort you.” Exposure therapy will not eliminate intrusive thoughts – everyone has bad thoughts – but most patients find that it can decrease their thoughts sufficiently that intrusive thoughts no longer interfere with their lives.

Cognitive Behavioural Therapy

Cognitive behavioural therapy (CBT) is a newer therapy than exposure therapy, available for those unable or unwilling to undergo exposure therapy. Cognitive therapy has been shown to be useful in reducing intrusive thoughts, but developing a conceptualisation of the obsessions and compulsions with the patient is important. One of the strategies sometimes used in Cognitive Behavioural Theory is mindfulness exercises. These include practices such as being aware of the thoughts, accepting the thoughts without judgement for them, and “being larger than your thoughts.”

Medication

Antidepressants or antipsychotic medications may be used for more severe cases if intrusive thoughts do not respond to cognitive behavioural or exposure therapy alone. Whether the cause of intrusive thoughts is OCD, depression, or PTSD, the selective serotonin reuptake inhibitor (SSRI) drugs (a class of antidepressants) are the most commonly prescribed. Intrusive thoughts may occur in persons with Tourette syndrome (TS) who also have OCD; the obsessions in TS-related OCD are thought to respond to SSRI drugs as well.

Antidepressants that have been shown to be effective in treating OCD include fluvoxamine (trade name Luvox), fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and clomipramine (Anafranil). Although SSRIs are known to be effective for OCD in general, there have been fewer studies on their effectiveness for intrusive thoughts. A retrospective chart review of patients with sexual symptoms treated with SSRIs showed the greatest improvement was in those with intrusive sexual obsessions typical of OCD. A study of ten patients with religious or blasphemous obsessions found that most patients responded to treatment with fluoxetine or clomipramine. Women with postpartum depression often have anxiety as well, and may need lower starting doses of SSRIs; they may not respond fully to the medication, and may benefit from adding cognitive behavioural or response prevention therapy.

Patients with intense intrusive thoughts that do not respond to SSRIs or other antidepressants may be prescribed typical and atypical neuroleptics including risperidone (trade name Risperdal), ziprasidone (Geodon), haloperidol (Haldol), and pimozide (Orap).

Studies suggest that therapeutic doses of inositol may be useful in the treatment of obsessive thoughts.

Epidemiology

A 2007 study found that 78% of a clinical sample of OCD patients had intrusive images. Most people with intrusive thoughts have not identified themselves as having OCD, because they may not have what they believe to be classic symptoms of OCD, such as handwashing. Yet, epidemiological studies suggest that intrusive thoughts are the most common kind of OCD worldwide; if people in the United States with intrusive thoughts gathered, they would form the fourth-largest city in the US, following New York City, Los Angeles, and Chicago.

The prevalence of OCD in every culture studied is at least 2% of the population, and the majority of those have obsessions, or bad thoughts, only; this results in a conservative estimate of more than 2 million affected individuals in the United States alone (as of 2000). One author estimates that one in 50 adults have OCD and about 10-20% of these have sexual obsessions. A recent study found that 25% of 293 patients with a primary diagnosis of OCD had a history of sexual obsessions.

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What is the European Psychologist?

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Introduction

European Psychologist is a quarterly peer-reviewed academic journal within the field of psychology.

Background

The journal was established in 1996 as the official organ of the European Federation of Psychologists’ Associations, and is published by Hogrefe Publishing. The editor-in-chief is Peter Frensch, of the Humboldt-Universität zu Berlin (English: Humboldt University of Berlin).

European Psychologist seeks to integrate across all specialisations in psychology and to provide a general platform for communication and cooperation among psychologists throughout Europe and worldwide. Integrative articles and reviews constitute the core material published in the journal. These state-of-the-art papers cover research trends and developments within psychology, with possible reference to European perceptions or fields of specialisation. Empirical articles will be considered only in rare circumstances when they present findings from major multinational, multidisciplinary or longitudinal studies, or present results with markedly wide relevance.

Abstracting and Indexing

European Psychologist is abstracted and indexed in Current Contents/Social and Behavioural Sciences, Social Sciences Citation Index, PsycINFO, PASCAL, and Scopus. According to the Journal Citation Reports, the journal has a 2016 (two-year) impact factor of 3.419.

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What is the Boston Graduate School of Psychoanalysis?

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Introduction

Boston Graduate School of Psychoanalysis is a private educational institution that focuses on training psychoanalysts, particularly in the field of modern psychoanalysis.

Founded in 1973, it only awards graduate degrees. Its main campus is in Brookline, Massachusetts.

Accreditation

The Boston Graduate School of Psychoanalysis, including its branch campus in New York, is accredited by the New England Association of Schools and Colleges, Inc. through its Commission on Institutions of Higher Education. It first received accreditation from the New England Association of Schools and Colleges (NEASC) in 1995, which opened psychoanalytic study to any qualified and engaged student irrespective of prior courses of study.

The school is the only regionally accredited school of psychoanalytic studies in the United States to grant graduate degrees.

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What is Defined Daily Dose?

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Introduction

The defined daily dose (DDD) is a statistical measure of drug consumption, defined by the World Health Organisation (WHO) Collaborating Centre for Drug Statistics Methodology (WHOCC).

It is defined in combination with the ATC Code drug classification system for grouping related drugs. The DDD enables comparison of drug usage between different drugs in the same group or between different health care environments, or to look at trends in drug utilisation over time. The DDD is not to be confused with the therapeutic dose or prescribed daily dose (PDD), or recorded daily dose (RDD), and will often be different to the dose actually prescribed by a physician for an individual person.

The WHO’s definition is: “The DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults.” The Defined Daily Dose was first developed in the late 1970s.

Refer to Prescribed Daily Dose, Average Daily Quantity, and Maintenance Dose.

Assignment

Before a DDD is assigned by the WHOCC, it must have an ATC Code and be approved for sale in at least one country. The DDD is calculated for a 70kg adult, except if this drug is only ever used in children. The dose is based on recommendations for treatment rather than prevention, except if prevention is the main indication. Generally there is only one DDD for all formulations of a drug, however exceptions are made if some formulations are typically used in significantly different strengths (e.g. antibiotic injection in a hospital vs tablets in the community). The DDD of combination tablets (containing more than one drug) is more complex, most taking into account a “unit dose”, though combination tablets used for high blood pressure take the number of doses per day into account.

The formula for determining the dose is:

  • If there is a single recommended maintenance dose in the literature, this is preferred.
  • :If there are a range of recommended maintenance doses then
    • If the literature recommends generally increasing from initial to maximum dose provided it is tolerated, pick the maximum dose.
    • If the literature recommends only increasing from an initial dose if not sufficiently effective, pick the minimum dose.
    • If there is no guidance then pick the mid point between the dose range extremes.

The DDD of a drug is reviewed after three years. Ad hoc requests for change may be made but are discouraged and generally not permitted unless the main indication for the drug has changed or the average dose used has changed by more than 50%.

Limitations

The DDD is generally the same for all formulations of a drug, even if some (e.g. flavoured syrup) are designed with children in mind. Some types of drug are not assigned a DDD, for example: medicines applied to the skin, anaesthetics and vaccines. Because the DDD is a calculated value, it is sometimes a “dose” not actually ever prescribed (e.g. a midpoint of two prescribed tablet strengths may not be equal to or be a multiple of any available tablet). Different people may in practice be prescribed higher or lower doses than the DDD, for instance in children, people with liver or kidney impairment, patients with a combination therapy, or due to differences in drug metabolism between individuals or ethnicities (genetic polymorphism).

Although designed primarily for drug utilisation research, data using the DDD can only give a “rough estimate” compared with actually collecting statistics on drug use in practice. The DDD is often use for long term research and analysis of drug utilisation trends over time, so changes to the DDD are avoided if possible, whereas changes in the actual daily dose prescribed for a population may often occur. For example, the Recorded Daily Dose (RDD) of simvastatin in Canada in 1997 was only 8% different to the DDD, but by 2006 it was 67% different. In 2009, the DDD of several statins were updated, with simvastatin changing from 15mg to 30mg.

The DDD is based on the maintenance dose, but in practice patients in a population will be on a mix of initial and maintenance doses.

Use and Misuse

The DDD can be used as the basis for calculating various indicators of drug utilisation. The indicator DDD per 1000 inhabitants per day can suggest what portion of a population are regularly using a drug or class of drugs. The indicator DDD per 100 bed days estimates on average how many inpatients are given a drug every day in hospital. The indicator DDDs per inhabitant per year can be used for drugs normally prescribed for short treatment duration (e.g. antibiotics) to indicate the average number of days in a year a person may take that treatment. The extent to which estimates using DDD reflect actual clinical practice depends on how close the DDD is to the typical prescribed dose in that country or setting and at that point in history.

Because the primary purpose of the ATC/DDD system is drug consumption measurement, the WHO recommend caution when considering its use for cost analysis: “DDDs, if used with caution can be used to compare, for example, the costs of two formulations of the same drug.” So, the cost per DDD of an extended-release tablet taken once a day compared with a standard tablet taken twice a day, may indicate the extended-release tablet costs much more to treat the same condition.

In contrast, using DDD to compare the cost of different drugs or drug groups is “usually not valid” according to the WHO. They recommend that “DDDs are not suitable for comparing drugs for specific, detailed pricing, reimbursement and cost-containment decisions”. The DDD may not necessarily compare well with the actual PDD, and two drugs in the same ATC group may not be equally effective at their DDD.

For example, an analysis of statin use in the Ontario Drug Benefit Programme, 2006-2007. The average cost per DDD of rosuvastatin was 21% more expensive than atorvastatin ($1.14 compared to $0.94), which would suggest the shift at the time from prescribing atorvastatin to prescribing rosuvastatin would result in increased costs to the healthcare budget. Both had a DDD at that time of 10mg, but 10mg was not the only dose prescribed. For example, atorvastatin once daily at 10mg, 20mg, 40mg and 80mg was prescribed 45%, 36%, 16% and 3% of the time respectively. If one compared cost per unit (daily tablet) then rosuvastatin was instead 24% cheaper than atorvastatin ($1.44 vs $1.90), and if one compares cost per RDD (recorded daily dose) then rosuvastatin was 26% cheaper than atorvastatin ($1.43 vs $1.93). An erroneous conclusion of a healthcare budget cost increase arises in this case from using cost per DDD. At the time, the RDD of rosuvastatin was similar to its DDD (12.6 mg vs 10mg), but the RDD of atorvastatin was twice its DDD (20.6 mg vs 10mg). The DDD of atorvastatin was revised in 2009 to 20mg.

The Canadian Patented Medicine Prices Review Board analysed the use of DDD for drug utilisation and cost analysis and offered recommendations. They particularly concentrated on the problems that occur when the RDD observed in the population deviates more than minimally from the DDD. They conclude that the DDD methodology “should generally not be used to interpret Canadian drug utilisation; should generally not be applied in cost analyses; and should generally not be applied in policy decisions”. The Board recommend that provided the agreement between DDD and RDD is known and minimal, then a cost per DDD “can provide a rough idea of the treatment cost” but “caution should still be used, as misinterpretation of the results based on the DDD methodology may still occur”. If the agreement between DDD and RDD is unknown or a significant disagreement is known, then the DDD methodology “should not be used in cost analyses”. In all cases, the Board state “The DDD methodology should not be used in guiding policy decisions regarding reimbursement, therapeutic substitution and other pricing decisions”.

Example

If the DDD for a certain drug is given, the number of DDDs used by an individual patient or (more commonly) by a collective of patients is as follows.

Drug usage (in DDDs) = (Items issued x Amount of drug per item) divided by DDD.

For example, the analgesic (pain reliever) paracetamol has a DDD of 3 g, which means that an average patient who takes paracetamol for its main indication, which is pain relief, uses 3 grams per day. This is equivalent to six standard tablets of 500 mg each. If a patient consumes 24 such tablets (12 g of paracetamol in total) over a certain span of time, this equals a consumption of four DDDs.

Drug usage in DDDs = (24 (items) x 500 (mg/item)) divided by 3000 mg = 4

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What is the Anatomical Therapeutic Chemical Classification System?

Published on by Andrew Marshall3 Comments

Introduction

The Anatomical Therapeutic Chemical (ATC) Classification System is a drug classification system that classifies the active ingredients of drugs according to the organ or system on which they act and their therapeutic, pharmacological and chemical properties.

Its purpose is an aid to monitor drug use and for research to improve quality medication use. It does not imply drug recommendation or efficacy. It is controlled by the World Health Organisation Collaborating Centre for Drug Statistics Methodology (WHOCC), and was first published in 1976.

Brief History

The ATC system is based on the earlier Anatomical Classification System, which is intended as a tool for the pharmaceutical industry to classify pharmaceutical products (as opposed to their active ingredients). This system, confusingly also called ATC, was initiated in 1971 by the European Pharmaceutical Market Research Association (EphMRA) and is being maintained by the EphMRA and Intellus. Its codes are organised into four levels. The WHO’s system, having five levels, is an extension and modification of the EphMRA’s. It was first published in 1976.

Coding System

This pharmaceutical coding system divides drugs into different groups according to the organ or system on which they act, their therapeutic intent or nature, and the drug’s chemical characteristics. Different brands share the same code if they have the same active substance and indications. Each bottom-level ATC code stands for a pharmaceutically used substance, or a combination of substances, in a single indication (or use). This means that one drug can have more than one code, for example acetylsalicylic acid (aspirin) has A01AD05 (WHO) as a drug for local oral treatment, B01AC06 (WHO) as a platelet inhibitor, and N02BA01 (WHO) as an analgesic and antipyretic; as well as one code can represent more than one active ingredient, for example C09BB04 (WHO) is the combination of perindopril with amlodipine, two active ingredients that have their own codes (C09AA04 (WHO) and C08CA01 (WHO) respectively) when prescribed alone.

The ATC classification system is a strict hierarchy, meaning that each code necessarily has one and only one parent code, except for the 14 codes at the topmost level which have no parents. The codes are semantic identifiers, meaning they depict information by themselves beyond serving as identifiers (namely, the codes depict themselves the complete lineage of parenthood). As of 07 May 2020, there are 6,331 codes in ATC; the table below gives the count per level.

ATC LevelCodesDifferent Names/Pharmaceuticals
11414
29494
3267262
4889819
550674363

Classification

In this system, drugs are classified into groups at five different levels.

First Level

The first level of the code indicates the anatomical main group and consists of one letter. There are 14 main groups:

CodeContents
AAlimentary tract and metabolism
BBlood and blood forming organs
CCardiovascular system
DDermatologicals
GGenito-urinary system and sex hormones
HSystemic hormonal preparations, excluding se hormones and insulins
JAnti-infectives for systemic use
LAntineoplastic and immunomodulating agents
MMusculo-skeletal system
NNervous system
PAntiparasitic products, insecticides, and repellents
RRespiratory system
SSensory organs
VVarious

Second Level

The second level of the code indicates the therapeutic subgroup and consists of two digits.

  • Example: C03 Diuretics.

Third Level

The third level of the code indicates the therapeutic/pharmacological subgroup and consists of one letter.

  • Example: C03C High-ceiling diuretics.

Fourth Level

The fourth level of the code indicates the chemical/therapeutic/pharmacological subgroup and consists of one letter.

  • Example: C03CA Sulfonamides.

Fifth Level

The fifth level of the code indicates the chemical substance and consists of two digits.

  • Example: C03CA01 furosemide.

Other ATC Classification Systems

ATCvet

The Anatomical Therapeutic Chemical Classification System for veterinary medicinal products (ATCvet) is used to classify veterinary drugs. ATCvet codes can be created by placing the letter Q in front of the ATC code of most human medications.

  • For example, furosemide for veterinary use has the code QC03CA01.

Some codes are used exclusively for veterinary drugs, such as QI Immunologicals, QJ51 Antibacterials for intramammary use or QN05AX90 amperozide.

Herbal ATC (HATC)

The Herbal ATC system (HATC) is an ATC classification of herbal substances; it differs from the regular ATC system by using 4 digits instead of 2 at the 5th level group.

The herbal classification is not adopted by WHO. The Uppsala Monitoring Centre is responsible for the Herbal ATC classification, and it is part of the WHODrug Global portfolio available by subscription.

Defined Daily Dose

The ATC system also includes defined daily doses (DDDs) for many drugs. This is a measurement of drug consumption based on the usual daily dose for a given drug. According to the definition, “[t]he DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults.”

Adaptations and Updates

National issues of the ATC classification, such as the German Anatomisch-therapeutisch-chemische Klassifikation mit Tagesdosen, may include additional codes and DDDs not present in the WHO version.

ATC follows guidelines in creating new codes for newly approved drugs. An application is submitted to WHO for ATC classification and DDD assignment. A preliminary or temporary code is assigned and published on the website and in the WHO Drug Information for comment or objection. New ATC/DDD codes are discussed at the semi-annual Working Group meeting. If accepted it becomes a final decision and published semi-annually on the website and WHO Drug Information and implemented in the annual print/on-line ACT/DDD Index on 01 January.

Changes to existing ATC/DDD follow a similar process to become temporary codes and if accepted become a final decision as ATC/DDD alterations. ATC and DDD alterations are only valid and implemented in the coming annual updates; the original codes must continue until the end of the year.

An updated version of the complete on-line/print ATC index with DDDs is published annually on 01 January.

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What is Anal Retentiveness?

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Introduction

An anal retentive person is a person who pays such attention to detail that it becomes an obsession and may be an annoyance to others.

The term derives from Freudian psychoanalysis.

Origins

In Freudian psychology, the anal stage is said to follow the oral stage of infant or early-childhood development. This is a time when an infant’s attention moves from oral stimulation to anal stimulation (usually the bowels but occasionally the bladder), usually synchronous with learning to control its excretory functions – in other words, any form of child training and not specifically linked to toilet training. Freud posited that children who experience conflicts, in which libido energy is under-indulged during this period of time, and the child is perhaps too strongly chastised for toilet-training accidents, may develop “anal retentive” fixations or personality traits. These traits are associated with a child’s efforts at excretory control: orderliness, stubbornness, and compulsions for control. Conversely, those who are overindulged during this period may develop “anal-expulsive” personality types.

Influence and Refutation

Freud’s theories on early childhood have been influential on the psychological community; the phrase anal retentive and the term anal survive in common usage. The second edition of the Diagnostic and Statistical Manual (DSM-II) introduced obsessive-compulsive personality disorder (OCPD), with a definition based on Freud’s description of anal-retentive personality. But the association between OCPD and toilet training is largely regarded as unsupported “pop-psychology” and therefore discredited by the majority of psychologists of the late 20th and early 21st centuries. There is no conclusive research linking anal stage conflicts with “anal” personality types.

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What is the Pollyanna Principle?

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Introduction

The Pollyanna principle (also called Pollyannaism or positivity bias) is the tendency for people to remember pleasant items more accurately than unpleasant ones.

Research indicates that at the subconscious level, the mind tends to focus on the optimistic; while at the conscious level, it tends to focus on the negative. This subconscious bias is similar to the Barnum effect.

What is the Barnum Effect?

The Barnum effect, also called the Forer effect or, less commonly, the Barnum-Forer effect, is a common psychological phenomenon whereby individuals give high accuracy ratings to descriptions of their personality that supposedly are tailored specifically to them, yet which are in fact vague and general enough to apply to a wide range of people.

Development

The name derives from the 1913 novel Pollyanna by Eleanor H. Porter describing a girl who plays the “glad game” – trying to find something to be glad about in every situation. The novel has been adapted to film several times, most famously in 1920 and 1960. An early use of the name “Pollyanna” in psychological literature was in 1969 by Boucher and Osgood who described a Pollyanna hypothesis as a universal human tendency to use positive words more frequently and diversely than negative words in communicating. Empirical evidence for this tendency has been provided by computational analyses of large corpora of text.

The story of Pollyanna is about an orphaned little girl, who is sent to live with her Aunt Polly, who is known for being stiff, strict, and proper. When thrown into this environment, Pollyanna seeks to keep and spread her optimism to others. This beloved literary character’s story shares the message that despite how hard things may seem, a sunny disposition can turn anyone and anything around.

Psychological Research and Findings

The Pollyanna principle was described by Margaret Matlin and David Stang in 1978 using the archetype of Pollyanna more specifically as a psychological principle which portrays the positive bias people have when thinking of the past (aka nostalgia). According to the Pollyanna principle, the brain processes information that is pleasing and agreeable in a more precise and exact manner as compared to unpleasant information. We actually tend to remember past experiences as more rosy than they actually occurred. The researchers found that people expose themselves to positive stimuli and avoid negative stimuli, they take longer to recognise what is unpleasant or threatening than what is pleasant and safe, and they report that they encounter positive stimuli more frequently than they actually do. Matlin and Stang also determined that selective recall was a more likely occurrence when recall was delayed: the longer the delay, the more selective recall that occurred.

The Pollyanna principle has been observed on online social networks as well. For example, Twitter users preferentially share more, and are emotionally affected more frequently by, positive information.

However, the only exception to the Pollyanna principle tends to be individuals suffering from depression or anxiety, who are more likely to either have more depressive realism or a negative bias.

Positivity Bias

Positivity bias is the part of the Pollyanna principle that attributes reasons to why people may choose positivity over negative or realistic mindsets. In positive psychology, it is broken down into three ideas: positive illusions, self deception, and optimism. Having a positive bias increases with age, as it is more prevalent in adults approaching older adulthood than younger children or adolescents. Older adults tend to pay attention to positive information, and this could be due to a specific focus in cognitive processing. In studies compiled by Andrew Reed and Laura Carstensen, they found that older adults (in comparison to younger adults) purposefully directed their attention away from negative material.

Criticisms

Although the Pollyanna principle can be seen as helpful in some situations, some psychologists say it may inhibit an individual from coping effectively with life obstacles. The Pollyanna principle in some instances can be known as “Pollyanna syndrome” and is defined by such sceptics as a person who is excessively positive and blind towards the negative or real. In regards to therapy or counselling, it is viewed as dangerous to both the therapist and patient.

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What is a Self-Report Inventory?

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Introduction

A self-report inventory is a type of psychological test in which a person fills out a survey or questionnaire with or without the help of an investigator.

Self-report inventories often ask direct questions about personal interests, values, symptoms, behaviours, and traits or personality types. Inventories are different from tests in that there is no objectively correct answer; responses are based on opinions and subjective perceptions. Most self-report inventories are brief and can be taken or administered within five to 15 minutes, although some, such as the Minnesota Multiphasic Personality Inventory (MMPI), can take several hours to fully complete. They are popular because they can be inexpensive to give and to score, and their scores can often show good reliability.

There are three major approaches to developing self-report inventories:

  • Theory-guided inventories are constructed around a theory of personality or a prototype of a construct.
  • Factor analysis uses statistical methods to organize groups of related items into subscales.
  • Criterion-keyed inventories include questions that have been shown to statistically discriminate between a comparison group and a criterion group, such as people with clinical diagnoses of depression versus a control group.

Items may use any of several formats: a Likert scale with ranked options, true-false, or forced choice, although other formats such as sentence completion or visual analogue scales are possible. True-false involves questions that the individual denotes as either being true or false about themselves. Forced-choice is a set of statements that require the individual to choose one as being most representative of themselves.

If the inventory includes items from different factors or constructs, the items can be mixed together or kept in groups. Sometimes the way people answer the item will change depending on the context offered by the neighbouring items.

Personality Inventories

Self-report personality inventories include questions dealing with behaviours, responses to situations, characteristic thoughts and beliefs, habits, symptoms, and feelings. Test-takers-are usually asked to indicate how well each item describes themselves or how much they agree with each item. Formats are varied, from adjectives such as “warm”, to sentences such as “I like parties”, or reports of behaviour “I have driven past the speed limit” and response formats from yes/no to Likert scales, to continuous “slider” responses. Some inventories are global, such as the NEO, others focus on particular domains, such as anger or aggression.

Problems

Unlike IQ tests where there are correct answers that have to be worked out by test takers, for personality, attempts by test-takers to gain particular scores are an issue in applied testing. Test items are often transparent, and people may “figure out” how to respond to make themselves appear to possess whatever qualities they think an organisation wants. In addition, people may falsify good responses, be biased towards their positive characteristics, or falsify bad, stressing negative characteristics, in order to obtain their preferred outcome. In clinical settings patients may exaggerate symptoms in order to make their situation seem worse, or under-report the severity or frequency of symptoms in order to minimise their problems. For this reason, self-report inventories are not used in isolation to diagnose a mental disorder, often used as screeners for verification by other assessment data. Many personality tests, such as the MMPI or the MBTI add questions that are designed to make it difficult for a person to exaggerate traits and symptoms. They are in common use for measuring levels of traits, or for symptom severity and change. Clinical discretion is advised for all self-report inventories.

Items may differ in social desirability, which can cause different scores for people at the same level of a trait, but differing in their desire to appear to possess socially desirable behaviours.

Popular Self-Report Inventories

  • 16 PF.
  • Beck Anxiety Inventory.
  • Beck Depression Inventory.
  • Beck Hopelessness Scale.
  • California Psychological Inventory (CPI).
  • CORE-OM.
  • Eysenck Personality Questionnaire (EPQ-R).
  • Geriatric Depression Scale.
  • Major Depression Inventory.
  • Minnesota Multiphasic Personality Inventory.
  • Myers-Briggs Type Indicator.
  • NEO Personality Inventory (NEO-PI-3).
  • Outcome Questionnaire 45.
  • PSYCHLOPS.
  • State-Trait Anxiety Inventory.

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What is the Substance Abuse and Mental Health Services Administration?

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Introduction

The Substance Abuse and Mental Health Services Administration (SAMHSA) is a branch of the US Department of Health and Human Services.

It is charged with improving the quality and availability of treatment and rehabilitative services in order to reduce illness, death, disability, and the cost to society resulting from substance abuse and mental illnesses. The Administrator of SAMHSA reports directly to the Secretary of the US Department of Health and Human Services. SAMHSA’s headquarters building is located outside of Rockville, Maryland.

Brief History

SAMHSA was established in 1992 by Congress as part of a reorganisation stemming from the abolition of Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA). ADAMHA had been established in 1973, combining the National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute on Drug Abuse (NIDA), National Institute of Mental Health (NIMH). The 1992 ADAMHA Reorganisation Act consolidated the treatment functions that were previously scattered amongst the NIMH, NIAAA, and NIDA into SAMHSA, established as an agency of the Public Health Service (PHS). NIMH, NIAAA, and NIDA continued with their research functions as agencies within the National Institutes of Health.

Congress directed SAMHSA to target effectively substance abuse and mental health services to the people most in need and to translate research in these areas more effectively and rapidly into the general health care system.

Charles Curie was SAMHSA’s Director until his resignation in May 2006. In December 2006 Terry Cline was appointed as SAMHSA’s Director. Dr. Cline served through August 2008. Rear Admiral Eric Broderick served as the Acting Director upon Dr. Cline’s departure, until the arrival of the succeeding Administrator, Pamela S. Hyde, J.D. in November 2009. She resigned in August 2015 and Kana Enomoto, M.A. served as Acting Director of SAMHSA until Dr. Elinore F. McCance-Katz was appointed as the inaugural Assistant Secretary for Mental Health and Substance Abuse. The title was changed by Section 6001 of the 21st Century Cures Act.

Organisation

SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on American’s communities.

Four SAMHSA offices, called Centres, administer competitive, formula, and block grant programs and data collection activities:

  • The Centre for Mental Health Services (CMHS) focuses on prevention and treatment of mental disorders.
  • The Centre for Substance Abuse Prevention (CSAP) seeks to reduce the abuse of illegal drugs, alcohol, and tobacco.
  • The Centre for Substance Abuse Treatment (CSAT) supports effective substance abuse treatment and recovery services.
  • The Centre for Behavioural Health Statistics and Quality (CBHSQ) collects, analyses, and publishes behaviour health data.

The Centres give grant and contracts to US states, territories, tribes, communities, and local organisations. They support the provision of quality behavioural-health services such as addiction-prevention, treatment, and recovery-support services through competitive Programmes of Regional and National Significance grants. Several staff offices support the Centres:

  • Office of the Administrator.
  • Office of Policy, Planning, and Innovation.
  • Office of Behavioural Health Equity.
  • Office of Financial Resources.
  • Office of Management, Technology, and Operations.
  • Office of Communications.
  • Office of Tribal Affairs and Policy.

Centre for Mental Health Services

The Centre for Mental Health Services (CMHS) is a unit of the Substance Abuse and Mental Health Services Administration (SAMHSA) within the US Department of Health and Human Services. This US government agency describes its role as:

The Center for Mental Health Services leads federal efforts to promote the prevention and treatment of mental disorders. Congress created CMHS to bring new hope to adults who have serious mental illness and children with emotional disorders.

As of March 2016, the director of CMHS is Paolo del Vecchio.

CMHS is the driving force behind the largest US children’s mental health initiative to date, which is focused on creating and sustaining systems of care. This initiative provides grants (now cooperative agreements) to States, political subdivisions of States, territories, Indian Tribes and tribal organisations to improve and expand their Systems Of Care to meet the needs of the focus population – children and adolescents with serious emotional, behavioural, or mental disorders. The Children’s Mental Health Initiative is the largest Federal commitment to children’s mental health to date, and through FY 2006, it has provided over $950 million to support SOC development in 126 communities.

Centre for Substance Abuse Prevention

The Centre for Substance Abuse Prevention (CSAP) aims to reduce the use of illegal substances and the abuse of legal ones.

CSAP promotes self-esteem and cultural pride as a way to reduce the attractiveness of drugs, advocates raising taxes as a way to discourage drinking alcohol by young people, develops alcohol and drug curricula, and funds research on alcohol and drug abuse prevention. CSAP encourages the use of ‘evidence-based programmes’ for drug and alcohol prevention. Evidence-based programmes are programmes that have been rigorously and scientifically evaluated to show effectiveness in reducing or preventing drug use.

Brief History and Legal Definition

CSAP was established in 1992 from the previous Office of Substance Abuse Prevention by the law called the ADAMHA Reorganisation Act. Defining regulations include those of Title 42.

Centre for Substance Abuse Treatment

The Centre for Substance Abuse Treatment (CSAT) was established in October 1992 with a Congressional mandate to expand the availability of effective treatment and recovery services for alcohol and drug problems. CSAT supports a variety of activities aimed at fulfilling its mission:

To improve the lives of individuals and families affected by alcohol and drug abuse by ensuring access to clinically sound, cost-effective addiction treatment that reduces the health and social costs to our communities and the nation.

CSAT works with States and community-based groups to improve and expand existing substance abuse treatment services under the Substance Abuse Prevention and Treatment Block Grant Programme. CSAT also supports SAMHSA’s free treatment referral service to link people with the community-based substance abuse services they need. Because no single treatment approach is effective for all persons, CSAT supports the nation’s effort to provide multiple treatment modalities, evaluate treatment effectiveness, and use evaluation results to enhance treatment and recovery approaches.

Centre for Behavioural Health Statistics and Quality

The Centre for Behavioural Health Statistics and Quality (CBHSQ) conducts data collection and research on ‘behavioural health statistics’ relating to mental health, addiction, substance use, and related epidemiology. CBHSQ is headed by a Director. Subunits of CBHSQ include:

  • Office of Programme Analysis and Coordination.
  • Division of Surveillance and Data Collection.
  • Division of Evaluation, Analysis and Quality.

Regional Offices

CMS has its headquarters outside of Rockville, Maryland with 10 regional offices located throughout the US:

  • Region I – Boston, Massachusetts:
    • Connecticut, Massachusetts, Maine, New Hampshire, Rhode Island and Vermont.
  • Region II – New York, New York:
    • New York State, New Jersey, US Virgin Islands and Puerto Rico.
  • Region III – Philadelphia, Pennsylvania:
    • Delaware, Maryland, Pennsylvania, Virginia, West Virginia and the District of Columbia.
  • Region IV – Atlanta, Georgia:
    • Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina and Tennessee.
  • Region V – Chicago, Illinois:
    • Illinois, Indiana, Michigan, Minnesota, Ohio and Wisconsin.
  • Region VI – Dallas, Texas:
    • Arkansas, Louisiana, New Mexico, Oklahoma and Texas.
  • Region VII – Kansas City, Missouri:
    • Iowa, Kansas, Missouri, and Nebraska.
  • Region VIII – Denver, Colorado:
    • Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming.
  • Region IX – San Francisco, California:
    • Arizona, California, Hawaii, Nevada, American Samoa, Guam, and the Northern Marina Islands.
  • Region X – Seattle, Washington:
    • Alaska, Idaho, Oregon, and Washington.

Strategic Direction

In 2010, SAMHSA identified 8 Strategic Initiatives to focus the Agency’s work. Below are the 8 areas and goals associated with each category:

  • Prevention of Substance Abuse and Mental Illness – Create prevention-prepared communities in which individuals, families, schools, workplaces, and communities take action to promote emotional health; and, to prevent and reduce mental illness, substance (including tobacco) abuse, and, suicide, across the lifespan
  • Trauma and Justice – Reduce the pervasive, harmful, and costly public-health impacts of violence and trauma by integrating trauma-informed approaches throughout health and behavioural healthcare systems; also, to divert people with substance-abuse and mental disorders away from criminal-/juvenile-justice systems, and into trauma-informed treatment and recovery.
  • Military Families – Active, Guard, Reserve, and Veteran – Support of our service men & women, and their families and communities, by leading efforts to ensure needed behavioural health services are accessible to them, and successful outcomes.
  • Health Reform – Broaden health coverage and the use of evidence-based practices to increase access to appropriate and high quality care; also, to reduce existing disparities between: the availability of substance abuse and mental disorders; and, those for other medical conditions.
  • Housing and Homelessness – To provide housing for, and to reduce the barriers to accessing recovery-sustaining programmes for, homeless persons with mental and substance abuse disorders (and their families)
  • Health Information Technology for Behavioural Health Providers – To ensure that the behavioural-health provider network – including prevention specialists and consumer providers – fully participate with the general healthcare delivery system, in the adoption of health information technology.
  • Data, Outcomes, and Quality – Demonstrating Results – Realise an integrated data strategy that informs policy, measures program impact, and results in improved quality of services and outcomes for individuals, families, and communities.
  • Public Awareness and Support – Increase understanding of mental and substance abuse prevention & treatment services, to achieve the full potential of prevention, and, to help people recognise and seek assistance for these health conditions with the same urgency as any other health condition.
  • Their budget for the Fiscal Year 2010 was about $3.6 billion. It was re-authorized for FY2011. Most recently, the FY 2016 Budget requests $3.7 billion for SAMHSA, an increase of $45 million above FY 2015.

Controversy

In February 2004, the administration was accused of requiring the name change of an Oregon mental health conference from “Suicide Prevention Among Gay/Lesbian/Bisexual/Transgender Individuals” to “Suicide Prevention in Vulnerable Populations.”

In 2002, then-President George W. Bush established the New Freedom Commission on Mental Health. The resulting report was intended to provide the foundation for the federal government’s Mental Health Services programmes. However, many experts and advocates were highly critical of its report, Achieving the Promise: Transforming Mental Health Care in America.

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What is the Abraham Low Self-Helps Systems?

Published on by Andrew Marshall3 Comments

Introduction

Abraham Low Self-Help Systems (ALSHS) is a non-profit organisation formed from the merger of Recovery International and the Abraham Low Institute.

ALSHS facilitates the estimated 600 worldwide Recovery International meetings and all projects formerly run by the Abraham Low Institute including the Power to Change programme. The organisation is named after Abraham Low, founder of the mental health self-help organisation now known as Recovery International.

Brief History

Recovery, Inc., often referred to simply as Recovery, was officially formed 07 November 1937, by neuropsychiatrist Abraham Low in Chicago, Illinois. Low created the organisation to facilitate peer support self-help groups for former mental patients and later allowed for participation of those who had not been hospitalised, but with a desire to improve their mental health. During the organisation’s annual meeting in June 2007 it was announced that Recovery, Inc. would thereafter be known as Recovery International. As of 2008 there were over 600 weekly Recovery International meetings held throughout North America, Ireland, the United Kingdom, Israel and India.

The Abraham Low Institute was founded in 1989 to develop programmes, in addition to Recovery, based on Low’s self-help principles. The Institute awarded grants to further scholarly research on Low’s work, provided research resources for people interested in Low’s methods, and developed the Power to Change programme and The Relatives Project.

On 01 January 2008 Recovery International merged with The Abraham Low Institute and provisionally renamed the new organisation Recovery International / The Abraham Low Institute (RI/TALI). Celinda Jungheim, a community volunteer from Los Angeles, was elected as president of the Board of Directors. Abraham Low Self-Help Systems was incorporated on 01 January 2009, completing the merger of Recovery International and The Abraham Low Institute. Abraham Low Self-Help Systems is now the provider of Recovery International community, phone and online meetings and The Power to Change programme, which was a programme of The Abraham Low Institute.

The Relatives Project

The Relatives Project, found in 1993, provides support for family and friends of people who have mental and emotional problems. The Relatives Project teaches coping skills and stress management through meetings similar to those held in Recovery International groups, but using literature written by Abraham Low specifically for the families of his patients. Relatives are taught to maintain empathy and unconditional positive regard for their ill relative, while reframing their domestic environment to provide an empowering atmosphere for all members. The Relatives Project groups are open to adults and teenagers, and allow professionals to observe but only to participate if it is in support of a family member’s mental health. Mental health becomes a shared goal for a family, and all family members share in responsibility to achieve it.

Power to Change

Power to Change is a cognitive-behavioural peer-to-peer programme based on Low’s self-help principles. Power to Change primarily teaches at-risk students and ex-prisoners principles of Low’s Self-Help system in peer-to-peer groups. Power to Change groups generally consist of 8-12 members, meeting weekly, who learn the principles of the Low Self-Help System by describing their personal experience of disturbing events and commenting on each other’s experiences using a highly structured format.

Specifically, Power to Change consists of five components:

  • A peer-to-peer process intended to provide a safe environment for members to disclose their experiences to a supportive group,
  • A meeting structure intended to keep discussion on topic,
  • A four-part format to help members frame their experiences as useful examples, and
  • Group feedback utilising a set of tools (principles of Abraham Low’s therapeutic technique).

The four-part example consists of an objective description an event; a report of the feelings, sensations, thoughts, and impulses experienced in the members mind and body; how the member used the Power to Change tools to manage the experience; and a self-endorsement to remind the member of the progress made and to reward their effort. The Power to Change groups use much of the language suggested in the Recovery International programme, such as identifying “temper” and avoiding judgment of right and wrong.

The W.K. Kellogg Foundation has provided grants for Power to Change since 2003. The most recent grant was awarded in November 2008, and will provide funding until November 2010.

Chicago Public Schools

In 2007 Urban Networks Associates (UNA) conducted an evaluation of Power to Change as it was implemented in seventeen secondary and middle schools in the Chicago Public School system. In each school 12-24 group sessions were held and facilitated by either staff from the Abraham Low Institute or by a local facilitator trained by the Abraham Low Institute. Participating students showed significant improvement in prosocial behaviour as measured by pre-testing and post-testing of emotional intelligence, specifically increasing self-restraint and decreasing violent behaviours. Although statistically significant, the effect sizes of changes were low or medium.

UNA’s SEM evaluation of the Power to Change logic model, the required steps and conditions for the program to be effective, found it fit the data collected well. To improve the effectiveness of the program UNA recommended improving communication with and training of local facilitators, encouraging students to develop plans to apply programme tools outside of the group, updating the literature used to make it more age appropriate for the young students, adding activities to encourage confidentiality of what was said in group meetings and developing more interactive activities to teach programme concepts. UNA also suggested asking for a commitment from participating schools to guarantee facilities were always available and that students would not be prohibited from attending group sessions.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Abraham_Low_Self-Help_Systems >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.