Prescribing Exercise By Dr. Lisa Smalheiser, Psy.D.

Which came first, the chicken or the egg? This question can be similarly applied to the link between exercise and mood symptoms. Research conducted by McKercher and colleagues (2013) found that people who are physically active are less depressed than people who are inactive. Additionally, people who were once active but then stopped suffer from depression more than those who have continued to maintain an active lifestyle. So the question therein lies: Is it that people who are happier to begin with are more physically active or is it the physical activity itself that can decrease, dampen, or remove the depression altogether?

Exercise has been prescribed by general practitioners and primary care physicians for some time now, and we know the general health benefits are countless. Well, why is it then that the mental health field has yet to implement this strategy with psychological and/or psychiatric disorders? Could a lifestyle change help alleviate years’ worth of anxiety and depression symptoms? Research that was published in The American Psychiatric Publishing Textbook of Psychopharmacology (2009) identified regular exercise as a viable alternative to psychopharmacology and a good complementary strategy to implement in conjunction with psychotherapy. This article is not to suggest exercise in place of drugs and therapy. Its purpose is to promote the use of exercise as a means of increasing the effectiveness of those traditional treatments and decrease the likelihood of remission through prescribing a self-administered and self-monitored treatment.

First, let me provide some statistics and rationale for my push for exercise as a promising therapeutic technique to combat troubling mood symptoms. The recovery rates for antidepressants alone are typically slightly below 50 percent (Casacalenda, 2002; Thase, 2001; Thase, 2005; Trivedi, 2011). With the addition of a secondary drug, a further 20 to 30 percent tend to improve (Trivedi, 2011). Medications can not only get expensive, but there can be unwanted side effects associated with them. Since it appears that most people require a concurrent treatment in order to control their depression, why not use exercise as this complementary treatment?

Blumenthal et al. (1999) conducted a study comparing the effects of regular cardiovascular exercise in adults over the age of 50, diagnosed with major depressive disorder, to Zoloft, a commonly prescribed antidepressant. Results demonstrated that the decreased level of depression in participants was equal in both the drug and exercise groups. Moreover, in a follow-up study, they found that the exercise group had a lower level of relapse than the drug group. In 2007, Blumenthal re-explored this phenomenon and discovered similar findings. Patients in the exercise and antidepressant groups did equally as well with respect to rates of remission, and both fared better than patients in the placebo condition. Through both studies, Blumenthal et al. (1999) and Blumenthal (2007), it appears that exercise provides reductions in the symptoms underlying major depressive disorder comparable to that of antidepressant drugs.

Some side effects of exercise include weight control, reduced risk of cardiovascular disease, type-2 diabetes, and some cancers, strengthen bones and muscles, improved ability to do daily activities, increased chances of a longer life span, etc. Those don’t sound too bad to me. Now, with this promising research, we can add improved mood and reduced risk of depressive and anxiety disorders through the use of exercise. Plus, an additional benefit is that exercise, as a form of medicine, isn’t likely to burn a hole in your wallet!

So what is it exactly that is underlying this phenomenon? Some suggest that exercise can alleviate depression by providing individuals with a sense of accomplishment from completing a meaningful activity. Others hypothesize that exercise has positive effects on the brain by normalizing sleep patterns. While several others believe that it is the increase in serotonin from exercise that reduces depression.

Not only have there been notable advancements in the area of exercise and depression, but researchers document encouraging findings in the use of exercise as a means for treating anxiety. Anxiety and exercise share some common characteristics. People who suffer from anxiety typically experience heavy perspiration, dizziness, increased heart rate, in addition to other nervous system actions typical of what are referred to as fight-or-flight sensations. These physical responses, in anxiety prone individuals are typically met with fear. Similarly, when people exercise, the body produces many of these same physical responses, with the difference being the absence of fear. Otto and Smits (2011) hypothesized that exercise may reduce the likelihood that these sensations will result in panic, and instead be associated with safety. After testing this theory, the study results determined that participants who completed the exercise program showed reductions in their sensitivity to anxiety, and Smits likened exercise to a form of exposure therapy.

Further exemplifying this phenomenon was a study conducted by Smits and colleagues (2011) where subjects were asked to breathe in CO2-enriched air, triggering those same symptoms typical of a panic attack. Of course, all subjects panicked in response. However, the interesting discovery was that those people who reported engaging in regular exercise in their daily lives were less likely to panic in response to the test than those who had lower activity levels. Conclusively, it appears that exercise could help ward off panic attacks by creating a new connection between these fight-or-flight symptoms and safety, rather than fear.

People nowadays are always looking for a quick fix. The good news is that the mood enhancing effects of exercise are almost instantaneous. If people know that exercise is so good for them, why is it so hard to do, and why is it that so few people do it? For the most part, when people are feeling down and depressed, people not only lack energy in general, but it can be hard to want to pick yourself up to do anything, let alone strenuous physical activity. Although the jury is still out there on the right prescription for type and amount of exercise, researchers have found that you don’t have to overdo it, and the type of aerobic activity isn’t as important. The important part is getting up, getting out there, getting moving. Something is better than nothing when it comes to exercise. Next time you go to the gym, don’t only take note of how you feel physically and the image you view in the mirror, but also be cognizant of your mental state at the time. You may find yourself feeling calmer, less anxious, less depressed, more confident, and hopefully, all around, happier.

Although the underlying factors and mechanisms behind this phenomenon have yet to be conclusively determined, one thing is for certain: exercise is not only good for the body, but for the mind too!

References

Alan F.S. & Nemeroff C.B. (2009). The American psychiatric publishing textbook of psychopharmacology. 4th edition. Arlington, VA: American Psychiatric Publishing.

Blumenthal J.A. et al. (1999). Effects of exercise training on older patients with major depression. Arch Intern Med, 159, 2349-2356.

Blumenthal J.A., Babyak M.A., Doraiswamy P.M., Watkins L., Hoffman B.M., Barbour K.A., et al. 2007). Exercise and pharmacotherapy in the treatment of major depressive disorder. Psychosomatic Medicine, (69), 587–596.

Casacalenda N., Perry J.C., & Looper K. (2002). Remission in major depressive disorder: A comparison of pharmacotherapy, psychotherapy, and control conditions. American Journal of Psychiatry, 159(8), 1354–1360.

McKercher C., Patton G.C., Schmidt M.D., Venn A.J., Dwyer T., & Sanderson K. (2013). Physical activity and depression symptom profiles in young men and women with major depression. Psychosomatic Medicine, 75(4), 366-374.

Otto, M & Smits, J. (2011). Exercise for mood and anxiety: Proven strategies for overcoming depression and enhancing well-being. Oxford University Press.

Smits A.J., Tart C.D., Rosenfield D., & Zvolensky M.J. (2011). The interplay between physical activity and anxiety sensitivity in fearful responding to carbon dioxide challenge. Psychosomatic Medicine, 73(6), 498-503.

Thase M.E., Entsuah A.R., & Rudolph R.L. (2001). Remission rates during treatment with venlafaxine or selective serotonin reuptake inhibitors. British Journal of Psychiatry, 178, 234–241.

Thase M.E., Haight B.R., Richard N., et al. (2005). Remission rates following antidepressant therapy with bupropion or selective serotonin reuptake inhibitors: A meta-analysis of original data from 7 randomized controlled trials. Journal of Clinical Psychiatry, 66, 974–981.

Trivedi M.H., Greer T.L., Church T.S., Carmody T.J., Grannemann B.D., Galper D.I., Dunn A.L., Earnest C.P., Sunderajan P., Henley S.S., & Blair S.N. (2011). Exercise as an augmentation treatment for nonremitted major depressive disorder: a randomized, parallel dose comparison. Journal of Clinical Psychiatry, 72(5), 677-684.

Healthy Sleep Habits Dr. Lisa Smalheiser, Psy.D.

The bed should be a place associated with rest and relaxation. It should be a space associated with shutting down. Unfortunately, the bed has become associated with a place of stress and worry. We put our heads on our pillows at night, and our minds start racing – all the things we did wrong, everything we have to do tomorrow, worries, regrets, etc. begin to overwhelm us. If you have trouble sleeping, all of these things should sound disturbingly familiar to you.

We need to re-establish that automatic association between bed and relaxation, and break the association between sleep and stress. Below are some great tips to get you started…

  1. Use your bed only for sleeping. No TV, No phone, No computer, No eating, and No other things that require you to be awake. (Sex is an exception to this rule). By limiting your in-bed activities to sleep, you train yourself to expect to sleep when you’re in bed.
  2. Don’t stay in bed for a long period of time if you’re having trouble sleeping. Ten to 15 minutes is a good rule of thumb, but try to rely on just knowing if you’re feeling sleepy or not rather than watching the clock. Being in bed and unable to fall asleep is likely to make you frustrated about not being able to sleep, which just makes it harder to fall asleep. Rather than lying in bed awake it’s generally better to go to another room and do something relaxing like watching TV or reading until you start to feel like you could fall asleep easily.
  3. Try to go to bed and wake up at the same time every day. Even if you have a hard time falling asleep it’s generally best to get up at your standard time in the morning. In the same way, avoid going to bed much earlier than your normal bedtime. Over time these habits will help to stabilize your sleep schedule.
  4. If possible, do not take naps. They tend to interfere with your ability to sleep well at night.
  5. Avoid caffeine in the afternoon and evening. Alcohol also tends to decrease the quality of sleep, even if it may make it easier to fall asleep.
  6. Avoid watching the clock when trying to fall asleep, which typically only leads to worrying about not falling asleep. Some people find that they need to turn the clock so they can’t see it at night, or to remove clocks that are easily visible in the dark.
  7. Eliminate as much as possible any factors that might disrupt your sleep—for example, fluid intake close to bedtime that causes trips to the bathroom; indigestion from eating too much close to bed; hunger from not eating enough in the evening; frequent awakenings caused by pets; and so forth.
  8. Try not to panic when having a bad night’s sleep. Most of us tend to “catastrophize” when we struggle to fall asleep or have our sleep interrupted, telling ourselves things like “I’ll be a complete wreck tomorrow!” In reality most of these fears are overblown, and only serve to increase our anxiety about falling asleep, thus further interfering with sound sleep.

Recommendations adapted from a treatment manual by Jack D. Edinger, PhD. If you require help for a chronic sleep problem, please consult with a medical or mental health professional.

Complementary Medicine and Alternative Medicine: An Integrative Health Approach By Dr. Lisa Smalheiser, Psy.D.

I truly believe that when it comes to defining health, in order to improve the well-being of each individual, we need to look at the whole person: mind, body, soul, and spirit. How we spend our mental and physical time and energy, and how we take care of our bodies is a huge part of my professional focus.

Psychology is defined as the study of the mind and behavior. This definition addresses the first piece of the puzzle, “our mental and physical time and energy,” but many mental health professions easily overlook the second part: “How we take care of our bodies.” When it comes to how I treat my clients, and people in general, I don’t follow a cookie cutter approach. What helps one person might not be what is best for the next. Everyone is unique, and should be treated as such. However, one thing that I do strongly advocate is the use of physical activity, most notably exercise, as a means to bolster any other forms of traditional therapy being provided. This article not only addresses the use of exercise and physical activity, but also other approaches that can add to the therapy an individual is receiving. In some cases, these other, less commonplace approaches, may act as a form of therapy in and of themselves.

With all of the emerging treatments for mental, physical, and emotional ailments available in today’s society, it can be difficult to tease out the good from the bad, the helpful versus the harmful, and what works from what doesn’t. The most recent surveys conducted report that 38 percent of Americans have started to incorporate mind/body practices and other natural products into their health care, and we are seeing a shift to less reliance solely on conventional medicine. While mainstream Western approaches may work for some, it is my belief that an integrative health approach, which can aid in overall well-being, may be the way to go.

You may be familiar with the concept of Complementary and Alternative Medicine, also known as CAM. The two terms, “complementary” and “alternative,” although sometimes used interchangeably, are varied with regard to their conceptual framework. One is not necessarily better than the other, and it is important for every person to find relief through an approach best suited for him or her individually. The term “complementary medicine” refers to the use of non-mainstream techniques and approaches that are used in combination with conventional medicine. The term “alternative medicine” refers to the use of non-mainstream techniques and approaches in place of conventional medicine. Take, for example, a patient diagnosed with cancer that would traditionally undergo some form of surgery in order to treat his or her condition. In order to be considered true alternative medicine, an approach would be utilized that would take the place of surgery, such as prescribing the patient a special diet to follow. Conversely, complementary medicine can be employed. This can be in the form of retaining the services of a qualified massage therapist to provide a comforting touch, providing instruction on how to use visual imagery for relaxation post-surgery, or through the use of aromatherapy during and after the surgery with the intention of reducing the discomfort a patient may feel surrounding the time of the procedure.

In 2007, a survey was conducted by the Centers for Disease control, known as the National Health Interview Survey (NHIS). The NHIS found that the most common mind and body practices included deep breathing, meditation, chiropractic and osteopathic manipulation, massage, yoga, progressive relaxation, and guided imagery. Other, less utilized but still valuable, approaches included acupuncture, tai chi and qi gong, yoga, hypnotherapy, and movement therapies, such as Pilates, Rolfing Structural Integration, and Trager psychophysical integration. In addition to mind and body practices, some people opt for the use of natural products, such as vitamins, minerals, probiotics, herbs, and botanicals, typically sold as dietary supplements.  The 2007 NHIS also found that the most common products being used as a form of complementary medicine (in those that utilized natural products) were omega 3 fish oils (37.4 percent in adults and 30.5 percent in children in past 30 days) and Echinacea (37.2 percent in children in past 30 days).

In the mental health field, mood disorders, such as depression and dysthymia, are among the most commonly reported. Not only are mood disorders widespread in the mental health field, but several studies have found that mood and anxiety disorders are found at higher percentages than any other chronic medical condition! Of course, there are countless psychotropic medications available, but it might be a mistake to not consider any other approaches. CAM techniques can be applied to a wide array of problems and disorders, including (but not limited to) psychotic disorders, mood disorders, anxiety disorders, PTSD, ADHD, conduct disorders, insomnia, cancer, chronic pain, obesity, etc. and improvements can be seen in the physical, mental, and emotional realms.

Studies show that most mood disorders go untreated, and the unmet need is greatest for highly vulnerable populations, including minority groups, low income individuals, individuals with less education, and those not covered by insurance. Since mood disorders not only affect our mental and emotional state, but also lead to decreases in everyday functioning and serious chronic physical illnesses, it is important that these ailments are addressed. As a result of medication-induced side effects, un-responsiveness to conventional treatment, inability to pay due to high cost or low income, and unavailability of conventional services, utilizing CAM practices may prove to be attainable, beneficial, cost-effective, but even more important, life-changing!

A fantastic body of research conducted by Jacobsen and colleagues in the early 1990’s on behavioral activation relates closely to this topic. They found that just doing activities can be very powerful in helping people who are depressed. Behavioral activation aims at helping depressed individuals to become reengaged in their lives by countering their typical patterns of avoidance and withdrawal. Individuals begin to find positive reinforcement through various means, and these activities then serve as a natural antidepressant. This idea relates closely to my thoughts on exercise as a powerful form of both alternative and complementary medicine. More on this topic will be addressed in upcoming posts.

There is an indisputable connection between your mind and body. Your physical health affects your psychological well-being, and your thoughts and emotions can, in turn, affect your physical health. What you choose to do or not do is up to you, and there is not one right solution for everyone. You have to decide what is best for you individually. With all of the different options out there, it may feel overwhelming to some, and at times may seem like a bit of trial and error. The take home message is: Do your research, but don’t be afraid to try something new.

 

References

Barnes, P. M., Bloom, B., & Nahin, R. L. (2008). Complementary and alternative medicine use among adults and children: United States, 2007. Retrieved from http://nccam.nih.gov/news/2008/nhsr12.pdf

Jacobson, N. S., Martell, C. R., & Dimidjian, S. (2001). Behavioral activation treatment for depression: Returning to contextual roots. Clinical Psychology: Science and Practice, 8(3), 255–270.

Kessler R.C., Demler O., & Frank R.G. et al. Prevalence and treatment of mental disorders, 1990–2003. N. Engl. J. Med. 352(24), 2515–2523 (2005).

Kessler R.C., Greenberg P.E., Mickelson K.D., Meneades L.M., & Wang P.S. The effects of chronic medical conditions on work loss and work cutback. J. Occup. Environ. Med. 43(Suppl. 3), 218–225 (2001).

National Center for Complementary and Alternative Medicine (NCCAM). (2011e). What is CAM? Retrieved from http://nccam.nih.gov/health/whatiscam/

The WHO World Mental Health Survey Consortium. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA 291(21), 2581–2590 (2004).

Man sleeping comfortably

Health Tip of the Day: Good Mental & Physical Health Begin with Good Sleep Habits

We all know that sleep is essential for good health but, during stressful periods,  sleep quality and quantity are often hardest hit.  According to the National Sleep Foundation, adults ages 18-64 need 7-9 hours of sleep every night.  Adults 65+ need 7-8 hours per night. Let’s be honest readers, how many of us actually achieve that?

We will often tell ourselves, “I’ll make up my sleep on the weekend,” but the hard truth is that there is no making up for a sleep deficit. After several nights of losing sleep—even a loss of just 1–2 hours per night—our ability to function suffers as if we haven’t slept at all for a day or two.  Our organs suffer, our brain suffers, our mood and ability to focus suffers.

We can practice the best diet and exercise routine, take the best medication, and participate in the best therapy, but we won’t be at our best without sleep.

Enough is enough!

Here are a few steps to begin taking today to improve sleep quality and quantity: https://www.sleepfoundation.org/articles/healthy-sleep-tips

Need to relax the mind?  There’s an app for that!  Try one of the following (available for both Apple and Android products):

  • Insight Timer
  • Calm
  • Headspace
  • Relax Melodies
  • Brainwaves

Are the things you tell your therapist really private?

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When you leave your psychotherapist’s office after an especially personal session, it’s comforting to know that everything you discussed remains within those four walls. But will it really? Just how bound to confidentiality is your therapist? Can they be legally coerced into revealing what you’ve talked about in private?

Privacy is what makes therapy work

“Psychologists understand that for people to feel comfortable talking about private and revealing information, they need a safe place to talk about whatever they’d like, without fear of that information leaving the room,” states the website of the American Psychological Association (APA). Psychologist Ali Mandelblatt of Lighthouse Health Group, LLC in Florida, backs up that claim, saying, “a client can tell his therapist his deeply held secrets knowing they will not leave the therapy room.”

There are, however, times when a therapist must breach a patient’s confidentiality and release personal information into the more public realm.

RelatedCan you photo be published without your consent?

As a professional, Mandelblatt cannot provide accurate information about confidentiality until she first determines who her client is and why he or she is seeking treatment. “Is the client voluntarily seeking treatment or is she court-ordered to treatment?’

In the first case, most of the information disclosed by the client would remain confidential. In the second case, however, the information the client discloses is not confidential. “Court-ordered treatment provides that the therapist report back to the Court in terms of the client’s progress and/or lack thereof,” explains Mandelblatt.

Laws are in place to support your privacy…

The Health Insurance Portability and Accountability Act (HIPAA) lays out national standards to protect the personal health information—including information about psychotherapy and mental health—of an individual.

Each state has its own standards above and beyond the level of protection provided by the HIPAA Privacy Rule. You can find out what laws and protections exist for you by contacting your state’s board of psychology. The contact information for each state’s board can be found at The Association of State and Provincial Psychology Boards.

…but there are exceptions

When you first visit a psychotherapist (psychologist, psychiatrist, or social worker), you should be provided with written information that details how your personal information will be handled. Exceptions to your privacy protection should be made clear. In the following instances, according to the APA, your therapist can share information without your written consent:

  • Psychotherapists may disclose private information without consent in order to protect the patient or the public from serious harm; for example, if you reveal a plan or intent to commit suicide or to harm or kill someone else.
  • Psychotherapists are required to report ongoing domestic violence, abuse, or neglect of children, the elderly, or people with disabilities. If, however, an adult discloses that they were abused as a child, the therapist is not necessarily bound to report that abuse, unless there are other children who are continuing to be abused.
  • Psychotherapists may release information if they receive a court order; for instance, if your records are subpoenaed in a legal case regarding your mental health, or if the treatment is court-ordered, as Mandelblatt indicates above.

“It should be noted even though these disclosures are ‘allowed,’ a client may still bring a complaint about the psychologist to the Board of Psychology,” adds Mandelblatt. “Confidentiality and breaches of confidentiality can often place a psychologist in a difficult situation legally, professionally, and ethically. Rapport may be ruined between the client and the psychologist after this breach, leading to a termination of the therapeutic relationship.”

Disclosure with consent

Your therapist may ask if they can share your personal information with other healthcare professionals when coordinated care is in order. This, too, is a policy that should be mentioned at your initial visit. Ultimately, you get to decide whether or not you’re okay with it.

“As a therapist and a forensic psychologist, it is initially my duty to help my clients understand confidentiality and the limits of confidentiality,” says Mandelblatt. “By doing this, I give my clients an opportunity to understand how the information they disclose to me can or may be used.”

As the patient, you are free to disclose as much or as little as you desire about your therapy sessions. You can tell family, friends, coworkers – anyone. Choosing to do so does not give permission to the therapist to do the same. “Psychologists are ethically bound to protect your privacy,” reads the APA website, “regardless of what information you choose to share with others.”

How much does your insurance company need to know?

Your health insurance company (or Medicare or Medicaid, if applicable) may need access to some of your personal information in order to pay for your treatment. In turn, the insurance company (or government program) is bound by the same HIPAA regulations that apply to your therapist. For example, the health insurance company may not share information about your treatment with your employer, even if your coverage is through that employer.

If you are uncomfortable with your insurance company having access to your private health records, you can circumvent it by paying out-of-pocket for your treatment.

Minors get slightly less privacy

This area, in particular, is one in which states differ. Typically, a parent or guardian is involved when a child under the age of 18 receives psychotherapy services. That involvement may be as limited as having an early discussion about what types of information everyone—the therapist, minor, and parents—agree should be shared. The APA website states that it is common for parents to agree to be informed only if their child is engaged in risky activities.

What happens when a child is over the age of 18 but still covered by their parents’ insurance? If the insurance is used to pay for the treatment, then the parents will receive an Explanation of Benefits (EOB) from the insurance company describing the services the child has received. The EOB will not reveal what was discussed during sessions with the therapist, only that the visits were made.

Bottom line: A professional psychotherapist will abide by the rules and laws that protect your privacy. And he or she will use those laws to protect you further – by breaking that confidence when necessary. Use the resources available to you to make sure your therapist is licensed and in good standing. And, if you feel that your privacy has been breached, seek help from an attorney to protect your rights.