Evidence Based Treatment for Addiction and Mental Illness 2022 | Counseling Tools

I'd like to welcome everybody. Today's presentation on co occurring disorders, current evidence, evidence based treatments. I'm your host, Dr. Donnelly Snipes. Today what we're going to talk about is current research on evidence based and promising practices for co occurring disorders. Most people with addictions also have other co occurring issues. Mood disorders, pain and PTSD top the list. I didn't go go in depth into personality disorders in this presentation because I think what we're really looking at, especially in early recovery, is addressing those mood disorders as people are sobering up and their neurotransmitters are getting kind of back in balance. Over the 20 or so years that I worked in community mental health, I found that for a lot of people as they go through the recovery process and their neurotransmitters get stabilized and you know, they develop healthier coping and communication skills, a lot of those symptoms that are similar to personality disordered behavior, I. E. Narcissistic, antisocial and borderline, most specifically, a lot of those abate significantly. So for me, I really shy away from giving a personality disorder diagnosis in the first six months of treatment in somebody who's in early recovery. But that's my own guideline. Obviously you'll use your clinical judgment. So anyway, what we're really talking about here are issues or our treatments that can be used to address all three of these issues. It's cross cutting treatments for co occurring disorders. Why? Because effective treatment requires concurrent treatment of all presenting biopsychosocial issues. If you work in addiction, you're probably familiar with the asam, so you know about the biopsychosocial dimensions. We look at biomedical con conditions, cognitive issues, recovery motivation and recovery environment. And there are two other dimensions that I can't think of right now. But it's important to look at all of those things. If you have somebody who comes into treatment who is struggling with clinical depression, who also is diagnosed with, you know, substance use disorder, if you help them get clean and sober, well that's great. But if they are clean and sober and they have no new skills and tools and they're not addressing the stuff that's causing the depression, the likelihood of them staying clean and sober for long is greatly released, reduced. Sorry. And likewise, if you have somebody who is presenting in clinic for a mood disorder and you know, through your assessment, through talking with them that they are abusing substances, that substance abuse is going to keep the neurotransmitters out of balance, which is going to impair their ability to recover as Effectively from, from the, the mood disorder or the PTSD potentially, and even the pain. So we do want to recognize that addiction, mood disorders, and physical health disorders, as well as recovery environments all interact. So cognitive behavioral therapy is still the gold standard for addiction, anxiety, d, dementia, depression, eating disorders, insomnia, OCD and schizophrenia. And as always, all of these links are available in the PDF of the PowerPoint in your classroom. You can click on the links and it will take you to the studies that describe the current state of knowledge on use for that particular intervention. In this case CBT with that particular condition. We didn't obviously, in an hour have enough time to do a deep dive into all of those. But suffice it to say that it is still the gold standard in many cases. Now remember, cognitive behavioral therapy is not just cognitive therapy. It's not just dealing with distortions and thinking patterns. It is also behavioral. We want to help people live a healthier lifestyle. One interesting caveat, or whatever you want to call it, I found with cbt, I haven't worked a whole lot with people with schizophrenia. That's probably been 2% of my caseload over, you know, over the years. But when you're using CBT with schizophrenia, you want to focus on motivational enhancement for agreed upon recovery goals, appropriate use of coping skills, working with their symptoms, understanding the experience of psychosis, strengthening their adaptive view of themselves, personal emotional issues or comorbid issues, relapse prevention, and family or social reintegration. Not everybody's going to reintegrate with their blood relatives, but these are all goals. And when you're working with someone with schizophrenia, you're not trying to convince them that their reality is wrong and yours is right. You're trying to help them live the highest quality of life as possible given their reality, their phenomenal phenomenological reality, how they feel, what they perceive is real. And I. I've told you before about one person that I worked with many, many years ago who had schizophrenia. And one of the things that was a trigger for him was the word the. The had very derogatory, satanic meeting meanings to him. So whenever he would hear that word, it would trigger him immensely. Well, think about it. When you're paying attention just to conversation, even while I'm talking today or while you're watching the news or anything else, how often that word, I'm trying not to say it right now, how often that word comes up and so you can understand or you can get an idea of how often this young man was triggered. So we worked on developing appropriate skills to help him when he felt triggered when he heard that particular word. We developed skills and tools that he could use in order to try to de escalate himself a little bit. And the, well, there I go. There's that word, use of that word and hearing that word was not egodistonic to him. It was very real. So trying to convince him that that particular word was not, you know, evil as he perceived it was not going to be an effective intervention for him at that point in time. So anyway, I thought it was interesting because we often don't think about using cognitive behavioral therapy with people with dementia or schizophrenia, but there are a lot of uses for it in terms of enhancing their quality of life in their current state state. Mindfulness based interventions are the second gold standard. They kind of tie now in the research literature, which I thought was fascinating. Now a lot of cognitive behavioral therapists use mindfulness based interventions as part of the behavioral aspect of it and even part of the cognitive aspect of it. But it is useful to recognize that mindfulness based interventions consistently outperform active control conditions like health education, relaxation and supportive psychotherapy. And what they meant by supportive psychotherapy was more akin to the terms, to the philosophy of Rogerian psychotherapy, where it wasn't active and directive. It was just helping people clear out those roadblocks. Mindfulness treatments were shown in general to have similar effectiveness with first line psychological and psychiatric interventions. So similar effectiveness with CBT and even psychopharmacology. And that was found to be true for children and adults. We can use mindfulness based interventions with children, helping children become more aware of their moment, more aware of themselves in, in the world, more aware of their triggers so they can take active steps. Even small children, you know, 1, 2, 3 years old can be helped to start learning mindfulness. Maybe not one, but two for certain. When you are talking to them, when you are comm. The communicating with them and they're upset, if you say it, it seems like you're really upset right now and the child will check in with them themselves. So helping them become more mindful in the moment is a great tool for prevention activities for later on. But mindfulness treatments were also shown to be very effective for older children who've already developed problems at enhancing their sense of personal agency and connection with themselves. Mindfulness treatments were also shown to be superior to wait list and control conditions with relatively little variation across disorders. And obviously I italicize that because I think that's important. We can use mindfulness very, very effectively for a Whole host of issues ranging from addiction and smoking cessation to depression, anxiety, pain and weight and eating management among others. Relaxation therapies are also really helpful and these kind of go along with behavioral therapies. Mindfulness relaxation therapies themselves use physiologic techniques like deep breathing, we've talked about that before or progressive muscular relaxation to regulate the sympathetic parasympathetic balance and reduce symptoms of arousal such as seen in chronic pain. Relaxation therapies can be very helpful in chronic pain as well as you know, the majority of other excitatory mood disorders, if you want to think about it that way. Anger, anxiety and addiction even where when people get aroused and they feel out of control of their emotions. Deep breathing and progressive muscular relaxation, meditation as well, all can help people slow their breathing, which slows their heart rate, which triggers the rest and digest. It triggers that down regulation of the HPA axis. So relaxation therapies can be very, very helpful. You can pair them with biofeedback and it doesn't have to be anything super technical. You can use a fitness monitor, you can use a heart rate strap, or you can just use counting breaths. But biofeedback is the act of taking something like breathing or heart rate that are not so much under normally something that you would consider under personal control and developing skills in order to regulate that aspect, regulate their breathing, regulate their heart rate. And this is also associated with. Biofeedback is associated with pain reduction, reduced depression, disability and muscle tension and improved coping in chronic musculoskeletal pain, headache and fibromyalgia. So for some of these things, for, well for most of these things in a non clinical setting, so something clients can do at home, you probably want to focus on either heart rate or respiration rate as they help themselves down regulate, as they help themselves calm down, trigger that rest and digest, you know, tone down that HPA axis that is going to be associated with more muscle relaxation, the release of GABA, the release of endorphins and, and the upregulation of 5 HT1 a serotonin that will help them feel better. Increases in endorphins and increases in serotonin also contribute to increases in pain tolerance. So as we help people learn how to relax and not go get so stressed, there are a lot of physiological effects that happen that can consequently reduce pain and help them deal with chronic issues. Another really interesting one and oh my gosh, there were so many articles. But another really interesting one is the use of virtual reality. Now through cognitive training Sensory immersion and social skills training. Rehabilitation. Using virtual reality therapies helps patients improve their quality of life. Now, this may not do everything, but there are a lot of things that ways that you can use virtual reality in order to stimulate a sense of self efficacy, a sense of mastery, to address phobias and fears, but also to stimulate relaxation. And we'll talk about those in a minute. VR assisted virtual reality, assisted burn and non burn wound care reduced opioid need by 39% compared to no virtual reality, while levels of pain and anxiety were similar. So the hypothesis here is that using the virtual reality redirected their attention and gave them a task, gave them a sense of personal agency where they could turn their attention from that pain for a moment. And even though their levels of pain and anxiety kind of stayed the same, they felt more in charge, they felt more empowered. In people with dementia, VR may provide enjoyable leisurely activities that may promote quality of life and psychological well being. And if we have time, at the end of the presentation, we'll talk about some of the really unique interventions with people with dementia, specifically in this case, reminiscence therapy. And reminiscence therapy uses triggers from the person's past. You know, a lot of times, especially in Alzheimer's, people with Alzheimer's disease cannot remember the recent past, but they can remember the distant past. So using virtual reality, helping them, helping put them back into that place where they can hear the music, you know, if it was big band or, and see the people that the way people dressed or whatever can help them connect with a happier time in their life and one that they remember and remember clearly. And that's associated when they have that sense of connection and reminiscence. It is associated with increased mood, increased quality of life, and reduced agitation. Depression and suicidality can also be another target for virtual reality as an adjunctive therapy. This is obviously not going to do everything, but since depression and suicidality are characterized by excessive negative imagery, and in positive, positive imagery, you know, which makes sense, when people are depressed, they're focusing on the negative and having a hard time seeing the positive. They developed this program called Edge of the Present. And in one study of 79 people using the Edge of the Present virtual reality intervention, hopelessness scores and negative mood decreased and their sense of presence was high. So this takes us back to mindfulness, because in this particular virtual reality scenario, people are also encouraged to be present in the moment, so they're not thinking about the things that they feel hopeless and helpless about. They're present in the moment they're able to engage in the virtual reality, they're able to notice and they're encouraged to notice some of the positive experiences and positive things that are in their, in their wake. So it, the article did not go into deep detail on the edge of the present intervention, but it did show some very robust effects. And I'm really excited to see what future studies will show there. And we've long talked about virtual reality for addressing anxiety and phobias and PTSD through exposure therapy, guided rehearsal or and and which helps people develop a sense of personal efficacy and, and agency in a situation. It helps them feel safer, for example, when they are getting ready to go on a hike, that if they see a snake, they know what to do, they, they've rehearsed it, they can walk through it and they know how to handle it. Another newer intervention that has come on the scene, you know, past 10 years or so is transcranial direct current stimulation or TDCS. Now this is a non invasive neuromodulatory technique. There are some that are invasive where they actually put electrodes in the brain. This is not what we're talking about here. Through tdcs people are finding a lot of relief. And I did include the article on TDCS in your classroom because again, that was one I could have done a two hour class on just in and of itself. So you can read about it, how it works. Basically, depending on where they put the electrodes, where they target the current stimulation has different effects on the person. Multiple Factors can alter TDCs, after effects and effectiveness, including the polarity, the duration of the treatment and the frequency of the stimulation and the current density of electrodes. If they put, you know, one electrode versus three electrodes, the stimulation and return electrode locations, you know, they talk very clearly in the article about where these electrodes are supposed to go. The neuroanatomy of the individual, not everybody is, you know, has exactly the same neuroanatomy, the underlying pathology or state of the person. If they have traumatic brain injury or if they've got a neurotoxic environment because of high anxiety, it may have different effects than if they are at peace, if they're calm and, or you know, obviously if they haven't had traumatic brain injury and any co administered drugs or treatments. Because transcranial direct current stimulation alters the or triggers responses in the neurons. If somebody is already taking medications, for example, that keep serotonin in that synaptic space longer, then they are going to have different reactions potentially than someone who's not taking an ssri. Obviously TDCS is not something that most of us are going to be able to be licensed to do, but it is important to know about it as an adjunctive therapy. Recurrent pain often leads to maladaptive neuroplasticity. Tdcs, it improves that neuroplasticity and it's been found as being, quote, probably effective in reducing neuropathic fibromyalgia, migraine and post operative pain. Now throughout the presentation, I'm going to use terms like probably effective because that is the, basically the level B standard for effectiveness. Your gold standards, your level A's are going to, you know, have much more research behind them, but your level Bs are found to be probably effective. That means there's a good chance that it could have a certain level of effectiveness. Obviously, just like with counseling or psychopharmacology. Note 1 treatment is probably going to work for every single person. TDCs may benefit motor function and likely improves cognition in people with Parkinson's disease. Again, going in there and encouraging neuroplasticity can potentially strengthen those neural connections and improve, you know, quality of life significantly for people with Parkinson's. TDCS improves motor rehabilitation in people with chronic and subacute stroke. So it's effective in treating depression in major depressive disorder without drug resistance. And this is an important point for people who have drug resistant major depressive disorder. They have found that TDCs, at least in the research that I read, they have found that TDCs didn't seem to be very effective. But in people who have, you know, I guess what you'd call run of the mill major depressive disorder, TDCs may be very effective. It's also probably effective for reducing auditory hallucinations and schizophrenia and probably effective in decreasing relapses and craving in alcohol addiction. They extrapolated a little bit and said that even though they haven't tested it as much in the studies that I was citing, even though they haven't tested it as much, they expect that some of the neuro circuits that are similar that are triggered in alcohol addiction are also triggered in other addictions. So it is possibly effective with other addictions. But the only article I found on tdcs with addiction was for specifically alcohol addiction. So the take home from that is to remember that TDCS can be an alternative to medication for some who aren't able to take medication. And, and so it's something to consider. It's also something to consider if your clients are struggling with something that is a chronic pain condition, either an autoimmune condition that's prompting inflammation, neuropathic pain, migraine, or you know, obviously acute post operative pain, pain itself is going to keep that HPA axis triggered. And extended periods of pain can cause HPA axis dysregulation, which as you all know, is going to likely lead to the development of at least transient mood symptoms. Nutritional interventions. You know, this is one of my favorites. Again, most of us are not licensed to be able to make nutritional prescriptions. However, it's important in terms of health education and health advocacy to make sure that people are educated about the impact of their nutrition on their mood as well as their health. Vitamins, minerals and several phytonutrients influence the expression of brain derived neurotropic factor or BDNF and serve as modifiable determinants of systemic inflammation. So if people are eating a healthier diet, they are likely to experience reduced inflammation. They are also likely to experience fewer mood symptoms. 13 main nutrients have been identified in implication in the pathophysiology of depression and systemic inflammation and include folate, iron, long chain omega 3 fatty acids, magnesium, potassium, selenium, thiamine, vitamin A, B6, B12, C, D and zinc. Most of those are pretty common in multivitamins. For example, most Americans do not get enough omega 3 fatty acids and get way too many omega 6s, so that is one of those target areas that may be helpful. Omega 3 fatty acids help that endocannabinoid system work effectively and they also are shown to help mitigate inflammation. Again, we cannot prescribe unless you're a registered dietitian. We cannot prescribe or tell people to start taking a supplement. But it's important that they understand that this is a potential avenue that could help them experience an increased quality of life and then we can make referrals to the appropriate professionals. Symptoms associated with deficiencies of these nutrients, especially when subclinical, include non specific fatigue, irritability, aches and pains, decreased immune function and heart palpitations. So we want to recognize that, for example, if somebody has subclinical deficiency of vitamin D, you know the doctor's going to say, oh, you're still within the healthy range. But, but if they're on the low end of the range, they may already be starting to experience some effects of having lower levels of that particular nutrient. Remember, the nutrients are essential to help the body break down the amino acids to make the neurotransmitters to that help people feel excited, feel motivated, get sleepy. They also are responsible for helping break down the Amino acids and the fats that are needed to make different hormones throughout the body. So nutrition is really important. What we put in our body is used in order to keep the whole thing running. In answer to Patricia's question, inflammation and health, HPA axis hyperactivation or dysregulation does contribute to systemic inflammation. Now, that's not the only thing that contributes to systemic inflammation. But yes, you're right. When somebody is under chronic stress or has ptsd, which would be a cause of chronic stress or chronic pain, maybe they got into a car accident or something, all of those can prompt a HPA axis dysregulation over time. You also have people who develop inflammation because their diet is poor and they start developing leaky gut. Now, you could argue that a poor diet is a stressor on the body which contributes to that. But in any event, yes, for most of our clients who are presenting with mood symptoms, they have been experiencing them for a while, which probably means that that HPA axis and their neurotransmitter imbalances are out of kilter for them. And it probably also means that there is that they are experiencing some level of systemic inflammation. We know that there is a direct correlation between systemic inflammation and at least 13 different inflammatory Cyto kindes and depressive symptoms. For example, 47% of studies found a positive impact of dietary intervention. So, you know, that's one of those that you can sort of take to the bank there because our current medications that we have, our psychotropics, don't even have this level of effectiveness. So we do are starting to realize that there's only so much you can do midstream if what's happening downstream, sleep, nutrition, you know, those sorts of things, if all of those things are out of whack. Gut health is increasingly also understood as a, as critical for brain health. We've talked in other videos about the gut brain axis. And yes, it's a thing your gut communicates with your brain through the vagus nerve. Along with being nutrient dense sources of vitamins and minerals, two components of plants are relevant to mental health, but not well represented in the literature. Fiber. When we eat fiber, it feeds the gut bacteria. So it goes into your system and gets down into your intestine and, and feeds those gut bacteria to keep all of those little workers happy and healthy and strong and in the right baby balance. You know, when you take antibiotics, for example, they go in and wipe out everything. And in order to get that appropriate microbial balance back, takes a while. So fiber feeds that Gut bacteria and the phytonutrients from plants, and we've heard a lot about those, serve as antioxidants. And these antioxidants go in your body and help your body clear oxidative stress. Now remember, HPA axis activation causes your body to rev up. When you're revved, you are producing toxic byproducts, oxidative stress faster. Your body can't clear it out as effectively and efficiently, it starts causing problems. When you are eating a diet that's high in antioxidants, it helps reduce some of that oxidative stress and, and consequently helps reduce some of the associated inflammation and sluggishness and apathy and all that other stuff. So food is good. Plant food can be very helpful. The darker the plant, you know, the richer the color of the plant, the richer in vitamins it generally is, is a good general rule. So iceberg lettuce, which is really pale, has fewer nutrients than romaine lettuce, for example. Vitamin D deficiency is associated with pain and muscle fatigue. A lot of people have vitamin D deficiency, especially in the winter. Skin pigmentation, obesity, northern latitudes and a poor diet can all lead to vitamin D deficiencies. Now, if you drink vitamin D enriched milk and you take a multivitamin that has vitamin D, not that I'm recommending these, just, you know, if that's something that you do, you may be fine on your vitamin D, especially if you're getting at least 15 to 30 minutes of outside time every day. But a lot of people who, you know, live in the North, I know one of you said it is incredibly chaotic weather in Baltimore right now, so you may not be getting as much sunlight as usual and your body uses the sun in order to make vitamin D. Vitamin D deficiency is associated with clinical depressive symptoms. That's why it's one of the first things that physicians will generally test for in somebody complaining of depression. Sleeplessness has been shown to induce a generalized state of hyperalgesia. So when you are sleep deprived, you tend to have a generalized lower pain threshold. That's something to, you know, think about, you know, think about for yourself if you've been sleep deprived for a period of time, not necessarily just one night, but like when you have a new baby in the house or a new puppy in the house, and you're getting up every four hours in order to feed them and toilet them and whatever else, over time it kind of starts wearing on you and you may notice that you feel achier or more painful. Sleeplessness is Also associated or lack of sufficient quality sleep is also directly correlated to increases in symptoms of anxiety and depression. Extended sleeplessness, you know, that goes on for, you know, weeks or months or worse, is associated with HPA axis dysfunction. When you wake up in the morning, your cortisol levels are supposed to be highest and decrease throughout the day. If you are not getting adequate quality sleep, your circadian rhythms are going to get out of whack. So your cortisol is probably not going to peak at the right times, which is going to be a problem. But also when you wake up and you're groggy, your brain tart triggers that HPA axis in order to ensure that you have the energy to, to fight or flee if necessary. It wants to keep you alert. Preferably not hyper alert, but alert, which means the HPA axis is going to run an overdrive. It's kind of like your inner coffee pot. Additionally, when people have a lack of quality, sufficient quality sleep, they also tend to turn to stimulants in order to help them stay awake. Whether it's nicotine or caffeine, those are tend to be the two biggies. Both of those stimulants are going to activate or hyperactivate that HPA axis and continued and and or excessive use of them will also contribute to HPA axis dysfunction. Interestingly, there are common neurobiological processes in sleep disturbance, addiction and mood disorders, particularly as it relates to the deep phase of sleep and REM sleep. And they actually have found that certain SSRIs will actually alter the REM stage of sleep as well. So they are recognizing that serotonin does play a significant role, not only in, you know, depression, for example, but also in helping you get to sleep and stay asleep and helping you work through those sleep stages, from light sleep to deep sleep and REM sleep addiction, mood disorders and sleep disturbances may reflect a neurobiological dysfunction and may not spontaneously recover, which leads to an increased risk of relapse. If you're working with someone who is struggling with depression, who is struggling with addiction, yes, you're going to do your best to help them feel better and address their cognitions and develop good coping skills. And, you know, the list goes on. But it's important to recognize that just assuming that once they start to feel better, they'll start to sleep better, that is a false premise. And it's important to work with people on sleep hygiene interventions because if they're clinically depressed, for example, they may not be practicing good sleep hygiene. And even when they start feeling better. They're not used to practicing that good sleep hygiene. They're not used to regulating their circadian rhythm, so they may not do it. Some of these things need to be conscious behavioral choices if sleep hygiene interventions aren't doing the trick and people are still feeling groggy, sleep studies and multidisciplinary interventions can also be useful. Ultimately, whether we're talking about autoimmune disorders, mood disorders or addiction, lack of quality sleep is a extreme risk factor for relapse. Over 10,000 people come to BetterHelp every day looking for a counselor. BetterHelp makes it easy for you to move your practice online and focus on what you love most, helping others. Better Help's easy to use platform, takes care of referrals and billing and provides a secured platform to communicate with your clients. Join more than 18,000 therapists at better Help helping to improve people's mental health and lives. Acupuncture is another one of those things and acupressure as well. That's been studied for a long time, but we don't talk about it a lot and we don't or I haven't seen it used a whole lot in integrated into practice, but it has been proven repeatedly. You can look in the Cochrane reviews, you can look in PubMed. There are, you know, hundreds of studies showing the effectiveness of acupuncture. And for those of you like me, who are sissies about needles, I just, I don't like needles at all. Or for people who are recovering injection drug users, acupuncture is generally not the best idea for them. That can be very triggering. Acupressure can work to accomplish a lot of this of similar effects. A systemic review of with meta with a meta analysis of acupuncture analgesia in the emergency setting found acupuncture provided statistically significant, clinically meaningful and improved levels of patient satisfaction with respect to pain relief. So that's a big check mark in the acupuncture area. If people can be offered acupuncture as a treatment instead of opioids, you know, I don't need to explain that one. In a meta analysis of almost 18,000 patients using acupuncture therapy for chronic musculoskeletal pain, osteoarthritis, that's as opposed to rheumatoid arthritis. We're talking about osteoarthritis, headache and migraine. Acupuncture was significantly better than both placebo and usual care. And they found that 90% of acupuncture benefit persisted at 12 months. So it's not one of those one and one, one of those things that you've got to do all the time over and over and over again. I'm sure you probably need tune ups. I don't know enough about acupuncture, but they found that it does have enduring effects at helping with providing analgesia. And there are other studies that have also looked at its effectiveness at reducing drug cravings. Massage, you know, acupuncture, we're talking about needles. Acupressure is a, an intense pressure. But massage can also be really effective. A single dose of massage therapy provided a significant improvement in post operative pain and anxiety compared to active comparators in the surgical pain populations. Let's think about this. And this can be true for postpartum as well. Massage triggers those relaxation chemicals. It triggers the gaba, it triggers your natural benzodiazepines, which are also muscle relaxing. So if some of your pain is coming from muscle tension, then you're, you may experience relief. Massage also increases levels of oxytocin and endorphins. And remember, endorphins are your natural opioid. So massage itself can get the painkilling juices flowing, so to speak, which can produce significant improvement in post operative pain. That is something that is important to recognize not only because, you know, it's just good to not overuse opioids and to have alternatives. But for people who are recovering from addiction, a lot of them will refuse anything stronger than an NED for, for pain relief. So massage is another really good option for them to help them with pain as well as acupressure. If they can work with an acupressure therapist to learn particular acupressure points that they can use at home, that can also be super effective for helping them address pain as well as cravings. Manual therapy, including massage, was effective for pain, stiffness and physical function in chronic pain. Bright light therapy is another one of those adjunctive treatments that you kind of hear about here and there, but it really is coming to the fore in terms of being an evidence based approach in dosing. What we're talking about is intensities of 5,000 to 10,000 lux. That is a lot of light that is really freaking bright. Measured at the level of the eyes and at a therapeutic distance of 60 to 80 centimeters from the light box for 30 minutes. Some studies went up to an hour and a half. The goal of the bright light therapy is to help reset those circadian rhythms. If you were in the class we did a couple weeks ago on circadian rhythms. You know that your circadian rhythms are responsible or involved in pretty much every system of your body from your gonadal system to your stress system to your sleep, to your pain management. You know, your circadian rhythms actually kind of get in there. Oh, and hunger and satiation. They found that bright light therapy is effective with seasonal affective disorder. You know, so those people who are struggling with, to, with having dark days now, most bright light therapy boxes do not emit the UV radiation that allows the body to convert to, to make vitamin D. What you're doing with the bright light therapy is, is setting those circadian rhythms, basically. So if they also have a vitamin D deficiency, bright light therapy will not fix that and they may need to look for other alternatives. Bright light therapy is potentially effective at improving both disordered eating behavior, specifically binge eating and night eating. Not anorexia and bulimia per se, but disordered or problematic eating disorder. Remember, your circadian rhythms are involved in the secretion of your hunger and satiation hormones. So that can help and also potentially effective at improving mood. Mainly they hypothesize because it helps reset those circadian rhythms. In people with Parkinson's disease, bright like therapy significantly improves motor dysfunction, including rigidity, tremor, nocturnal movements and postural imbalance, depression and anxiety. Sleep dysfunction, including insomnia, excessive daytime sleepiness and overall fragmentation of the sleep wake cycle. Well, that is a lot. And this is another one that since I was only doing a cursory overview of some of the latest research about event interventions for co occurring disorders, I didn't do a deep dive to be able to explain exactly how it helps with the motor dysfunction. But it's interesting to notice that it does. And Patricia, it could be very true. The bright light therapy does impact dopamine levels. So that very well could be one of the reasons that it helps with those motor symptoms. So that's a great hypothesis, but also we're, we're adjusting the circadian rhythms, which we tend to see get out of, out of whack in people with Parkinson's and Alzheimer's, etc. In people with bipolar disorder, bright light therapy significantly reduces the severity of depression in patients who are on psychotropic medications and in patients who are not on psychotropic medications. It significantly decreased disease severity. And this could be a game changer for people who are, who, who have bipolar disorder and are pregnant or postpartum. A lot of the medications that are prescribed for people who need a mood stabilizer are not safe to take during Pregnancy or during breastfeeding. So a lot of mothers, when I worked on the mother baby unit, um, all of our moms were taken off mood stabilizer medications during their pregnancy. And that was really, really incredibly hard on the individual as well as, you know, the whole unit because they would end up having, you know, episodes obviously because the, the mood was no longer being stabilized. So in people who are pregnant and postpartum, you know, breastfeeding, bright light therapy might be something to seriously consider to help them manage their disease severity during the period where they're not able to take the mood stabilizing medications. Now there are some cautions with bright light therapy that I thought were important to bring to your attention because you think, well, it's light, what can it do? Well, it does more than you think. Evening administration of bright light therapy can increase the incidence of sleep disturbances. Well, it makes sense. If your body thinks that it's time to start getting sleepy, then it needs to be getting darker outside. And if you get bright light therapy that morning sunlight basically right in your face, then it confuses the pineal gland and the person may not be able to get quality sleep. People who are bipolar may switch to hypomania during therapy. So that is an important thing to think about. You know, obviously if you've got to choose between the lesser of two evils, sometimes in a residential setting where somebody is monitored 24 hours a day, if they switch into a hypomanic episode, it's probably manageable, but that's going to be something that the, you know, attending physician has to make, obviously has to make that call. Suicidality may sporadically occur, especially early in treatment. This also makes sense from the perspective of when people are clinically depressed, whether it's unipolar or bipolar, and they have absolutely no energy as they start coming out of that depression and start to get a little bit more energy, that's one of the times, one of the pivot points where they are at much higher risk of suicidality. So if somebody's clinically depressed, they start using bright light therapy in addition to, you know, cognitive, behavioral, whatever, they start feeling more energetic and, and better, then they may be at risk for suicidality at that point for that reason. So we do need to make sure that we are regularly screening. And as I said, circadian rhythms are involved in everything. And menstrual irregularities have been reported in people who use bright light therapy. It makes sense. The menstrual cycle is on a 28 day ish cycle for people, you know, give or Take and if you are, and that is controlled by their circadian rhythms. So if you're monkeying with the circadian rhythms, you're obviously also going to be impacting the gonadal system. CBT and mindfulness are still the gold standard to address the cognitive and HPA axis and aspects of a variety of disorders. And when I say HPA axis aspects, what I'm really talking about is helping them address, be, be more present, be more aware of what's going on so they can intervene early through mindfulness and using cognitive behavioral strategies including sleep, nutrition and addressing cognitive distortions in order to reduce their overall anxiety and anger, depression, hopelessness. So they're not triggering that HPA axis constantly. Other therapies, and most of these are adjunctive, you're not going to use them instead of everything else. But other therapies that have been shown to be beneficial include bright light therapy, improved quality of sleep, relaxation activities, massage, acupuncture and acupressure, virtual reality, aromatherapy, music therapy, and animal assisted therapy. Now those last ones are gaining acceptance through continued research. And if you stick with me after class, I'm going to review some of the current best practices for people with dementia. And they really talk a lot about using aromatherapy, music therapy and animal assisted therapy in people who are experiencing dementia, whether it's alcohol related or otherwise. So for those of you who are here for the CEUs and need to get on with your day, class is over. So thank you for being here. If you've got questions, I would love to answer them. And if you want to stick around, I will go through those last few slides that talk about disorder specific current best practices. It is also linked and it is available in the PowerPoint in your classroom. So if you don't want to stick around, but you want the information, then you can read it for yourself at your leisure. Mindfulness can be effective at calming the HPA axis because we do when we're being mindful, we're focusing on the present moment, we're focusing on our breath, we're focusing on something we see, hear, smell. So we are turning our attention to theoretically a benign stimulus. So our monkey mind is not going six ways until Sunday. For that reason, it helps with down regulation of the HPA axis. Additionally, part of mindfulness practice, everyone I've ever looked at or read is deep breathing. And that deep breathing automatically slows everything down and triggers that rest and digest paradox. So that also helps tamp down the HPA axis. So yes, it is a combination of going into Another state, as you, as you put it, but also just intentionally slowing ourselves down a little bit. The quiz is available in the classroom, so you can go in there and take that at your leisure. And I will see you on Thursday, everybody. Have a great day. Now remember, if you want to stick around, I will go through these next few slides. If you're looking for particular evidence based practices and guidelines, slide 18 in the presentation links you to repositories from SAMSA, the American Psychological association, the American Psychiatric association, the National Institute for Health and Care Excellence, which is abbreviated nice. They're kind of like the SAMSA of Europe, the center for Clinical Interventions, the VA and Department of Defense website, the Registered Nurses association of Ontario. A lot of theirs, their best practice guidelines really pertain more specifically to hospital based work. And then there is a final link for guidelines from other international resources. There are, you know, Germany and other places, certain countries have their own best practices guidelines that are out there. And it's always interesting, in my opinion, to look and see what other countries are doing to help people out. So in terms of dementia, there are two categories of non pharmacological practices that are being found to be very effective. Sensory practices, specifically aromatherapy has been found to have a positive effect on agitation. Obviously it depends on the essential oil that's used. Lavender, chamomile, bergamot, all have had positive effects. Anything, any of the aromatherapy oils, essences that trigger serotonin, that trigger the endocannabinoids, is probably going to have a positive effect on agitation. Massage has also been found to have positive effects on agitation, aggression, anxiety, depression and even disruptive vocalizations. With massage, we are prompting the body to release those relaxation chemicals, those gaba, which is what benzodiazepines act on. We're activating those GABA receptors and multi sensory stimulation involves stimulation of multiple senses through a combination of light, calming sounds, smells or tactile stimulation to overcome, overcome apathy or induce calm in people who are agitated. And this is where VR can be very helpful because it provides the visual stimulation. You can combine that with calming music or nature sounds and aromatherapy to get a more holistic, multi dimensional effect. Validation therapy is individual or group practice designed to validate the perceived reality and emotional experience of the individual. Now the research I found on validation therapy was specific for dementia, but I wonder, and I did not find any studies on this, but I wonder how effective it would be in disorders that have a psychotic component. Validation therapy has been found to have positive effects on agitation, apathy, irritability, and even nighttime disturbance, which kind of makes sense. When people feel validated, when they feel like other people are listening and understanding, then they often tend to feel safer. When they feel safer, their HPA axis is not as hypervigilant. Reminiscence therapy, which we talked about earlier, has a positive effect on mood and depressive symptoms. Now, a lot of times with reminiscence therapy, VR is not used. Instead, they use pictures, photo albums, or even like jewelry or something else from the person's past that when they hold it or they see it, it triggers that past memory. Music therapy either receptive or participatory activities with music therapy promote well being, foster sociability, create familiarity, and reduce anxiety and agitation depending on the music. And this part of this could be reminiscence therapy. If you are exposing them to music that comes from a positive time in their past, it may help them feel more relaxed and at ease because they feel felt at that point in time like they were in sync, their mind and body was in sync with one another, and it wasn't nearly as scary of a time. There are a lot of different ways to use music therapy, but it in, in particular, in people with dementia and Alzheimer's, it has been found to be exceptionally helpful, as has pet therapy. And this is not animal assisted therapy. This is which uses animals to teach a skill or a concept. In pet therapy, it is merely the presence of the animal and the calming effects of the animal that are beneficial for reducing agitation, apathy and disruptive behavior. In terms of eating disorders, current best practices still indicate that a lot of times they can be managed on outpatient. There are indications in the guidelines for stepping up care all the way up through hospitalization. All of the guidelines that I looked at indicated that hospitalization should be considered for patients who have failed at outpatient care or who are at high risk for medical complications based on their weight status. If they're extremely low weight, behavioral factors like they are refusing to eat or they're purging severely their vital signs. If they are not their vital signs are not vital signs are not stable. Obviously you want medical supervision, any psychiatric comorbidity, specifically suicidality and the environmental aspects. If they are not in a supportive environment for recovery, then hospitalization may be a better alternative for early recovery while they're getting there, developing these new skills. All seven guidelines recommended family based therapy, particularly for younger patients, which makes sense. Older patients, you know, adults may not be living in a household with anybody else, but younger patients typically are living in a household with other people. So to create a supportive recovery environment, it's often important to involve the family in the recovery process. For individual psychotherapy, most guidelines recommended cognitive behavioral focusing on the symptoms and modification of dysfunctional behavioral patterns and cognitions. There is a great book out there by Barbara McFarland, Brief Therapy for Eating Disorders that provides a lot of suggestions. It's one of the first books I read when I started learning about working with people with eating disorders. Interpersonal Psychotherapy can be used to treat an eating disorder through resolving interpersonal problems in the context of the disorder. Basically it looks at what is the function of this behavior in this context right now and how does this relate to your feelings of powerlessness or inability to communicate your wants, thoughts and needs. There are the Maudsley anorexia nervosa treatment for adults uses a cognitive interpersonal so they smush them together approach and I link to that. You can look at what's involved in the Maudsley protocol. The center for Clinical Interventions is a treasure trove of workbooks for using as discussion prompts in, in group using for you know, out of session work, whatever you want to use it for. But it they have workbooks for just, well, not just about. There are about 20 common presenting issues that they have free downloadable PDF workbook workbooks available online for for other eating disorders guidelines. Because eating disorders are a unique challenge primarily because the person with the eating disorder is often in a compromised physiological state. So and a lot of people have difficulty understanding, you know, the function of the eating disorder. They see it as being something that's about food and it's much greater than that. The fear of fat, the fear of loss of control, the, you know, if you work with people with eating disorders, you know that it is a very complex condition. So the National Institute for Health Care Health and Care Excellence, nice, the American Counseling Association, American Psychiatric Psychiatric association and SAMSA recently launched the national center of Excellence for Eating Disorders and then NITA National Eating Disorders association is also out there. But these four have your peer reviewed guidelines that are available and tons and tons of research and resources. Internet gaming disorder is the last one we're going to talk about again. After six weeks, the group that received CBT reported significantly fewer weekly gaming hours and Internet gaming disorder symptoms compared to no intervention control group. But in that particular study they didn't do a pre test post test so they're not sure. You know, between the. At the end of the study the people who had Internet gaming disorder were, were gaming significantly fewer hours compared to the no intervention control group. But how many hours was each person gaming before for the intervention? So it's really difficult to see the magnitude of the progress. A second randomized control trial compared bupropion plus eight sessions of CBT2 bupropion for adolescents with comorbid Internet gaming disorder and major depressive disorder. There were no statistically significant between group differences in reductions in depression symptoms. However, the cognitive behavioral therapy group showed significantly greater reductions on time spent gaming and gaming disordered symptoms compared to the medication only group at post treatment. So CBT really gives a sense of personal efficacy and helps people develop skills and tools to address their triggers other than gaming. All righty. So that's it on the Some of the Specific ones I know there's been a lot of talk and research about the use of ketamine for suicidality and treatment resistant depression. However, when you're working with a co occurring population, those people who have concurrent addiction as well as mood and or physical health issues, ketamine is probably not one of those best practices because of its risk for triggering relapse. So you know, I haven't. I didn't even go there for this presentation, but obviously I found enough to hit the highlights. Now there are articles that are in your classroom if you're interested in learning more. If you want to know about particular best practices for a particular disorder, email me@supportlce.com and I will gladly do the research in PubMed and send you some links to those articles because you know that's one of my hobbies. I don't know why. Anyhow, everybody have a fabulous weekend or week and I will see you on Thursday.