Meeting Your Goals When You Have ADHD

Meeting Your Goals When You Have ADHDAs someone with attention deficit hyperactivity disorder (ADHD), you probably know all too well the difficulty of accomplishing your goals. It can seem utterly daunting.

That’s because realizing goals taxes the executive functions in your brain, said Roberto Olivardia, Ph.D, a clinical psychologist and clinical instructor in the department of psychiatry at Harvard Medical School. These functions include everything from organizing to prioritizing to making decisions to managing time, he said.

Tedious tasks are especially tough. “Laundry, paying bills, attending business meetings — things that are not intrinsically interesting can put an adult with ADD into a tailspin of inaction,” said Terry Matlen, ACSW, a psychotherapist and author of Survival Tips for Women with AD/HD.

Lack of reward with long-term goals adds to the challenge.

“ADHD brains are low in dopamine, a neurotransmitter associated with reward, arousal and motivation. Because of this, ADHD brains are starving for instant stimulation and reward,” Olivardia said.

It can seem like the odds are stacked against you in meeting your goals. But while accomplishing goals might be more challenging if you have ADHD, the key is to find the best strategies for you.

That’s what Matlen and Olivardia have done. In addition to being successful practitioners and seasoned experts in ADHD, both Matlen and Olivardia have ADHD. Here, they share insights to help you accomplish your goals.

1. Brainstorm backward. First, write down your final goal, Matlen said, “then go backward from there, and write down [all] the steps needed to accomplish the goal.” While it might seem silly, do this for seemingly straightforward tasks, too, she said. Take laundry, for instance. It’s boring and repetitive, has many steps and no one pats you on the back when you’re finished, she said.

Matlen suggested breaking it down like this: Write down, “Do family laundry.” Next, write out each step, such as:

  1. Pick up laundry from every room, and put it in the basket.

  2. Take baskets to laundry room.
  3. Sort lights and darks.
  4. Sort cold water and warm water. And so on.

Write this list on a poster, and paste it in your laundry area. As Matlen said, writing out specific steps gives your brain a roadmap to follow.

Splitting your goals into steps also helps you realize that success is within reach. When you’re working on a big project, it can feel demoralizing to realize that you haven’t finished it yet, Olivardia said. But when you break your goal into steps, you’re able to say, “I completed 4 out of 10 steps,” he said.

2. Reward yourself for every step. “People with ADHD have a higher degree of motivation if they get rewards along the way,” Olivardia said. So consider how you can reward yourself for every step accomplished.

3. Just do it. People with ADHD struggle with procrastination, which becomes especially problematic when you think you need to be motivated to get started. You don’t, Olivardia said. “In fact, getting started can get you motivated,” he said. (Here’s more tips on getting motivated when you have ADHD.)

4. Set a timer for one hour. “Time is an amorphous concept to those with ADHD,” Olivardia said. Setting a timer gives you “concrete parameters to work from,” he said. Plus, after the hour, you might even want to do more work, he added.

5. Focus on the end feeling. Visualize yourself finishing the project – and how great you’ll feel once you do, according to both experts. “Sometimes we focus too much on the actual task, rather than how it will make us feel when it’s completed,” Matlen said. Focus, for instance, on how good you’ll feel after paying your taxes, she said.

“Since ADHD-ers can lose a sense of urgency or excitement around a task easily, you may need to keep that alive in your imagination,” Olivardia said.

6. Focus on self-care. Whenever people with ADHD hyper-focus on a task, they ditch healthy self-care, such as getting enough sleep or even drinking enough water, Olivardia said. You worry that stopping will sabotage your progress, he said. “However, being tired and hungry are the very things that will guarantee that you will lose steam,” he said. So make sure you’re taking care of your bare essentials, including sleeping and eating well.

7. Take breaks. If you’re getting distracted easily – also common in ADHD – Olivardia suggested taking a complete break for 10 minutes. Then return to your task.

8. Work with a partner. Partnering up is especially helpful for tedious tasks, Matlen said. “If bill paying is a horrifying experience, set up a time each month with a friend and do it together,” she said.

Having a friend who keeps you accountable for your goal also helps, Olivardia said. “Sometimes just knowing that you will be reporting your progress — or lack of progress — can provide you with the sense of focus to stick with it,” he said.

9. Get creative. Think of how you can make meeting your goals a more enjoyable or interesting experience. For instance, play music when you’re cleaning your house or use colorful stickers for filing, Matlen said.

10. Get help. Hiring outside help doesn’t just help you meet your goal; it might even save you money. For instance, if you hire a bookkeeper to pay your bills and balance your account once a month, you’ll likely save money on bank and other late fees in the long run, Matlen said.

11. Don’t assume that you can’t accomplish goals.  “Most importantly, never assume that you are not meant to accomplish great things because you have ADHD,” Olivardia said. “It can feel that way because you know that you are executing goals in a different manner from your non-ADHD counterparts,” he explained. But there’s nothing wrong with using a different strategy.

One size never fits all. The key is to find specific tactics that work well for you. And, again, don’t forget that even though meeting your goals might be challenging, as Olivardia said, you can absolutely accomplish great things.

USA Today Publishes Harmful Prejudice, Misinformation About People with Mental Health Concerns

USA Today Publishes Harmful Prejudice, Misinformation About People with Mental Health ConcernsUSA Today on Thursday published an editorial hopefully entitled, Editorial: Fix broken mental health system. Which would be fine as a stand-alone piece advocating more money, focus and resources for our nation’s patchwork system of mental health and recovery care.

Instead, they — like many well-meaning but apparently brain-dead newspapers — tie the need to fix our mental health care system — something others have been advocating for for decades — to recent headline-news grabbing acts of atrocious violence.

Only buried in this hypocritical, two-faced gutter-piece editorial do you find the truth — “Only the tiniest fraction of the mentally ill ever become violent, and then, usually when they fail to get treatment.” It’s even worse than that — statistically speaking, mental illness is a horrible predictor of violence, and nobody who’s read the research would ever suggest otherwise.

I have no problem with you advocating to help people with mental health concerns. I have a big problem if you’re doing so because of violence in America. The two have little to no connection with one another.

People let to get all riled up and angry when something tragic occurs. It’s one way many of us cope and try to figure out such events. But when we respond to tragic events with action, we’re likely to do so in a way that makes little sense in the overall, broader picture.

The fact is people with mental health conditions are no more likely to be violent than is the general population.
~ Wayne Lindstrom

For instance, every year in America, over 12,000 people a year are murdered — most by some sort of gun. Nobody gets upset at that huge number, or that 30,000+ people a year who take their own lives.

Instead, the thing that USA Today wants us to get motivated by are these horrific acts of violence that barely read in the overall number of deaths per year due to gun violence. USA Today doesn’t seem to care about the 30,000+ people each year who, because of untreated depression or other mental health concerns, choose to end their lives.1

Wayne Lindstrom, the CEO of Mental Health America, on the other hand, gets it right in his response to the crummy piece of what passes for “insightful opinion” at USA Today:

The premise that we can predict or prevent violent acts is unsupported. Even in the case of severe mental illnesses, mental health professionals possess no special knowledge or ability to predict future behavior.

The fact is people with mental health conditions are no more likely to be violent than is the general population. Continuing to link violence and mental illness only stigmatizes people and deters them from seeking care.

We whole-heartedly share and endorse these words. We stand proudly with Mental Health America and other organizations who’ve read the research and know that linking mental illness to violence is like linking terrorism to a specific religion — it’s a feel good strategy imbeciles do to make themselves feel better.

USA Today rues the good ole days, when we could lock up anyone society disagreed with or didn’t like the looks of in a mental hospital (nowadays referred to an inpatient psychiatric hospital): “Many states have become so strict that it is almost impossible to get people committed until they are in deep crisis, or try to commit suicide or harm someone.” Awww, what a shame — we actually have a reasonable, humane standard before trying to take someone’s freedom away from them.

USA Today should be ashamed of itself for publishing an editorial that only reinforces the discrimination, stigma and prejudice against people with mental health concerns. They continue to spread misinformation about the link between mental illness and violence,2 and suggest we have some sort of magical powers of foresight that would allow us to predict these kinds of incidents with such accuracy, it would be like the science-fiction story, “Minority Report” (we don’t have such magical powers, sorry).

 

USA Today crap editorial: Editorial: Fix broken mental health system

Wayne Lindstrom’s response: Opposing view: Don’t link violence with mental illness

Footnotes:

  1. Worse, they cite the example of Seung-Hui Cho — who actually had contact with mental health professionals!
  2. There really isn’t much of one, according to you know, the actual research.

Don’t Ask Me What I Do, Instead Ask Me Who I Am

Don't Ask Me What I Do, Instead Ask Me Who I AmI carry a few different business cards in my purse. Because I never know what conversation I will have with a stranger at any given time.

A month ago I fetched cream for my coffee at a café in South Bend, Indiana. Naturally my family didn’t know a soul in the joint. However, by the time I returned to my table, I knew some incredibly intimate (not to mention interesting) details about the daughter of the man next to me who was reaching for a napkin: his daughter is bipolar; she was anorexic as a teenage ballerina; and she’s on some of the same meds as I am.

I ended up giving him a business card with everything but my email scratched out.

I didn’t want to have the conversation of what I do for living.

It doesn’t have anything to do with who I am.

And that’s why I get so annoyed that we have to start all of our conversations with that question.

As a country, we are obsessed with our jobs: An understatement. Our professions are central to our self-identities and our industries define who we are. We don’t even know how to vacation. It doesn’t matter that United States workers receive far fewer vacation days than other workers in other industrialized countries because American employees fail to take the time off that they have accrued. Our European friends shake their heads at that one.

I remember how refreshing it was to ask a French couple “what they did” (I plead guilty) at a swim meet for our kids.

“We are skiers,” they said emphatically. No equivocation. No insecurity. No approval-seeking.

That was who they are and were proud of being, and told me a hell of a lot more about them than had they rattled off their resumes starting with their last places of employment: “I’m an accountant with Ernst & Young.” “I’m a consultant with Booz Allen Hamilton.” “I’m a program manager with Northrup Grumman.” Snore. Snore like Gramma.

My conundrum is that I wear a few different hats at the present moment, so I, in fact, don’t really know what I am. I know what my ministry or innate purpose in life is — to provide hope to those who struggle intensely with depression and other mood disorders — but it’s not related to what I do for a living as a government contractor. One pays with blessings, the other is generous with benefits. And, unfortunately in this country, most benefits are tied to your job, so while following your dream is all good and noble, you might get screwed if your appendix bursts like mine did a year ago and you need some quick medical attention. Passion, at times, has to take a back seat to medical care and other life necessities.

Upon meeting someone new, part of me hopes I will never hear the dreaded four words (what-do-you-do) because then I wouldn’t have to assess how I am going to respond — with my pragmatic communications-consultant role, or with the idealistic wanting-to-save-the-world profile.

At the least, it would be nice to delay the work conversation toward the second-half of the conversation, after the other top three questions: Where are you from? Why are you here? (conference, cocktail hour, reunion, fundraiser, Chuck E Cheese), How many kids do you have and what are their ages and when were they potty trained?

For this reason, I’ve always loved writer Oriah Mountain Dreamer’s poem, The Invitation, that went viral 15 years ago and was later published in a book. May we all share this vision one day.

It doesn’t interest me what you do for a living. I want to know what you ache for, and if you dare to dream of meeting your heart’s longing. It doesn’t interest me how old you are. I want to know if you will risk looking like a fool for love, for your dream, for the adventure of being alive.

It doesn’t interest me what planets are squaring your moon. I want to know if you have touched the center of your own sorrow, if you have been opened by life’s betrayals or have become shriveled and closed from fear of further pain! I want to know if you can sit with pain, mine or your own, without moving to hide it or fade it, or fix it.

I want to know if you can be with joy, mine or your own, if you can dance with wildness and let the ecstasy fill you to the tips of your fingers and toes without cautioning us to be careful, to be realistic, to remember the limitations of being human.

It doesn’t interest me if the story you are telling me is true. I want to know if you can disappoint another to be true to yourself; if you can bear the accusation of betrayal and not betray your own soul; if you can be faithless and therefore trustworthy.

I want to know if you can see beauty even when it’s not pretty, every day, and if you can source your own life from its presence. I want to know if you can live with failure, yours and mine, and still stand on the edge of the lake and shout to the silver of the full moon, “Yes!”

It doesn’t interest me to know where you live or how much money you have. I want to know if you can get up, after the night of grief and despair, weary and bruised to the bone, and do what needs to be done to feed the children. It doesn’t interest me who you know or how you came to be here. I want to know if you will stand in the center of the fire with me and not shrink back.

It doesn’t interest me where or what or with whom you have studied. I want to know what sustains you, from the inside, when all else falls away. I want to know if you can be alone with yourself and if you truly like the company you keep in the empty moments.

Best of Our Blogs: January 11, 2013

Ever have days when you think you got it all figured out? You’ve learned to communicate better, be more patient, and feel self-confident, imperfections and all. Then you get slammed by a day that makes you question everything.

That’s the type of day I had. Late for a doctor’s appointment. Late for a meeting. Suddenly, not so confident I can take on the world when I can’t seem to take control of my life. This comes after months of meditating, tai chi and yoga. Surprisingly, it did little to abate incessant and unnecessary insecurities and anxieties I felt over something so unimportant. I guess I assumed life would be easier. But I realized that taking responsibility for your life and being mindful of each moment made things more challenging. It was up to me to choose whether I was going to beat myself up for being out of control or learn to let it all go (the former being a lot easier than the latter).

It’s a question you may have also asked yourself recently. If so, know that it’s okay to get riled up sometimes. It’s okay if you have a bad day and make a mistake. There’s always tomorrow to right what we’ve wronged yesterday.

This week our bloggers are helping you to stop getting caught up in failure so you can choose to accept what is and let go. So whether you’re having trouble sticking with your 2013 resolutions or just want to communicate better, you’ll find it all here minus the judgment and the perfectionism.

8 Tips to Improve Your Communication
(Parenting Tips) – Think you’re a good communicator? Find out how what you say can hurt, not help your relationships. Then read these 8 things you can do about it.

3 Steps to Making Intentions Stick in the New Year
(Mindfulness & Psychotherapy) – Having trouble keeping to those New Year’s resolutions? Don’t be so hard on yourself! Find out why imperfection and failure are part of the process.

Love: The Healthy Addiction?
(Sex & Intimacy in the Digital Age) – Can love be as destructive as an addiction? Here’s how to know if you’re love is healthy or an emotionally unhealthy addiction.

Beware the Trap of Perfectionism: An ADHD Lesson
(ADHD from A to Zoë) – Perfectionism can get the best of us. Zoë shares how having ADHD can make it particularly insidious.

Developing Creativity: Notable Research and Books in 2012
(The Creative Mind) – An interesting new topic in neuroscience is cognitive flexibility. It delves into both creativity and intelligence and how they are intertwined.

Time to Rethink Separating Out the Psychiatric Record?

Time to Rethink Separating Out the Psychiatric Record?Traditionally, most hospitals have separated out the psychiatric record from a patient’s medical record. This was done historically because of the stigma and discrimination associated with psychiatric concerns — and the serious lack of training in medical school for physicians to understand such information in proper context.

As hospitals move to electronic records, the default behavior has been to simply keep things as they are — so no more processes than necessary have to change at the same time. This means keeping the psychiatric information in the electronic record segregated from a patient’s medical information.

But in an intriguing new study just published — on a very small cohort — researchers found that where hospitals allowed any properly authorized medical staffer to access the patient’s psychiatric information in the electronic health record (EHR), hospital readmissions went down.

Perhaps it’s time to re-evaluate whether opening up the sharing of such information among all doctors on a patient’s treatment team might actually be a good thing.

To get the data, the researchers surveyed 18 hospitals on the 2007 U.S. News and World Report list of the “Best Hospitals in the United States.”

“Of that group, eight hospitals (44 percent) kept most or all of their inpatient psychiatric records electronically, and five (28 percent) let non-psychiatrist physicians see mental health records, including psychiatric admission notes, discharge summaries, notes from the emergency department, and consultation notes.”

Just four hospitals did both. Among this latter group, however, readmission rates for psychiatric patients were substantially lower than at the others on the list. Here’s what they found:

Top teaching hospitals that provided non-psychiatrists with electronic access to inpatient psychiatric records had up to 39% lower rates of readmissions within 7, 14, and 30 days of initial discharge than comparable institutions that did not include inpatient psychiatric notes in their EHRs. Full access also cut 7-day readmission rates by as much as to 27% when compared to hospitals that did not let primary care and emergency physicians see psychiatric records in the EHR

I only have one concern — that non-psychiatrist physicians treat the psychiatric information with the same care they would as if it were their own information. Sometimes doctors are a little too loose with a patient’s medical information when talking to other docs — especially in public places where many others may hear (like an elevator).

I’m also concerned that stigma, discrimination, prejudice and misunderstanding are still fairly rampant among some physicians — especially in certain specialties. Without proper education and training, I worry that some doctors may misuse or inappropriately share information gleaned from a patient’s psychiatric record. Proper education and training could readily solve this concern, however.

Patients, too, ultimately benefit from such increased sharing, as this study — if confirmed by others — demonstrates. If patients are afraid of this development, I usually find information is the best remedy — showing patients exactly what is and isn’t in their medical and psychiatric charts. Patients, of course, have a right to view their medical and psychiatric records in their entirety. In most instances, once a patient sees how little is actually in their psychiatric or mental treatment progress notes (if it’s being properly maintained), they’re usually satisfied.

I’m a big believer in the benefits of transparency and open communication. If giving doctors access to all relevant data of a patient — including their psychiatric history — can help patients receive better care, why not do it?

 

Read the full article: Sharing Psychiatry EHR Data Cuts Readmission Rates

Is Distance Treatment the Wave of the Future?

With advances in technology, distance learning on college campuses has exploded over the last decade.  And as time passes, the mental health community is taking note.

Students want to study when they want and how they want.  Distance learning makes education available to those who wouldn’t otherwise be able to get off of work, travel to class or spend hours in lectures.  

That same increase in convenience and availability could have a real impact for people seeking psychological treatment. Is distance treatment ready to take off?

People who must maintain jobs, care for children or aging parents, don’t have cars or access to public transportation or want to learn material that is not offered where they live can all benefit from distance learning. These are often the same reasons people struggle to access mental health services.

And there is a large body of research that suggests distance learning and traditional classroom learning provide the same quality of education. Distance learning is no longer considered a sub-standard educational option.

So, how can these benefits apply to receiving psychological treatment?

Treatment available online or at a distance could certainly help people with difficulties in getting to therapy sessions and incorporating treatment into a busy lifestyle. It would also enable people to access specific treatment modalities not otherwise available to them.

And, according to the American Psychological Association, psychologists have begun using electronic communication such as email, Skype and various forms of videoconferencing to augment treatment. But, while technology surges ahead, licensing laws and guidelines for providing safe and ethical distance treatment are still catching up.

A recent article reporting on the use of phone therapy in Monitor on Psychology suggests that talking on the phone with a therapist can provide the same, or even better, results for some.

In this study, conducted by University of Cambridge researchers, British adults with mild and moderate depression and anxiety disorders who received cognitive behavioral-based therapy via the phone benefited as much, if not more, than those who received face-to-face therapy. Those with severe symptoms did not see the same results.

This study also found that telephone therapy was less expensive than traditional therapy and was conducted as part of a national initiative in Britain aimed at increasing people’s access to therapy.

The telephone is only one of many options for providing distance treatment. The number of mental health tools available is rapidly increasing. And many in the field agree that it’s time for practitioners to embrace technology and what it has to offer in delivering interventions.

One-on-one treatment cannot be replaced.  Nor should it.  However, the need for treatment providers to meet the changing and growing mental health needs of the population has caused the ΑΡΑ Insurance Trust and the Association of State and Provincial Psychology Boards to launch a task force to develop guidelines for tele-psychology practice.

So what are some of the alternatives to one-on-one therapy?  According to a cover story in the APA Monitor they include the following:

  • Behavioral intervention technologies, such as those that deliver care via the Internet or mobile phones
  • Computer programs for depression and other disorders, which typically teach principles of cognitιve-behavioral therapy or some other evidence-based treatment

Although these treatment options are appealing and there is a growing body of research to suggest that many are effective, it is important to proceed with caution.  It is essential to ensure that individuals get the right treatment and that treatments offered have been studied and found effective.

We Underestimate Our Changes: The End of History Illusion

We Underestimate Our Changes: The End of History IllusionIt’s like déjà vu all over again. ~Yogi Berra

Yep. That’s me in my fabulous Nehru tux getting ready for my prom date. I was about as spiffy then as spiffy could be. The tux was rented, but I had my regular Nehrus in the closet. They were next to my bell-bottoms, tie-dyes and 8-tracks.

What happened?

The Nehru went out of style around 11:55 p.m. the night of the prom and I had to hang on to my bell-bottoms and tie-dyes for about 30 years for them to come back around into fashion. The 8-tracks? They gave way to those newfangled cassettes.

How could I have been so wrong about the future of Nehrus and 8-tracks? Actually, when I think about it, I was wrong about a lot of things: The Afro perm I thought would look spectacular on me forever, the Beatles never breaking up, my best friend Kevin and I being pals for life, the Osborn 55-pound “portable” computer, and the 8-track tape player (which cost me a week’s salary) I had installed in my car. Naturally I thought my prom date would never change.

But in spite of my convictions at the time I was about as wrong as wrong could be. The good news is I am not alone.

Research recently reported on in the New York Times about a study on self-perception published in Science shows that individuals at every age and demographic make this kind of error: They call it the End of History Illusion because at each age we tend to underestimate the changes we will go through in the coming decade — even when we can point to all the changes we’ve been through in the last 10 years.

We think — somehow — that we have arrived at a more evolved plateau of being. We tend to think we are in a good enough place, perhaps even somewhat satisfied, and that things are not going to change that much. This builds on research that shows we do better at remembering who we were than predicting how much we will change. That brings us to the bad news.

I am (we are) about to do it all over again. Right now the chances are we are thinking the same thing about our future — we believe we are going to live, love and long for where, who, and what we are thinking about right now. But the research says it just ain’t so. This too is a transient state.

Professor Daniel Gilbert and postdoctoral fellow Jordi Quoidbach of Harvard and Timothy D. Wilson of the University of Virginia studied over 19,000 participants ranging in age from 18 to 68 in an online questionnaire. Each phase of life group underestimates how much they are likely to change in the coming decade. In other words, the research demonstrated that at every age we describe more changes in the past 10 years than we would have predicted a decade ago.

According to Gilbert, “What these data suggest, and what scads of other data from our lab and others suggest, is that people really aren’t very good at knowing who they’re going to be and hence what they’re going to want a decade from now.”

How could this be? Mounting evidence indicates that we are influenced by what is happening to us now to the point that it creates a distortion of what we want and what will make us happy in the future. These findings were made popular by Daniel Gilbert’s bestselling book Stumbling on Happiness . He noted that there is a cognitive bias as to what makes us happy. This bias makes us predict very poorly what will make us happy in the future.

It is a hard pill to swallow. But the fact remains that we tend to make systematic mistakes about what is going to make us happy downstream. The advice? Don’t imagine your future. Use others’ experience to chart your course. We have lots of data about what people experience in different life stages. This is a more realistic guide to how you are going to feel once you have those experiences – not your own imagination of what it will be like. (In other words, hold off on that tattoo you were thinking of getting until you talk to someone who has had one for a while.)

Or you can simply remember the words of Yogi Berra: The future ain’t what it used to be.

Additional Reading

Quoidbach J., Gilbert, D.T., and Wilson, T.D. The End of History Illusion. Science 4 January 2013: 96-98. [DOI:10.1126/science.1229294]

Kaiser Permanente’s eCare for Moods Racks up Another ‘Win’

Kaiser Permanente's eCare for Moods Racks up Another 'Win'In the last decade, Kaiser Permanente launched a web-based service known as eCare for Moods, meant to help support patients within their health care system with bipolar disorder. Over the years, there’s been some research to support the use of this online tool to help improve patient outcomes.

In the November 2012 issue of Psychiatric Services, another study was published demonstrating the effectiveness of this free online tool for Kaiser Permanente customers. The study, by Hunkeler et al. (2012), found that depressed patients who had access to and used the eCare system had better outcomes — reduced depression and better overall health.

But although the research team clearly believes this is a “win” for eCare for Moods, after examining their data, I’m not so sure. If it’s a win, it’s more of a statistical win than a win for reducing a patient’s depression symptoms.

First, let’s get out of the way the fact that more than half of the study authors (out of 12) are affiliated with Kaiser, the publishers of the eCare system (parts of which Kaiser has also applied for patents, suggesting a potential revenue motive underlying some of this1 ). Obviously, when you work for an organization and are researching that organization’s tool for effectiveness — and possible later license or such — there might be some… ahem… incentives for a positive finding.

The study was designed to measure depression symptomology of participants who were divided into two groups. One group would have access to Kaiser’s proprietary eCare for Moods online web-based support and messaging system, in addition to their usual mental health care. The other would have just the usual mental health care provided by Kaiser. This design helps ensure that the primary difference between the two groups is the eCare for Moods program.

The program itself is comprised of a secure, password-protected website that provides personalized self-monitoring tools, secure messaging with the patient’s eCare manager — a trained psychiatric nurse — 8 depression psychoeducational modules, an appointment calendar, and a monitored discussion group (which you could only access after completing all 8 modules). eCare was only offered during the first year of the study. The second year of the study was just ongoing assessment of how the two groups were still doing, to see if the effects of eCare — if any — wore off over time.

How participants were doing was measured in telephone interviews after the initial interview was conducted in-person. The interviews included a number of different health surveys and questions designed to measure progress.

Which brings me to the second nitpick — why didn’t the study authors use a standardized and recognized measure for depression symptoms? Instead, these 12 researchers decided to make up their own, with no rationale for doing so (and no psychometrics provided on their made-up depression scale):

All interviews included an assessment of depressive symptoms experienced over the previous two weeks with questions adapted from the SCID. This provided a psychiatric status rating of the severity of current depression on a 6-point scale derived from the research diagnostic criteria2

Worse, the interviewers then had the subjects recreate a week-by-week blow of their mood for the previous 6 months. By memory. Could most people accurately recall how they were feeling three weeks ago — much less 3 months ago?

So the researchers were reliant on accurate memory recall to fill in the blanks every 6 months. It’s not clear why they didn’t simply have participants keep paper-and-pencil journal logs or use some other more frequent data recording method if they wanted weekly data tallies.3

Weird.

Depression Scores Decrease — for Everyone

The third problem is that the average depression score at the baseline of the study was 3.88 (eCare group) or 3.65 (usual care group). According to the researchers, depression is scored as: “3, moderate impairment; 4, marked impairment but below DSM-IV criteria for [a depression] episode.” In other words, the average of the participants was somewhere below the threshold to actually diagnose anything but the mildest of depression.

But if you think that’s bad, wait — it gets worse.

After a full year of treatment, the eCare group still averages a 3.00 — moderate impairment (technically, still depressed). They’ve dropped nearly a full point on the scale, but that’s it. According to the criteria, they’re still pretty much as depressed as they were when they started (as a group). The usual care group after one year looks pretty darned similar — a 3.10. While they’ve only dropped a half point (since the group wasn’t as severely depressed as the eCare group), their improvement is less impressive. But again, as a group, still depressed.

At the end of 2 years, no statistically significant change occurred in the eCare group — now it’s at a 2.95 average score. Same with the usual care group — now at a 3.11.4

Now, unfortunately, the clinical trials record doesn’t note what specific primary outcome measure they had planned to use. So we can’t know if they decided to change the primary outcome measure because it was even less impressive than what we’re seeing here.5

That’s okay — the researchers had another way to make these results look more impressive than they are. They also measured the “presence of depression” (as though depression was like an off/on switch). Any score less than 3 on the PSR means depression isn’t “present” any longer. Score 3 or higher and you’ve still got depression.

If this sounds arbitrary, that’s because it is. It is one of the ways researchers today get around the fact that a treatment isn’t really as effective as they hoped it would be. (Of course, the eCare group came out on top in this measure.)

Summary

The upshot? Here’s a study demonstrating the statistical effectiveness of a treatment intervention supplement — eCare for Moods — that likely had very little real world benefit for the patients who were using it. One of the areas that stand out in the data with a difference between the two groups — learning new coping skills — could be attributed to the psychoeducational modules the program offered.

These modules, of course, could be offered to the general public today and help potentially thousands learn new coping skills.

The eCare system itself has problems with keeping its audience. While 90 percent of patients logged into the system during the first 6 months, that dropped to under 50 percent in the next 6 months. Only 4.6 (on average) of the 8 educational modules were completed by participants — less than half of participants completed the full 8 (a problem common among virtually all online psychoeducational interactive learning modules).

While I appreciate that eCare for Moods can be a helpful supplement to people with mood disorders — such as depression or bipolar disorder — I feel like this research team may have overreached in extolling the benefits of the program. I’m not so sure that weekly depression severity was significantly different from the usual care group, given the data presented in this article alone.

 

References

Hunkeler, E.M. et al. (2012). A web-delivered care management and patient self-management program for recurrent depression: A randomized trial. Psychiatric Services, 63, 1063-1071.

 

Footnotes:

  1. Yes, even non-profits can have a revenue, if not profit, motive.
  2. Criteria, I should note, that were first proposed back in 1978 — long before the DSM-III-R made the scene. The researchers list no rationale for using this depression scoring method — as opposed to one of the well-researched and regularly-used depression measures. The researchers also fail to acknowledge this as a limitation in the article.
  3. The researchers make no note of this methodology concern in their limitations discussion. Ideally, the study would be designed to incorporate data directly from patients themselves, without retrospective memory coming into play, or the potential bias of the interviewer.
  4. p = 0.047 in a time-by-treatment repeated-measures design
  5. This study took a really long time — more so than usual — to make it into publication. This study was begun in 2002 (and was supposed to include bipolar patients too) with data collected primarily in 2003 and 2004. Its results were first presented at a conference in 2009, and it finally appeared in a journal in late 2012. Draw your own conclusions.

5 Questions You Need to Ask About Your New Year’s Resolutions

5 Questions You Need to Ask About Your New Year's ResolutionsIt’s fun to think about New Year’s resolutions, and I always make them (in fact, I make resolutions throughout the year). If my happiness project has convinced me of anything, it has convinced me that resolutions — made right — can make a huge difference in boosting happiness.

So how do you resolve well? This is trickier than it sounds.

Samuel Johnson, a patron saint of my happiness projects, was a chronic resolution-maker and resolution-breaker. He alluded to the importance of making the right resolutions in a prayer he wrote in 1764, when he was fifty-five years old.

“I have now spent fifty-five years in resolving; having, from the earliest time almost that I can remember, been forming schemes of a better life. I have done nothing. The need of doing, therefore, is pressing, since the time of doing is short. O GOD, grant me to resolve aright, and to keep my resolutions, for JESUS CHRIST’S sake.”

Sound familiar? How often have you thought something along these lines, yourself? The fact that a genius like Dr. Johnson wrote this is very comforting to me.

So, how do you resolve aright, and keep your resolutions? Ask yourself these questions…

1. Ask: “What would make me happier?”

It might mean more of something good — more fun with friends, more time for a hobby. It might be less of something bad — less yelling at your kids, less nagging of your spouse. It might be fixing something that doesn’t feel right — more time spent volunteering, a move. Or maybe you need to get an atmosphere of growth in your life by learning something new, helping someone, or fixing something that isn’t working properly.1

2. Ask: “What concrete action would bring change?”

People often make abstract resolutions. “Be more optimistic,” “Find more joy in life,” “Enjoy now,” are hard to measure and therefore difficult to keep. Instead, look for a specific, measurable action. “Distract myself with fun music when I feel gloomy,” “Watch at least one movie each week,” “Buy a plant for my desk” are resolutions that will carry you toward those abstract goals.

3. Ask: “Am I a ‘yes’ resolver or a ‘no’ resolver?”

Some people resent negative resolutions. They dislike hearing “don’t” or “stop” (even from themselves) or adding to their list of chores. If this describes you, try to find positive resolutions: “Take that dance class,” “Have lunch with a friend once a week.” Along those lines, my sister told me, “I don’t want a negative. I tell myself, ‘I’m freeing myself from French fries,’ not ‘I’m giving up French fries.’”

Or maybe you respond well to “no.” I actually do better with “no” resolutions; this may be related to the abstainer/moderator split. A lot of my resolutions are aimed at getting me to stop doing something, or to do something I don’t really want to do — such as Don’t expect gold stars. There’s no right way to make a resolution, but it’s important to know what works for you. As always, the secret is to know your own nature. 2

4. Ask: “Am I starting small enough?”

Many people make super-ambitious resolutions and then drop them, feeling defeated, before January is over. Start small! We tend to over-estimate what we can do over a short time and under-estimate what we can do over a long time, if we make consistent, small steps. If you’re going to resolve to start exercising (one of the most popular resolutions), don’t resolve to go to the gym for an hour every day before work. Start by going for a ten-minute walk at lunch. The humble resolution you actually follow is more helpful than the ambitious resolution you abandon. Lower the bar!

5. Ask: “How will I hold myself accountable?”

Accountability is the secret to sticking to resolutions — think AA and Weight Watchers. There are many ways to hold yourself accountable; for example, I keep my Resolutions Chart (if you’d like to see my chart, for inspiration, email me). Or you might want to join or launch a Happiness Project group, for people doing happiness projects together. Accountability is why #2 is so important. A resolution to “Eat healthier” is harder to track than “Eat salad for lunch three times a week.”

If you want to make 2013 a happier year, probably the best place to start is by working on your relationships; strong relationships are key to a happier life. If you’re intrigued, consider joining the 21 Day Relationship Challenge. Every day, for 21 days, I’ll suggest a resolution. (And don’t worry: nothing that takes a lot of time, energy, or money! Many are fun!)

?Have you found any strategies or questions that have helped you successfully keep resolutions in the past? What resolutions did you make?

Footnotes:

  1. These questions relate to the First Splendid Truth.
  2. That’s the Fifth Splendid Truth.

13 Healthy Ways to Comfort Yourself

13 Healthy Ways to Comfort YourselfWhenever you’re anxious, sad or overwhelmed or simply need some soothing, it helps to have a collection of comforting — and healthy — tools to turn to.

But some calming activities don’t work for everyone.

For instance, some people are allergic to bath salts, while others can’t drink herbal tea because of possible drug interactions (e.g., blood thinners). Many of us also can’t afford manicures or massages. And most of us are pressed for time.

So we asked three experts for their take on how readers can truly soothe their minds and bodies without needing more money, time or anything else, for that matter. Below are 13 strategies anyone can use to comfort themselves when they’re having a bad day.

1. Stretch your body.

Anxiety tends to hijack the body. While everyone stores anxiety in different spots, common areas are the jaw, hips and shoulders, according to Anna Guest-Jelley, a body empowerment educator, yoga teacher and founder of Curvy Yoga. She suggested standing up and doing a full-body stretch. “Reach your arms overhead then slowly fold forward [and] slowly open and close your mouth as you do.”

2.Take a shower.

Taking a shower after a rough day always makes Darlene Mininni, Ph.D, MPH, author of The Emotional Toolkit, feel better. And she’s certainly not alone. Now research is illuminating why cleansing may wash away our woes.

Mininni cited this interesting review, which notes “a growing body of research suggests…after people cleanse themselves, they feel less guilty about their past moral transgressions, less conflicted about recent decisions, and are less influenced by recent streaks of good or bad luck.”

3. Visualize a peaceful image.

The image you pick can be anything from the sun to ocean waves to a furry friend, Guest-Jelley said. She suggested combining the visualization with breath, and repeating the sequence several times. As you inhale and reach your arms out in front of you, hold the image in your mind, she said. Then exhale and bring both hands to your heart, all the while thinking of the image, she said.

4. Speak compassionately to yourself.

Being self-compassionate boosts mental health, Mininni said. (Some research even suggests that it helps you reach your goals.) This means extending yourself some kindness as you would to a good friend, she said.

Unfortunately, being self-compassionate doesn’t come naturally to many of us. Fortunately, you can learn to treat yourself with consideration and care. Here are some ideas on being kinder to yourself and cultivating self-compassion.

5. Reach out.

Reach out to people you trust to support you. “We are wired to connect with others and to comfort each other through emotional and physical connection,” said Julie Hanks, LCSW, a therapist and blogger at Psych Central.

6. Ground yourself.

When stress strikes, some people feel lightheaded or like they’re floating outside their bodies, Guest-Jelley said. Making a point to feel your feet against the ground can help, she said. “Grounding your feet can bring you back into your body and help you navigate what you want to do next,” she said. “Visualize thick roots growing down from your feet into the center of the Earth, rooting you and giving you a firm foundation.”

7. Listen to soothing music.

“Create a playlist of soothing songs that help you to slow down or connect with memories or positive experiences,” Hanks said. We’ve mentioned before the benefits of listening to calming music. Pairing soothing tunes with deep breathing helps, too, according to one study, which found it lowered blood pressure.

8. Practice mindfulness.

To practice mindfulness, “You don’t need to sit like a pretzel,” Mininni said. Simply focus on what you’re doing right now, whether that’s washing the dishes, walking to your car or sitting at your desk, she said. Pay attention to the sights, scents and sounds surrounding you, she said.

For instance, if you’re washing the dishes, focus on the scent of the soap and the hot water cascading from the faucet and onto your hands, she said.

Mininni applies mindfulness to her feelings. In the moment, she asks herself what her emotion feels like. Doing this actually allows her to detach from her feelings and thoughts and simply observe them as if she were watching a movie. This helps you get out of your head and into your body, she said.

9. Move your body.

According to Hanks, “If you’re feeling tempted to engage in self-destructive behavior to calm down, engage in something positive and active, like exercise or playing a physical game.”

10. Picture the positive.

When we’re anticipating a potentially stressful situation, we start thinking of all the different ways it can go wrong. Again, you can use visualization to your advantage. “To pull yourself out of [an] internal dramalogue, try imagining the situation going well,” Guest-Jelley said. “Feel what you want to feel in the moment and see yourself disengaging from tricky conversations [and] situations,” she said.

11. Zoom out.

Look at the situation or stressor from a bigger perspective, Hanks said. “When you’re in the moment, current challenges seem enormous, but placing your situation into the ‘bigger picture’ of your life may help you realize that you may not need to give it so much emotional energy,” she said.

For instance, she suggested asking yourself: “Will this matter in one year? In fie years? When I reach the end of my life, how important will this situation be in retrospect?”

12. Practice alternate nostril breathing.

Breathing techniques are an instant way to soothe your body. Taking deep, slow breaths tells your brain that everything is OK, which then calms the rest of the body. Guest-Jelley suggested going through this series:

  • Using your dominant hand, “make a U-shape with your thumb and pointer finger.
  • If you’re using your right hand, press your right thumb into your right nostril, gently closing it. Inhale through your left nostril.
  • Next, press your right index finger against your left nostril, closing it, as you release your thumb from the right nostril – allowing yourself to exhale through the right nostril.
  • Repeat by inhaling through the right nostril, then closing it and exhaling through the left nostril.
  • Continue like this for at least 10 full breaths.”

13. Let yourself feel bad.

Remember that you don’t have to fix your feelings right away. It’s important to have a toolbox of healthy strategies to turn to at any time. But don’t feel guilty for feeling bad or fault yourself if you aren’t seeing rainbows and unicorns.

Mininni stressed the importance of giving yourself permission to acknowledge and honor your feelings and stay with them. “Sometimes it’s OK to just say I’m having a really crappy day,” she said.

Plus, “Feelings have a purpose,” she said. They send us important messages that something isn’t quite right, she said. When you’re ready to feel better, then reach for a healthy strategy, she said.