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Yoga classes were found to be more effective than a self-care book for patients with chronic low back pain at reducing symptoms and improving function, but they were not more effective than stretching classes, according to a study published Online First by the Archives of Internal Medicine.
"Despite the availability of numerous treatments for chronic back pain, none have proven highly effective, and few have been evaluated for cost-effectiveness," the authors provide as background information. "Self-management strategies, like exercise, are particularly appealing because they are relatively safe, inexpensive, and accessible and may have beneficial effects on health beyond those for back pain. One form of exercise with at least 'fair' evidence for effectiveness for back pain is yoga, which might be an especially promising form of exercise because it includes a mental component that could enhance the benefits of its physical components."
Karen J. Sherman, Ph.D., M.P.H., from Group Health Research Institute, Seattle, and colleagues designed a study to determine whether yoga is more effective than conventional stretching exercises or a self-care book for primary care patients with chronic low back pain. A total of 228 adults with chronic low back pain were randomized to 12 weekly yoga classes (92 patients) or conventional stretching exercise classes (91 patients), or a self-care book that provided information on causes of back pain and advice on exercising, lifestyle modifications and managing flare-ups (45 patients). The main outcomes measured were back-related functional status and how much the back pain was bothering the patients. Telephone interviews were conducted at baseline, and at six, 12, and 26 weeks after randomization.
"Back-related dysfunction declined over time in all groups," the authors report. Compared with the self-care group, the yoga group reported superior function at 12 and 26 weeks (average difference, -2.5 and -1.8, respectively) and the stretching group reported superior function at six, 12 and 26 weeks (-1.7, -2.2, -1.5, respectively). "There were no statistically or clinically significant differences between the yoga and stretching groups" at any time point, the authors note.
"We found that physical activity involving stretching, regardless of whether it is achieved using yoga or more conventional exercises, has moderate benefits in individuals with moderately impairing low back pain. Finding similar effects for both approaches suggests that yoga's benefits were largely attributable to the physical benefits of stretching and strengthening the muscles and not to its mental components." The benefits of these approaches may last several months, the authors conclude.
Commentary: Comparative Effectiveness Studies in Chronic Low Back Pain
In an accompanying commentary, Timothy S. Carey, M.D., M.P.H., from Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, writes, "The study by Sherman et al in this issue is an excellent example of a pragmatic comparative effectiveness trial."
"This research now represents best evidence for stretching therapies. Support by payers for these therapies will be very helpful through partial financial support for the classes. Such support will encourage patients to utilize the classes, representing a value-based reimbursement policy."
"We physicians should refer our patients for exercise, practitioners should work to standardize treatments, and payers should encourage these treatments through minimization of copayments for therapies that have both effectiveness and modest cost. Comparative effectiveness research, when well conducted, can assist us in making these clinical and policy recommendations."
Monday, October 24, 2011
Friday, October 14, 2011
Direct access to physical therapists associated with lower costs and fewer visits
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A new study suggesting that "the role of the physician gatekeeper in regard to physical therapy may be unnecessary in many cases" could have significant implications for the US health care system, says the American Physical Therapy Association (APTA).
The study, published ahead of print September 23 in the journal Health Services Research (HSR), reviewed 62,707 episodes of physical therapy using non-Medicare claims data from a Midwest insurer over a 5-year period. Patients who visited a physical therapist directly for outpatient care (27%) had fewer visits and lower overall costs on average than those who were referred by a physician, while maintaining continuity of care within the overall medical system and showing no difference in health care use in the 60 days after the physical therapy episode.
The study is noteworthy because services delivered by physical therapists account for "a significant portion" of outpatient care costs in the United States, according to the study, and some health insurance plans require a physician referral for reimbursement of these services. In addition, although 46 states and the District of Columbia now allow some form of direct access to physical therapists, some of them nonetheless impose restrictions if patients have not been referred by a physician.
"Physical therapists have long known that direct access to our services is safe and effective," said APTA President R. Scott Ward, PT, PhD. "The elimination of referral requirements and other restrictions has been a priority of APTA for decades. This study provides further evidence that direct access to physical therapists could go a long way toward helping to make health care more affordable and accessible for all. We encourage researchers and insurers to continue to further investigate this important issue that could have a profound impact on patient care."
"When patients choose direct access to a physical therapist, it does not mean the end of collaboration with their physician, nor does it diminish continuity of care," added Thomas DiAngelis, PT, DPT, president of APTA's Private Practice Section. "We believe the results of this study will support our efforts to work with legislators and physician groups to establish policies that reduce unnecessary regulations, improve access, and build models of delivery that best serve the patient and the health care system. Although this study focused on direct access, it is not about the provider. It is about the patient. It means better opportunities to provide the proper care to those who need it, when they need it."
Led by Jane Pendergast, PhD, professor of biostatistics and director of the Center for Public Health Studies at the University of Iowa, the study retrospectively analyzed 5 years (2003-2007) of private health insurance claims data from a Midwest insurer on beneficiaries aged 18-64 in Iowa and South Dakota. A total of nearly 63,000 outpatient physical therapy episodes of care were analyzed – more than 45,000 were classified as physician-referred and more than 17,000 were classified as "self-referred" to physical therapists. Physical therapy episodes began with the initial physical therapist evaluation and ended on the last date of services before 60 days of no further visits. Episodes were classified as physician-referred if the patient had a physician claim from a reasonable referral source in the 30 days before the start of physical therapy. Researchers found that self-referred patients had fewer physical therapy visits (86% of physician-referred) and lower allowable amounts ($0.87 for every $1.00 of physician-referred) during the episode of care, after adjusting for age, gender, diagnosis, illness severity, and calendar year. In addition, overall related health care use – or care related to the problem for which physical therapy was received, but not physical therapy treatment – was lower in the self-referred group after adjustment. Examples of this type of care might include physician services or diagnostic testing. Potential differences in functional status and outcomes of care were not addressed.
"Health care use did not increase in the self-referred group, nor was continuity of care hindered," the researchers write. "The self-referred patients were still in contact with physicians during and after physical therapy. Concerns about patient safety, missed diagnoses, and continuity of care for individuals who self-refer may be overstated."
According to Rick Gawenda, PT, president of APTA's Section on Health Policy and Administration, the study should cause insurers and policymakers to rethink the physician gatekeeper concept when it comes to physical therapist services. "Evidence shows that, in the case of physical therapy, the physician gatekeeper model is doing exactly the opposite of what it was originally designed to do; it does not reduce ineffective and duplicate care nor reduce health care costs," says Gawenda. "It's time to end the physician referral requirement in every state, and it's time for all payers to embrace direct access to physical therapists."
Earlier research has supported direct access to physical therapists, but the new HSR study is the most comprehensive to date. A 1994 study analyzed 4 years of Blue Cross Blue Shield of Maryland claims data and found that total paid claims for physician referral episodes to physical therapists were 2.2 times higher than the paid claims for direct access episodes. In addition, physician referral episodes were 65% longer in duration than direct access episodes and generated 67% more physical therapy claims and 60% more office visits. The HSR study looked at a far more extensive number of episodes than the previous study, and also controlled for illness severity and other factors that could have affected the patients' outcomes.
"In summary," the researchers write, "our findings do not support the assertion that self-referral leads to overuse of care or discontinuity in care, based on a very large population of individuals in a common private health insurance plan with no requirement for PT [physical therapy] referral or prohibition on patient self-referral. We consistently found lower use in the self-referral group, after adjusting for key demographic variables, diagnosis group, and case mix. We also found that individuals in both groups were similarly engaged with the medical care system during their course of care and afterwards."
###
A new study suggesting that "the role of the physician gatekeeper in regard to physical therapy may be unnecessary in many cases" could have significant implications for the US health care system, says the American Physical Therapy Association (APTA).
The study, published ahead of print September 23 in the journal Health Services Research (HSR), reviewed 62,707 episodes of physical therapy using non-Medicare claims data from a Midwest insurer over a 5-year period. Patients who visited a physical therapist directly for outpatient care (27%) had fewer visits and lower overall costs on average than those who were referred by a physician, while maintaining continuity of care within the overall medical system and showing no difference in health care use in the 60 days after the physical therapy episode.
The study is noteworthy because services delivered by physical therapists account for "a significant portion" of outpatient care costs in the United States, according to the study, and some health insurance plans require a physician referral for reimbursement of these services. In addition, although 46 states and the District of Columbia now allow some form of direct access to physical therapists, some of them nonetheless impose restrictions if patients have not been referred by a physician.
"Physical therapists have long known that direct access to our services is safe and effective," said APTA President R. Scott Ward, PT, PhD. "The elimination of referral requirements and other restrictions has been a priority of APTA for decades. This study provides further evidence that direct access to physical therapists could go a long way toward helping to make health care more affordable and accessible for all. We encourage researchers and insurers to continue to further investigate this important issue that could have a profound impact on patient care."
"When patients choose direct access to a physical therapist, it does not mean the end of collaboration with their physician, nor does it diminish continuity of care," added Thomas DiAngelis, PT, DPT, president of APTA's Private Practice Section. "We believe the results of this study will support our efforts to work with legislators and physician groups to establish policies that reduce unnecessary regulations, improve access, and build models of delivery that best serve the patient and the health care system. Although this study focused on direct access, it is not about the provider. It is about the patient. It means better opportunities to provide the proper care to those who need it, when they need it."
Led by Jane Pendergast, PhD, professor of biostatistics and director of the Center for Public Health Studies at the University of Iowa, the study retrospectively analyzed 5 years (2003-2007) of private health insurance claims data from a Midwest insurer on beneficiaries aged 18-64 in Iowa and South Dakota. A total of nearly 63,000 outpatient physical therapy episodes of care were analyzed – more than 45,000 were classified as physician-referred and more than 17,000 were classified as "self-referred" to physical therapists. Physical therapy episodes began with the initial physical therapist evaluation and ended on the last date of services before 60 days of no further visits. Episodes were classified as physician-referred if the patient had a physician claim from a reasonable referral source in the 30 days before the start of physical therapy. Researchers found that self-referred patients had fewer physical therapy visits (86% of physician-referred) and lower allowable amounts ($0.87 for every $1.00 of physician-referred) during the episode of care, after adjusting for age, gender, diagnosis, illness severity, and calendar year. In addition, overall related health care use – or care related to the problem for which physical therapy was received, but not physical therapy treatment – was lower in the self-referred group after adjustment. Examples of this type of care might include physician services or diagnostic testing. Potential differences in functional status and outcomes of care were not addressed.
"Health care use did not increase in the self-referred group, nor was continuity of care hindered," the researchers write. "The self-referred patients were still in contact with physicians during and after physical therapy. Concerns about patient safety, missed diagnoses, and continuity of care for individuals who self-refer may be overstated."
According to Rick Gawenda, PT, president of APTA's Section on Health Policy and Administration, the study should cause insurers and policymakers to rethink the physician gatekeeper concept when it comes to physical therapist services. "Evidence shows that, in the case of physical therapy, the physician gatekeeper model is doing exactly the opposite of what it was originally designed to do; it does not reduce ineffective and duplicate care nor reduce health care costs," says Gawenda. "It's time to end the physician referral requirement in every state, and it's time for all payers to embrace direct access to physical therapists."
Earlier research has supported direct access to physical therapists, but the new HSR study is the most comprehensive to date. A 1994 study analyzed 4 years of Blue Cross Blue Shield of Maryland claims data and found that total paid claims for physician referral episodes to physical therapists were 2.2 times higher than the paid claims for direct access episodes. In addition, physician referral episodes were 65% longer in duration than direct access episodes and generated 67% more physical therapy claims and 60% more office visits. The HSR study looked at a far more extensive number of episodes than the previous study, and also controlled for illness severity and other factors that could have affected the patients' outcomes.
"In summary," the researchers write, "our findings do not support the assertion that self-referral leads to overuse of care or discontinuity in care, based on a very large population of individuals in a common private health insurance plan with no requirement for PT [physical therapy] referral or prohibition on patient self-referral. We consistently found lower use in the self-referral group, after adjusting for key demographic variables, diagnosis group, and case mix. We also found that individuals in both groups were similarly engaged with the medical care system during their course of care and afterwards."
###
Tuesday, October 11, 2011
Ginger Root Supplement Reduced Colon Inflammation Markers
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Ginger supplements reduced markers of colon inflammation in a select group of patients, suggesting that this supplement may have potential as a colon cancer prevention agent, according to a study published in Cancer Prevention Research, a journal of the American Association for Cancer Research.
Suzanna M. Zick, N.D., M.P.H., a research assistant professor at the University of Michigan Medical School, and colleagues enrolled 30 patients and randomly assigned them to two grams of ginger root supplements per day or placebo for 28 days.
After 28 days, the researchers measured standard levels of colon inflammation and found statistically significant reductions in most of these markers, and trends toward significant reductions in others.
Inflammation has been implicated in prior studies as a precursor to colon cancer, but another trial would be needed to see how ginger root affects that risk, Zick said.
“We need to apply the same rigor to the sorts of questions about the effect of ginger root that we apply to other clinical trial research,” she said. “Interest in this is only going to increase as people look for ways to prevent cancer that are nontoxic, and improve their quality of life in a cost-effective way.”
Zick is a naturopathic doctor (N.D.), which is a four-year degree that supplements a traditional medical education with instruction on the proper use of natural therapies, diet, nutrition and other alternative treatments. Her program is one of eight in the country, compared with about 135 traditional medical schools.
Ginger supplements reduced markers of colon inflammation in a select group of patients, suggesting that this supplement may have potential as a colon cancer prevention agent, according to a study published in Cancer Prevention Research, a journal of the American Association for Cancer Research.
Suzanna M. Zick, N.D., M.P.H., a research assistant professor at the University of Michigan Medical School, and colleagues enrolled 30 patients and randomly assigned them to two grams of ginger root supplements per day or placebo for 28 days.
After 28 days, the researchers measured standard levels of colon inflammation and found statistically significant reductions in most of these markers, and trends toward significant reductions in others.
Inflammation has been implicated in prior studies as a precursor to colon cancer, but another trial would be needed to see how ginger root affects that risk, Zick said.
“We need to apply the same rigor to the sorts of questions about the effect of ginger root that we apply to other clinical trial research,” she said. “Interest in this is only going to increase as people look for ways to prevent cancer that are nontoxic, and improve their quality of life in a cost-effective way.”
Zick is a naturopathic doctor (N.D.), which is a four-year degree that supplements a traditional medical education with instruction on the proper use of natural therapies, diet, nutrition and other alternative treatments. Her program is one of eight in the country, compared with about 135 traditional medical schools.
Wednesday, September 21, 2011
Complementary and Alternative Medicine Treatments for Mood Disorders
Mood disorders are among the most prevalent mental health issues today. While medication is available, more and more people are turning to complementary and alternative medicine (CAM), including herbal remedies, acupuncture, and meditation to help manage their mood disorders.
Andrew Newberg, MD, director of Research,Daniel Monti, MD, medical and executive director and Aleeze Moss, PhD, instructor of the Mindfulness-Based Art Therapy program at the Jefferson-Myrna Brind Center of Integrative Medicine at Thomas Jefferson University Hospital review the most commonly used CAM practices in the management of patients with mood disorders and the available data on CAM use for mood disorders in the recent issue of Expert Reviews in Neurotherapeutics.
Mood and anxiety disorders include a broad range of diagnoses such as major depression; dysthymia, a type of mild depression, and others.
A 2007 National Health Interview Survey (NHIS) showed that almost 40 percent of adults use CAM, with Americans with depression more likely to use CAM remedies than conventional antidepressants or psychotherapy.
Newberg, Monti and Moss evaluated CAM modalities across four categories: natural products; mind-body medicine and manipulative and body-based practices; and other CAM practices. A snapshot of their findings is outlined here:
Natural Products
Botanical medicines, vitamins, minerals and natural products found to positively impact patients with mood disorders, include: Hypericum (St. John’s Wort); S-adenosyl-methionine- an amino acid essential in production and delivery of dopamine, serotonin and norepenephrine throughout the brain; Omega-3 fatty acids- essential fatty acids (EFAs) play a role in maintaining brain structure and function. Research shows that reduced levels of EFAs may be associated with depression. The most common source of EFAs is fish oil.
Mind-body practices
Meditation, yoga, qi-gong, tai-chi and acupuncture are among the most commonly used. Yoga is effective in improving anxiety and depression, suggests a growing body of research; Meditation-based practices such as mindfulness-based stress reduction and mindfulness-based cognitive therapy have supporting data suggesting therapeutic benefit, including decreases in depression, anxiety and distress for a variety of health conditions, including mood disorders; Acupuncture- inconclusive evidence shows acupuncture can be a beneficial treatment modality for mood disorders.
Other CAM products
There are several CAM products that are used for mood disorders, but many have little supporting data. A few that do include: TRP and 5-HTP, amino acid precursors of serotonin, and the botanical Rhodiola rosea.
The popularity of CAM interventions within the general Western population continues to grow as does the body of rigorous research into the effects and mechanisms of CAM interventions for mood disorders.
“As the field grows, we anticipate that the data will be able to provide a more detailed evaluation of CAM interventions with more practical applications regarding potential benefit effects and helping to avoid adverse effects,” conclude Drs. Newberg and Monti and Moss.
Editor’s Note: Click here to view today’s Jefferson University
Andrew Newberg, MD, director of Research,Daniel Monti, MD, medical and executive director and Aleeze Moss, PhD, instructor of the Mindfulness-Based Art Therapy program at the Jefferson-Myrna Brind Center of Integrative Medicine at Thomas Jefferson University Hospital review the most commonly used CAM practices in the management of patients with mood disorders and the available data on CAM use for mood disorders in the recent issue of Expert Reviews in Neurotherapeutics.
Mood and anxiety disorders include a broad range of diagnoses such as major depression; dysthymia, a type of mild depression, and others.
A 2007 National Health Interview Survey (NHIS) showed that almost 40 percent of adults use CAM, with Americans with depression more likely to use CAM remedies than conventional antidepressants or psychotherapy.
Newberg, Monti and Moss evaluated CAM modalities across four categories: natural products; mind-body medicine and manipulative and body-based practices; and other CAM practices. A snapshot of their findings is outlined here:
Natural Products
Botanical medicines, vitamins, minerals and natural products found to positively impact patients with mood disorders, include: Hypericum (St. John’s Wort); S-adenosyl-methionine- an amino acid essential in production and delivery of dopamine, serotonin and norepenephrine throughout the brain; Omega-3 fatty acids- essential fatty acids (EFAs) play a role in maintaining brain structure and function. Research shows that reduced levels of EFAs may be associated with depression. The most common source of EFAs is fish oil.
Mind-body practices
Meditation, yoga, qi-gong, tai-chi and acupuncture are among the most commonly used. Yoga is effective in improving anxiety and depression, suggests a growing body of research; Meditation-based practices such as mindfulness-based stress reduction and mindfulness-based cognitive therapy have supporting data suggesting therapeutic benefit, including decreases in depression, anxiety and distress for a variety of health conditions, including mood disorders; Acupuncture- inconclusive evidence shows acupuncture can be a beneficial treatment modality for mood disorders.
Other CAM products
There are several CAM products that are used for mood disorders, but many have little supporting data. A few that do include: TRP and 5-HTP, amino acid precursors of serotonin, and the botanical Rhodiola rosea.
The popularity of CAM interventions within the general Western population continues to grow as does the body of rigorous research into the effects and mechanisms of CAM interventions for mood disorders.
“As the field grows, we anticipate that the data will be able to provide a more detailed evaluation of CAM interventions with more practical applications regarding potential benefit effects and helping to avoid adverse effects,” conclude Drs. Newberg and Monti and Moss.
Editor’s Note: Click here to view today’s Jefferson University
Friday, August 19, 2011
Doctors, Nurses Often Use Holistic Medicine for Themselves
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Source: Health Behavior News Service
U.S. health care workers, especially doctors and nurses, use complementary and alternative medicine (CAM) far more than do workers in other fields, according to a new study. CAM includes diverse therapies outside the realm of conventional medicine. Overall, 76 percent of health care workers report CAM usage, compared with 63 percent of the general working population.
Health care workers use chiropractic treatment, massage and acupuncture for conditions that conventional medicine does not address well, said study co-author Lori Knutson, executive director of the Penny George Institute for Health and Healing with Allina Hospitals and Clinics in Minneapolis. While conventional providers often treat common issues such as back pain with pain medication, holistic providers address root causes, she said.
The researchers used data from the 2007 National Health Interview Survey, analyzing responses from 14,329 working adults. Their findings appear online in the journal Health Services Research.
Among respondents, 1,280 worked in health care and fell into four categories: (1) providers including doctors and nurses; (2) technicians, for instance, sonographers; (3) support workers such as nursing assistants and (4) administrative personnel not providing patient care.
The study looked at practitioner-based CAM, such as acupuncture; self-treatment with CAM, such as practicing Pilates; and any CAM usage such as following a vegetarian diet, meditating and taking certain herbs.
Doctors and nurses had more than twice the odds of having used a practitioner-based CAM method during the prior year and nearly three times the use of self-treatment with CAM than support workers.
“As insiders, health care workers understand what’s missing in our medical system. They’re more educated than others about orthodox and alternative medicine,” said Joya Lynn-Schoen, M.D., a psychiatrist by training who instead practices alternative medicine, offering patients homeopathy, nutrition and chelation therapies. “Mainstream medicine will say, ‘Here’s a pill’ or ‘Have an operation” or ‘There’s nothing wrong with you. You’re just tired.’
“We may be opening Pandora’s box by disclosing utilization of CAM by conventional providers,” Knutson said. “I prefer to believe that this will create an opening for both provider and patient in optimizing health for the whole person.” Knutson added that consumers ought to know that providers use CAM and that health care workers should know that their peers use CAM, although perhaps without discussing it.
How shocked consumers would actually be by their doctors’ use of CAM is questionable, however. The researchers used a broad definition of CAM that includes practices as commonplace as deep breathing, meditation and massage, and ones as complex as biofeedback, hypnosis and chelation therapy, which involves administration of chemicals called chelating agents to eliminate heavy metals such as lead, arsenic or mercury from the body. To discover the depth of doctors’ and nurses’ involvement with the more esoteric approaches will require further research.
TERMS OF USE: This story is protected by copyright. When reproducing any material, including interview excerpts, attribution to the Health Behavior News Service, part of the Center for Advancing Health, is required.
Friday, July 29, 2011
Practicing positive activities may serve as an effective, low-cost treatment for people suffering from depression
Practicing positive activities may serve as an effective, low-cost treatment for people suffering from depression, according to researchers at the University of California, Riverside and Duke University Medical Center.
In “Delivering Happiness: Translating Positive Psychology Intervention Research for Treating Major and Minor Depressive Disorders,” a paper that appears in the August 2011 issue of the Journal of Alternative and Complementary Medicine, the team of UCR and Duke psychology, neuroscience and psychopharmacology researchers proposed a new approach for treating depression – Positive Activity Interventions (PAI).
PAIs are intentional activities such as performing acts of kindness, practicing optimism, and counting one’s blessing gleaned from decades of research into how happy and unhappy people are different. This new approach has the potential to benefit depressed individuals who don’t respond to pharmacotherapy or are not able or willing to obtain treatment, is less expensive to administer, is relatively less time-consuming and promises to yield rapid improvement of mood symptoms, holds little to no stigma, and carries no side effects.
More than 16 million U.S. adults – about 8 percent of the population – suffer from either major or chronic depression. About 70 percent of reported cases either do not receive the recommended level of treatment or do not get treated at all, according to the National Institute of Mental Health. Globally, the World Health Organization estimates that depression affects more than 100 million people.
Although antidepressants can be lifesaving for some individuals, initial drug therapy produces full benefits in only 30 percent to 40 percent of patients. Even after trying two to four different drugs, one-third of people will remain depressed.
The research team – Kristin Layous and Joseph Chancellor, graduate students at UC Riverside; Sonja Lyubomirsky, professor of psychology and director of the Positive Psychology Laboratory at UC Riverside; and Lihong Wang, M.D., and P. Murali Doraiswamy, M.B.B.S., FRCP, of Duke University – conducted a rigorous review of previous studies of PAIs, including randomized, controlled interventions with thousands of normal men and women as well as functional MRI scans in people with depressive symptoms.
“Over the last several decades, social psychology studies of flourishing individuals who are happy, optimistic and grateful have produced a lot of new information about the benefits of positive activity interventions on mood and well-being,” Lyubomirsky said.
However, such findings have not yet entered mainstream psychiatric practice.
“Very few psychiatrists collaborate with social scientists and no one in my field ever reads the journals where most happiness studies have been published. It was eye-opening for me as a psychopharmacologist to read this literature,” Doraiswamy said.
Lyubomirsky said that after she and Doraiswamy exchanged notes, “the obvious question that popped up was whether we can tap into the PAI research base to design interventions to galvanize clinically depressed people to move past the point of simply not feeling depressed to the point of flourishing.”
Although the paper found that positive activity interventions are effective in teaching individuals ways to increase their positive thinking, positive affect and positive behaviors, only two studies specifically tested these activities in individuals with mild depression.
In one of these studies, lasting improvements were found for six months. Effective PAIs used in the study included writing letters of gratitude, counting one’s blessings, practicing optimism, performing acts of kindness, meditating on positive feelings toward others, and using one’s signature strengths, all of which can be easily implemented into a daily routine at low cost.
People often underestimate the long-term impact of practicing brief, positive activities, Lyubomirsky said. For example, if a person gets 15 minutes of positive emotions from counting her blessings, she may muster the energy to attend the art class she’d long considered attending, and, while in class, might meet a friend who becomes a companion and confidant for years to come. In this way, even momentary positive feelings can build long-term social, psychological, intellectual, and physical skills and reserves.
The researchers’ review of brain imaging studies also led them to theorize that PAIs may act to boost the dampened reward/pleasure circuit mechanisms and reverse apathy – a key benefit that does not usually arise from treatment with medication alone.
“The positive activities themselves aren’t really new,” said Layous, the paper’s lead author. “After all, humans have been counting their blessings, dreaming optimistically, writing thank you notes, and doing acts of kindness for thousands of years. What’s new is the scientific rigor that researchers have applied to measuring benefits and understanding why they work.”
A major benefit of positive activities is that they are simple to practice and inexpensive to deliver.
“If we’re serious about tackling a problem as large as depression, we should be as concerned about the scalability of our solutions as much as their potency,” Chancellor said,
While PAIs appear to be a potentially promising therapy for mild forms of depression,” Doraiswamy cautioned, “they have not yet been fully studied in people with moderate to severe forms of depression. We need further studies before they can be applied to help such patients."
Kim Jobst, a physician and editor-in-chief of the Journal of Alternative and Complimentary Medicine, said the review provides one location in which to reference all relevant PAI findings to date, and includes recommendations that should prove useful to researchers, clinicians and the public. The journal is devoted to publishing research about novel and unconventional treatment approaches.
In “Delivering Happiness: Translating Positive Psychology Intervention Research for Treating Major and Minor Depressive Disorders,” a paper that appears in the August 2011 issue of the Journal of Alternative and Complementary Medicine, the team of UCR and Duke psychology, neuroscience and psychopharmacology researchers proposed a new approach for treating depression – Positive Activity Interventions (PAI).
PAIs are intentional activities such as performing acts of kindness, practicing optimism, and counting one’s blessing gleaned from decades of research into how happy and unhappy people are different. This new approach has the potential to benefit depressed individuals who don’t respond to pharmacotherapy or are not able or willing to obtain treatment, is less expensive to administer, is relatively less time-consuming and promises to yield rapid improvement of mood symptoms, holds little to no stigma, and carries no side effects.
More than 16 million U.S. adults – about 8 percent of the population – suffer from either major or chronic depression. About 70 percent of reported cases either do not receive the recommended level of treatment or do not get treated at all, according to the National Institute of Mental Health. Globally, the World Health Organization estimates that depression affects more than 100 million people.
Although antidepressants can be lifesaving for some individuals, initial drug therapy produces full benefits in only 30 percent to 40 percent of patients. Even after trying two to four different drugs, one-third of people will remain depressed.
The research team – Kristin Layous and Joseph Chancellor, graduate students at UC Riverside; Sonja Lyubomirsky, professor of psychology and director of the Positive Psychology Laboratory at UC Riverside; and Lihong Wang, M.D., and P. Murali Doraiswamy, M.B.B.S., FRCP, of Duke University – conducted a rigorous review of previous studies of PAIs, including randomized, controlled interventions with thousands of normal men and women as well as functional MRI scans in people with depressive symptoms.
“Over the last several decades, social psychology studies of flourishing individuals who are happy, optimistic and grateful have produced a lot of new information about the benefits of positive activity interventions on mood and well-being,” Lyubomirsky said.
However, such findings have not yet entered mainstream psychiatric practice.
“Very few psychiatrists collaborate with social scientists and no one in my field ever reads the journals where most happiness studies have been published. It was eye-opening for me as a psychopharmacologist to read this literature,” Doraiswamy said.
Lyubomirsky said that after she and Doraiswamy exchanged notes, “the obvious question that popped up was whether we can tap into the PAI research base to design interventions to galvanize clinically depressed people to move past the point of simply not feeling depressed to the point of flourishing.”
Although the paper found that positive activity interventions are effective in teaching individuals ways to increase their positive thinking, positive affect and positive behaviors, only two studies specifically tested these activities in individuals with mild depression.
In one of these studies, lasting improvements were found for six months. Effective PAIs used in the study included writing letters of gratitude, counting one’s blessings, practicing optimism, performing acts of kindness, meditating on positive feelings toward others, and using one’s signature strengths, all of which can be easily implemented into a daily routine at low cost.
People often underestimate the long-term impact of practicing brief, positive activities, Lyubomirsky said. For example, if a person gets 15 minutes of positive emotions from counting her blessings, she may muster the energy to attend the art class she’d long considered attending, and, while in class, might meet a friend who becomes a companion and confidant for years to come. In this way, even momentary positive feelings can build long-term social, psychological, intellectual, and physical skills and reserves.
The researchers’ review of brain imaging studies also led them to theorize that PAIs may act to boost the dampened reward/pleasure circuit mechanisms and reverse apathy – a key benefit that does not usually arise from treatment with medication alone.
“The positive activities themselves aren’t really new,” said Layous, the paper’s lead author. “After all, humans have been counting their blessings, dreaming optimistically, writing thank you notes, and doing acts of kindness for thousands of years. What’s new is the scientific rigor that researchers have applied to measuring benefits and understanding why they work.”
A major benefit of positive activities is that they are simple to practice and inexpensive to deliver.
“If we’re serious about tackling a problem as large as depression, we should be as concerned about the scalability of our solutions as much as their potency,” Chancellor said,
While PAIs appear to be a potentially promising therapy for mild forms of depression,” Doraiswamy cautioned, “they have not yet been fully studied in people with moderate to severe forms of depression. We need further studies before they can be applied to help such patients."
Kim Jobst, a physician and editor-in-chief of the Journal of Alternative and Complimentary Medicine, said the review provides one location in which to reference all relevant PAI findings to date, and includes recommendations that should prove useful to researchers, clinicians and the public. The journal is devoted to publishing research about novel and unconventional treatment approaches.
Tuesday, July 26, 2011
Transcendental Meditation improves brain functioning in ADHD students
A non-drug approach to enhance students' ability to learn
A random-assignment controlled study published today in Mind & Brain, The Journal of Psychiatry (Vol 2, No 1) found improved brain functioning and decreased symptoms of attention-deficit/hyperactivity disorder, ADHD, in students practicing the Transcendental Meditation® (TM) technique. The paper, ADHD, Brain Functioning, and Transcendental Meditation Practice, is the second published study demonstrating TM's ability to help students with attention-related difficulties.
The first exploratory study, published in Current Issues in Education, followed a group of middle school students diagnosed with ADHD who meditated twice a day in school. After 3 months, researchers found over 50% reductions in stress, anxiety, and ADHD symptoms. During the study, a video was made of some students discussing what it felt like to have ADHD, and how those experiences changed after 3 months of regular TM practice.
In this second study, lead author, neuroscientist Fred Travis, PhD, director of the Center for Brain, Consciousness and Cognition, joined principal investigator Sarina J. Grosswald, EdD, a George Washington University-trained cognitive learning specialist, and co-researcher William Stixrud, PhD, a prominent Silver Spring, Maryland, clinical neuropsychologist, to investigate the effects of Transcendental Meditation practice on task performance and brain functioning in 18 ADHD students, ages 11-14 years.
The study was conducted over a period of 6 months in an independent school for children with language-based learning disabilities in Washington, DC. The study showed improved brain functioning, increased brain processing, and improved language-based skills among ADHD students practicing the Transcendental Meditation technique..
What was Measured
Students were pretested, randomly assigned to TM or delayed-start comparison groups, and post-tested at 3- and 6-months. Delayed-start students learned TM after the 3-month post-test.
EEG measurements of brain functioning were taken while students were performing a demanding computer-based visual-motor task. Successful performance on the task requires attention, focus, memory, and impulse control.
In addition, students were administered a verbal fluency test. This test measured higher-order executive functions, including initiation, simultaneous processing, and systematic retrieval of knowledge. Performance on this task depends on several fundamental cognitive components, including vocabulary knowledge, spelling, and attention.
Theta/Beta Power Ratios and ADHD
Using EEG measurements, the relationship of theta brain waves to beta brain waves can be diagnostic of ADHD. Dr. Joel Lubar of the University of Tennessee has demonstrated that the theta/beta ratio can very accurately identify students with ADHD from those without it.
While theta EEG around 4-5 Hz is commonly associated with daydreaming, drowsiness, and unfocused mental states, theta EEG around 6-8 Hz is seen when one focuses on inner mental tasks, such as memory processing, identifying, and associating.
"In normal individuals, theta activity in the brain during tasks suggests that the brain is blocking out irrelevant information so the person can focus on the task," said Dr. Travis. "But, in individuals with ADHD, the theta activity is even higher, suggesting that the brain is also blocking out relevant information."
And when beta activity, which is associated with focus, is lower than normal," Travis added, "it affects the ability to concentrate on task for extended periods of time.
"Prior research shows ADHD children have slower brain development and a reduced ability to cope with stress," said Dr. Stixrud. "Virtually everyone finds it difficult to pay attention, organize themselves and get things done when they're under stress," he explained. "Stress interferes with the ability to learn—it shuts down the brain. Functions such as attention, memory, organization, and integration are compromised."
Why the TM Technique
"We chose the TM technique for this study because studies show that it increases brain function. We wanted to know if it would have a similar effect in the case of ADHD, and if it did, would that also improve the symptoms of ADHD," said Dr. Grosswald.
Dr. Stixrud added, "Because stress significantly compromises attention and all of the key executive functions such as inhibition, working memory, organization, and mental flexibility, it made sense that a technique that can reduce a child's level of stress should also improve his or her cognitive functioning."
The Transcendental Meditation technique is an effortless, easy-to-learn practice, unique among categories of meditation. "TM does not require concentration, controlling the mind or disciplined focus—challenges for anyone with ADHD," Grosswald added.
There is substantial research showing the effectiveness of the TM technique for reducing stress and anxiety, and improving cognitive functioning among the general population. "What's significant about these new findings," Grosswald said, "is that among children who have difficulty with focus and attention, we see the same results. The fact that these children are able to do TM, and do it easily, shows us that this technique may be particularly well-suited for children with ADHD."
Transcendental Meditation produces an experience of restful alertness, which is associated with higher metabolic activity in the frontal and parietal parts of the brain, indicating alertness, along with decreased metabolic activity in the thalamus, which is involved in regulating arousal, and hyperactivity.
With regular practice, this restfully alert brain state, characteristic of the TM technique, becomes more present outside of meditation, allowing ADHD students to attend to tasks. "In a sense," Dr. Travis said, "the repeated experience of the Transcendental Meditation technique trains the brain to function in a style opposite to that of ADHD."
Improved Brain Functioning
During the practice of the Transcendental Meditation technique, coherence is found across different EEG frequencies. After meditation, the brain utilizes this increased functioning ability to support the performance of a task in an integrated manner.
Three months of TM practice resulted in significant decreases in theta/beta ratios and increased verbal fluency. This translates into improved executive function and more efficient cognitive processing.
During the first 3 months of the study, the theta/beta ratios of the control group (delayed start) actually increased. After learning, and practicing TM for 3 months, this group experienced dramatic decreases in theta/beta ratios and increased verbal fluency as well.
Student and Parent Surveys
Students reported that the TM technique was enjoyable and easy to do. They felt calmer, less stressed, and better able to concentrate on their schoolwork. They also said they were happier since they started TM. This correlated with reports from the parents.
At the end of the research, the parents completed a questionnaire to assess their perceptions of changes in five ADHD-related symptoms in their children from the beginning to the end of the study. There were positive and statistically significant improvements in the five areas measured: a) Ability to focus on schoolwork, b) Organizational abilities, c) Ability to work independently, d) Happiness, and e) Quality of sleep.
Promising Results
The combined results were significant. There was a 48% reduction in the theta/beta power ratios and a 30% increase in brain coherence after the 6-month period. Studies have shown that pharmaceuticals decrease theta/beta power ratios by 3%, and neurofeedback by 25%.
"These are very encouraging findings," said Dr. Stixrud. "Significant improvement in the theta/beta ratio without medication and without having to use any expensive equipment is a big deal, as is significant improvement in student happiness and student academic functioning reported by the parents."
"While stimulant medication is very beneficial for some of my clients with ADHD," Stixrud added, "the number of children who receive great benefit from medicine with minimal side-effects is relatively small. The fact that TM appears to improve attention and executive functions, and significantly reduces stress with no negative side-effects, is clearly very promising." Stixrud said he hoped these findings would lead to more research on the use of TM with children and adolescents.
In conclusion, these findings warrant additional research to assess the impact of Transcendental Meditation practice as a non-drug treatment for ADHD, and to track meditating students' improved academic achievements.
FACT SHEET
Attention-Deficit/Hyperactivity Disorder (ADHD)
• Attention-deficit/hyperactivity disorder (ADHD)—characterized by inattentiveness, impulsivity, and hyperactivity—is diagnosed in almost 10% of children ages 4-17 years, representing 5.4 million children.
• The Center for Disease Control and Prevention reported among children with current ADHD, 66.3% were taking medication for the disorder. In total, 4.8% of all children ages 4-17 years (2.7 million) were taking medication for ADHD. The majority of them stay on it into adulthood.
• The rate of prescriptions for Attention-Deficit/Hyperactivity Disorder in the U.S. has increased by a factor of five since 1991—with production of ADHD medicines up 2,000 percent in 9 years.
• The commonly used drugs for ADHD are stimulants (amphetamines). These drugs can cause persistent and negative side-effects, including sleep disturbances, reduced appetite, weight loss, suppressed growth, and mood disorders. The side-effects are frequently treated with additional medications to manage insomnia or mood swings. Almost none of the medications prescribed for insomnia or mood disturbances are approved by the Food and Drug Administration (FDA) for use with children.
• The long-term health effects of ADHD medications are not fully known, but evidence suggests risks of cardiac disorders and sudden death, liver damage and psychiatric events. It has also been found that children on long-term medication have significantly higher rates of delinquency, substance use, and stunted physical growth.
• A new study, Study raises questions about long-term effects of ADHD medication, the first of its kind, released February 17, 2010 by the Government of Western Australia's Department of Health, found that "long-term use of drugs such as Ritalin and dexamphetamine may not improve a child's social and emotional well-being or academic performance." The chair of the Ministerial Implementation Committee for Attention Deficit Hyperactivity Disorder in Western Australia said in the Department's press release, "We found that stimulant medication did not significantly improve a child's level of depression, self perception or social functioning and they were more likely to be performing below their age level at school by a factor of 10.5 times."
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