Anxiety, Panic & Health

Generic Drugs: Are They Safe and Effective? Part One

Mike Nichols — Fri, 18 May 2012 23:04:01 +0000

The 1980′s and 90′s saw a boom in the development of psychiatric medications. The 20-year limit on their exclusive patents are now expiring, and more and more generic versions of these drugs are becoming available.

Generic drugs are almost always cheaper than their brand name counterparts, so insurance companies insist on dispensing generics whenever possible.

The public is confused and suspicious of the generic drugs being pushed on them by their insurers. Are these medications as effective and safe as the brand names? Do they introduce new side effects?

This article is the first of a two-part series written to provide you with answers. This part will give you a quick overview of generic drugs: What they are, how they are certified by the U.S. Food and Drug Administration (FDA) and how to identify them. The section headings are:

What is a generic drug?
How is a generic drug certified by the FDA?
How can I tell if my medication is generic?

Be sure to read Part Two of this series!
Part Two covers some of the most important issues and questions about generic drugs under the following headings:
    • Issues: Are generic and brand name drugs identical?
    • Issues: What about generics’ effectiveness?
    • Issues: What about generics’ side effects?
    • Issues: Generic drug labels don’t have to be updated
    • Issues: Doctors’ attitudes toward generic drugs

What is a generic drug?

Generic drugs are FDA certified equivalents of brand name drugs

The U.S. Food and Drug Administration (FDA) regulates and certifies all drugs prescribed by physicians in the United States, including generic drugs.

The FDA certification requirements for a new drug are quite stringent. It must pass a number of strictly defined and carefully controlled clinical tests showing its effectiveness and safety. Thousands of pages of documentation are mandated.

It is very expensive to develop a new drug and get FDA certification. So the FDA grants a patent to the drug company, giving them the right to market the new drug for twenty years without competition.

When a drug’s patent runs out, other companies can submit medications to the FDA for certification as the equivalent of the brand name drug. These drugs are called “generics” and may be substituted for a brand name drug by doctors and pharmacists.

Generics cost less than brand name drugs, since there is little research and development or marketing costs involved in their manufacture and sales. Insurance companies usually require the use of generics unless there is a medically valid reason to use the brand name drug.

How is a generic drug certified by the FDA?

A generic drug’s chemical must work the same way as the brand name’s

The FDA sets up many hurdles for drug makers of generics to jump on the way to certification as equivalent to a brand name drug. The main questions that have to be answered are: [1] [2]

Does it have the same active ingredient working in the same way?
Does it have the same strength for a given dosage?
Does the body absorb and use the drug in the same way at the same rate?
Is the dosage form and way it’s administered the same?

Drugs that pass these tests are termed “therapeutically equivalent” and certified as a generic substitute for the brand name drug.

How can I tell if my medication is generic?

Brand name drugs are labeled by their names – generics by their chemicals

You can spot a generic drug by its label: The active chemical’s name is written prominently instead of the brand name.

The brand name it substitutes for is in smaller letters, usually below the chemical name. The generic’s manufacturer name will be in small type somewhere on the bottle.

On a brand name drug, its name and dosage is printed below your name. The manufacturer’s name is usually right under the brand name. For example:

A generic drug is required to look different from the brand name drug. So if the brand name pill is a blue triangle, the generic drug might be a yellow circle. Look for the pill color and other identifying marks on the labels of both generic and brand name drugs.

The way a generic drug is administered must be the same as the brand name. For example, if the brand name medication is a pill, the generic must be a pill, too – it cannot be a capsule.

What do you think?

I often express gratitude that I’m dealing with my mental illnesses in the 21st century and not in the 1970′s or 1950′s or – horrors! – the 1400′s.

There have been great strides made in psychiatric medication over the past twenty years. Fortunately, some of the old “tried and true” drugs like Wellbutrin® and Paxil® still help many people and have been around long enough to have cheaper generic versions.

But we’re all different physically and mentally. The bottom line with psychiatric medication is that any given drug will work differently in every person. The same is true for generic versions of brand name pills.

I’ve only scratched the surface on the subject of generic drugs. Let me know if you would like more articles about them.

As always, your comments are welcome! If you have enjoyed this post, please consider subscribing to this blog, either via RSS or email at the top of your screen. It’s free! You can also follow me on Twitter from the same place. I would also appreciate your sharing this post using your favorite social media, such as StumbleUpon or Digg. Just click the little green “ShareThis” button at the bottom of this post.

PLEASE NOTE: The contents of this article are provided for informational purposes only. The author is not a trained or licensed medical professional and has based the article on authoritative information from outside sources as given in the footnotes. This article is not intended as a substitute for advice from a trained and licensed medical professional.

FOOTNOTES
1. Nightengale, Stuart L. Therapeutic Equivalence of Generic Drugs – Letter to Health Practitioners. January 28, 1998. U.S. Food and Drug Administration website. http://www.fda.gov/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/ApprovalApplications/AbbreviatedNewDrugApplicationANDAGenerics/ucm073182.htm. Accessed 4/26/12. ↑
2. Lowers, Jane; Howland, Robert H. Generic vs Branded Psychiatric Medications: Is There a Difference? Medscape website: http://www.medscape.com/viewarticle/762343. Section 1. Accessed 4/25/12 ↑

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Generic Drugs: Are They Safe and Effective? Part Two

Mike Nichols — Fri, 18 May 2012 22:43:06 +0000

More and more of the early psychiatric medications are reaching the end of their 20-year exclusive patents.

That means still-effective drugs like Wellbutrin®, Lamictal® and Paxil® now have generic equivalents. These generics are cheaper, and of course the insurance companies insist that they be prescribed instead of the brand names.

Part One of this two-part series provided information on how generic drugs are certified by the U.S. Food and Drug Administration and how to identify their pill bottles.

This article, Part Two, addresses a number of issues surrounding generics such as effectiveness, side effects, labeling and doctors’ attitudes toward them. The topics covered are:

Issues: Are generic and brand name drugs identical?
Issues: What about generics’ effectiveness?
Issues: What about generics’ side effects?
Issues: Generic drug labels don’t have to be updated
Issues: Doctors’ attitudes toward generic drugs

Be sure to read Part One of this series!
Part One provides basic information about generics, including how to read the pill bottle:
    • What is a generic drug?
    • How is a generic drug certified by the FDA?
    • How can I tell if my medication is generic?

Issues: Are generic and brand name drugs identical?

Mostly. To be therapeutically equivalent, a generic drug must match the brand name drug’s: [1]

Chemical properties
Rate of spread in the body
Extent of absorption
Targeting of the same body area

The FDA allows some variance between generics and brand names

The FDA allows some variability between the brand name and generic drugs in the test results – as much as a cumulative 45%, though the effective percentage is smaller. Therefore, certified generic drugs may not be exactly the same as a brand name. This variability has been questioned by some, but the FDA remains confident in their tests.[2]

Issues: What about generics’ effectiveness?

Psychiatric generics must be as close as possible to the brand names

Similar effectiveness is important when switching from a brand name drug to a generic and vice versa.

This is critical with psychiatric medications since a person’s drug “cocktail” is often delicately balanced over a long period of time. Some psychiatric drugs can act slowly, so it might be weeks before knowing if the new drug is effective.

There are three effectiveness problems that pop up when using generic drugs:

The FDA tests only the generic’s active chemical and its behavior in the body.
The FDA tests allow a relatively wide range of variability when measuring a generic’s performance, so no generic will be a perfect match.
A generic drug can come from any of a number of manufacturers, each with its own variations from the brand name. The pill you get in this bottle may be from a different manufacturer as the one from your next bottle.

As for changed effectiveness, scientists and doctors cannot tell you why many (or most) psychiatric drugs work, only that they do work with some people.

Even though a generic drug has tested as being therapeutically equivalent to a brand name drug, that doesn’t mean that a particular individual may not find the drug ineffective or requiring a different dosage.

Always note a generic drug’s manufacturer on the bottle (see Part One). If you are having an effectiveness problem, a changed drug manufacturer could be the source.

Issues: What about generics’ side effects?

The FDA does not test the color dyes or filler material of generics

Many people find that they experience new or heightened side effects when a generic drug is substituted for the brand name. These are often related to the way a generic drug is manufactured and packaged.

The FDA tests only a drug’s active chemical, and not any other part of the generic medication’s coloring dyes and filler that make up a pill. They assume that a generic drug will have the same side effects and safety profile as a brand name drug if it passes all its chemical tests.[3]

Some people report allergic reactions to dyes used for coloring the generic drug or to filler materials in the pill. If you are having problems with side effects, talk with your doctor. It could be that switching to a different generic manufacturer will reduce side effects. Some insurance companies allow a doctor to prescribe a brand name medication if the patient has problems with a generic drug.

Issues: Generic drug labels don’t have to be updated

Generics must have the same label information as the original brand name

The FDA mandates that a generic drug have the same label information as the brand name’s label at the time it was first approved. If a brand name manufacturer subsequently updates its label to reflect new findings (for example, side effects or drug interactions), the generic manufacturer is under no obligation to use the new label according to FDA regulations.

The U.S. Supreme Court decided the Pliva, Inc. v. Mensing case in 2011. A generic form of a brand name drug was administered to a person, resulting in bad side effects not listed on the label. The brand name drug’s label had been updated to show the side effect, but not the generic drug.

The Supreme Court ruled that a generic manufacturer can’t necessarily be held liable for a safety change in the brand name drug’s label. Rather, the generic manufacturer is bound to maintain the label of the brand name drug according to the FDA guidelines.[4]

A discussion of what to do about the labeling of generic drugs is beyond the scope of this article. Suffice it to say, you should know the manufacturer of every generic drug you are administered and look up the warning labels of both the generic and the brand name drugs to make sure they are the same. See Part One for how to read the label on a pill bottle.[5]

Issues: Doctors’ attitudes toward generic drugs

Over 25% of doctors won’t use generics for themselves or their families

Almost 50% of doctors surveyed in a recent study expressed concerns about the quality of generic drugs. Over 23% believed they were not as effective as brand name drugs, and more than 25% would not use generic drugs for themselves or for their families.[6]

Physicians are on the front lines, and hear first-hand patients’ complaints about generic drugs. But who do they report these problems to?

Generic drug manufacturers do not accept anecdotal complaints and do not do any testing other than that required by the FDA, since they cannot change the drug’s labeling anyway.

Complaints must go to the original brand name’s manufacturer, and for many older drugs the original manufacturer may no longer be making it. And remember, generic drug manufacturers are only required to have the same label information as the brand name at the time of initial testing and certification.

Again, this is a subject that is beyond the intent of this article. The best course of action is to:

Use a well-informed doctor
Research the drugs you are taking thoroughly
Don’t be shy about expressing your concerns to your doctor

What do you think?

I’ve had a number of problems with generic drugs, both with effectiveness and side effects.

For example, my doctor and I did battle for a year with my insurance company. I needed a brand name medication because I had tried several other generic drugs with zero to awful results (like rashes, swelling and increased depressive episodes). The company dodged with “you’re too old,” “try one of the others again,” and then saying the drug couldn’t be prescribed by a psychiatrist at all. We finally won, but it was a long, frustrating fight.

I’ve come to regard a new generic as I would an entirely new drug rather than a brand name’s functional equivalent. It may do everything the same, but it’s just as likely that it will require dosage adjustments or have side effects severe enough to stop taking it.

I’ve only scratched the surface on the subject of generic drugs. Let me know if you would like more articles about them.

FOOTNOTES
1. Author unknown. Nomenclature (as excerpted from the Orange Book): Therapeutic Equivalence-Related Terms. FDA website: http://www.fda.gov/ohrms/dockets/ac/05/briefing/2005-4137B1_07_Nomenclature.htm. Accessed 4/28/12. Accessed 4/28/12. ↑
2. ]Lowers, Jane; Howland, Robert H. Generic vs Branded Psychiatric Medications: Is There a Difference? Medscape website: http://www.medscape.com/viewarticle/762343. Section 3. ↑
3. Pharmacother, Ann et al. Physician perceptions about generic drugs. 2011. Medline Medscape abstract. http://www.medscape.com/medline/abstract/21205953. ↑
4. Lowers, Jane; Howland, Robert H. op cit. Section 4. ↑
5. Medline Plus, an agency of the National Institutes of Health, has a searchable database of drug information, both for brand names and generics. It is very reliable and updated regularly. http://www.nlm.nih.gov/medlineplus/druginformation.html. Accessed 4/28/12.↑
6. Lowers, Jane; Howland, Robert H. op cit. Section 3. ↑

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4 Great Articles for You: Your Occasional Reader

Mike Nichols — Thu, 19 Apr 2012 20:33:50 +0000

After a long hiatus, I’m back with four more interesting articles for you to read. Sunbeams, rainbows and bluebirds! Nothing to bring you down, and everything to lighten your mood.

Here’s a list. To read them all, just click the “Read the entire article” link:

FDA Approves Generic Lexapro for Depression, Anxiety
Mentoring scheme helps anxiety sufferers
Panic in Paradise — Honeymoon Ruined by Agoraphobia and Panic
Mobile app lets you "Tweet-A-Beer" — Perfect for agoraphobic beer lovers!

FDA Approves Generic Lexapro for Depression, Anxiety

Many people take Lexapro for Anxiety Disorders, and it can become quite costly after a while. Good news!

In March, 2012 the U.S. Food and Drug Administration approved the first generic Lexapro (escitalopram tablets) to treat both depression and generalized anxiety disorder in adults. Of course, generic drugs are much less expensive than name-brand medications.

Mentoring scheme helps anxiety sufferers

This short article in The Telegraph describes a mentoring program sponsored by Anxiety UK, based in Manchester, England. A person suffering from an Anxiety Disorder is paired with a person who has overcome their own Anxiety Disorders. It sounds like a successful project, and one that would bear fruit in your location. If your local mental health organizations don’t have something like this, why not suggest it?

Panic in Paradise — Honeymoon Ruined by Agoraphobia and Panic

Kara Baskin describes her years of suffering from Panic Attacks and Agoraphobia, and how they ruined her Hawaiian honeymoon. Her description of a panic attack is one of the best I’ve read:

A panic attack offers the kind of slow-motion inevitability that I imagine a heart attack might, or drowning. Your heart pounds, your chest tightens, you sweat and gasp as dread sets in. It’s like looking at the world from inside an aquarium: Everyone is moving so languidly, so infuriatingly unaware — while you’re rattling around inside yourself on speed wondering where your next breath might come from, or if it will come at all.

Kara had tried medication before, but it either made her feel like a zombie or ballooned her weight. Finally she gave in and she and her new husband saw a psychiatrist, who gave her prescriptions for Zoloft and Valium. She says,

I was reluctant to take the medicine, of course. That’s the cruel irony: When you’re at psychological odds, the last person you can rationalize with is yourself. I was scared to feel different; I was scared to feel anything at all.

She continued to suffer after taking the medication, afraid to even step outside for more than two minutes. Finally,

…my medication took hold. It was sudden and intense. I awoke seized with energy… I grabbed a rake, hustled outside, and began sweeping leaves from our patio like a madwoman. It was imperative to me that this patio… look spotless. I spent hours out there … willing myself to the real world because I didn’t want to go back inside.

A great article – highly recommended.

Mobile app lets you "Tweet-A-Beer" — Perfect for agoraphobic beer lovers!

Do you love beer. I mean really, really love beer? But are you stuck in the house by your latest round of agoraphobia? Afraid you’ll fall apart in a crowded bar? Can’t quite get out of the house due to your OCD?

Theres an app for that! “Tweet-a-Beer” lets you buy beers for others, and when you’re better, lets others buy a beer for you.

Now if there were an app for Anxiety Disorders…

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Adult Separation Anxiety Disorder: Its Roots and Branches – Ryan Rivera

Mike Nichols — Mon, 16 Apr 2012 08:14:34 +0000

'Couple' by Mary Neighbor

Articles on Adult Separation Anxiety Disorder have drawn large numbers of comments on Anxiety, Panic & Health. People are confused and hurting, with lives disrupted or even destroyed by the disorder.

There is no consensus among mental health care professionals about Adult Separation Anxiety Disorder. In fact, despite the millions of people suffering, it is not even recognized by the American Psychological Association. There has been some tentative research in the past two decades, but there have been few studies compared with other Anxiety Disorders.

Ryan Rivera, is publisher and founder of the Calm Clinic website. In the following must-read article he writes about his observations on the Adult Separation Anxiety Disorder.

In the past, on this website and others, there has been an exploration of an often ignored psychological issue that affects millions of people in America at some point in their lives – Adult Separation Anxiety Disorder.

As many as 21 million Americans suffer from ASAD

It’s believed that as many as 21 million men and women in the United States (6.6%) may suffer from this type of disorder, according to Katherine Shear [1]. But psychological guidelines – including the DSM-IV-TR, and the upcoming DSM-V (the diagnostic manual used by mental health professionals) – fail to recognize it as its own mental health problem.

This is unfortunate, but it’s also somewhat strange. Psychological scientists often have been considered too quick to consider something a disorder. Yet here is a clear, valid psychological issue that appears to me to be largely ignored.

Why is this Happening?

I have a theory. My theory is that Adult Separation Anxiety Disorder (ASAD) is a potential cause of a variety of personality behaviors that are considered completely separate issues. Further, ASAD is manifesting itself in ways that are not easily attributed to the symptoms of the disorder. For example:

• Extreme Jealousy

Jealousy is often, and rightfully, linked to the need for control. But jealousy may also be caused by two other additional factors: attachment issues, and anxiety associated with the loss of the primary figure of attachment. This is supported by research by Sharpsteen and Kirkpatrick [2] It shows that attachment style plays a key role in the materialization of jealousy. This backs the idea that anxiety itself may be fueling the negative thoughts that create jealous behaviors.

• Strict Parenting

Parents with ASAD may also manifest their own attachment issues into strict or overly attached parenting. Some studies, including those by Vijaya Manicavasagar [3], have indicated a link between overprotective parents, adult separation anxiety, and panic disorder. Logically, it would seem that parents unable or unwilling to separate from their children and/or experiencing severe worry and concern in their absence may be experiencing a type of attachment problem.

• Long-Lasting Broken Relationships

Staying in a bad relationship caused by ASAD?

A personal theory of mine – one that isn’t likely to be researched, let alone be supported by research – is that some type of Adult Separation Anxiety may be one of the reasons many men and women stay in less than ideal relationships for an extended period of time.

While divorce rates are on the decline, around 40-50% of marriages in America end in divorce.[4] Anecdotally there are millions of couples that seem to be staying with a partner that isn’t making them happy, going against the entire purpose of intimate relationships. Fear of being separated from their partner may be what keeps them together long past their expiration date. Developing an emotional bond with a new partner (rebound dating) quickly after a breakup may be a side effect.

Research by Vijaya Manicavasagar and associates [5] has shown that those with ASAD seem to have a preoccupation with relationships that would indicate this theory has some evidentiary support, albeit tangentially. Since relationships can have a profound effect on happiness and mental health, that makes it a serious issue.

• Additional Manifestations

Does ASAD appear as just a quirk to mental health professionals?

It’s also possible that ASAD is responsible for dependent friendships, “clingy” behavior, and other less noticeable but serious concerns. While ASAD in its purest form appears as though it would be a debilitating disorder (at least to me), it’s easily possible that men and women are suffering from a type of Adult Separation Anxiety Disorder that simply comes off as a character or personality quirk that psychologists and general society are quick to ignore.

Treating Adult Separation Anxiety Disorder

Whether psychologists want to acknowledge ASAD as a serious disorder or not should be irrelevant to the treatment. The research on attachment styles alone seems to indicate a correlation between attachment and anxiety and panic attacks, among many other disorders. In my experience the issue itself does appear to frequently affect the quality of life of those that live through it.

Avoiding the issue altogether seems nonsensical. Psychologists and psychiatrists need to look at attachment styles and behaviors with each of their patients. In my opinion there is a high probability that separation anxiety has an effect on these patients’ mental health symptoms.

Ryan Rivera

About the Author: Ryan Rivera has pushed for more responsible treatments for those suffering from Anxiety and Panic attacks. He is publisher and founder of the Calm Clinic. The site has a wealth of articles about Anxiety and Panic, plus things you can do to reduce their effects on your life and well-being.

As always, your comments are welcome! Check out “Further Reading” below for more of Manicavasagar’s research on ASAD. If you have enjoyed this post, please consider subscribing to this blog, either via RSS or email at the top of your screen. It’s free! You can also follow me on Twitter from the same place. I would also appreciate your sharing this post using your favorite social media, such as StumbleUpon or Digg. Just click the little green “ShareThis” button at the bottom of this post.

Further reading:
Professor Vijaya Manicavasagar is a leading researcher of Adult Separation Anxiety Disorder. A large number of his research papers can be found at PubMed, many of them full-text and free.

FOOTNOTES
1. Shear K, Jin R, Ruscio AM, Walters EE, Kessler RC. Prevalence and correlates of estimated DSM-IV child and adult separation anxiety disorder in the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163(6):1074–1083. doi: 10.1176/appi.ajp.163.6.1074.↑
2. Sharpsteen, Don J., Kirkpatrick, Lee A. Romantic jealousy and adult romantic attachment. Journal of Personality and Social Psychology, Vol 72(3), Mar 1997, 627-640↑
3. Manicavasagar V, Silove D, Wagner R, Hadzi-Pavlovic D. Parental representations associated with adult separation anxiety and panic disorder-agoraphobia. Aust N Z J Psychiatry. 1999;33(3):422–428. doi: 10.1046/j.1440-1614.1999.00566.x↑
4. Unknown Author. (Unknown Year). Divorce Rate. Last accessed 4/15/2012.↑
5. Manicavasagar V, Silove D, Marnane C, Wagner R. Adult attachment styles in panic disorder with and without comorbid adult separation anxiety disorder. Aust N Z J Psychiatry. 2009 Feb;43(2):167-72. PubMed PMID: 19153925.↑

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Exposure Therapy: Eliminating Anxiety Disorder’s Fear, Part 2

Mike Nichols — Thu, 20 Aug 2009 20:36:01 +0000

You have a fear of spiders, or of flying, or of crowds. Are you just sitting there suffering? It’s time to try Exposure Therapy!

Exposure therapy is a type of Behavioral Therapy used to help the patient confront a feared situation, object, thought, or memory and dispel its power to produce fear and anxiety. It involves reliving a traumatic experience in a controlled, therapeutic environment.

The Anxiety Disorders can paralyze the sufferer with ever-mounting avoidance behaviors. While successful for the moment, avoidance just sets aside the fear and anxiety triggered by a situation. They are sure to come back, stronger than ever.

Exposure therapy has been shown to be effective with many of the Anxiety Disorders, including Social Phobia (SAD), Generalized Anxiety Disorder (GAD), panic attacks and Panic Disorder, Agoraphobia, Adult Separation Anxiety Disorder (ASAD), Post Traumatic Stress Disorder (PTSD), and specific phobias.

This is the second of a two-part series of articles on Exposure Therapy. It focuses on tips to make your Exposure Therapy successful. Today’s installment has these headings:

Exposure Therapy: Better in real life or in imagination?
Tips for successful Exposure Therapy experiences

Yesterday’s Part 1 describes Exposure Therapy and what goes into a typical Exposure Therapy plan:

Exposure Therapy is based on habituation
Exposure Therapy counteracts Anxiety Disorders’ avoidance
Exposure Therapy is a part of Cognitive Behavioral Therapy
Characteristics of a typical Exposure Therapy plan

Exposure Therapy: Better in real life or in imagination?

Exposure Therapy in the thoughts or imagination is more difficult

Exposure Therapy may be done in vivo (in real life) or in the thoughts or imagination. In vivo exposure is more effective than exposure using the imagination. While anxiety or other discomfort may get worse in the first few minutes of in vivo exposure, it is important to continue the experience until the discomfort has diminished.

Examples of exposure in vivo are resuming driving after being in a traumatizing accident, or returning to a now-safe location where an assault once occurred.

Exposure in imagination or in thoughts involves the person recounting traumatic memories in their mind until they lose their sting. While treating exposure in imagination is sometimes unavoidable, it is harder for you and the therapist to create an exposure plan, and more difficult for both of you to evaluate your progress. Your therapist will teach you a number of techniques for coping with the stress and fear that accompany exposing yourself to traumatic thoughts.

Your therapist will have you use several tools to guide you through the steps of your exposure plan. Some of these include keeping a journal, guided reading, or making recordings. For example, you may confront fearful thoughts by saying them aloud repeatedly, writing, reading and rewriting a biography of the events or recording them on a tape and playing them over and over until they are no longer distressing.

Tips for successful Exposure Therapy experiences

Your commitment to your Exposure Therapy is key to its success!

The skill and experience of your therapist is very important to developing and evaluating an Exposure Therapy plan. However, your efforts are even more important for its success. You will be the one executing the steps in your plan, both in your therapy sessions, and more essentially, outside them.

You will be on your own 167 hours of the week outside your one-hour therapist’s appointment! It will be your responsibility to initiate and complete your exposure exercises, and in some cases, to determine when to move on to the next step.

Here are some tips for making your Exposure Therapy exercises successful and confidence-building:

Keep your final goal firmly in mind at all times. Picture yourself being successful in overcoming the feared object or situation and living your life free of their power.
Always have in mind your exposure plan’s steps toward success. Each should be small enough that success is easy, and close enough to the next that you can move on as you are able. Your plan may be explicit, in the form of increasingly challenging tasks, or implicit, in the form of a set of principles for escalating the exposure.
One step at a time: Follow your plan and don’t suddenly jump into the deep end. It’s tempting in the glow of success to want to skip steps in your plan, but you are only inviting failure if you do.
At every stage, your self-exposure should be completely voluntary, and should offer an easy way to terminate it. By choosing not to escape, and practicing a better response, you are weakening your learned avoidance behaviors and learning new ways to think about the situation.
Stay in the situation and try not to leave or quit if you suddenly feel anxious. Use the techniques your therapist has taught you such as rational thinking, focusing, controlled breathing, and relaxation. If you have to end the exposure, try to do it again as soon as possible. However, it may be that the step was too big for you, and you need to repeat the previous step again to gain confidence.
Repeat the successful exposure experience before moving on to the next step, since doing something only once can be interpreted as a fluke! The more often you do something challenging, the more you will feel comfortable in the situation.
Regular practice is very important. Try to do your exposure exercises as much as you can, rather than letting long periods of time come between repetitions. Just like learning the guitar, regular practice is more effective than occasional practice.
Ups and downs are a part of life. Some days will be good days when your exposure task will be easy, and there will be other days when it is almost impossible. Try not to beat yourself up on the bad days with negative self-talk. Rather, accept it for what it is — a not-so-good day! If you have a series of bad days, it might be wise to repeat the previous step until you gain more self-confidence.
Be aware of avoidance: It’s what got you into your problem in the first place! By not doing something that you fear, you are only making it harder for yourself, and allowing your avoidance to grow and keep your fears alive and healthy. Remember, it is you who are in control of your anxiety, and it is you who can decrease and manage it, as well.

Don’t miss yesterday’s Part 1 of the series!

Yesterday’s Part 1 describes Exposure Therapy and what goes into a typical Exposure Therapy plan. If you missed it, be sure to read it now to better understand what Exposure Therapy can do for you! The topics of discussion in Part 1 are:

Exposure Therapy is based on habituation
Exposure Therapy counteracts Anxiety Disorders’ avoidance
Exposure Therapy is a part of Cognitive Behavioral Therapy
Characteristics of a typical Exposure Therapy plan

What do you think?

As with many of life’s experiences, you only get out of Exposure Therapy what you put into it. You have to have the desire to end the constriction and suffering that your avoidance causes. You must endure the discomfort of exposure to that which causes that suffering, and do it repeatedly and on an ever-more-challenging basis.

But you are not suddenly thrown to the lions: The exposure plan will present the feared situation to you in small steps that are designed for success. Your therapist will prepare you by helping you learn coping strategies that will defend you, not only in the series of exposures, but against other fear-triggering experiences you will have throughout life.

I have been through Exposure Therapy for my Agoraphobia, and I can say without hesitation that it works magnificently. Where I was once confined to the house, I now go where I want with a minimum of anxiety and fear — if any at all.

Do you have situations that you avoid? Do you think Exposure Therapy might be able to help you?
Do you think you could do Exposure Therapy on you own, without the help of a therapist?

What can you do now?

Your comments are always welcome, and are important to this blog’s community! Leave a comment now, or read the comments.

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Resources used in this post:
Andrews, G.; Crino, R.; Hunt, C.; Lampe, L.; Page, A. (1994). The Treatment of Anxiety Disorders. Cambridge, England: Cambridge University Press. (Quoted) Retrieved October 1, 2008 from Shyness & Social Anxiety Treatment Australia Web site: http://www.socialanxietyassist.com.au/treatment/exposure.shtml
Anxiety Treatment Center. (2006). Exposure and Response Prevention Therapy. Retrieved October 1, 2008 from Anxiety Treatment Center Web site: http://www.anxietytreatmentexperts.com/cbt_exposure_therapy.asp
Atherton, J.S. (2005). Learning and Teaching: Cognitive Dissonance and Learning. Retrieved October 3, 2008 from Learning and Teaching Web site: http://www.learningandteaching.info/learning/dissonance.htm
ChangingMinds. (2002). Cognitive Dissonance. Retrieved October 3, 2008 from ChangingMinds Web site: http://changingminds.org/explanations/theories/cognitive_dissonance.htm
HealthyPlace. (2008). Exposure Therapy for Anxiety Disorders, Panic Attacks. Retrieved October 1, 2008 from HealthyPlace Web site: http://www.healthyplace.com/Communities/Anxiety/treatment/exposure_therapy.asp
Hoffman, Hunter. (2008). VR Therapy for Spider Phobia. Retrieved October 1, 2008 from HITLab Web site: http://www.hitl.washington.edu/projects/exposure/
Katz-Wise, Sabrina; Poore, Ralph. (2006, November 10). Exposure therapy. Retrieved October 1, 2008 from RevolutionHealth Web site: http://www.revolutionhealth.com/articles/exposure-therapy/aa131258
Madison, N. (2008). What is Exposure Therapy? Retrieved October 1, 2008 from WiseGeek Web site: http://www.wisegeek.com/what-is-exposure-therapy.htm
Mindsite. (2008, March 12). Exposure Therapy. Retrieved October 1, 2008 from MindSite Web site: http://www.mindsite.com/article/229/exposure_therapy
PTSD Facts for Health. (2008). Exposure Therapy. Retrieved October 1, 2008 from PTSD Facts for Health Web site: http://ptsd.factsforhealth.org/exposure.html
Rapee,R.M., (1998), Overcoming Shyness and Social Phobia. Cambridge, MA: Lifestyle Press.
Terri. (2007, February 24). Exposure Therapy for Treating PTSD. Retrieved October 1, 2008 from A Soldier’s Mind Web site: http://soldiersmind.com/2007/02/24/exposure-therapy-for-treating-ptsd/

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Exposure Therapy: Eliminating Anxiety Disorder’s Fear, Part 1

Mike Nichols — Mon, 17 Aug 2009 06:00:48 +0000

The neighbor’s dog barks night and day. If you have gotten used to it, you have used one of the root principles of Exposure Therapy.

Exposure therapy is a type of Behavioral Therapy used to help the patient confront a feared situation, object, thought, or memory and dispel its power over them. It involves reliving a traumatic experience in a controlled, therapeutic environment.

In a way, Exposure Therapy is related to the old maxim “face your fears,” but instead of jumping into a terror-inducing situation with both feet, therapy usually advocates a carefully planned, gradual approach to alleviating fears.

This two-part series of articles describes what Exposure Therapy is, and offers tips to make your Exposure Therapy successful. Today’s installment has these headings:

Exposure Therapy is based on habituation
Exposure Therapy counteracts Anxiety Disorders’ avoidance
Exposure Therapy is a part of Cognitive Behavioral Therapy
Characteristics of a typical Exposure Therapy plan

Tomorrow’s part of the article will continue the discussion under these headings:

Exposure Therapy: Better in real life or in imagination?
Tips for successful Exposure Therapy experiences

Exposure Therapy is based on habituation

Habituation: Just getting used to the annoying things in life

Exposure therapy is based on the principle that we get used to things that are just annoying and not truly dangerous if the experience is not overwhelming. This is called habituation, and it occurs naturally in over 95 percent of all people.

For example, you visit a friend in a large city who lives in an apartment right beside an elevated railroad. It is very annoying every time a train screeches by, shaking the building and rattling the windows to the point that conversation becomes difficult.

You might say to your friend, “How do you live in all this noise?” And the friend might answer, “What noise?”
If you only visited for a few days, you would leave with a belief that your friend lives in an impossible situation. If you were to stay for a week or two, you too would become habituated to the noise, and no longer be annoyed by passing trains.

In the same way, Exposure Therapy gradually habituates the patient to the feared thing — be it a situation, an item, a memory, or a thought. Through exposure, it gradually loses its power to produce fear and anxiety, with the goal being that it is no longer even noticed.

Exposure Therapy counteracts Anxiety Disorders’ avoidance

Avoidance is the key features of Anxiety Disorders

One of the key components of the Anxiety Disorders is the tendency to avoid the situations, thoughts, and objects that trigger anxiety. This avoidance builds upon itself: real things that cause anxiety are avoided, then more related real things are avoided, then imaginary things related to the real things, then imaginary things related to the imaginary things — until your life is a minefield of things to be avoided.

Avoidance does provide temporary relief from anxiety, but it never lasts. There’s always a new situation that requires some sort of negotiation with your anxious fears, causing you to once again use avoidance as your first line of defense.

Exposure Therapy works in opposition to the typical, self-prescribed avoidance approach. It recognizes the fears behind the learned avoidance behavior, and names the triggers that produce your Anxiety symptoms. Exposure Therapy uses a carefully devised plan of exposure to the feared situation to gradually defuse its anxiety-producing power, to the point that it has no ability to produce anxiety at all.

Exposure Therapy is a part of Cognitive Behavioral Therapy

Cognitive Behavioral Therapy is effective treatment

Cognitive Behavioral Therapy (CBT) has been shown to be one of the most effective kinds of psychotherapy for dealing with the Anxiety Disorders. It has two basic components:

It helps to change thinking patterns (cognitions) that have prevented individuals from overcoming their fears.
The behavioral component helps individuals to slowly come in contact with their fears. This is done through Exposure and Response Prevention Therapy (ERP) and is designed to systematically desensitize a person to their fears.

Exposure Therapy within CBT is based on our natural tendency to habituate ourselves to situations, along with a concept called cognitive dissonance. “Cognition” is simply any mental process that we have involving knowledge, attitude, emotion, belief, or behavior. “Dissonance” is a term borrowed from music, meaning the grating together of two conflicting, incompatible notes. The theory of cognitive dissonance states that contradicting cognitions serve as a driving force that causes the mind to acquire or invent new thoughts or beliefs, or to modify existing beliefs, so as to reduce the amount of dissonance between cognitions.

For example, you may enter Exposure Therapy with the fear of flying. You hold the thought in your mind that flying is unsafe, which produces fearful sensations in your mind and body. Your therapy will teach you that airplanes have an admirable safety record, and though uncomfortable, flying is nothing to fear. During the course of your Exposure Therapy, the two conflicting, or dissonant, thoughts — fear of flying and the safety of flying — gradually resolve themselves into a belief that flying is safe and nothing to fear: a consonance of thoughts.

Characteristics of a typical Exposure Therapy plan

What a good Exposure Therapy plan looks like

Your therapist will work with you to determine what your root fears are, and to develop a plan to confront them in a controlled manner. While some therapists may determine that the best solution is what is called “flooding,” wherein you are exposed to the full situation all at once, most will create a plan that will gradually expose you to the fear until it is dissipated.

Along with an exposure plan, you will be taught relaxation techniques, such as breathing exercises, and other coping skills to deal with emotional and physical distress and fear. Using these techniques helps you maintain a sense of control whenever you are confronted with the feared object, situation, or distressing thought or memory.

The basic principles of Exposure Therapy are:

Gradual exposure
Repeated and regular exposure
Prolonged exposure

Gradual exposure You and your therapist will create an exposure plan, with gradual steps that lead to full exposure to the feared situation. Each step should be difficult enough to provoke some anxiety, but easy enough for you to be fairly confident you can do it. Once you can successfully cope with a step, you can move on to a more difficult situation and gradually work up your most feared scenarios.

It is important not to confront a feared situation that is far too difficult for you. If you tackle something too stressful without sufficient preparation, you may become extremely anxious or even have a panic attack. Such a negative experience would only strengthen the association between fear and the setting that provokes it. Therefore, it is important to follow your plan exactly, without skipping steps.

Repeated and regular exposure You need to confront your feared situations frequently and regularly if you are going to overcome your anxiety. If your exposures are too far apart your fear will rise again by the next time you confront it. Your therapist will likely give you exposure assignments to practice between sessions. It is important that you do these assignments several times in order to become confident enough to move to the next step.

Prolonged exposure You should stay in the feared situation until your anxiety starts to decrease. Your past pattern was to attempt a feared situation, but then choose to escape or avoid it. When you avoid or leave feared situations two things happen:

Your fear of the anxiety-triggering situation increases even more.
The idea that avoidance is a helpful strategy is strengthened because your escape caused a decrease in anxiety.

However, if you stay in the feared situation your anxiety will eventually decrease, and the next time you confront the situation you will be less anxious. A good exposure plan will never put you in a situation that is too much for you — keep this in mind as you challenge yourself to cope with each exposure step.

Don’t miss tomorrows’ installment with tips for success!

Today’s installment discusses what Exposure Therapy is and what a good plan looks like. Tomorrow’s part of the article will continue the discussion, and also provides tips for making Exposure Therapy a successful experience:

Exposure Therapy: Better in real life or in imagination?
Tips for successful Exposure Therapy experiences

What do you think?

As mentioned, Exposure Therapy has a lot in common with the notions of conventional wisdom. We know that we must face our fears, but the only way we know how is to face them in all their fury, which is bound to be unsuccessful and produce even more anxiety. The advantage of formal Exposure Therapy is that the therapist is experienced in helping people discover their core fears, and developing a plan for gradually confronting them. The therapist can also help you learn techniques to cope with your fears during your exposure practice — techniques that will help you for the rest of your life.

I’m reminded of when I was a little boy. My uncles threw me into the deepest part of the swimming hole to “teach me to swim.” All that did was almost drown me and reinforce my fear of the water. It was only through swimming lessons — with its gradual steps toward learning the skill — that I learned to swim and not fear the water.

The old maxims tell us to throw ourselves into the middle of feared situations and just be brave. All that does is to create more fear and cause for avoidance. It is only through a well-planned and executed program of exposure that we will learn to conquer our fears and dispel the power they have over us.

Have you had any experience with Exposure Therapy? How has it helped you?
Exposure Therapy is closely related to normal habituation. Have you been able to overcome fears on your own using a gradual approach?

What can you do now?

Your comments are always welcome, and are important to this blog’s community! Leave a comment now, or read the comments.

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Study Shows Very High Rate of PTSD Among Veterans

Mike Nichols — Tue, 21 Jul 2009 11:18:25 +0000

Almost 40 percent of Iraq and Afghanistan veterans receiving health care from VA hospitals have one or more mental disorders.

A new study, published in the July 16 online edition of the American Journal of Public Health, reported this and other shocking news about the mental health of our veterans of the Middle East wars.

The study’s principal author, Dr. Karen H. Seal, an assistant professor of medicine and psychiatry at the University of California, San Francisco, had even more distressing news. She said:

When the definition is expanded to include diagnoses of mental health disorders or psychosocial behavioral problems such as homelessness, or both, 43 percent of these veterans received these diagnoses.

If previous history with Vietnam-era veterans is any guide, the burden of mental illness will follow these veterans for many years to come. The research reported on in this post seems to back this idea up.

The findings of the study and its implications are detailed under the following headings:

How the study was conducted?
What were the findings of the study?
The incidence of mental illness among veterans is accelerating
It can take years for Anxiety Disorders such as PTSD to develop
What are the implications of the study?

How the study was conducted?

The health records of 289,328 Iraq and Afghanistan veterans entering Veterans Affairs (VA) health care from April 1, 2002 to April 1, 2008 were studied by researchers at the San Francisco Veterans Administration (VA) Medical Center and the University of California, San Francisco. This number accounts for about 40 percent of returning veterans.

Mark Kaplan, a professor of community health at the School of Community Health at Portland State University in Oregon, noted that the study only covers veterans who have received care at the VA, but there are many more with serious mental health problems that are either seeking care privately or not at all. He said,

This study adds to what we know about this population, however, that’s the veterans who seek care at the VA system. But if you look at the total population of veterans from all wars, there are one-third of all veterans who have these problems.

What were the findings of the study?

Well over a third of the returning veterans, 37 percent, received a diagnosis of having a mental disorder. Of these, the largest groups of diagnoses were:

22 percent: Post Traumatic Stress Disorder (PTSD)
17 percent: depression
7 percent: alcohol use disorder
3 percent: drug use disorder

Many veterans had several mental health problems. In fact, 29 percent of veterans with mental health issues were diagnosed with two different conditions, and 33 percent were diagnosed with three or more. Women were at higher risk for depression than were men, but men had over twice the risk for drug use disorders.

Active duty veterans younger than 25 years had higher rates of PTSD and alcohol and drug use disorder diagnoses compared with active duty veterans older than 40 years. Greater combat exposure was associated with higher risk for PTSD.

Veterans older than 40 with the National Guard or the Reserves were more likely to develop PTSD and substance abuse disorders than those under 25. Dr. Seal said a possible reason is that older reservists go to war from established civilian lives, with families and full-time jobs, making combat trauma potentially more difficult to absorb. She continued:

It’s the disparity between their lives at home, which they are settled in, and suddenly, without much training, being dropped into this situation.

The incidence of mental illness among veterans is accelerating

Dr. Seal states that, “What’s really striking is the dramatic acceleration in mental health diagnoses, particularly PTSD, after the beginning of the conflict in Iraq,”

The increase in mental illness diagnoses accelerated after the invasion of Iraq in 2003, the researchers found, increasing 4 to 7 times. Among the group of veterans who enrolled in veterans health services during the first three months of 2004, 15 percent received mental health diagnoses after one year. But after four years, the number had nearly doubled, to 27.5 percent.

Dr. Seal attributed the rising number of diagnoses to several factors: repeat deployments; the perilous and confusing nature of war in Iraq and Afghanistan, where there are no defined front lines; growing public awareness of PTSD; unsteady public support for the wars; and reduced troop morale. She said that “waning public support and lower morale among troops may predispose returning veterans to mental health problems, as occurred during the Vietnam era.”

It can take years for Anxiety Disorders such as PTSD to develop

Dr. Seal said often it takes more than a year for symptoms of PTSD to appear and diagnosis to be made. She said,

The longer we can work with a veteran in the system, the more likely there will be more diagnoses over time. It sometimes takes time, given the stigma associated with mental illness, before we are able to break through the barriers and have patients tell us what is happening.

This finding supports the recent move to extend VA benefits to five years of free health care, which allows VA doctors the time to detect and treat more mental illness in returning combat veterans, the researchers said.

Kaplan noted that it is not uncommon for problems such as PTSD to arise years, even decades, after service. “We don’t know the full emotional toll of the wars in Iraq and Afghanistan,” he said.

What are the implications of the study?

Dr. Seal believes that more resources are needed to deal with the problem of mental illness among returning veterans. She states that:

After the start of the Iraq War, there is a growing burden of mental illness, particularly post-traumatic stress disorder (PTSD), that will require increased allocation of resources for better detection and early intervention to prevent chronic mental illness, which threatens individual veterans, their families and communities.

Simon A. Rego, associate director of psychology training at Montefiore Medical Center in New York City, says,

An important and often overlooked finding here was that a lack of social support — being separated, divorced, widowed, etc.– may pose a serious risk for new post-deployment mental health problems.

Rego emphasizes that this underscores the need for social support services for returning veterans who are unmarried and/or without social support. He continues:

All too often we focus on treating the symptoms but fail to address the individual’s social context. Based on the data here, a failure to do so could lead to increased risk in developing new mental health problems.

What do you think?

I live in the city that is host to Fort Benning, one of the largest army installations in the world. There is a continual flow of new recruits coming in for training, combat-ready soldiers being deployed to Iraq and Afghanistan, and veterans returning from the wars. The health and well-being of these troops is a matter of no small concern to not only the Army, but to the entire community.

The results of the study reported on in this article are distressing to me for two reasons: I am shocked how many veterans are returning home, burdened by a load of mental woe and illness that will follow them the rest of their lives; and I cannot help but think of the millions of veterans of former wars whose mental disorders went undiagnosed, and whose lives were lived out in pain and frustration.

Do you think that the dramatic rise in diagnoses of mental illness in veterans is due to better diagnostic techniques, or the increasing difficulties of the wars?
Congress has increased the length of time a veteran can be treated by the VA to 5 years. Do you think it should be longer still given the long gestation of PTSD?

What can you do now?

Your comments are always welcome, and are important to this blog’s community! Leave a comment now, or read the comments.

Get free updates by RSS or email!

Why not share this article with others!

Resources Used in This Post
Chong, Jia-Rui. (2009, July 16). Percentage of veterans with mental health problems jumps dramatically. Retrieved July 21, 2009 from Los Angeles Times web site: http://latimesblogs.latimes.com/booster_shots/2009/07/veterans-mental-health-veterans-affairs-study-.html
Dao, James. (2009, July 16). Vets’ Mental Health Diagnoses Rising. Retrieved July 21, 2009 from The New York Times web site: http://www.nytimes.com/2009/07/17/health/views/17vets.html?_r=1&ref=health
Grohol, John. (2009, July 18). Veterans’ Mental Health Concerns Rising. Retrieved July 21, 2009 from PsychCentral web site: http://psychcentral.com/news/2009/07/18/veterans-mental-health-concerns-rising/7199.html
Reinberg]]Reinberg, Steven. (2009, July 16). Many Veterans Need Mental Health Care. Retrieved July 21, 2009 from HealthScout web site: http://www.healthscout.com/news/1/629099/main.html
Seal, Karen; Metzler, Thomas; Gima, Kristian; Bertenthal, Daniel; Maguen, Shira; Marmar, Charles. (2009, July 16). Trends and Risk Factors for Mental Health Diagnoses Among Iraq and Afghanistan Veterans Using Department of Veterans Affairs Health Care, 2002-2008. Retrieved July 21, 2009 from American Journal of Public Health web site: http://www.ajph.org/cgi/content/abstract/AJPH.2008.150284v1

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Is What You’re Reading Junk? Evaluating the Quality of Mental Health Websites, Part 2

Mike Nichols — Wed, 15 Jul 2009 23:30:27 +0000

The internet is a minefield full of inaccurate, biased sites.

How do you tell the difference between good information and bad information? You need a guide to help you evaluate sites, to tell whether the articles presented are valid and accurate, to discover when someone is trying to sell you something, and to discern between a legitimate view and a crackpot’s rant.

This two-part series of articles is intended to be a guide for you in your search for trustworthy information. It outlines the collective wisdom of medical librarians, mental health professionals, professional associations, and other experts who surf the web every day to discover quality information in support of clinical and scientific decision making by professionals responsible for the nation’s mental health.

Today’s information, part 2 of the series, is presented under the following headings:

How old is the information? When was it published or reviewed?
Does the site support the doctor-patient relationship?
Privacy, advertising, and other policies should be clearly stated
How does the site interact with visitors?

Be sure to read yesterday’s installment, too. It discussed these topics:

What is the purpose of the site?
Who owns the site? How is it funded?
Be on guard for bias and competing interests
Authorship and affiliation are important
Authority and cited sources

How old is the information? When was it published or reviewed?

Mental health information eventually becomes stale in light of ongoing research, so it needs to be constantly updated to reflect the most recent knowledge and understanding available. Publication and review dates allow an internet user to judge how current and relevant the information is likely to be.

Current misinformation is still misinformation, so currency is no guarantee by itself of reliable, quality mental health information. But this is one more piece of information you can look for to help you judge the overall accuracy and reliability of the article you are reading.

Web sites should be reviewed and updated on a regular basis. It is particularly important that mental health information be current. The most recent update or review date should be clearly posted. Even if the information has not changed, you want to know whether the site owners have reviewed it recently to ensure that it is still valid.

All Anxiety, Panic & Health articles are clearly dated below the title. Review dates are listed at the end of the article.

Does the site support the doctor-patient relationship?

Many sites, especially those selling “cures,” implicitly sever the doctor-patient relationship and substitute their remedies for professional mental health care solutions. They often will openly challenge the validity of professional mental health care in favor of their product. It is typical that none of the site’s claims relating to benefits and performance are backed up with anything more than customers’ testimonials. If any medical endorsement is presented at all, it will be from a single source whose authority is questionable.

Reputable sites hold the doctor-patient relationship as inviolable and recommend consulting your doctor before using (and hopefully, buying) their product.

Any mental health information on such sites should be approached with extreme caution. Be instantly suspicious if the emphasis is on selling you a product or touting a product.

Anxiety, Panic & Health holds the doctor-patient relationship in highest regard, and never seeks to violate or diminish that relationship in any way. This is stated clearly in my Disclaimer.

Privacy, advertising, and other policies should be clearly stated

Every site should have a privacy and advertising policy at a minimum, even if it’s as simple as, “We don’t collect personally identifiable information on this site, nor do we accept advertising.” That’s a policy that is clear, concise, and transparent. If you can’t glance at a site’s policy and pick up the main points, the site may not be worth spending too much time on.

For a privacy policy, the main points are what information they collect from you and what do they do with it. Frequently you are asked for your email address and name to register, subscribe, or become a member of a health-related site. In addition, web sites routinely track the path users take through their sites to determine what pages are being used through the use of “cookies.” You should know that many sites sell the information you provide to other companies, and that “cookies” can be used not only to follow you as you browse the internet, but identify you for advertising purposes.

You should look for and read the site’s privacy policy before giving them any information. If the site does not have a privacy policy, do not provide them with any personal data under any circumstances. If you suspect that the site uses cookies, either turn them off in your browser or leave immediately.

The main points for an advertising policy are whom do they allow to advertise on their site, whether the advertisers have any say over their content, and what do they do with their revenues. If you don’t agree with their answers, or their answers are hard to discern from their policies, move along to another, more transparent site.

Anxiety, Panic & Health’s policies are grouped under the “Policies” tab in the menu. There you will find:

A “Disclaimer” stating my qualifications for writing and editing articles
A Comment Policy” that describes the do’s and don’ts of commenting on articles
A “Funding and Advertising Policy” that lays out ownership, funding, and advertising on this site
A “Privacy Statement” that describes the data collected from visitors to this site, and what is done with that information

How does the site interact with visitors?

There should always be a way for you to contact the site owner if you run across problems, have questions, or want to send feedback. Somewhere on the screen should be a “Contact” or similarly worded link that will allow you to interact with the site owner or their representative. If the site provides no contact information, or if you can’t easily find out who runs the site, use caution. If you do contact the site, another gauge of their credibility is the promptness of their reply and whether it is a form letter or a personal note.

If the site hosts chat rooms or other online discussion areas, it should tell visitors what the terms of using this service are. Is it moderated? If so, by whom, and why? It is always a good idea to spend time reading the discussion without joining in, so that you feel comfortable with the environment before becoming a participant.

Anxiety, Panic & Health has a “Contact” tab in the menu on every screen. It sends an email directly to me. I answer all emails promptly. Users can interact with other readers and me by writing comments at the end of articles. I reply to all comments quickly, and if necessary will send an email to the commenter.

Be sure to read yesterday’s installment

It discussed important topics that you should be aware of under the headings:

What is the purpose of the site?
Who owns the site? How is it funded?
Be on guard for bias and competing interests
Authorship and affiliation are important
Authority and cited sources

What do you think?

I have a specialized browser optimized for search, DEVONagent. I can enter a search query and get sites from many sources on the internet that a Google search alone would miss. Sometimes it produces hundreds of hits that are closely related to my search terms. It never ceases to amaze and surprise me how many sites are invalidated based on the criteria outlined in this guide — at least half of them, and according to the search keywords, sometimes more.

This is disturbing to me, since many people innocently put in a search term, and pick only the first two or three at the top of Google’s list for their information. Often these are the most inaccurate they could find!

What has been your experience searching for information?
Have you found the information available to be accurate, or biased and unreliable?
What do you think of this series? Has it helped you in any way?

What can you do now?

Your comments are always welcome, and are important to this blog’s community! Leave a comment now, or read the comments.

Get free updates by RSS or email!

Why not share this article with others!

Resources used in this post:
Grohol, John M. (2007, January 11). Reliability and Validity in a Web 2.0 World. Retrieved June 25, 2008 from Psych Central web site.
Grohol, John M. (2007, December 4). Evaluating the Quality of Mental Health Websites. Retrieved June 25, 2008 from Psych Central web site.
Kroski, Ellyssa. (2006, February 20). Authority in the Age of the Amateur. Retrieved October 21, 2008 from Infotangle web site.
Medical Library Association. (2008, July 25). A User’s Guide to Finding and Evaluating Health Information on the Web. Retrieved October 27, 2008 from Medical Library Association web site.
Medline Plus. (2006, February 13). Medline Plus Guide to Healthy Web Surfing. Retrieved October 27, 2008 from Medline Plus web site.
National Cancer Institute. (2005, September 1). How to Evaluate Health Information on the Internet: Questions and Answers. Retrieved October 27, 2008 from National Cancer Institute web site.
National Center for Complementary and Alternative Medicine. (2008, August 27). 10 Things to Know About Evaluating Medical Resources on the Web. Retrieved October 27, 2008 from National Center for Complementary and Alternative Medicine web site.
National Institute on Aging. (2005, August). Health Quackery: Spotting Health Scams. Retrieved October 27, 2008 from National Institute on Aging web site.
Schloman, Barbara F. (2002, December 16). Information Resources: Quality of Health Information on the Web: Where Are We Now? Retrieved October 27, 2008 from The Online Journal of Issues in Nursing web site.
Winker, Margaret; Flanagin, Annette; Chi-Lum, Bonnie; White, John; Andrews, Karen; Kennett, Robert; DeAngelis, Catherine; Musacchio, Robert. (2008, August 1). Guidelines for medical and health information sites on the Internet. Retrieved October 22, 2008 from American Medical Association web site.

Related Posts:

Is What You’re Reading Junk? Evaluating the Quality of Mental Health Websites, Part 1

Mike Nichols — Wed, 15 Jul 2009 03:01:28 +0000

The internet allows patients, consumers, physicians, and other mental health care professionals to quickly access mental health information.

Millions of Americans search for mental health information on the web every year. Whether the information is needed for personal reasons or for a loved one, millions of mental health-related web pages are viewed. Sometimes the information found is authoritative, unbiased, and just what was needed. Other searches end in the retrieval of inaccurate, even dangerous, information.

How do you know whether the site you’re looking at presents valid, up-to-date information, or whether it is trying to sell you something, the rantings of a lunatic with an axe to grind, or otherwise bogus?

This article is intended to be a guide for you in your search for trustworthy information. It outlines the collective wisdom of medical librarians, mental health professionals, professional associations, and other experts who surf the web every day to discover quality information in support of clinical and scientific decision-making by professionals responsible for the nation’s mental health.

This is the first of a 2-part series. The information for today is presented under the following headings:

What is the purpose of the site?
Who owns the site? How is it funded?
Be on guard for bias and competing interests
Authorship and affiliation are important
Authority and cited sources

Tomorrow’s installment, Part 2, will continue with the topics:

How old is the information? When was it published or reviewed?
Does the site support the doctor-patient relationship?
Privacy, advertising, and other policies should be clearly stated
How does the site interact with visitors?

What is the purpose of the site?

This is the first question you should ask. Is the site informational? Is it intended to sell you something? Is the author ranting about a pet peeve or an off-the-wall theory?

The website should clearly state whether the information is intended for the consumer or the health professional. Many health information websites have two different areas — one for consumers, one for professionals. The design of the site should make selection of one area over the other clear to the user.

This question is related to who runs and pays for the site. An “About This Site” link should be present on the site. If it’s not there, it should raise red flags. But if it’s there, use it. The purpose of the site should be clearly stated and should help you evaluate the trustworthiness of the information.

Anxiety, Panic & Health’s purpose is clearly stated in both the “About” and the “My Story” articles.

Who owns the site? How is it funded?

Any good health-related Web site should make it easy for you to learn who is responsible for the site and its information. and how it is funded.

Can you easily identify the site sponsor? Sponsorship is important because it helps establish the site as respected and dependable. Does the site list advisory board members or consultants? This may give you further insights on the credibility of information published by the site.

The web address itself can provide additional information about the nature of the site and the sponsor’s intent.

A government agency or site sponsored by the Federal government has .gov in the address.
An educational institution is indicated by .edu in the address.
A professional organization such as a scientific or research society will be identified as .org. For example, the American Cancer Society’s website is http://www.cancer.org/.
Commercial sites are most often identified by .com, and will identify the sponsor as a company, for example Merck & Co., the pharmaceutical firm.
Non-commercial sites can be designated by .com, too, and also .net. The .com in the address is often chosen to make the site appear more professional or authoritative. Anxiety, Panic & Health has a .com address for these reasons.

The site should fully disclose the identities of commercial and noncommercial organizations that have contributed funding, services, or material to the site. Look for an “about us” page to check to see who runs the site. Know who is responsible for the content. Advertisements should be labeled. They should say “Advertisement” or “From our Sponsor.”

Anxiety, Panic & Health’s ownership and funding is stated in its “Funding and Advertising Policy” statement. Its advertisements are clearly labeled.

Be on guard for bias and competing interests

Nearly every author of every article ever written has an unspoken agenda that guides their writing. Psychologists, and even researchers, can be influenced by their background and education. Psychiatrists are often influenced by pharmaceutical marketing materials and their own medical training.

Educated internet users can use this understanding of an author’s motivations to help discern the value of information found online. A research news brief from the National Institute of Mental Health is likely to be less biased than a research news brief from a pharmaceutical company. A press release from a university describing some new therapy research will tend to be more biased than the actual peer-reviewed study.

Beware of sites selling products or services. A site selling Anxiety “cures” has an obvious bias, and any articles found there should be taken with a large grain of salt. A pharmaceutical company’s site may have a mix of factual articles, such as drug information, and articles biased in favor of their products. Someone selling their psychotherapy services online may subtly shape their articles (or links to other articles) to reflect a more pro-therapy stance. The key is to understand that this bias exists in many articles found online, and to use caution in relying on the information they provide.

Anxiety, Panic & Health’s “Funding and Advertising Policy” clearly states that I do not accept payment for reviews, favorable articles, or any other content that would potentially conflict with the editorial policies of this site or violate the trust of my readers. To minimize bias, every article is backed up with authoritative sources for all information.

Authorship and affiliation are important

Every page on the internet has been authored by someone, somewhere, at some specific time in the past. Unfortunately, most pages on most sites do not include this very basic information. Every article should name its author, the date it was written, and include information about the author, including affiliations. If there is no short biography or affiliations listed, look for an “about” page for this information.

If authorship and affiliation are not readily evident, the reader should question the validity of the article. Authorship also helps one determine possible bias in the article’s presentation of information.

Every Anxiety, Panic & Health article has the author and date clearly displayed at the head of the article. My biography and affiliations are in the “About” and the “My Story” articles. Other affiliations are listed under the sidebar heading,”Friendly Links.” Guest authors are clearly identified and have a short biography.

Authority and cited sources

One of the major points of contention raised by critics about blogging and online information is that it lacks filters. In other words, it is missing the editorial process: the fact checker correcting inaccurate information, the copy editor tweaking grammar, and the editor determining objectivity and relevance. In print publications, authority resides both in the identity of the author and with the publisher. This combination of individual and institutional authority lends the reader valuable clues about the credibility of the source material. This kind of authority is missing on the internet.

An important way to check the authority of mental health information online is to look for cited sources. Articles should have clinical research, authoritative articles and books, and other trustworthy sources of information as an integral part of the information provided. Every medical fact or figure should have references to back it up.

A person seeking mental health information online is seeking a balanced and authoritative understanding of the condition. However, this has become increasingly difficult because some websites and blogs blur the lines between facts and opinions. And sometimes we as readers tend to confuse facts with opinions — or emphasize one over the other — to the detriment of understanding.

If the article is the author’s opinion, it should be clearly stated. Opinions or advice should be clearly set apart from information that is “evidence-based” (that is, based on research results). Beware of articles that do not offer external medical evidence to back up their claims, or that do not make it clear that the opinion or advice offered is personal.

Anxiety, Panic & Health’s articles always have resources listed, and in the case of medical information every fact and figure is footnoted or backed up by an authoritative source. Opinion articles are clearly categorized as such. This is especially important, since I am not a mental health professional, as stated in my “Disclaimer.”

Don’t miss tomorrow’s installment!

Tomorrow’s installment, Part 2, covers important topics that you are sure not to want to miss. It will continue with the topics:

How old is the information? When was it published or reviewed?
Does the site support the doctor-patient relationship?
Privacy, advertising, and other policies should be clearly stated
How does the site interact with visitors?

What do you think?

Searching for reliable mental health information on the web can be a very frustrating experience. Often a source that seems promising turns up to be promoting a product or a theory that is unproved and unprovable. Search long enough and you will even run into rampant plagiarism of articles from one bad source to another!

What is your experience of searching the internet for medical or mental health information?
Have you ever been frustrated by the volume of unreliable sites?
Do you have an opinion about the trustworthiness of commercial sites?

What can you do now?

Your comments are always welcome, and are important to this blog’s community! Leave a comment now, or read the comments.

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5 More Interesting Articles for You: Your Occasional Reader

Mike Nichols — Fri, 10 Jul 2009 20:30:30 +0000

Here I am again with another mental health miscellany for you! It’s not all tragic, either — there’s some right good humor mixed in!

But first: a birthday announcement. On June 25th, Anxiety, Panic & Health celebrated its first year of existence. During that time I’ve posted 132 articles and have had 834 comments on them. The top 5 articles were:

“A National Shame: The Mentally Ill Homeless” with 5158 readers
“I’m Dying: What a Panic Attack Feels Like” with 3484 readers
“Questions and Answers: Antidepressants for Anxiety Disorders” had 3467 readers
“Obama’s and McCain’s Positions on Mental Health Care” was read 2793 times
“What Can I Do? Helping a Friend or Family Member with a Mental Illness” had 2440 readers

Rather than bore you with any more introductory blather, let’s get right to it. You’ll get a taste of what’s in store for you from the headlines of the sections:

A Pioneer of brain imaging talks about her career and research
Eyewitnesses may be more witness than eyes
A touch — well, more of a whack — of psychiatric humor!
Senior citizens may quit taking their medicine when the Medicare “Doughnut Hole” hits
Materialistic people form strong brand connections when they fear death — really!
Finally, another “Where have you been?”

A Pioneer of brain imaging talks about her career and research

Nancy C. Andreason is a neuroscientist and psychiatrist at the University of Iowa. She has pioneered the use of imaging technology for learning about the physiology of the brain. She has studied such questions as:

How do the nervous systems of extremely creative people differ from those of the rest of us?
How is the brain physiology of the mentally ill different from that of normal people?
Why do people with schizophrenia lose brain tissue at a more rapid rate than healthy people of comparable age?
Why is it that the more drugs you’ve been given, the more brain tissue you lose?
At what point is human brain maturation complete and at what point do our brains naturally decline and lose tissue?

In the New York Times article, she speaks about the policy and ethical implications of her research, her research with schizophrenics, and the progress of imaging technology over her long career. It’s a very interesting, though brief, interview that I’m sure you’ll enjoy. The article is “Using Imaging to Look at Changes in the Brain: A Conversation with Nancy C. Andreason”

Eyewitnesses may be more witness than eyes

Research at the University of London shows that stress and fear reduce the likelihood of a witness’ ability to identify a perpetrator. They found that the higher a witness’ anxiety and stress at the moment of an event simulating a crime, the less likely they will be able to identify the “criminal” in a lineup.

The head of the research team, Tim Valentine, says that, “The research doesn’t suggest there is anything wrong with the identification procedures that the police use, but does demonstrate just how difficult it can be for a victim to identify the offender.”

A touch — well, more of a whack — of psychiatric humor!

Have you ever looked at the personals section of a newspaper or magazine? There are some really strange ads to be found there!

Well, this article purports to be selected personal ads from the American Psychiatric Association’s dating website. It’s got such gems as:

Female with adult attention-deficit disorder seeks male for—look at that bird! What is that? An egret? I love their long necks.

Guy with self-defeating personality disorder thinks he’s funny but isn’t. Seeking alcohol-free/drug-free female. Must be willing to treat me poorly, undermine any happiness I may experience, and stop me if I’m about to accomplish something I could potentially be proud of.

Read the rest at “Selected Personals from the American Psychiatric Association’s Dating Website.”

Senior citizens may quit taking their medicine when the Medicare “Doughnut Hole” hits

A short article in the Wall Street Journal reports that a sizable proportion of the 3.4 million Medicare patients who hit the “Doughnut Hole” in coverage quit taking their medication rather than pay full price out of pocket. The piece also describes exactly what the “Doughnut Hole” is.

It’s sad — no, more than that: tragic — when the elderly have to stop taking their medications because they can’t afford them. So many people need a regular dosage to maintain acceptable health, particularly diabetics, heart patients, and those with other chronic conditions. I’m hopeful that, among all the other plans for health care now being discussed, the “Doughnut Hole” in drug coverage can be stopped up!

Read the rest of the story: “Some Seniors Quit Taking Medicine When Medicare Doughnut Hole Hits.”

Materialistic people form strong brand connections when they fear death — really!

A study by the Journal of Consumer Research has found that materialistic people tend to form strong connections to particular product brands when their level of anxiety about death is high.

This finding is counterintuitive: We thought all along that materialistic individuals are weakly connected to brands and use them only as superficial status badges. Well, weren’t we wrong?

A short and interesting article from Science Daily. Well worth the read just for the incredulity it produces: “Materialism And Death Anxiety Lead To Brand Loyalty.”

Finally, another “Where have you been?”

I’ve had another long absence from the blog: about two months. You may recall I was AWOL for a bit longer earlier in the year. There were no new articles written during the last period, and I was barely able to keep up with the comments — in fact, I’m still catching up.

The hiatus was caused by another bipolar cycle that dipped into a deep depression for a while. I have the rapid cycling variety of bipolar disorder, and it’s not unusual for me to swing wildly from high to low to high again within a matter of days. What’s more unusual for me is that the cycles are lasting much longer recently.

I enjoyed a 9-month period of feeling “normal” last year, and I’m hoping that my current mood will last just as long, if not longer.

I’m not asking for anything more than your understanding of why I disappear for a month or two at a time. I’ve come a long way, but I’m still learning how to be productive when I don’t feel like it. But I’m learning, slowly but surely, and some day I will be able to bridge across the bad cycles.

What can you do now?

Your comments are always welcome, and are important to this blog’s community! Leave a comment now, or read the comments.

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