Bipolar Support Groups.com blog

Study and Practice to:

• Search for meaning and purpose in everyday life
• Emphasize authority of the individual over tradition
• Continue to evolve ideas and images of God
• Live with doubts and questions
• Disavow authoritative religious tradition
• Therapeutically approach spiritual practices
• Work for both personal and planetary transformation
• Reject exclusivism and the traditional ideas of heaven and hell
• Be receptive to interfaith dialogue and interspiritual explorations
• Perceive nature as a spiritual path and sign of the Divine
• Live out the dynamics of contemplation and sacred activism
• Shuck the doctrine of sin and being “born bad”

1 / 9   Remembering the Good Times

When you’re living under the weight of depression, it’s easy to get stuck in a cycle of negative emotions. But new research shows that a specific way of recalling happy memories could help boost your moods. A British study published in the journal Clinical Psychological Science found that people who recalled positive memories using a “method of loci” strategy — a strategy that involves associating memories with physical objects or locations — could remember more of their memories over time than people who simply grouped them by similarities. Even if you don’t use this method to recall memories, simply thinking back to good times can help lift your mood. Here are a few ways to recall the good times in your life.

2 / 9   Haul Out the Photo Albums

Everyone has them — albums or shoe boxes full of photographs from years past. Opening up these caches and shuffling through the photos can be an effective mood-booster when you’re battling depression. Looking at old photos and appreciating things in your past could generate positive thoughts and emotions, said Marla W. Deibler, PsyD, a clinical psychologist and founder and executive director of the Center for Emotional Health of Greater Philadelphia.

3 / 9   Write It Down

Committing good memories to paper can help them become more concrete and also serve as a way to preserve those details you may forget later, Deibler said. So grab a notebook and pen and start writing about something fun you’ve done. You might even buy a special journal just to help with this approach to conquering major depressive disorder — and soon find yourself with a smile on your face as you think back on these special experiences

9 / 9   Keep Working With Your Mental Health Professional

When you’re experiencing symptoms of a major depressive disorder — like persistent sadness, feelings of hopelessness, and loss of interest in normal activities — recalling good memories isn’t an adequate treatment on its own. But as you work with yourpsychotherapist or other mental health professional, he can help you channel these memories in a way that reinforces your therapy and depression medications to help you feel better.

4 / 9   Look at Keepsakes

Do you still have your corsage from senior prom? A ticket stub from a movie you enjoyed seeing years ago? Sifting through these mementos can also be a way of remembering special times and providing a respite from major depressive disorder. Make the time to hunt through your attic for that old box of treasure and see what’s inside. You could find a memento that you forgot you had. (You knew you were saving that stuff for something, right?)

5 / 9   Connect With People From Your Past

A great way to relive happy memories is by talking with the people who helped make them with you. “People with depression can be very isolated,” Deibler said. “Just connecting with others is very helpful — telling stories about things in the past, reminiscing about meaningful events in your lives. It can help you to feel good about what’s happened.” So, call up that old college roommate or high school friend for a brunch or lunch date — you’ll probably leave with a smile on your face.

6 / 9   Go to Your Happy Place

Visualizing a time when you felt happy and secure can be a good way to deal with emotionally difficult moments, said Toni Coleman, LCSW, CMC, a psychotherapist and dating coach in McLean, Va., who uses this strategy with some of her clients. “Often what they choose is an experience in which they were truly and completely in the moment, without the concerns and distractions that get in the way of peacefulness,” Coleman says. Then, during times of distress in your journey with a major depressive disorder, the happy place can be recalled using meditation techniques. Coleman likens it to “bottling up a happy moment and saving it for those rainy days ahead.”

7 / 9   Put Your Memories on Display

Why keep mementos from your past stuffed in a drawer? Displaying photos and keepsakes around your house can help trigger happy memories more frequently because you’ll see the items more often during the course of your day, said Carole Lieberman, MD, a psychiatrist in Beverly Hills, Calif. Take a few minutes to put those pictures into frames and hang them on your wall. Not only will you add interest to your décor, you’ll add a potential mood-booster to lessen your depression.

8 / 9   Remember …With Caution

Not everyone reacts to memories the same way, and for some, remembering can actually cause a further slip into depression. “Some people can become sad and reminiscent of things that are no longer in their lives,” Deibler said. “That’s not helpful, obviously.” If you find that recalling things from your past brings you down rather than lifts you up, you’ll need to try a different tactic for a major depressive disorder.

9 / 9   Keep Working With Your Mental Health Professional

When you’re experiencing symptoms of a major depressive disorder — like persistent sadness, feelings of hopelessness, and loss of interest in normal activities — recalling good memories isn’t an adequate treatment on its own. But as you work with yourpsychotherapist or other mental health professional, he can help you channel these memories in a way that reinforces your therapy and depression medications to help you feel better.

Much more needs to be done to help spot those at risk and assist them, experts say.

About half of Americans will experience some form of mental health problem at some point in their life, a new government report warns, and more must be done to help them.

Mental health issues run the gamut from depression to post-traumatic stress disorder to suicide, and many of those suffering presently do not get help, experts say.

The new report, from the U.S. Centers for Disease Control and Prevention, tallied the national burden of mental illness based on country-wide surveys.

There are “unacceptably high levels of mental illness in the United States,” said Ileana Arias, principal deputy director of the CDC. “Essentially, about 25 percent of adult Americans reported having a mental illness in the previous year. In addition to the high level, we were surprised by the cost associated with that — we estimated about $300 billion in 2002.”

The high cost includes care for the illness and lost productivity, Arias said.

It isn’t clear why so many Americans suffer from mental illness, Arias added. “This is an issue that needs to be addressed,” she said, not only because of the illness itself, but because mental disorders are associated with other chronic illnesses such as heart disease and cancer.

And while having a psychiatric illness is tough enough, the stigma surrounding these diagnoses adds to the burden, experts said.

“Mental illness is frequently seen as a moral issue or an issue of weakness,” Arias explained. “It is a condition no different from cancer or other chronic diseases. People need to accept the difficulties they are having and avail themselves of the resources that are available.”

The report was published Sept. 2 as a supplement to the CDC’s Morbidity and Mortality Weekly Report.

One survey done in 2009 by the Substance Abuse and Mental Health Services Administration found that 11 million people — nearly five percent of the population — experienced serious mental illness during the past year, defined as conditions that affected the ability to function.

In addition, some 8.4 million Americans had suicidal thoughts in the past year and 2.2 million made plans to kill themselves. One million attempted suicide, the report found.

Information from other sources confirmed these numbers, with slight variations, the report said.

Dr. John Newcomer, professor of psychiatry and behavioral sciences at the University of Miami Miller School of Medicine, believes the problem may be even bigger than the CDC report indicates.

For example, state Medicaid programs spend a great deal on drugs to treat mental illness, which the CDC didn’t take into account, Newcomer said. “For several years the top three drugs were antipsychotic drugs,” he noted.

Also, many people with mental illness hide the problem from others, Newcomer said. The CDC report looked at people already in the health-care system, “but there is a big problem with underdiagnosis and undertreatment,” he said.

Dr. Alan Manevitz, a clinical psychiatrist at Lenox Hill Hospital in New York City, said healthy living — getting enough sleep, eating right, exercising — can help people avoid some mental illness.

“Understanding how to deal with psychological stresses is also important,” he said. “How to deal with emotional reactivity and stress tolerances are also important skills to develop early in life.”

Manevitz said people should always seek help for mental health troubles whenever “you are not functioning well in your life and isolating yourself.”

Although mental health awareness and understanding are high in countries around the world, stigma and discrimination are still prevalent.

When Maria Yerema was diagnosed with clinical depression in the late 1990’s, she made the decision not to hide it—even though there was a prevailing belief that people who are mentally ill end up in institutions.

“The whole ‘mental illness’ label still kind of had the ‘One Flew Over the Cuckoo’s Nest’ attachment,” says Yerema, who at the time was manager of 15 stores in a large retail chain. “No one talked about it, and there was no awareness of how common it was, and no understanding of what the diagnosis meant. Today people are much more aware. There isn’t so much shame attached to the diagnosis. There is more understanding that it is an illness not a personality trait.”

Although the world is now more educated and often aware that mental illnesses aretreatable and manageable, the stigma that Yerema recognized in the nineties is still a serious problem for people with mental illness around the world.

A multi-nation study released today, in a historic stigma-focused issue of theAmerican Journal of Public Health, revealed that across cultures there are aspects of mental health that formulated a universal “backbone” of stigma. This study organized researchers from 16 countries—including the United States, Germany, Spain, Great Britain, Hungary, Bulgaria, Bangladesh, Cypress, South Korea, Iceland, the Philippines, New Zealand, and South Africa—and it looked at stigmarelated to depression and schizophrenia from the point of view of each particular culture.

“We had two sets of findings,” says Bernice A. Pescosolido, PhD, principle investigator of the study and lead author of The Backbone of Stigma: Identifying the Global Core of Public Prejudice Associated with Mental Illness.  “We wanted to know how high the level of knowledge in terms of recognition that there were mental health issues, that treatment was available and should be sought.  And the really good news is that across the countries the level of this kind of mental health literacy is quite good. So that message has been received.”

“But in terms of prejudice and discrimination, there are still these issues,” she says. “It turns out there are five kinds of issues, no matter what country you are looking at and they include things about workplace, marrying into the family, having an authority position, teaching children, and other jobs where people will be concerned a person with a mental illness would be unpredictable,” she says. “The irony is that we probably so work closely on the job with people who have mental health problems. We probably do have people in our families with this. But they don’t disclose, for the very reason that we are documenting in the study: They are afraid of the response of others to them once they have that label or mark of mental illness.”

Stigma is not just a sense of shame or hiding a condition. It impacts cultures in numerous ways, says Dr. Pescosolido:

•  It has effects on the amount of resources we are willing to devote to mental health as opposed to mental health or heart disease.
• The Global Burden of Disease Study showed that by 2020 depression is going to be the second leading cause of morbidity across the globe. And yet it receives nowhere near the societal attention, funding, research money that either cancer or cardiac disease do.
• “Courtesy stigma,” which is prejudice by association, impacts people in the mental health field who feel they are not given the same respect as people that work in other areas of medicine.
• Families, by virtue of having someone in the family with a mental illness, feel that people avoid them.

The stigma also becomes a block between people with mental illness and treatment that could greatly help them, says Rebecca Palpant Shimkets, Assistant Director of the Carter Center Mental Health Program. She has worked alongside former first lady Rosalynn Carter, a longtime advocate for the mentally ill since her days in the White House.

“When we talk about stigma, it’s not just, ‘oh, you know, you carry a mark of shame,’” says Palpant Shimkets. “I don’t think we can talk about stigma without talking about discrimination. There’s that real fear there that if I do seek treatment, what will happen to me. Will I be labeled as crazy, or will it have an impact on my job? Or will my family turn against me? There is deep a connection between stigma and discrimination.”  She believes that because of the stigma mental health systems are the first to be sacrificed to budget cuts.

As an expert on stigma, she suggests three keys that can bring us closer to healing stigma:

Media can help. “For the longest time there was only sensational reporting, only around major events that were dramatic that exhibited bizarre behaviors from somebody with a mental illness. And there simply were not stories about recovery and about what mental illnesses truly were and how prevalent they are. We are seeing much, much more of that—but we still have a long way to go.”

Policy Change. “Policy is a solution and an answer in some of those areas. We can’t really change the way people feel but we can say, “It’s wrong to discriminate.” We have to have systems that support people in getting the care that they need.  Hopefully, as people access more services, they recover, we have systems that work, and that attitudes and hearts will follow.”

Speaking out.  “People who have the lived experience of mental illness—via one episode of depression—or somebody living with a chronic condition like schizophrenia need to talk about it. When it feels right for them—come out and talk, and say, this happens to me too.  I think that can have a great impact too.”

Maria Yerema is one of those people who has shared her personal story.  In fact she tried to move through her darkest days of depression by writing her way out. The result was her book, No Longer Alone-365 Loving Suggestions on How to Recover From Depression (Blue Raven Books, 2012).

“I decided that I was not going to be ashamed and that I was going to focus on healing,” she says. “Deciding not to hide my journey of recovering from depression has been the best decision I made. I was absolutely astounded at how many people were going through that same thing that I was, or was close to someone who was. It helped me realize that depression is really common, and that because of fear, we are suffering alone.  Being open meant that I could explain my behavior in terms of being ill and getting well, instead of trying to hide what I was going through. “

Dr. Tamar Chansky, a licensed psychologist and author of Freeing Yourself from Anxiety (DaCapo, 2012), says it is also important for those who are not mentally ill to reach in and find our own compassion and understanding. “We see a broken leg and we can relate– we sense what it would be like to feel that pain and to have trouble walking,” she says. “The anguish that someone experiences from depression, or the limitations on mobility one has with panic, we may think. ‘I don’t feel that way– so why do they.’ But If we think about how any of us feel on a bad day– and what we would want from others around us– judgment or understanding– we see how quickly we can actually relate to the invisible needs and obstacles that someone with a mental illness experiences. We don’t want others to judge us or tell us we shouldn’t feel the way we do, we want them to either give us space or give us support–this is the key to overcoming stigma.”

Pescosolido, a sociology professor at Indiana University, has been researching stigma since the early nineties and says that the article released today is just the start of looking at how countries around the world deal with mental health issues and the stigma attached.

“I think the important thing, from a public health perspective, is it gives us a real sense of where we have to go in terms of further work to increase acceptance and inclusion,” she says. “And to decrease this tremendous disparity and mortality between people who have mental health issues and those who don’t.”

There comes a time in recovery from a mental illness when you wake up one morning and say to the mirror, “I’m ready to end my treatment.” This is a time of celebration and achievement, putting all the skills you’ve learned from psychotherapy into everyday use. And for many, it’s also thetime to stop taking medication.

Diana Spechler’s piece in the New York Times, 10 Things I’d Tell My Former (Medicated) Self, is chock full of good advice for anyone suffering from a mental health concern who’s looking to change or discontinue treatment. While it’s hard to generalize about switching treatments or getting off of a certain medication, some advice bears emphasis.

First, the choice is yours regarding when to call it quits, just as with any aspect of your treatment. But you should do so in consultation with your treatment providers, who can help you avoid the common pitfalls many people experience when trying to end medication on their own.

Discontinuing a medication at the end of treatment can be incredibly difficult, depending upon the specific drug you’re trying to stop taking. Most commonly prescribed antidepressants, for instance, can be hard to discontinue because of the side effects you may experience as your dose is lowered. Doctors often don’t appreciate these difficulties, since many of them have never been on the medications they’re prescribing ― much less ever tried to get off of them.

Tapering Off of Your Medication

Tapering off a medication, or cutting the dose, slowly over a long period of time is usually the prescribed method for discontinuing many psychiatric drugs. The period of time can vary anywhere from four weeks to four months, and I’ve known people who’ve taken as long as a year to get off of certain medications. For some people and some medications, the tapering schedule may need to be long and slow ― and there’s little reason to rush it.

Just as it was important to find the right medication at the right dose to help in your treatment, finding the tapering schedule that works best for you and your body is important. This is not the time to blindly do as your doctor instructs, since your doctor may not know the withdrawal symptoms you’re experiencing (unless you’ve shared them with him or her). Be vocal, especially if you feel the agreed-upon tapering schedule is not working out for you. Call your doctor and talk to him or her if your withdrawal symptoms are too much. Your doctor can help you find a tapering schedule and dosage that will work better.

Healthy Body, Healthy Mind

All things connect to our moods: thinking ultimately comes not only from our brains, but also from our bodies. That is why exercise is so often recommended, because it’s an important component in helping heal your mind, too.

Good nutrition and diet are also valuable supports that can help build a healthy foundation for your mind to thrive on. While I don’t subscribe to the idea that you’ll benefit most from following a particular diet, I do believe that watching what you eat, cutting down on snacks and fast food, and making healthier choices in general results in feeling better. Ignore or discount the value of exercise and nutrition, and your recovery will be harder ― and longer ― than it has to be.

Sleep, too, is a basic building block for good mental health. Too many of us mistakenly believe we can “make up” sleep on the weekends, or tell ourselves, “I’ll get more sleep when the kids are older.” Neither of these things helps your mental health right here, right now. Make a commitment to fixing any sleep deficits or problems now, because you’ll enjoy the mental health benefits almost immediately.

Avoid Stress

Echoing Spechler’s advice not to undergo a relationship breakup while you’re stopping treatment, I’d take that one step further: avoid any and all stressful, major changes in your life. When you’re switching or discontinuing medications, keep the rest of your life as even-keeled and stress-free as possible.

This is not the time to plan any major life events, such as changing jobs, moving into a new home or apartment, or getting married. Keep everything else in your life as simple and stable as possible, since you’re going to need all your stress reserves to help you deal with the medication changes.

Reach Out to Your Emotional Support System

In the fog of depression or the hypervigilance of anxiety, we may not realize that our friends and other supporters are still there for us. As Spechler noted, whether it’s a friend across the country, or an online friend on Facebook or in some other emotional support group, you have a group of people who care about you.

You may need them a little more often during this time of transition — and that’s perfectly okay. Some people feel comfortable discussing such issues with their friends, while others prefer keeping them private. In either case, most friends will respond with compassion and empathy in your time of need — as long as you don’t overuse one friend’s attention too much.

In Conclusion

All good things must come to an end, including — for most people — an end to their treatment for a mental health concern. While it takes some thoughtful planning and care to end treatment and discontinue the medication that’s helped you recover, it’s also a great time to celebrate your achievement: You’ve beat it. And while it doesn’t mean you won’t need help in the future, for now the future is looking bright once again.

John M. Grohol, PsyD, is a pioneer in online mental health and psychology. Recognizing the educational and social potential of the Internet, in 1995 Dr. Grohol helped transform the way people could access mental health and psychology resources online. Pre-dating the National Institute of Mental Health and mental health advocacy organizations, he was the first to publish the diagnostic criteria for common mental disorders, such as depression, bipolar disorder, and schizophrenia.

Photo credit: Thinkstock

By Ben Whitcomb, Special to Everyday Health

My name is Ben Whitcomb. I am a father, a husband, a retired tattoo artist, and many other things. If you are a gamer, you may know me as BPgamer77, the bipolar video game guy from YouTube. (Yes, the BP stands for bipolar.)

That’s right, I said bipolar video game guy. I am a survivor of and live every day with bipolar disorder.

My life has been filled with bad and often hasty decisions, deep dark periods of depression, irritable and energized moments of mania, and paralyzing anxiety. I have had audible and visual hallucinations and blackouts where I can’t remember what I have said or done. I’ve been suicidal and had mood swings I wouldn’t wish on my worst enemy. Yet here I am today, still alive and taking it day by day, me and my monster.

Sleeplessness, Depression, a Breakdown

Originally, my general practitioner diagnosed me with depression and insomnia after I had gone several weeks on very little sleep. I was prescribed sedatives and antidepressants and sent on my way, never really knowing what was lurking just under the surface.

In late 2001 I was in the early stages of what would be a bad separation, and by August I had suffered my first breakdown, triggered by my impending split from my now ex-wife. I wound up admitting myself to a local hospital here in Missouri for attempting to take my life. In the psych ward I was diagnosed as borderline manic-depressive (bipolar disorder wasn’t called bipolar back then).

I served my mandatory 72-hour stay, and with a little stretching of the truth and a higher dosage of the same antidepressant that hadn’t really done much for me, I was released back into the world. Honestly, that’s where I thought it had ended. I took my meds like a good boy and never really thought about the diagnosis very much again.

I should have paid more attention.

Off Meds, Then Deep Into Mood Swings

Like many people who live with bipolar disorder, during a period where things were going great I decided I no longer needed my meds and stopped taking them cold turkey without even contacting my doctor. Yet another bad decision. Life was good for a while. I re-married the woman of my dreams and started a new career in my dream field of tattooing. My wife and I started a family and things were going great. But my monster was growing restless.

By late 2010 my mental health had deteriorated to the point where I was suffering major mood swings on an all-too-regular basis, and that’s when the blackouts started. I would be irritable and manic and then angry for no reason at all, and like a light switch being flipped, I would be in a blackout. Never aware of what I said or did during these times, I realized that I needed help before it cost me the one thing I valued more than anything — my family. This is where my life turned upside down for the better.

At this point, I took to the Internet to find a doctor who could help and thankfully found a reputable psychiatrist close to home. Things were still far from easy. Finding the right cocktail of medications for a bipolar survivor can be quite a challenge in itself. But eventually, together, my doctor and I found a combination of mood stabilizing, anti-anxiety, and anti-psychotic medications that seems to work well for me. I am very grateful to that man and to my family for sticking with me through all of my trials and tribulations. It hasn’t been easy for any of us.

I still suffer from mood swings — bouts of both depression and mania. Social anxiety and the occasional hallucination always liven up the room. My illness cost me my tattooing job. Even with the meds, I couldn’t deal with the anxiety it causes me.

But my bipolar disorder did one very important thing for me: It made me realize that it was okay to need help and helped me find my true calling — trying to help others like me.

Today, I work from home. I create content for my YouTube channel I try to provide entertaining video game commentary and content. Video games have always been a form of therapy for me, and I share that with the world. The main goal of my channel, though, and the most important part, is spreading mental health awareness, putting an end to age-old stigmas and, I hope, saving lives along the way. If my videos reach just one person who needs help at the right time, if I help just one person understand that they are not alone, then it’s all been worth it.

I am BPgamer77, and you are not alone!

Ben Whitcomb is a 37-year-old devoted father and husband. He lives in Missouri with two of his three children, his wife, and the family dog. From home, he creates content for his YouTube channel as BPgamer77, in partnership with the YouTube network Maker GEN/Maker Studios. In his weekly series Mental Health Mondays, he spreads awareness of mental illness to help stop the stigma associated with it, and he shares his message that you are not alone. Follow him onFacebook and Twitter.

Behavioral therapies are recommended before resorting to drugs in a number of common conditions, such as ADHD in young children and chronic insomnia in adults. But practitioners have objected that there are barriers to providing behavioral therapies to large numbers of patients and that drug treatments are simply more practical.
We contacted a variety of experts in ADHD and sleep disorders via email to ask:

What barriers of this sort have you seen in your own practice?
Have you prescribed drugs as first-line treatment even while knowing that behavioral therapies might be a better choice?
What needs to be done to make behavioral therapies more widely and easily available?
The participants this week are:
Max Wiznitzer, MD, a pediatric neurologist at University Hospitals Rainbow Babies Children’s Hospital in Cleveland

Daniel J. Buysse, MD, UPMC professor, sleep medicine and professor, psychiatry and clinical and translational science at University of Pittsburgh School of Medicine
Bradley R. Berg, MD, PhD, FAAP, division director, McLane Children’s Pediatrics – Austin/Round Rock at Baylor Scott & White Health in Round Rock, Texas.
Karl Doghramji, MD, director, Sleep Disorders Center at Thomas Jefferson University Hospital and professor, Psychiatry and Human Behavior at Thomas Jefferson University in Philadelphia
David Fassler, MD, clinical professor, psychiatry at the University of Vermont College of Medicine in Burlington
Philip Gehrman, PhD, CBSM, assistant professor, Department of Psychiatry, Perelman School of Medicine at University of Pennsylvania in Philadelphia

Simon Rego, PsyD, director, CBT Training Program at Montefiore Medical Center/Albert Einstein College of Medicine in New York City
Kathleen Armstrong, PhD, NCSP, professor & director, pediatric psychology, USF Department of Pediatrics at University of South Florida in Tampa
Alex Mabe, PhD, professor and chief of psychology, Department of Psychiatry and Health Behavior at Augusta University’s Medical College of Georgia in Augusta
Access to Professionals
Wiznitzer: The major barriers are access to professionals and parental acceptance of the therapy. Access is affected by limited number of or no available professionals (psychologist, social worker, counselor, or therapist) for the needed intervention, location distance or time availability (for working families), length of waiting list, and insurance plan limitations on who to see and how many appointments to have. Parents can view therapy as too slow or difficult to implement, an excessive time commitment, too complicated and not easy to understand, or not a real medical intervention. Additional barriers include insurance limitations on therapist choices, cost of therapy, and child resistance to the intervention (challenges the “power” they have acquired in the home).

Buysse: The main barrier to behavioral therapies is inadequate access. There are far too few clinicians trained in Cognitive-Behavioral Therapy for Insomnia (CBT-I) relative to the number of patients with insomnia. Although several online, self-guided CBT-I programs are also available, most people do not know about them, and most insurance plans do not pay for them.
Berg: The biggest barriers to behavioral therapies are the lack of access as well as the time commitment involved. Many [pediatric patients] are failing school or in danger of being expelled. Behavioral therapy takes a prolonged period of time (often months to years) and students often do not have this time to turn themselves around before serious consequences ensue. We also have a reasonable lack of mental health providers who accept many of the common insurances. This makes it difficult to find behavioral therapy for patients in a timely manner. I have patients who have been waiting for several months to get in to see a mental health provider to start with behavioral therapy.
Fassler: Many young children with ADHD respond well to behavioral interventions. However, parents often have difficulty identifying and accessing such resources. In many areas, there are too few clinicians with appropriate training and expertise to provide such therapy. Even where providers exist, limited reimbursement often creates additional barriers. I fully concur with the CDC’s recommendation that health care providers and parents should work together to make sure young children with ADHD are receiving the most effective and appropriate treatment possible.
Gehrman: There are two main barriers to behavioral treatment of insomnia. First is lack of awareness, as most providers who treat patients with insomnia don’t even know it exists (although the new guidelines will help with that), nor do most patients with insomnia. Second is lack of trained providers. Most mental health or sleep medicine providers are not trained in this type of treatment.
What Works

Armstrong: Behavioral parent training using an evidenced-based intervention such as Parent Child Interaction Therapy (PCIT) is the gold standard treatment for children ages 3-7 with ADHD, and is recommended as first approach by the American Academy of Pediatrics. Effect sizes for PCIT are larger (1.43) compared with stimulant medication (0.9); parents prefer this option to medication when given the choice; results are documented to last up to 6 year. That being said, PCIT requires sufficient mental health coverage and trained providers to deliver it effectively. Medicaid does not typically cover PCIT, only medication. And parents have to commit to 10-16 weekly visits and home practice for this approach to work.
Buysse: Self-guided internet CBT-I interventions are one answer. In one of our current NIH-funded clinical trials, we are comparing internet CBT-I to a brief behavioral treatment conducted by a live therapist over the telephone or videoconferencing. These approaches are likely to reach a lot more people.
Mabe: Families are often reluctant to try behavioral therapies to address the problems with ADHD in children, because the effort is more intense than just giving the child a pill. Moreover, many parents believe that they have already tried to use behavioral approaches to the child’s problem behaviors and have concluded that ‘they don’t work.’ The research supports a different conclusion, however, on this last objection to behavioral therapies. Specifically, we are learning that the use of behavioral management and organizational strategies in children with ADHD is usually effective, and the children do get better when proper techniques are applied and everyone is patient with the process. Positive results often take more time with behavioral therapies, but the results are similar to those observed with medication. Additionally, the benefits of behavioral therapies may be broader and may even last longer.
Medication Not First-Line Option
Buysse: I always provide my patients with behavioral sleep advice, even when I also prescribe a medication. When you think about it, even taking a pill is a behavior, and requires instruction. For instance, part of a behavioral intervention for insomnia involves recommendations for what time to go to bed, what time to get out of bed — and what time to take the prescribed medications. Hypnotic medications taken at the wrong time of day can be ineffective or cause side effects.
Wiznitzer: Occasionally, parents have been resistant to any therapy implementation or have not been able to access an appropriate provider. In those circumstances, medication can be started with the parents’ understanding that this treatment can improve attention span and decrease impulsivity but will not teach the child how to behave or how to learn. When an improvement from medication is noted, a discussion about the use of behavioral therapy can then lead to acceptance of combined intervention. On must remember that there are some children for whom medication is necessary from the beginning.
Gehrman: As a psychologist I cannot prescribe drugs so this was never an option. Plus, I have been trained in behavioral treatment since very early in my professional development so this has always been my main focus.
Berg: Although I always recommended behavioral therapies as well, I often do resort to medications for the reasons listed above.
Education Solutions
Rego: Educate consumers about the impressive, research-backed benefits of cognitive behavioral therapy (CBT), not just for insomnia, but also for anxiety, depression, and a host of other psychological disorders, by publishing articles about it and discussing it in reputable mainstream media outlets like this one, increase training in CBT by adding courses into graduate programs for mental health workers and by offering workshops and supervision in CBT to those already in the field, and increase access to CBT by modifying the ways in which the treatment can be delivered — such as through websites and apps — while being sure to study these modified versions so we can verify that they are equally effective as the original treatment.
Berg: The biggest things that need to be done to make behavioral therapy more accepted and available is early diagnosis as well as increasing access. Often we see students in the office who have been struggling for 2 or 3 years before there brought to medical attention.
Gehrman: Patients and providers need to be educated about this treatment option. There also needs to be larger efforts to train providers to deliver this treatment.
Staffing Solutions
Doghramji: In the long run, we need a greater number of trained CBT-I therapists who can provide treatment at an affordable cost to a wide variety of patients. Providing training to paraprofessional staff in clinical settings is important. Other practical measures include the recent development of group treatment strategies, therapies involving a diminished number of sessions, and utilization of online resources. The emergence of telemedicine has also begun to make CBT-I a more readily available treatment resource.
Wiznitzer: Availability of well trained and knowledgeable therapists for this population, making sure that they are identified to healthcare providers, educators, day care providers, and families (so they can be accessed), make sure that cost is not an impediment, educate parents that behavioral therapies are proven treatments when appropriately implemented (i.e., be an informed consumer) and utilize technologies, such as videoconferencing and the Internet, as vehicles for parent education and therapist access.
Armstrong: More comprehensive and better health insurance for mental health; more providers with training and expertise to provide evidence-based interventions.
LAST UPDATED 06.01.2016