ابنتي تخاف ولا تبتعد عني؟

السلام عليكم ورحمة الله وبركاته
دكتور انا عندي بنت عمرها 4 سنوات 8 اشهر تخاف كثير من الخروج وحدها ولا تذهب مع اختها للعب مع بنات الجيران لاتخرج للعب لا معي تخاف فقداني كثيرا حتى اني ادخلتها للروضه وكانت لاتجلس حتى اجلس ولا تكتب مع المعلمه حتى اكون بجانبها لاتحدث عند الغرباء وتخاف منهم تحدثت كثير معاها ولاكن بدون فائدة تذكر ماذا افعل معاها ؟ وهل يحتاج للامر عرضها على طبيب ؟

ارجوك يادكتور مساعدتى
ولك جزيل الشكر والتقدير

مثل هذه الالعاب تزيد ثقتها بنفسها

لا تستجيبي لصراخ و اتركي المكان و كافئيها عندما تعبر عن نفسها بهدوء

Prof. Koen Demyttenare, Placebo Vs. SSRIs ..What is beyond?

Prof. Koen Demyttenare

MD, PhD

University Psychiatric Center

KU Leuven

Leuvene, Belgium

He is academic Chair of the Universiy of psychaitric Center KU leuven and head of the research group of psychiaty in the

is the the University Psychiatric Center Leuven. He has written numerous articles, particularly on the role of positive emotions in depression.

Mechanism of action of agomelatine , towards a dimensional approach to depression

Self-worth is essential for being a fully-actualized individual. When we don’t love ourselves, we compromise our relationships and every other part of our lives. We simply can’t function at an optimal level and fulfill our potential for happiness and success. Low self-worth undermines our happiness with a variety of self-sabotaging behaviors, such as:

Neediness, insecurity, and people-pleasing

Defensiveness and hypersensitivity

Difficult, chaotic relationships

Eating disorders

Hypervigilance, extreme fear of making mistakes

Passive-aggressiveness

Perfectionism

Poor personal boundaries

Poor communication skills

Poor social skills

Promiscuity

Sexual dysfunction

Underachievement

Workaholic behaviors

Inauthenticity, wearing a mask

Self-love is so difficult because the world often doesn’t reflect back to us what we’d like to believe about ourselves. We may accept the concept that we are worthy, and hopefully loving family and friends reinforce that. But out in the harsh world, we encounter criticism, comparisons, and judgements. We are told we aren’t good enough, and eventually we believe it.

We’ve forgotten how to trust ourselves and rely on our own beliefs and judgements. Instead we look to others to build us up and manufacture our self-esteem. If others don’t like the person we are, we struggle to become someone else who meets the world’s approval.

Also we get trapped in “the negativity bias,” an evolutionary adaptation in which we pay much more attention to negative beliefs and events than positive. We are simply wired to focus more on our flaws and shortcomings than on our positive qualities.

With all of these challenges undermining our efforts for worthiness, it’s no wonder so many people suffer with low self-esteem. In order to embrace our true worthiness, we have to learn new ways of thinking and responding to the input we receive from the world around us.

Here are some ideas :

1. Define worthiness for yourself.

Examine your own values. Define your integrity. Get clear on what YOU believe, what kind of person you want to be, and how you want to live your life — within the context of what is realistically attainable. Create your own personal operating system for life, without relying on what others think is best for you.

2. Become aware of your thoughts.

Start paying attention to the nature of your thoughts and how often you think negative things about yourself. Simply this awareness will help you disengage from the thoughts, if only for a few minutes. Diminish the reality and power of your negative thoughts by identifying them. Say something to yourself like, “There are those negative thoughts again. Look at what they are doing to me.”

3. Filter your perceptions.

As you become more aware of your thinking patterns, begin to filter your thoughts by applying the light of reality to them. Ask yourself, “Is my thought really the truth? Is it the entire truth or just my perception of the truth?” Challenge all of your negative thoughts, and seek out evidence that contradicts your negative beliefs. Do what you can to loosen your grasp on self-limiting beliefs.

4. Create new environments.

If certain environments or situations highlight or reinforce your feelings of low self-worth, change your environment. Put yourself in situations more often where you feel successful, confident, accepted, and happy. Play to your strengths, and focus on your natural aptitudes rather than struggling against something that constantly brings you down.

5. Find the right tribe.

If you are surrounded by critical, judgmental people, this will further entrench your feelings of low self-worth. Find supportive friends who are easy to be around, caring, fun, and happy. Let go of people who put you down, try to manipulate you, or treat you poorly. This isn’t always easy to do, but letting go of just one negative person can have a huge impact on your day-to-day feelings.

6. Practice realistic optimism.

When you really don’t believe you’re lovable, affirming that you are lovable feels false. Rather than making blanket statements about your self-worth, identify more honest, but optimistic affirmations you can say to yourself. For example, you might say, “Today I’m not as accomplished as I want to be, but I know I can improve and feel better about myself.” Improvement is always possible, and working on an improvement goal will make you feel better about yourself.

7. Learn the power of acceptance.

Maybe you don’t like your face or your body. Maybe you aren’t the funniest or most engaging person in your circle. You might look at other people and long to be like them. There are some realities in life that will never change. You can struggle against them or learn to accept them. By accepting, you free your energy to focus on other more productive, positive endeavors. You practice acceptance by facing your flaws honestly and relaxing your heart and mind.

8. Change what you can.

If positive change is possible, then do whatever you can to change your behaviors, choices, and actions to support your feelings of self-love. Just remember that outward change alone won’t make you feel more lovable. You’ll feel better about yourself for taking action, but that action must be supported with inner work on your thoughts and beliefs.

9. Celebrate your differences.

Sometimes the very thing we loathe about ourselves is considered our best, most unique quality by others. If you were the black sheep of your family, you might believe you are the “odd” one. But as an adult, other people regard your personality or lifestyle as interesting and attractive. Don’t strive to fit in. Celebrate being unique.

10. Practice gratitude.

During the times when you catch yourself in negative thinking, switch gears entirely and focus on gratitude. Make a list of everything you are grateful for in your life — from the most insignificant to the most important. Don’t just jot things down quickly. Really focus on each item on the list, and think about how you’d feel without it. Study after study has shown that the regular practice of gratitude helps improve your outlook and feelings of happiness.

11. Show compassion for yourself.

Pretend you are your own best friend, and show the kind of compassion to yourself you would show to someone you care about. Rather than putting yourself down, use words of encouragement and support. You are as deserving of kindness as anyone, so set the stage for that by treating yourself kindly.

12. Learn healthy communication skills.

Being able to communicate your feelings and fears in mature, non-confrontational, healthy ways is critical to self-esteem and improved relationships. Everyone has insecurities, but rather than hide or diminish them, improve your emotional intelligence so you are less reactive and more authentic.

13. Be willing to set boundaries.

When we don’t love ourselves, often we let others take advantage of us. Sometimes we don’t even know this is happening because we haven’t created firm boundaries. Decide how you want to be treated and what you will and won’t tolerate. This may be difficult if you’re accustomed to letting others have their way. Start by communicating one new boundary at a time and practicing holding firm with it.

14. Speak up for yourself.

Part of creating and following through on your boundaries is learning to speak up for yourself. If others say or do things you don’t like, or if you have ideas or input you previously held back for fear of offending someone, try stepping out of your comfort zone and speaking your mind. You can do this calmly but decisively, even if you have to pretend at first.

15. Take care of yourself.

You show love and compassion for yourself when you treat your body, mind, and emotions with care. That means eating healthy foods, exercising, getting enough sleep, going to the doctor, taking care of your hygiene, having a support system, and finding ways to stimulate your mind. When you treat yourself as someone with value, you’ll feel more valuable.

16. Find your passion.

When you find something you love as your career or even as a hobby, you’ll have a new purpose for your life. A passion gives you a reason to get up in the morning, as you’re eager and engaged in what you are doing. You’ll find you use your natural skills and aptitudes with your passion, and this reinforces a positive self-perception. Knowing your passion allows you to be authentic and express yourself through your interests and endeavors. You don’t have to pretend to be something you aren’t.

17. Simplify and create balance.

A complicated, overly scheduled life drains your energy and creates anxiety. Decide how much order and balance you want in your life, and begin cutting back on the tasks, obligations, and material things that don’t add to your life. This will give you breathing room to pursue your passion, work on yourself, and redefine how you want to spend your time and energy. Giving yourself this space is a way of showing love to yourself.

18. Deal with past wounds.

If there’s something from your childhood or more recent past that has impacted your self-esteem and restricted your ability to love yourself, then take action to heal those wounds. Find a professional counselor who can help you navigate through the past pain and work with you to learn new ways of relating to yourself and others.

19. Practice forgiveness.

To love yourself, you must first forgive yourself and forgive others who have hurt you. You forgive yourself in the same way you forgive a loved one who genuinely seeks forgiveness. You offer it freely and with compassion. Beating yourself up over and over again is an exercise in futility. Do what needs to be done to right any wrongs and regain your integrity, and then let it go. If others have wounded you, offer the same forgiveness to them — even if they don’t seek it. The ability to forgive is a huge step toward self-respect and wholeness.

20. Show the love you want to others.

If you want love, understanding, and compassion, treat others with the same. Become the kind of person you want to surround yourself with. Don’t offer love in order to be validated or get something in return. Offer unconditional love with no expectations. The more you can give love freely, the more love you have for yourself.

Learning to love yourself is a process. As you begin to trust yourself and define your needs and desires, you’ll find you need less and less validation and reinforcement from others. You’ll create experiences and relationships that match your values and authentic desires, reinforcing your essential worth and lovability.

With every mindful effort and shift in thinking, you’ll find you respect yourself and see yourself as deserving of your own love.

– See more at: http://liveboldandbloom.com/12/self-confidence/how-to-love-youself#sthash.4OevmXTf.dpuf

Help your child to read

Find ideas that work for your family with your child and their current development.

Read to your child.
Play rhyming games.
Sing the alphabet song with them.
Label things with their names from an early age.
Go to the library or get your own home library.
Have non fiction books as well as fiction available .
Tell stories.
Have books all over your house.
Teach the letter sounds by emphasizing the sounds in words they hear often from a young age.
Provide fun and interesting books to read.
Get a magazine subscription and read it together.
make play dough letters.
Play the alphabet game on road trips.
Read the mail together.
Make reading nook.
Clap out syllables.
Make letter crafts.
Make reading time.
Notice letters around!
Learn about how books work and other concepts of print.
Let them choose their own books at the library or bookstore.
Leave them notes in their lunch boxes .
Play with foam letters in the bath. Use bath toys to make up and tell stories.
Make your own books.
Play eye spy with letters and letter sounds. ” I spy something that starts with the letter B. Buh buh book!”
Give your children books as gifts.
Make up silly songs together.
Ask them to read the pictures to you before they can read the words.
Play library.
Read the book then see the movie for a family treat.
Play with word families.
Read books with no words and share storytelling duties.
Let them see you reading for fun.
Read nursery rhymes.
Explore and trace tactile letters.
Play listening games.
Retell and have your children retell stories after reading them.
Ask your child questions about elements of the story as you read with them. This works on comprehension.
Read books at lunchtime .
Take books with you when you travel.
build with letters blocks.
Do word search.
Play sight word games.
Download an e-reader app on your smartphone and instead of handing them it to play a game make it a treat to use it to read.
Read comics and graphic novels with them.
Talk your your kids using regular words not “kiddie” words.
Read them poetry.
Get their bodies moving to learn letters.
Read them their favorite book over and over and over even if it’s making you want to poke your eyes out.
Make reading part of their bedtime routine from day one!!

4 Easy Ways to Organize Content For E-Learning

Say you’re designing an e-learning course and you’ve got all of your content pulled together and ready to go. You’ve sifted through your materials and you’ve sorted the “nice to know” from the “need to know”. Now, you’re ready to start laying out the content in your course…. but you’re feeling a bit stuck.

You’re thinking: how do I organize this content? How do I decide what to present first, and what to present last? How do I make sure I don’t overwhelm my learners with too much information at once? Order and organization is very important for humans. You want to set up your learners for success and present content in a way that can help your learners focus on what they need to know, and not get confused by how the content is organized.

So if you’re wondering those exact questions, don’t fret, simply read on to discover four simple systems you can use to organize the content in your next course.

Alphabetically

This is often a straightforward and logical way of organizing content, and since we all learn the alphabet at a very young age, it’s an intuitive and traditional system for organization. This system lets learners easily find specific information. This works particularly well for presenting textual content such as terminology or keywords.

For example, you’re presenting your learners with industry buzz words and their definitions. It would make perfect sense to present those buzz words in alphabetical order.

Categorically

Sometimes the best way to share your content is to break it up into categories, particularly when there’s a lot of content that seems a bit overwhelming when shared all at once.

For example,

say you’re creating an e-learning course for a sales team about all the products available in an organization. Instead of having all the products presented at once, which could be intimidating and scary for a learner, you can break them up into categories: Electronics, Outdoor Living, etc. and let them explore smaller and more manageable sections at a time.

Order of Importance

Another effective approach for organization content is to place items in order of importance, remembering that learners are probably focusing more at the start of your course, and losing steam (and potentially interest and attention span) as the content progresses. Remember this and place your most important content up-front.
For example, if you’re developing a product course for your sales team, would you present the 500$ Rust-proofing kit as your first product, or would you start by showing them the 30,000$ car. Probably the car, as it’s more important and would lead to much more income.

Sequentially

When sharing a process or a task, it’s a great idea to share this information sequentially. It makes more sense for the learner if they view steps 1-2-3 in that order, than if they viewed the steps backwards or in a mixed up order. Showing a sequential order can help learners retain the order of the process when they have to carry it out themselves. Anything that happens over a timeline or period of time can usually be organized sequentially.

For example, your e-learning course will train the sales people on how to close a sale with a customer. It would make sense to share that process in a chronological order, starting with how to approach and greet the customer, how to handle objections, and finally, how to close. Going about this process in another order could be detrimental to the learning process by confusing your learners.

مهارات في العمل

في بعض المهن تتنافس الخدمة التليفونية

و العمل يكون ممتلئا بالمشاعر و أحيانا التوتر فيتطلب من ذلك بعض المهارات الدبلوماسية لناء المكالمة أو المقابلة أو الابقاء عليها

لا تقرأ تقرير أو شئ أثناء مقابلتك أو حديثك و لا تنشغل عن محدثك بشاشة الكمبيوتر

لا تنقر لوحة المفاتيح اثناء الحديث

حافظ على المحمول (الجوال) مغلق و قت الاجتماع

حافظ على وقت العمل

لا تبالغي في العطور

حافظ على هيئة مقبولة مهما طالت فترة العمل ولا تفتح قميصك

احترم خصوصيات الآخرين و غض بصرك عم أوراق و شاشات كمبيوتر الآخرين و غض البصر هو من أكرم و اسمى مكارم الأخلاق

كن مهذبا و كن بشوشا

كن مؤدبا و كن مرنا

اشكر من يساعدك

اعتذر عما لا تستطيع عمله أو القيام به

اعتذر عن خطأ اقترفته و اسأل المساعدة للتصحيح

من الاخطاء الجسيمة

لا تسأل عن عمر أحد و لا راتبه و لا المكافأة التي حصل عليها و اذا قيل بارك و هنئ بابتسامة

لا تسأل عن احوال زوجية لللآخرين

ولا علاقات خارجية

معرفة مثل هذه الأشياء تعيق سير العمل ولا تخدم في شئ و لا تعود عليك معرفتها الا بالهموم فاذا عرفت انكر علمك بالشئ

لا تسأل عن تفاصيل مرض بل اسأل عن الصحة عامة

يمكنك ان تمتدح مظهر واناقة و لكن لا تسأل عن أسعار ملابس

How to learn too much in too little time!!

Yes you can do it in little time you can learn too much , here is how

1) Chunking

There’s a reason why your eyes naturally gravitate to the numbered items in a blog post or bullet points in a news story.

It’s because our brains are hard-wired to crave organization.

Due to our preference for structure, it’s far easier for us to remember information when it’s categorized into discrete buckets as opposed to random bits of unrelated data.

With this in mind, sales reps should try to break down complex topics into more manageable mental categories, and seek to find patterns in the information they take in.

2) Sequencing

It wouldn’t make a lot of sense to read the last chapter of a physics book before the first.

The order in which we learn things has an impact on how well we understand a subject.

Sequencing is the practice of mentally prioritizing what is most important to learn first, and what can wait until later. Trying to take it in all at once is a recipe for recall disaster.

3) Connecting

Finding commonalities and similarities between things you already know well and the subject you’re learning can help you get up to speed in your new field much faster.

Does one buyer’s company remind you of another customer’s organization? Fantastic — reinforce that connection in your mind to cut back your ramp time.

4) Dumping

No matter how fast you learn to learn, you physically can’t remember everything. Trying to will only serve to exhaust and confuse you.

That’s why dumping is such a necessary strategy. Documenting information in some way means you don’t have to memorize it — you can simply look at or listen to your notes when the need arises.

This tactic also frees up space in your memory to internalize content that you do need to keep continuously top of mind.

5) Practicing

Practice makes perfect is true in numerous professions, but especially so in sales. When a rep needs to learn about a new product, a new line of messaging, or a new approach, the best way, according to Jill, is through role-playing. Just like any other skill, learning needs to be practiced in order for it to stick.

6) Prioritizing

Sequencing is a way of mental prioritizing, but reps should also practice prioritization in their day-to-day work for maximum learning effectiveness. Multitasking takes a toll mentally, so make sure to only focus on one task at a time — especially if that task is studying.

Three-Minute Assessment Identifies Delirium in Older Adults

Sharon K. Inouye, MD, MPH, a study author and a researcher from the Beth Israel Deaconess Medical Center in Massachusetts, developed the Confusion Assessment Method (CAM) in 1990. In this study, she and her co-authors found the three-minute diagnostic interview for CAM-defined delirium (3D-CAM) was particularly effective in identifying delirium in patients with dementia.

“Hospitals throughout the world are increasingly recognizing the importance of delirium as a major preventable adverse event,” Dr. Inoye said. “The 3D-CAM holds great promise as an important advance for delirium care specifically, and for acute care of elders more generally.”

The researchers noted that estimates indicate more than 2.5 million elderly individuals in the United States may have their hospital stays complicated by delirium, but the condition typically is undetected and can lead to serious complications. In most clinical settings, the average detection rate of delirium is between 12% and 25%, according to the researchers.

This study took place at four general medicine units in an academic medical center and included 201 patients who were at least age 75. The median age was 84, and 28% of patients had dementia.

Each participant in this study received a clinical assessment for delirium and dementia that lasted between 60 and 90 minutes. An expert panel found that 21% of the participants had delirium and 28% had dementia before getting admitted into the hospital.

After the clinical assessment, research assistants administered the 3D-CAM, which consisted of 20 items and only took three minutes on average to complete. The research assistants did not know the results of the clinical assessment.

The researchers found that the 3D-CAM correctly identified 95% of patients with delirium and 94% of patients without delirium.

“As growing numbers of older adults are being hospitalized, it’s critically important that doctors, nurses, and other hospital care providers be able to recognize delirium,” said lead author Edward Marcantonio, MD, SM, Director of the Aging Research Program in the Division of General Medicine and Primary Care at BIDMC and Professor of Medicine at Harvard Medical School. “We wanted to develop a brief and simple method to make this easier to accomplish, and we are extremely happy with the 3D-CAM results.”

How to sleep well despite chronic pain

Chronic pain and insomnia are an unhealthy combination. According to the National Sleep Foundation, chronic pain disturbs the slumber of one in five Americans at least a few nights a week. Whether it’s from a bad back, arthritis, or headaches, chronic pain puts you in double jeopardy: the pain robs you of restful sleep and makes you more fatigued, and thus more sensitive to pain.

But you can start to break this vicious circle.

“For chronic pain conditions, what you need is good sleeping habits from the beginning — things that will last,” says Dr. Padma Gulur, a pain medicine specialist at Harvard-affiliated Massachusetts General Hospital. That means relying on the brain’s natural sleep drive as much as possible.

Try “relaxing distraction”

Some relaxation techniques use basic rhythmic breathing meditation;

others focus on guided imagery,

in which you imagine being in a calm, peaceful location.

Find something that appeals to you and helps you fall asleep. You might look for these exercises on CD or consider group or individual training and sleep education.

Getting back to sleep

For some people, chronic pain not only makes it harder to fall asleep, but can also interrupt sleep. Simply shifting position in bed can trigger pain from a back condition or arthritic knee.

One approach is to take your pain medication right before bed. Check with your doctor to be sure that fits into your treatment plan. If pain does wake you in the middle of the night, first try meditation, visualization, or whatever relaxing distraction you favor. But if it doesn’t work, getting up to read a book in a quiet room with low light can help you to get back to sleep. Avoid loud sounds and bright light (that means TVs, smartphones, tablets, and computers).

Staying on a regular sleep schedule is also important. Go to bed at the same time every night and, no matter how the night goes, rise the next day at the same time and remain awake until your planned sleep time. This helps to set your internal sleep clock and enhances the natural sleep drive.

Quick review for schizophrenia updates

Professor Tarek Asaad, professor of psychiatry , ain shams university, faculty of medicine.
Here are several briefs of the same lecture about the updates in clinical and pharmacological research in bipolar and unipolar mood disorders,given in madinah , saudi arabia , march 2014.

First Blood Test for Depression?

Northwestern University researchers recently identified nine RNA blood markers unique to patients with major depression and developed a blood test they believe could diagnose the disorder in adults.

Their study is published in the September 16 online Translational Psychiatry.

Their research involved 64 adults: 32 patients diagnosed with major depressive disorder after a clinical interview, and 32 control subjects without major depressive disorder.

By analyzing participants’ blood samples, researchers discovered nine RNA blood markers with significantly different levels in patients with depression compared to patients without depression.

Such markers, researchers said, offer an objective basis for a depression diagnosis.

After participants with depression received 18 weeks of cognitive behavioral therapy, their blood was analyzed again. Researchers identified changed levels of specific biomarkers in patients who—according to clinical interviews and self-reported symptoms—benefitted from the intervention.

Those changes, researchers said, provide the first biological evidence demonstrating the effects of cognitive behavioral therapy.

Researchers also examined the nine RNA blood markers at baseline of patients who then went on to improve with cognitive behavioral therapy. They found a distinct biomarker pattern, or fingerprint, that was not present in patients who did not improve with cognitive behavioral therapy.

References

1. Redei EE, Andrus BM, Kwasny MJ, et al. Blood transcriptomic biomarkers in adult primary care patients with major depressive disorder undergoing cognitive behavioral therapy. Translational Psychiatry. 2014 Sept. 16. [Epub ahead of print].

2. First blood test to diagnose depression in adults [press release]. EurekAlert!: Washington, DC; Sept. 16, 2014.

How can you help your Bipolar friend?

1. Never give up hope

Looking back, the first 10 years of my more than two decades of dealing with bipolar disorder were a seemingly insurmountable struggle, but my loved ones never gave up hope. Despite a situation that often created frustration and hopelessness, they never doubted my recovery. Today, they continue to instill that same undying confidence.

There is one piece of advice for anyone who loves someone with bipolar disorder, and it is this: keep the faith and never give up. There have been many times when there was nothing but hope, and you have living proof that it kept me going. So, let your hope for a loved one spread—it’s contagious.

2. Take some time

Time is one of the hardest concepts to convey to people. We all want immediate results, but with bipolar disorder, so-called overnight success can, in fact, extend to years. Studies show that it can take 10 years or more to even obtain an accurate diagnosis (Living with Bipolar Disorder: How Far Have We Really Come? Depression and Bipolar Support Alliance [DBSA] Constituency Survey, 2001). In my own case, it took eight years before someone accurately put a name to my struggle.

With bipolar disorder, there are simply no quick fixes. Thinking there is a miracle cure only makes matters worse, so instead, help your loved one set realistic goals. The road to recovery is not a straight shot; it’s a winding path with delays, downtimes, and detours. Remember progress can be made, but it takes time. Let patience be your guide.

3. Face the facts

Be willing to acknowledge that bipolar disorder is a legitimate, organic disorder. Saying something like, “It’s all in your head,” or “Just snap out of it,” denies that reality. As with diabetes or cancer, bipolar disorder requires medical treatment and management. And as with other chronic conditions, bipolar disorder is initially unfamiliar and frequently unpredictable. It can be gut-wrenching and at times, scary.

It also helps to face the facts when it comes to our current mental health system. If you find it to be disorganized and disconnected, imagine what the patient is experiencing. With your support, a patient can be guided through the maze, find the best care, and stick to a workable treatment plan.

4. Adopt the right attitude

How you see things does matter. With the amount of stigma and discrimination that exist in society at large, the last thing a patient needs is misguided thinking coming from family and friends. More support is needed, not more shame. The more your response is based on reality and not on myths, the more your support can make a difference.

All too often, family members make a loved one feel as though it isn’t bipolar but rather a character flaw or something brought on by the person. Some even view an occasional setback as though it spells permanent doom. Such flawed thinking may be common, but it’s harmful to the person facing bipolar disorder who needs constructive feedback, not destructive rhetoric.

5. Get educated

People who have bipolar disorder often deny that anything’s wrong, and frequently, they don’t stay on their medications. It’s important to learn about these and other nuances of the disorder. Fortunately, there are many resources available today, especially compared to 25 years ago, not the least of which is the Internet.

A national clothing store uses the slogan: “An educated consumer is our best customer.” To support your loved one, consider adopting a similar notion. An educated family member or friend is our best advocate and our greatest source of support.

6. Treat us like adults

A psychiatrist once commented that my body (at the time) was 30-years-old physically, but I was 45 intellectually, and 15 emotionally. Talk about a tough pill to swallow! Bipolar disorder can arrest a person’s emotional maturity and produce behavior that appears very adolescent and reckless.

Please remember, however, that while someone who has bipolar may act like a child, there is an adult underneath. The world of the person who has bipolar disorder can be full of chaos and confusion, and low self-esteem is common. It can make a big difference when you continue to acknowledge and show respect for the grown human being who is struggling behind all the symptoms.

7. Give us some space

Living with a serious illness is a daunting task. It can be a foreign concept to separate yourself from someone you want to help. But as a support person, it is best to establish a loving distance between yourself and the person who has bipolar.

Set boundaries and establish consequences that encourage those who have bipolar to seek recovery on their own, all the while expressing your concern and willingness to help. Be supportive, patient, and understanding—without being used. Effective encouragement is helpful; enabling is not.

8. Forget the past

Frustration often accompanies bipolar disorder. Family and friends can spend countless hours—if not years—wondering what went wrong. Avoid making matters worse by wallowing in the past.

Pointing fingers solves nothing, blaming is not the answer, and getting angry only makes matters worse. Bitterness and resentment can sometimes act as a trigger and incite more of the behavior you want to stop. Instead, focus on helping make tomorrow better. That’s true support.

9. Take care of yourself

The family suffers right along with the person who has bipolar disorder, so, it’s important for you to develop your own coping skills. Only if you take care of yourself can you help. All too often caregivers end up becoming ill.

During training, emergency medical technicians are taught to never put their lives in obvious jeopardy to save someone else’s. If they did so, they’d be unable to help anyone. Likewise the same is true for you while you are caring for your loved one. Remember that you have yourself—and probably others—to care for as well.

10. Find a healthy balance

There are so many questions: “How much should I be willing to do?” “Should we use tough love?” “How long does this go on?” “How long should we wait before we intervene?” and on and on and on. Bipolar disorder is tough. It’s like walking a tightrope sometimes, where you’ve got to learn to balance your own welfare with the interest you have in supporting the person with bipolar.

You also have to find a healthy balance when it comes to the support you offer. Learn to take things in stride, one day at a time. There’s a time to help and a time to step back; a time to speak and a time to listen; a time to be patient and a time to be insistent.

Now, you have some valuable points to ponder as you help your loved one pursue recovery. The more you’re in the know, the better equipped you are to offer the type of support that can make a positive difference. The reward is a brighter, happier future—for everyone involved.

refrence:

http://bphope.com/Item.aspx/202/points-to-ponder-help-from-parents-partners-and-pals

Building Self-Confidence

From the quietly confident doctor whose advice we rely on, to the charismatic confidence of an inspiring speaker, self-confident people have qualities that everyone admires.

Self-confidence is extremely important in almost every aspect of our lives, yet so many people struggle to find it. Sadly, this can be a vicious circle: people who lack self-confidence can find it difficult to become successful.

After all, most people are reluctant to back a project that’s being pitched by someone who was nervous, fumbling, and overly apologetic.

On the other hand, you might be persuaded by someone who speaks clearly, who holds his or her head high, who answers questions assuredly, and who readily admits when he or she does not know something.

Self-confident people inspire confidence in others: their audience, their peers, their bosses, their customers, and their friends. And gaining the confidence of others is one of the key ways in which a self-confident person finds success.

The good news is that self-confidence really can be learned and built on. And, whether you’re working on your own self-confidence or building the confidence of people around you, it’s well-worth the effort!

How Confident do you Seem to Others?

Your level of self-confidence can show in many ways: your behavior, your body language, how you speak, what you say, and so on. Look at the following comparisons of common confident behavior with behavior associated with low self-confidence. Which thoughts or actions do you recognize in yourself and people around you?

Self-Confident	Low Self-Confidence
Doing what you believe to be right, even if others mock or criticize you for it.	Governing your behavior based on what other people think.
Being willing to take risks and go the extra mile to achieve better things.	Staying in your comfort zone, fearing failure, and so avoid taking risks.
Admitting your mistakes, and learning from them.	Working hard to cover up mistakes and hoping that you can fix the problem before anyone notices.
Waiting for others to congratulate you on your accomplishments.	Extolling your own virtues as often as possible to as many people as possible.
Accepting compliments graciously. “Thanks, I really worked hard on that prospectus. I’m pleased you recognize my efforts.”	Dismissing compliments offhandedly. “Oh that prospectus was nothing really, anyone could have done it.”

As you can see from these examples, low self-confidence can be self-destructive, and it often manifests itself as negativity. Self-confident people are generally more positive – they believe in themselves and their abilities, and they also believe in living life to the full.

What is Self-Confidence?

Two main things contribute to self-confidence: self-efficacy and self-esteem.

We gain a sense of self-efficacy when we see ourselves (and others similar to ourselves) mastering skills and achieving goals that matter in those skill areas. This is the confidence that, if we learn and work hard in a particular area, we’ll succeed; and it’s this type of confidence that leads people to accept difficult challenges, and persist in the face of setbacks.

This overlaps with the idea of self-esteem , which is a more general sense that we can cope with what’s going on in our lives, and that we have a right to be happy. Partly, this comes from a feeling that the people around us approve of us, which we may or may not be able to control. However, it also comes from the sense that we are behaving virtuously, that we’re competent at what we do, and that we can compete successfully when we put our minds to it.

Some people believe that self-confidence can be built with affirmations andpositive thinking . At Mind Tools, we believe that there’s some truth in this, but that it’s just as important to build self-confidence by setting and achieving goals – thereby building competence. Without this underlying competence, you don’t have self-confidence: you have shallow over-confidence, with all of the issues, upset and failure that this brings.

Building Self-Confidence

So how do you build this sense of balanced self-confidence, founded on a firm appreciation of reality?

The bad news is that there’s no quick fix, or five-minute solution.

The good news is that building self-confidence is readily achievable, just as long as you have the focus and determination to carry things through. And what’s even better is that the things you’ll do to build self-confidence will also build success – after all, your confidence will come from real, solid achievement. No-one can take this away from you!

So here are our three steps to self-confidence, for which we’ll use the metaphor of a journey: preparing for your journey; setting out; and accelerating towards success.

Step 1: Preparing for Your Journey

The first step involves getting yourself ready for your journey to self-confidence. You need to take stock of where you are, think about where you want to go, get yourself in the right mindset for your journey, and commit yourself to starting it and staying with it.

In preparing for your journey, do these five things:

Look at What You’ve Already Achieved

Think about your life so far, and list the ten best things you’ve achieved in an “Achievement Log.” Perhaps you came top in an important test or exam, played a key role in an important team, produced the best sales figures in a period, did something that made a key difference in someone else’s life, or delivered a project that meant a lot for your business.

Put these into a smartly formatted document, which you can look at often. And then spend a few minutes each week enjoying the success you’ve already had!

Think About Your Strengths

Next, use a technique like SWOT Analysis to take a look at who and where you are. Looking at your Achievement Log, and reflecting on your recent life, think about what your friends would consider to be your strengths and weaknesses. From these, think about the opportunities and threats you face.

Make sure that you enjoy a few minutes reflecting on your strengths!

Think About What’s Important to You, and Where you Want to Go

Next, think about the things that are really important to you, and what you want to achieve with your life.

Setting and achieving goals is a key part of this, and real self-confidence comes from this. Goal setting is the process you use to set yourself targets, and measure your successful hitting of those targets. See our article on goal setting to find out how to use this important technique, or use our Life Plan Workbook to think through your own goals in detail (see the “Tip” below).

Inform your goal setting with your SWOT Analysis. Set goals that exploit your strengths, minimize your weaknesses, realize your opportunities, and control the threats you face.

And having set the major goals in your life, identify the first step in each. Make sure it’s a very small step, perhaps taking no more than an hour to complete!

Start Managing Your Mind

At this stage, you need to start managing your mind. Learn to pick up and defeat the negative self-talk which can destroy your confidence.

Use imagery techniques.

And Then Commit Yourself to Success!

The final part of preparing for the journey is to make a clear and unequivocal promise to yourself that you are absolutely committed to your journey, and that you will do all in your power to achieve it.

If as you’re doing it, you find doubts starting to surface, write them down and challenge them calmly and rationally. If they dissolve under scrutiny, that’s great. However if they are based on genuine risks, make sure you set additional goals to manage these appropriately.

Either way, make that promise!

Tip:

Self-confidence is about balance. At one extreme, we have people with low self-confidence. At the other end, we have people who may be over-confident.

If you are under-confident, you’ll avoid taking risks and stretching yourself; and you might not try at all. And if you’re over-confident, you may take on too much risk, stretch yourself beyond your capabilities, and crash badly. You may also find that you’re so optimistic that you don’t try hard enough to truly succeed.

Getting this right is a matter of having the right amount of confidence, founded in reality and on your true ability. With the right amount of self-confidence, you will take informed risks, stretch yourself (but not beyond your abilities) and try hard.

Step 2: Setting Out

This is where you start, ever so slowly, moving towards your goal. By doing the right things, and starting with small, easy wins, you’ll put yourself on the path to success – and start building the self-confidence that comes with this.

Build the Knowledge you Need to Succeed

Looking at your goals, identify the skills you’ll need to achieve them. And then look at how you can acquire these skills confidently and well. Don’t just accept a sketchy, just-good-enough solution – look for a solution, a program or a course that fully equips you to achieve what you want to achieve and, ideally, gives you a certificate or qualification you can be proud of.

Focus on the Basics

When you’re starting, don’t try to do anything clever or elaborate. And don’t reach for perfection – just enjoy doing simple things successfully and well.

Set Small Goals, and Achieve Them

Starting with the very small goals you identified in step 1, get in the habit of setting them, achieving them, and celebrating that achievement. Don’t make goals particularly challenging at this stage, just get into the habit of achieving them and celebrating them. And, little by little, start piling up the successes!

Keep Managing Your Mind

Stay on top of that positive thinking, keep celebrating and enjoying success, and keep those mental images strong. You can also use a technique like Treasure Mapping to make your visualizations even stronger!

And on the other side, learn to handle failure. Accept that mistakes happen when you’re trying something new. In fact, if you get into the habit of treating mistakes as learning experiences, you can (almost) start to see them in a positive light. After all, there’s a lot to be said for the saying “if it doesn’t kill you, it makes you stronger!”

Step 3: Accelerating Towards Success

By this stage, you’ll feel your self-confidence building. You’ll have completed some of the courses you started in step 2, and you’ll have plenty of success to celebrate!

This is the time to start stretching yourself. Make the goals a bit bigger, and the challenges a bit tougher. Increase the size of your commitment. And extend the skills you’ve proven into new, but closely related arenas.

Tip 1:

Keep yourself grounded – this is where people tend to get over-confident and over-stretch themselves. And make sure you don’t start enjoying cleverness for its own sake…

Tip 2:

If you haven’t already looked at it, use our How Self Confident Are You? quiz to find out how self-confident you are, and to identify specific strategies for building self-confidence.

As long as you keep on stretching yourself enough, but not too much, you’ll find your self-confidence building apace. What’s more, you’ll have earned your self-confidence – because you’ll have put in the hard graft necessary to be successful!

Goal setting is arguably the most important skill you can learn to improve your self-confidence. If you haven’t already read and applied our goal setting article, you can read it here .

Key Points

Self-confidence is extremely important in almost every aspect of our lives, and people who lack it can find it difficult to become successful.

Two main things contribute to self-confidence: self-efficacy and self-esteem. You can develop self-confidence with these three steps:

Prepare for your journey.
Set out on your journey.
Accelerate towards success.

Goal setting is probably the most important activity that you can learn in order to improve your self-confidence.

Build your self-confidence with James Manktelow and Amy Carlson.

Atypical Antipsychotics Associated with Acute Kidney Injury in Older Adult

eldely

The atypical antipsychotics quetiapine (Seroquel), risperidone (Risperdal), and olanzapine (Zyprexa)—commonly prescribed off-label to help manage behavioral symptoms of dementia—are associated with increased risk of acute kidney injury in older adults, suggests a study published last week in the Annals of Internal Medicine.

Researchers found that participants prescribed quetiapine, risperidone, or olanzapine were more than 1.5 times more likely to be hospitalized with an acute kidney injury within 90 days of receiving the prescriptions than participants not prescribed one of the drugs in the population-based cohort study.

In addition, the medications were associated with an increased risk of hypotension (RR 1.91) and acute urinary retention (RR 1.98) in older adults compared with nonusing older adults. Among older adults prescribed one of the medications, death by any cause was significantly higher than among adults who were not prescribed the medications (RR 2.39 for recipients).

“The findings support current safety concerns about the use of these drugs in older adults,” researchers wrote in their conclusion.

Researchers came to their findings after evaluating adverse outcomes of 97,777 outpatients 65 and older in Ontario, Canada, who received a new prescription for quetiapine, risperidone, or olanzapine between 2003 and 2012. The study also included 97,777 additional older adults who were not prescribed the drugs.

وماذا بعد انتحار روبين ولييم؟

الرجل الذي أضحك الملايين في الشرق و الغرب على السواء و أدخل البسمة و السرور عليهم لم يجد من يفرح قلبه و يجعله يبتسم للحياة الدنيا فيأخذ القرار في غاية الصعوبة و الاستحالة وبكل اتلصميم للخلاص من حياته

كان عبقريا بكل المقاييس ليس فقط في القدرة على التمثيل و تجسيد الشخصيات بل كان عنده روح الدعابة و المرح و قدرة خارقة على التواصل و الضحك مع الآخرين

لم يشفع له تاريخ النجاح و الشهرة ولم يفرح قلبه دخوله الى أي شارع فتتهافت القلوب و الناس من حوله روبين و ليم الذي جسد حياة الطبيب مكتشف علاج الباركنسون في فيلمة الاستيقاظ يتأثر بدواء المرض ذاته و يشعر بيأس قاتل وهو الذي خاض حربا ضروس مع الادمان و استطاع الخروج منه وعاد للكحوليات مرات بعد التوقف و اليأس

ماذا يمكن أن يمنحه الله أكثر من ذلك مال و شهرة و نجومية ونجاح و أوسكار حتى يقنع بحياته و يسعى للفلاح في الأرض

مع قمة اليأس وقمة التردد و الخنوع و الاستسلام

قمة الاصرار على الخلاص

ماذا بعد الموت ؟ لن يجيب علينا روبين و ليم ولن يتسن لنا المعرفة من أحد ذهب فلن يعود أحد

فسبقته و بالطريقة ذاتها داليدا المطربة المشهورة صاحبة الأغنية الرائعة حلوة يا بلدى و كذلك الفيس بريسلي الذي كان يقود سيارة بمقود و اكصدام من الذهب الخالص و غيرهم كثيرون !!

فمن ذهب لن يعد و لن يتكلم أبدا

هل هي غرفة مظلمة أم مضيئة ؟ اذا كانت غرفة أصلا

هل هناك ألم أم راحة ؟

من سيكون معي و مع من أتحدث

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الحياة الدنيا بعدها الحياة العليا … و الحياة العليا فيها خلود اما مع الشقاء أو مع النعيم

وبعد الحياة الدنيا هناك فترة البرزخ

حتى إذا جاء أحدهم الموت قال رب ارجعون ( 99 ) لعلي أعمل صالحا فيما تركت كلا إنها كلمة هو قائلها ومن ورائهم برزخ إلى يوم يبعثون ( 100 ) ) المؤمنون

وهي حياة فيها بصر شديد الوضوح

لَقَدْ كُنْتَ فِي غَفْلَةٍ مِنْ هَٰذَا فَكَشَفْنَا عَنْكَ غِطَاءَكَ فَبَصَرُكَ الْيَوْمَ حَدِيدٌ” ق50

و يمكنك أن ترى الجنة و النار تشاهدها أمامك و قد تتألم من شدة الخوف ..ان الساعة قادمة و الحساب قادم

النَّارُ يُعْرَضُونَ عَلَيْهَا غُدُوّاً وَعَشِيّاً وَيَوْمَ تَقُومُ السَّاعَةُ أَدْخِلُوا آلَ فِرْعَوْنَ أَشَدَّ الْعَذَابِ [غافر:46

نرى حياة البرزخ في الحلم حينما تكون النفس نائمة

“اللَّهُ يَتَوَفَّى الأَنفُسَ حِينَ مَوْتِهَا وَالَّتِي لَمْ تَمُتْ فِي مَنَامِهَا فَيُمْسِكُ الَتِي قَضَى عَلَيْهَا المَوْتَ وَيُرْسِلُ الأُخْرَى إِلَى أَجَلٍ مُّسْمًّى إِنَّ فِي ذَلِكَ لآيَاتٍ لِّقَوْمٍ يَتَفَكَّرُونَ” (الزمر42

والبرزخ ليس فيه زمن فسنقضي فيه آلاف وملايين السنين و كانها ساعة أو يوما أو بعض يوم

: { كَأَنَّهُمْ يَوْمَ يَرَوْنَ مَا يُوعَدُونَ لَمْ يَلْبَثُوا إلاَّ سَاعَةً مِّن نَّهَارٍ بَلاغٌ فَهَلْ يُهْلَكُ إلاَّ الْقَوْمُ الْفَاسِقُونَ} [الأحقاف: ٥٣

{قَالَ كَمْ لَبِثْتُمْ فِي الأَرْضِ عَدَدَ سِنِينَ * قَالُوا لَبِثْنَا يَوْمًا أَوْ بَعْضَ يَوْمٍ فَاسْأَلِ الْعَادِّينَ } [المؤمنون: 112 – 113].

{وَيَوْمَ تَقُومُ السَّاعَةُ يُقْسِمُ الْـمُجْرِمُونَ مَا لَبِثُوا غَيْرَ سَاعَةٍ كَذَلِكَ كَانُوا يُؤْفَكُونَ} [الروم: ٥٥].

( ويوم يحشرهم كأن لم يلبثوا إلا ساعة من النهار يتعارفون بينهم قد خسر الذين كذبوا بلقاء الله وما كانوا مهتدين ( 45 ) المؤمنون

ثم تأتي ساعة الحساب لما أسلفنا في الحياة الدنيا .. كل قول قلته وفعل فعلته و سريرة في صدرك كننت بها .. كل غل وحقد حملته و كيد كدته وأذى اقترفته

يَوْمَ يُنفَخُ فِي الصُّورِ وَنَحْشُرُ الْمُجْرِمِينَ يَوْمَئِذٍ زُرْقًا * يَتَخَافَتُونَ بَيْنَهُمْ إن لَّبِثْتُمْ إلاَّ عَشْرًا * نَحْنُ أَعْلَمُ بِمَا يَقُولُونَ إذْ يَقُولُ أَمْثَلُهُمْ طَرِيقَةً إن لَّبِثْتُمْ إلاَّ يَوْمًا} [طه: 102 – 104].

{أَفَرَأَيْتَ إن مَّتَّعْنَاهُمْ سِنِينَ * ثُمَّ جَاءَهُم مَّا كَانُوا يُوعَدُونَ * مَا أَغْنَى عَنْهُم مَّا كَانُوا يُمَتَّعُونَ} [الشعراء: 205 – 207].

مشهد في غاية الرعب و الذهول ولكن

هناك وجوه مستبشرة ووجوه عليها قترة

وُجُوهٌ يَوْمَئِذٍ مُّسْفِرَةٌ (38)ضَاحِكَةٌ مُّسْتَبْشِرَةٌ (39) وَوُجُوهٌ يَوْمَئِذٍ عَلَيْهَا غَبَرَةٌ (4

ثم تأتي حياة الخلود و هي الحياة العليا

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كان روبين و غيرة مثقفا جدا و لكن هل كان على يقين من هذا

مؤكد انه عرفه و سمعه من العديد بأشكال مختلفه ولكن هل كان على يقين

مرض الاكتئاب الذهاني مع شرب الكحول المفرط يفقد صاحبة القدرة على التمييز و البصيرة فيأخذ قراربتصميم للخلاص من الحياة الدنيا و التي هي الجسر الوحيد ليصلني الى الحياة العليا ويضمن لي شئ أفضل

و يبقى حدث روبين وليم ابتلاء لايمان و عقيدة الغير فتزداد الحيرة لدى البعض و يزداد اليقين لدى البعض الآخر فمن زاد يقينه يسعى بشكل أسرع لترتيب أوراقة للأعداد والعمل لحياته العليا فلا شهره و لا جاه و لا سلطان و لا مال له قيمة الا اذا سخرت كل هؤلاء لخدمتك في الحياة القادمة الخالدة

وكل ما فعلت في حياتك الدنيا يجب أن يكون عملا خالصا لوجه الله و ليس للأجر الدنيوي أو للظهور بالتليفزيون أو الاعلام أو الشهرة العقيمة واذا أخذتها فلا تفقدك نفسك لأنك دائما و مهما وصلت ستظل تسأل نفسك و ماذا بعد .. والاجابة انه بعد ذلك الحياة العليا

اذن فأين الحلم الذي عشت على تحقيقة .. يمكنك أن تسعى عمر حياتك الدنيا كله لتحقيقة لخير هذه الأرض و هذا التراب ولن تحققه و لكنك ستنتقل الى الحياة العليا بناء على قدر ما سعيت

و الطبيب النفسي في أمر .. عائلة تخاف على ابنها هل هو يعاني من نفس مرض وليم ؟ ما همو تشخيص وليم؟

أو زيادة في وصمة المرض النفسي انهم يقتلون أنفسهم؟

أو رواج في العيادة النفسية لمن كان ينكر المرض و يرفض العلاج فيسارع للعلاج لأنه سمع كلمات من مريض العائلة تشبه كلمات يأس وليم؟

كل هذه النمازج مرت علينا في العليادة النفسية في وقت قصي جدا فور اذاعة خبر انتحار وليم بشنق نفسه

تشخيص وليم ليس مهما فأيا كان تشخيصة اضطراب وجداني ثنائي القطب .. اكتئاب ذهاني ..ادمان متعافي …أو منتكس ..فكان حوله من الأطباء من لم نشك أبدا في علمهم و قدرتهم على العلاج السليم و التشخيص الدقيق و لا الاهتمام

ولكن كان احساسه بالعار و العزلة و الوحدة برغم كل من حولة .. تسارع الأطباء على التلفاز كان منهم من يتحمس للعلاج الدوائي و آخر للعلاج النفسي المعرفي و منهم من يتكلم و يشرح و لا يقول شئ خاص بوليم بل بميول الانتحار

يبقى لنا شئ واحد هو أخذ شكوى المريض النفسي بمحمل الجد

من الأهل قبل الطبيب>>>>>>>>>>>

و الله الموفق والمستعان

How Clinicians Should Respond to the Death of Robin Williams

by Andrew Penn, RN, MS, NP, CNS, APRN-BC

When Robin Williams committed suicide this week, he shocked a nation who had delighted for years in the bright light of his rapid-fire, witty humor [1].

Many were left asking: “How could this funny man be suffering so profoundly?” And how should we as mental health professionals respond to such a public suicide?

I suspect that part of what gave Mr. Williams such a universal appeal was not just his humor, but his humanity. Mr. Williams brought a sense of pathos to his work on the screen. Pathos is the actor’s ability to convey emotion, particularly the shadowy feelings of sadness and shame, in such a way that it evokes compassion from the viewer. It is the ability to communicate an aspect of our shared human experience of suffering.

Pathos is also the root of “pathology,” and there has been much speculation about Mr. Williams’ mental state in recent years and at the time of his suicide. His struggles with substance use and recovery were well known. He was more circumspect about other mental health problems, admitting battles with sadness [2].

The actual diagnosis wasn’t (and still isn’t) important. People with mental illness often remain in the shadows about their struggles because of shame. This shame leads those effected to feel isolated in their experience, fearing judgment from others [3].

Despite the best efforts from anti-stigma advocates and from biological psychiatry, many people continue to feel shame for having a mental illness. On the one hand, we try to de-stigmatize mental illness through public awareness campaigns. On the other, we criticize those who speak too much or too publicly about their struggles as being attention seeking, even histrionic. It is as if we encourage transparency but then reject it when it makes us uncomfortable.

So what is the appropriate response from us as mental health professionals? As sad as Mr. Williams’ death is, it is also an opportunity to have a more candid dialogue about mental health and suicide, not only publicly as a society, but also more importantly, among the people we know personally.

How do we use our positions, our titles, the esteem that others have for us as clinicians, and our knowledge about mental health to advance the dialogue about mental suffering in our culture? Our friends, our families, and our social networks look at mental health professionals as leaders in these matters. How do we want to direct the conversation?

Cultural changes happen from one individual to another. Acceptance of previously stigmatized issues in American culture—same-sex relationships, racial integration, women’s equality, the list goes on—did not change writ large but rather with small, incremental changes in attitudes that were passed, person to person until acceptance became a new norm and intolerance became stigmatized.

What if, when we speak of Mr. Williams’ suicide, we speak not of something that happens to other people, but to people that we know and care about?

Part of the force of shame is to make people feel like they are separate, that they are an “other.” What if feelings of depression and thoughts of suicide were viewed as something that can happen to us and to those who we love, not just to “other” people? What if we used the platforms of social media and the conversations that we have with our colleagues in the hallway as a means of conveying an attitude that these experiences of depression, and even suicidal ideation, can happen, and then modeling an openness and willingness to discuss these experiences?

Even with the bright light that Robin Williams brought to the world, he also had his demons sequestered in the shadows. We all do. He used humor to cast light into these shadows, to drive the demons away.

His humor, often outrageous, made us laugh because he said the things that we all were thinking but that we thought were impolite or impertinent to say. We laughed together, with him, and at ourselves. By laughing at those demons, he took the power away from them, but sadly, not for long enough. Eventually, they rallied around him and destroyed him. We can’t change that. But we can change the tone of the conversation around mental illness, nudging it slowly but tirelessly towards acceptance, so that others need not suffer the same solitary fate.

Adjunctive Lithium Effective for Second Generation Antidepressants, Tricyclics

Antidepressant augmentation with lithium seems effective for both tricyclic antidepressants and second generation antidepressants, according to a recent systematic review and meta-analysis published in the online Journal of Affective Disorders.

While previous research on lithium augmentation focused mostly on tricyclic antidepressants, this meta-analysis covered lithium augmentation with tricyclic antidepressants as well as second generation antidepressants. Some 237 patients with unipolar major depression were involved in the meta-analysis’ nine randomized, placebo-controlled trials.

Overall, the odds ratio for lithium compared with placebo was 2.89, researchers reported. Side effects were rare and were no more frequent with lithium than placebo.

“Despite its efficacy,” the authors noted, “use of lithium augmentation remains infrequent.”

The meta-analysis’ limitations included small study sizes and limited data for patients who were resistant to treatment, researchers reported.

—Jolynn Tumolo

Little Evidence to Support Sleep/Wake Drugs for Shift Workers: Study

By Kathryn Doyle

NEW YORK – Many shift workers use over-the-counter and prescription drugs to stay awake or fall asleep at the appropriate times – but the evidence behind those practices is weak, researchers say.

Use of these drugs for this purpose “has been studied to a very limited extent and the studies that have been published mostly have not been of sufficient quality to allow firm conclusions,” said Dr. David Neubauer, associate director of the Johns Hopkins Sleep Disorders Center in Baltimore, Maryland.

“Considering the large number of people who do shift work, it certainly is unfortunate that minimal research has been performed to offer clinical guidance to address the problems of inadequate alertness or sleepiness,” Neubauer, who was not involved with the new study, told Reuters Health by email.

For the study, Dr. Juha Liira of the Finnish Institute of Occupational Health in Helsinki and colleagues gathered data from 15 trials involving 718 participants. The trials evaluated the effect of melatonin and hypnotic drugs on sleep after the shift, and the effect of modafinil, armodafinil and caffeine plus naps on sleepiness during the shift.

Taking a nap and caffeine before a night shift may improve alertness, and daytime melatonin may add around 24 minutes of extra sleep during daylight hours, but the evidence is weak.

For some workers, modafinil improves alertness at work but carries the risk of side effects like headache and nausea, and rarely a serious skin rash syndrome.

In general, the authors cautioned, “The evidence was of low quality and mostly from small trials. Both sleep and alertness promoting agents have potentially serious adverse effects. Therefore, we need more trials to determine the beneficial and harmful effects of these drugs.“

They did not respond to a request by Reuters Health for comment.

Roughly 15% of the U.S. workforce usually worked the night shift in 2004, according to a Bureau of Labor Statistics report cited in the review.

For many workers, falling asleep isn’t a problem, since they tend to be sleepy getting off the night shift.

The bigger challenge is remaining asleep long enough.

“Anyone with significant problems associated with shift work – whether excessive sleepiness at work or driving home, or with getting sufficient sleep during the hours off work – should confer with his or her primary care provider,” Neubauer added. “Some people have much greater difficulty adapting to a shift work schedule and may benefit from behavioral approaches or medications.”

Many workers use caffeine to stay awake at night, and fewer use prescription medications, but they can have a place for some patients, he said.

Caffeine and melatonin can be purchased over the counter in various formulations. Modafinil (Provigil) and armodafinil (Nuvigil) require a prescription.

Claire C. Caruso told Reuters Health by email that shift work, and long work hours, can put workers’ health and safety at risk “by disturbing sleep and circadian rhythms and reducing time for family and non-work responsibilities.”

Caruso, who was not a part of the new review, is a research health scientist at the National Institute for Occupational Safety and Health in Cincinnati.

There are non-pharmacologic ways to reduce the strain of shift work, she said.

Aside from improving work schedules to allow for more time for sleep, managers can institute policies and systems in the workplace to reduce fatigue, she said.

Also, workers can try to allow enough time for getting to sleep and use good sleep practices, like keeping the bedroom dark, maintain a bedtime routine and avoiding screens for an hour before sleep.

Workers can also educate the important people in their lives about their special needs to reduce conflicting demands from work and home life, Caruso said.

“Stimulants and sleep medications can have side effects, can become addictive, and generally have been tested for short-term use,” she said. “In addition, they do not completely remedy the effects of inadequate sleep, and questions remain about their long-term use.”

SOURCE: http://bit.ly/1sRWLZh

The Cochrane Library 2014.

keep your memory sharp at any age

Never too late

As we grow older, we all start to notice some changes in our ability to remember things.

Maybe you’ve gone into the kitchen and can’t remember why, or can’t recall a familiar name during a conversation. You may even miss an appointment because it slipped your mind. Memory lapses can occur at any age, but we tend to get more upset by them as we get older because we fear they’re a sign of dementia, or loss of intellectual function. The fact is, significant memory loss in older people isn’t a normal part of aging—but is due to organic disorders, brain injury, or neurological illness, with Alzheimer’s being among the most feared.

Most of the fleeting memory problems that we experience with age reflect normal changes in the structure and function of the brain. These changes can slow certain cognitive processes, making it a bit harder to learn new things quickly or screen out distractions that can interfere with memory and learning. Granted, these changes can be frustrating and may seem far from benign when we need to learn new skills or juggle myriad responsibilities. Thanks to decades of research, there are various strategies we can use to protect and sharpen our minds. Here are seven you might try.

1. Keep learning

A higher level of education is associated with better mental functioning in old age. Experts think that advanced education may help keep memory strong by getting a person into the habit of being mentally active. Challenging your brain with mental exercise is believed to activate processes that help maintain individual brain cells and stimulate communication among them. Many people have jobs that keep them mentally active, but pursuing a hobby or learning a new skill can function the same way. Read; join a book group; play chess or bridge; write your life story; do crossword or jigsaw puzzles; take a class; pursue music or art; design a new garden layout. At work, propose or volunteer for a project that involves a skill you don’t usually use. Building and preserving brain connections is an ongoing process, so make lifelong learning a priority.

2. Use all your senses

The more senses you use in learning something, the more of your brain will be involved in retaining the memory. In one study, adults were shown a series of emotionally neutral images, each presented along with a smell. They were not asked to remember what they saw. Later, they were shown a set of images, this time without odors, and asked to indicate which they’d seen before. They had excellent recall for all odor-paired pictures, and especially for those associated with pleasant smells. Brain imaging indicated that the piriform cortex, the main odor-processing region of the brain, became active when people saw objects originally paired with odors, even though the smells were no longer present and the subjects hadn’t tried to remember them. So challenge all your senses as you venture into the unfamiliar. For example, try to guess the ingredients as you smell and taste a new restaurant dish. Give sculpting or ceramics a try, noticing the feel and smell of the materials you’re using.

3. Believe in yourself

Myths about aging can contribute to a failing memory. Middle-aged and older learners do worse on memory tasks when they’re exposed to negative stereotypes about aging and memory, and better when the messages are positive about memory preservation into old age. People who believe that they are not in control of their memory function are less likely to work at maintaining or improving their memory skills and therefore are more likely to experience cognitive decline. If you believe you can improve and you translate that belief into practice, you have a better chance of keeping your mind sharp.

4. Use Calenders and planners

Take advantage of calendars and planners, maps, shopping lists, file folders, and address books to keep routine information accessible. Designate a place at home for your glasses, purse, keys, and other items you use often. Remove clutter from your office or home to minimize distractions, so you can focus on new information that you want to remember.

5. Repeat what you want to know

When you want to remember something you’ve just heard, read, or thought about, repeat it out loud or write it down. That way, you reinforce the memory or connection. For example, if you’ve just been told someone’s name, use it when you speak with him or her: “So, John, where did you meet Camille?” If you place one of your belongings somewhere other than its usual spot, tell yourself out loud what you’ve done. And don’t hesitate to ask for information to be repeated.

6. Space it out

Repetition is most potent as a learning tool when it’s properly timed. It’s best not to repeat something many times in a short period, as if you were cramming for an exam. Instead, re-study the essentials after increasingly longer periods of time — once an hour, then every few hours, then every day. Spacing out periods of study is particularly valuable when you are trying to master complicated information, such as the details of a new work assignment. Research shows that spaced rehearsal improves recall not only in healthy people but also in those with certain physically based cognitive problems, such as those associated with multiple sclerosis.

7. Make a mnemonic

This is a creative way to remember lists. Mnemonic devices can take the form of acronyms (such as RICE to remember first-aid advice for injured limbs: Rest, Ice, Compression, and Elevation) or sentences (such as the classic “Every good boy does fine” to remember the musical notes E, G, B, D, and F on the lines of the treble clef).

Don’ts for better Body language

1. Don’t cross your arms or legs – You have probably already heard you shouldn’t cross your arms as it might make you seem defensive or guarded. This goes for your legs too. Keep your arms and legs open. 2. Have eye contact, but don’t stare – If there are several people you are talking to, give them all some eye contact to create a better connection and see if they are listening. Keeping too much eye-contact might creep people out. Giving no eye-contact might make you seem insecure. If you are not used to keeping eye-contact it might feel a little hard or scary in the beginning but keep working on it and you’ll get used to it.

3. Don’t be afraid to take up some space – Taking up space by for example sitting or standing with your legs apart a bit signals self-confidence and that you are comfortable in your own skin. 4. Relax your shoulders – When you feel tense it’s easily winds up as tension in your shoulders. They might move up and forward a bit. Try to relax. Try to loosen up by shaking the shoulders a bit and move them back slightly.

5. Nod when they are talking –

nod once in a while to signal that you are listening.

But don’t overdo it and peck like Woody Woodpecker.

6. Don’t slouch, sit up straight –

but in a relaxed way, not in a too tense manner.

7. Lean, but not too much –

If you want to show that you are interested in what someone is saying, lean toward the person talking. If you want to show that you’re confident in yourself and relaxed lean back a bit. But don’t lean in too much or you might seem needy and desperate for some approval. Or lean back too much or you might seem arrogant and distant.

8. Smile and laugh –

lighten up, don’t take yourself too seriously. Relax a bit, smile and laugh when someone says something funny. People will be a lot more inclined to listen to you if you seem to be a positive person. But don’t be the first to laugh at your own jokes, it makes you seem nervous and needy. Smile when you are introduced to someone but don’t keep a smile plastered on your face, you’ll seem insincere.

9. Don’t touch your face – it might make you seem nervous and can be distracting for the listeners or the people in the conversation.

10. Keep your head up –

Don’t keep your eyes on the ground, it might make you seem insecure and a bit lost. Keep your head up straight and your eyes towards the horizon.

11. Slow down a bit –

this goes for many things. Walking slower not only makes you seem more calm and confident, it will also make you feel less stressed. If someone addresses you, don’t snap your neck in their direction, turn it a bit more slowly instead.

12. Don’t fidget

and try to avoid, phase out or transform fidgety movement and nervous ticks such as shaking your leg or tapping your fingers against the table rapidly. You’ll seem nervous and fidgeting can be a distracting when you try to get something across. Declutter your movements if you are all over the place. Try to relax, slow down and focus your movements.

13. Use your hands confidently

instead of fidgeting with your hands and scratching your face use them to communicate what you are trying to say. Use your hands to describe something or to add weight to a point you are trying to make. But don’t use them to much or it might become distracting. And don’t let your hands flail around, use them with some control.

14. Lower your drink.

Don’t hold your drink in front of your chest. In fact, don’t hold anything in front of your heart as it will make you seem guarded and distant. Lower it and hold it beside your leg instead.

15. Realise where you spine ends –

You might sit or stand with a straight back in a good posture. Your spine ends in the back of your head. Keep you whole spine straight and aligned for better posture.

16. Don’t stand too close –

one of the things we learned from Seinfeld is that everybody gets weirded out by a close-talker. Let people have their personal space, don’t invade it.

17. Mirror –

Often when you get along with a person, when the two of you get a good connection, you will start to mirror each other unconsciously. That means that you mirror the other person’s body language a bit. To make the connection better you can try a bit of proactive mirroring. If he leans forward, you might lean forward. If she holds her hands on her thighs, you might do the same. But don’t react instantly and don’t mirror every change in body language. Then weirdness will ensue.

18. Keep a good attitude –

last but not least, keep a positive, open and relaxed attitude. How you feel will come through in your body language and can make a major difference.

Ten Rules of Bad Studying

1. Passive rereading—

sitting passively and running your eyes back over a page. Unless you can prove that the material is moving into your brain by recalling the main ideas without looking at the page, rereading is a waste of time.

2. Letting highlights overwhelm you.

Highlighting your text can fool your mind into thinking you are putting something in your brain, when all you’re really doing is moving your hand. A little highlighting here and there is okay—sometimes it can be helpful in flagging important points. But if you are using highlighting as a memory tool, make sure that what you mark is also going into your brain.

3. Merely glancing at a problem’s solution and thinking you know how to do it.

This is one of the worst errors students make while studying. You need to be able to solve a problem step-by-step, without looking at the solution.

4. Waiting until the last minute to study.

Would you cram at the last minute if you were practicing for a track meet? Your brain is like a muscle—it can handle only a limited amount of exercise on one subject at a time.

5. Repeatedly solving problems of the same type that you already know how to solve.

If you just sit around solving similar problems during your practice, you’re not actually preparing for a test—it’s like preparing for a big basketball game by just practicing your dribbling.

6. Letting study sessions with friends turn into chat sessions.

Checking your problem solving with friends, and quizzing one another on what you know, can make learning more enjoyable, expose flaws in your thinking, and deepen your learning. But if your joint study sessions turn to fun before the work is done, you’re wasting your time and should find another study group.

7. Neglecting to read the textbook before you start working problems.

Would you dive into a pool before you knew how to swim? The textbook is your swimming instructor—it guides you toward the answers. You will flounder and waste your time if you don’t bother to read it. Before you begin to read, however, take a quick glance over the chapter or section to get a sense of what it’s about.

8. Not checking with your instructors or classmates to clear up points of confusion.

Professors are used to lost students coming in for guidance—it’s our job to help you. The students we worry about are the ones who don’t come in. Don’t be one of those students.

9. Thinking you can learn deeply when you are being constantly distracted.

Every tiny pull toward an instant message or conversation means you have less brain power to devote to learning. Every tug of interrupted attention pulls out tiny neural roots before they can grow.

10. Not getting enough sleep.

Your brain pieces together problem-solving techniques when you sleep, and it also practices and repeats whatever you put in mind before you go to sleep. Prolonged fatigue allows toxins to build up in the brain that disrupt the neural connections you need to think quickly and well. If you don’t get a good sleep before a test, NOTHING ELSE YOU HAVE DONE WILL MATTER.

Study with the following skills

1. Use recall.

After you read a page, look away and recall the main ideas. Highlight very little, and never highlight anything you haven’t put in your mind first by recalling. Try recalling main ideas when you are walking to class or in a different room from where you originally learned it. An ability to recall—to generate the ideas from inside yourself—is one of the key indicators of good learning.

2. Test yourself.

On everything. All the time. Flash cards are your friend.

3. Chunk your problems.

Chunking is understanding and practicing with a problem solution so that it can all come to mind in a flash. After you solve a problem, rehearse it. Make sure you can solve it cold—every step. Pretend it’s a song and learn to play it over and over again in your mind, so the information combines into one smooth chunk you can pull up whenever you want.

4. Space your repetition.

Spread out your learning in any subject a little every day, just like an athlete. Your brain is like a muscle—it can handle only a limited amount of exercise on one subject at a time.

5. Alternate different problem-solving techniques during your practice.

Never practice too long at any one session using only one problem-solving technique—after a while, you are just mimicking what you did on the previous problem. Mix it up and work on different types of problems. This teaches you both how and when to use a technique. (Books generally are not set up this way, so you’ll need to do this on your own.) After every assignment and test, go over your errors, make sure you understand why you made them, and then rework your solutions. To study most effectively, handwrite (don’t type) a problem on one side of a flash card and the solution on the other. (Handwriting builds stronger neural structures in memory than typing.) You might also photograph the card if you want to load it into a study app on your smartphone. Quiz yourself randomly on different types of problems. Another way to do this is to randomly flip through your book, pick out a problem, and see whether you can solve it cold.

6. Take breaks.

It is common to be unable to solve problems or figure out concepts in math or science the first time you encounter them. This is why a little study every day is much better than a lot of studying all at once. When you get frustrated with a math or science problem, take a break so that another part of your mind can take over and work in the background.

7. Use explanatory questioning and simple analogies.

Whenever you are struggling with a concept, think to yourself, How can I explain this so that a ten-year-old could understand it? Using an analogy really helps, like saying that the flow of electricity is like the flow of water. Don’t just think your explanation—say it out loud or put it in writing. The additional effort of speaking and writing allows you to more deeply encode (that is, convert into neural memory structures) what you are learning.

8. Focus.

Turn off all interrupting beeps and alarms on your phone and computer, and then turn on a timer for twenty-five minutes. Focus intently for those twenty-five minutes and try to work as diligently as you can. After the timer goes off, give yourself a small, fun reward. A few of these sessions in a day can really move your studies forward. Try to set up times and places where studying—not glancing at your computer or phone—is just something you naturally do.

9. Eat your frogs first.

Do the hardest thing earliest in the day, when you are fresh.

10. Make a mental contrast.

Imagine where you’ve come from and contrast that with the dream of where your studies will take you. Post a picture or words in your workspace to remind you of your dream. Look at that when you find your motivation lagging. This work will pay off both for you and those you love!

29 ways to be creative

Avoid teaching your kids!

1. It’s OK to disrespect your body.

Do you abuse your body by overeating or going on crash diets? Drink too much alcohol? Say cruel things about your appearance, when you look in the mirror? Your child is learning how to value his or her body by watching your example. What kind of example do you want to set? 2. Relationships with electronic devices matter more than human relationships. Do you sleep with your smartphone practically tucked under your pillow? Flip through emails on your iPad when your partner is telling a story at the dinner table? If so, then you’re teaching your kids that intimate involvement with an electronic screen is more important than people sharing quality time with each other.

3. Dessert is a reward for being “good.”

dessert-1

Ever say something like this to your child? “If you’re a good girl at Grandma’s, you can have a cookie when we get home.” Many well-intentioned parents bribe kids with food. It’s tempting to offer a treat as a reward for good behavior. It’s an easy, quick way to get kids to cooperate … at least, for a little while. But it’s a dangerous lesson to teach — one that can result in unhealthy eating patterns that are tough to change later, as an adult.

4. It’s OK to cheat … as long as you don’t get caught. communication_skill Here’s an example: “Oops, the waiter forgot to charge us for your meal. Guess we’re getting a free dinner, tonight! Come on, let’s go. Hurry!” If you teach your kid that cheating is OK (as long as you don’t get caught) you’re doing your kid a tremendous disservice. Your kid is far more likely to cheat on a test, violate the law, or be unfaithful to a partner later in life. Because you’ve taught them that there aren’t any consequences … as long as you cover your tracks.

5. It’s OK to flake out.

Do you tell people that you’ll call them and then you don’t? Do you say that you’ll finish something by a certain time, and then flake out? When you consistently break your word, you’re teaching your child that personal integrity doesn’t mean much, and reliability isn’t important.

6. Sex can be used as a bargaining chip. Do you withhold sex from your partner as a “punishment?” Or lay on tons of affection once he (or she) has done what you want? Your kid might be too young to understand exactly what’s going on, but he or she will pick up on the underlying message: Sex can be used to control people and get what I want

. 7. Other people’s needs and desires are more important than your own. Do you hold back on sharing who you really are? Do you keep quiet, instead of asking for what you truly want? It’s natural to want to be liked and accepted. But when you don’t follow your heart, you’re sending the message to your kid that what you truly desire doesn’t matter. When it comes to your child’s future happiness and satisfaction, that’s one of the most dangerous lessons of all.… If you’re reading this and feeling guilty because you’ve done things that you shouldn’t have, don’t be hard on yourself! (Punishing yourself for making a mistake — that’s yet another lesson that you don’t want to teach your kids!) Instead, make a commitment to become more aware of how you behave, and celebrate the important changes that you’re going to make. Your kid learns from you, every day. From your words and actions. From your presence and absence. From the way you treat yourself and others. You can choose to change the lesson plan … starting now. ref: http://www.mindbodygreen.com/

Ketamine is a safe drug and will revolutionalise the treatment of depression

First UK study of ketamine for people with severe depression

Health | Science

03 Apr 14

Ketamine had a rapid antidepressant effect in some patients with severe depression

The first UK study of the use of ketamine intravenous infusions in people with treatment-resistant depression has been carried out in an NHS clinic by researchers at Oxford Health NHS Foundation Trust and the University of Oxford.

‘Ketamine is a promising new antidepressant which works in a different way to existing antidepressants. We wanted to see whether it would be safe if given repeatedly, and whether it would be practical in an NHS setting. We especially wanted to check that repeated infusions didn’t cause cognitive problems,’ explains principal investigator Dr Rupert McShane, a consultant psychiatrist at Oxford Health and a researcher in Oxford University’s Department of Psychiatry.

The researchers confirmed that ketamine has a rapid antidepressant effect in some patients with severe depression who have not responded to other treatments. These are patients suffering from severe depression which may have lasted years despite multiple antidepressants and talking therapies. Although many patients relapsed within a day or two, 29% had benefit which lasted at least three weeks and 15% took over two months to relapse.

Ketamine did not cause cognitive or bladder side effects when given on up to six occasions, although some people did experience other side effects such as anxiety during the infusion or being sick. The team have now given over 400 infusions to 45 patients and are exploring ways to maintain the effect. They report their findings in the Journal of Psychopharmacology. The study was funded by National Institute for Health Research (NIHR) Research for Patient Benefit Programme.

We’ve seen remarkable changes in people who’ve had severe depression for many years

Dr Rupert McShane

Dr McShane, also of the Radcliffe Department of Medicine at the University, says: ‘We’ve seen remarkable changes in people who’ve had severe depression for many years that no other treatment has touched. It’s very moving to witness. Patients often comment that that the flow of their thinking seems suddenly freer. For some, even a brief experience of response helps them to realise that they can get better and this gives hope.’

In treatment-resistant depression, electroconvulsive therapy (ECT) is sometimes considered. Although ECT is effective, this benefit has to be balanced against the risk of memory loss. There is a need for developing more treatment options.

In the past few years, small randomised controlled trials have consistently shown that a single infusion of ketamine has a substantial and rapid antidepressant effect in some patients with treatment-resistant depression who have been taken off other antidepressants. In those single dose studies, patients typically, though not always, relapse within a week.

In the Oxford study, 28 patients with treatment-resistant depression were treated over three weeks. They received either three or six ketamine infusions lasting 40 minutes in the recovery room of a routine ECT clinic at the Warneford hospital, part of Oxford Health NHS Foundation Trust. Memory tests were carried out a few days after the final infusion. Patients reported their mood symptoms daily via text or email.

The antidepressant response sometimes took a second ketamine infusion to become apparent. Three days after the last infusion, the depression scores had halved in 29% of the patients. In those that responded to the treatment, the duration of benefit varied widely, lasting between 25 days and eight months (median 2.3 months).

The ketamine did not cause memory or bladder problems. Some patients became anxious during the infusions and some did not complete the course because they did not feel they were benefiting. A few were sick and one fainted. The patients were severely depressed and episodes of suicidal behaviour (such as had occurred before the infusions) also occurred during the study, but suicidal ideas diminished overall.

Most patients experienced some short-lived ‘dissociative’ effects from the ketamine – their perceptions might be distorted slightly, they felt disconnected from their body – but these only occurred while the drug was being infused and were not connected to the antidepressant effect. They did not feel euphoric with the treatment.

The ECT clinic worked well as the setting for the ketamine treatment because all the necessary facilities and experienced staff were already in place and the treatment could be incorporated into the twice weekly clinic routine.

Ketamine is a licensed medical drug and is very widely used as an anaesthetic and in pain relief. It is also used as a recreational drug or drug of abuse, and is to be reclassified as a Class B banned substance by the Home Office. However, the doses used are very different. When used on the street at a level of several grams a day, severe bladder problems occur and cognitive function is impaired. The dose used in this study was no more than 80 mg (80 thousandths of a gram) every week in the controlled and closely monitored setting of an NHS hospital.

The team has now treated 45 patients in total. Of these, nine (20%) have benefited to the point where it was thought worthwhile to have further intermittent ketamine treatments. Of these nine, four are currently continuing ketamine treatment, one is in remission (is not currently depressed) without treatment, and four relapsed and have gone on to other treatment. As with its use for chronic pain, there has been no evidence of addiction when given regularly over up to two years.

‘Intravenous ketamine is an inexpensive drug which has a dramatic, but often short-term, effect in some patients whose lives are blighted by chronic severe depression,’ says Dr McShane.

He adds: ‘We now need to build up clinical experience with ketamine in a small number of carefully monitored patients. By trying different infusion regimes and adding other licensed drugs, we hope to find simple ways to prolong its dramatic effect.’

Serial infusions of low-dose ketamine for major depression

¹Department of Psychiatry and Psychology, Mayo Clinic, Rochester, USA
²Department of Anesthesiology, Mayo Clinic, Rochester, USA

Keith G Rasmussen, Department of Psychiatry, Mayo Clinic, Rochester, MN 55905, USA. Email: [email protected]

Abstract

Background: Single infusions of ketamine have been used successfully to achieve improvement in depressed patients. Side effects during the infusions have been common. It is not known whether serial infusions or lower infusion rates result in greater efficacy.

Methods: Ten depressed patients were treated with twice weekly ketamine infusions of ketamine 0.5 mg/kg administered over 100 min until either remission was achieved or four infusions were given. Side effects were assessed with the Young Mania Rating Scale (YMRS) and the Brief Psychiatric Rating Scale (BPRS). Patients were followed naturalistically at weekly intervals for four weeks after completion of the infusions.

Results: Five of 10 patients achieved remission status. There were no significant increases on the BPRS or YMRS. Two of the remitting patients sustained their improvement throughout the four week follow-up period.

Conclusions: Ketamine infusions at a lower rate than previously reported have demonstrated similar efficacy and excellent tolerability and may be more practically available for routine clinical care. Serial ketamine infusions appear to be more effective than a single infusion. Further research to test relapse prevention strategies with continuation ketamine infusions is indicated.

Intranasal Ketamine Promising For Treatment-Resistant Major Depression

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Results from a newly published study indicate that intranasal ketamine spray can produce a rapid and sustained antidepressant effect within 24 hours, and was well tolerated in a small group of patients with treatment-resistant major depressive disorder.

This is the first study to show benefits with an intranasal formulation of ketamine. Previous research has indicated that intravenous ketamine may have a role in helping patients with major depressive disorder and suicidal ideation.

The study was published online in the Biological Psychiatry on April 2.

In a double-blind, crossover study, the researchers randomized 20 patients with major depressive disorder to ketamine (a single 50 mg dose) or saline. Change in depression severity was measured using the Montgomery-Asberg Depression Rating Scale. Secondary outcomes included changes in self-reports of depression, anxiety, the durability of response, as well as the proportion of responders. Eight patients met response criteria to ketamine within 24 hours versus one on saline, out of 18 patients completing two treatment days with ketamine or saline.

Ketamine, one of the most common NMDA receptor antagonists. (Photo credit: Wikipedia)

In the study, ketamine was found to be safe with minimal dissociative effects or changes noted in blood pressure or heart rate. The intranasal route for drug delivery has been of interest to investigators because it is non-invasive, and may offer rapid absorption and delivery. In addition, the ease of administration may potentially improve compliance.

“We found intranasal ketamine to be well tolerated with few side effects,” said Kyle Lapidus, MD, PhD, Assistant Professor of Psychiatry, at the Icahn School of Medicine at Mount Sinai.

ball-and-stick model of (R)-ketamine (Photo credit: Wikipedia)

Ketamine, an FDA-approved anesthetic which is an NMDA receptor antagonist, has been used in animals and humans for many decades. Ketamine has also been a drug of abuse and can lead to adverse psychiatric or cognitive problems when abused. In low doses, ketamine has already shown promise in providing rapid relief of depression, with tolerable side effects.

“One of the primary effects of ketamine in the brain is to block the NMDA [N-methyl-d-aspartate] glutamate receptor,” said James W. Murrough, MD, principal investigator of the study, and Assistant Professor of Psychiatry and Neuroscience, and Associate Director of the Mood and Anxiety Disorders Program at the Icahn School of Medicine at Mount Sinai. “There is an urgent clinical need for new treatments for depression with novel mechanisms of action. With further research and development, this could lay the groundwork for using NMDA targeted treatments for major depressive disorder.”

“What we have here is a proof of concept study,” stated co-author Dr. Dennis S. Charney, the Anne and Joel Ehrenkranz Dean of the Icahn School of Medicine at Mount Sinai and President for Academic Affairs for the Mount Sinai Health System, and a world expert on the neurobiology and treatment of mood disorders, “and we consider the results very promising. We hope to see this line of research further developed so that we have more treatments to offer patients with severe, difficult-to-treat major depressive disorder.”

Ketamine, which acts by blocking the NMDA receptor, has a more rapid effect in alleviating symptoms of depression (within hours) compared to more standard medications such as SSRIs which take many weeks to months to begin to have effects. In fact, serial ketamine infusions have shown promise compared to the effect of a single dose of ketamine for treatment-resistant depression. Overall, medications such as SSRIs may only be moderately effective, leaving up to a third of depressed patients resistant to medical therapy.

“Currently, there is an important unmet need for additional antidepressant options,” Lapidus explained. “Many patients fail to respond to many medication treatments and even if response is achieved, there often is a long delay in treatment efficacy.”

“Although more research is needed to confirm the antidepressant effects and to determine how to extend this potential benefit, our findings suggest that intranasal ketamine can have antidepressant properties and limited side effects even when given in addition to other ongoing antidepressant medications,” added Lapidus.

Lapidus explained that they noted these effects in both a highly treatment-resistant population and in subjects with fewer antidepressant failures.

Whether ketamine holds promise for use in the emergency department as a “rescue medication” to alleviate the symptoms of depression has intrigued both researchers and the public.

“Our research provides a proof of concept for intranasal ketamine in depression. In this context, it remains too early to advocate treatment clinically in any setting.” said Lapidus.

Lapidus believes that additional research is required before clear clinical recommendations can be formulated. But he also felt that there was clear promise for the utility of the approach in the near future.

“Our findings suggest that intranasal ketamine may be easily and rapidly administered and previous studies have included administration of ketamine in emergency rooms as well as other contexts,” explained Lapidus. “Providing medication via an intranasal route could also reduce the level of support services needed relative to an intravenous infusion.”

Whether intranasal ketamine can be a game change in the management of depression as rescue or even longer term therapy will likely be debated from this study.

“A growing body of evidence continues to support a possible role for ketamine as a rapid-acting antidepressant. A specific role in acute symptom exacerbations has not been directly addressed in our study, but rapid-action could potentially have increased utility in such situations,” said Lapidus.

“It is difficult to completely predict the long-term implications of our research. Our recent study of intranasal ketamine in depression builds on previous findings with intravenous ketamine from our group at Mount Sinai and others including work by Drs. Dennis Charney, James Murrough, Dan Iosifescu, Sanjay Mathew, and Carlos Zarate”.