gppsychotherapist spring 2012 vol. 19, #2spring 2012 vol ... · research network (pprnet) has been...

psychotherapist

CBT Tips................................................... 3

Management of Adult ADHD ................. . 5

Psychotherapy Practice Research Network (PPRNet) .................................................. 12

Book Review: The Dialectic Behaviour Therapy Skills Workbook ........................ 15

Psychopharmacology Corner: Refractory OCD........................................ 18

GPGPGPGPpsychotherapistpsychotherapistpsychotherapistpsychotherapistGPpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistpsychotherapistpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistpsychotherapistpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistpsychotherapistpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistpsychotherapistpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistpsychotherapistpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistGPpsychotherapistpsychotherapistpsychotherapistGPpsychotherapistpsychotherapistpsychotherapistpsychotherapistJournal of the General Practice Psychotherapy Association

psychotherapistpsychotherapistpsychotherapistSpring 2012 Vol. 19, #2

psychotherapistSpring 2012 Vol. 19, #2

psychotherapistpsychotherapistSpring 2012 Vol. 19, #2

psychotherapistpsychotherapistpsychotherapistpsychotherapistSpring 2012 Vol. 19, #2




psychotherapist

Inside

When you receive this, spring will be here with blossoms and fl owers everywhere!

GPPA 25th Annual ConferenceI hope everyone has signed up for the GPPA Conference on Models of Therapy: Joining With Patients Where They Need to Heal. If not, sign up as soon as possible! It is April 27-28 2012 at the Radisson Admiral Hotel, 249 Queen’s Quay West Toronto, Ontario. Plan to come to the 25th Anniversary Dinner on Friday evening, celebrating 25 years of conferences, where we will be hearing from some of our long time members and some new members.

A GPPA Retreat is being organized, with the date set for November 9 -11, 2012. It will be at YMCA Geneva Park near Orillia, Ontario, which is a beautiful country se� ing, as many of you know. The Topic is The Power of Self-Care in Health Care: caring for ourselves as a foundation for the care of others. Drs. Natasha Graham and Larry Nusbaum will be facilitating the programme. It will be very important for people to sign up quickly. The YMCA are reserving some rooms for us, but if we need more, it will be on a fi rst come, fi rst serve basis and we know lots of you want to come! Get your reservations in to Carol as soon as possible!

The Psychotherapy Practice The Psychotherapy Practice Research Network (PPRNet) has been awarded a Canadian Institutes for Health Research (CIHR) planning and meeting grant to launch the PPRNet..

Dr. Giorgio A. Tasca, Chair of Psychotherapy Research at O� awa University, has wri� en to thank the GPPA for sending a le� er in support of the PPRNet’s application for a grant. Please see the article he has wri� en in this edition of the GP Psychotherapist. There will be opportunities for us to work together in the future and this is indeed exciting.

The Steering Commi� eeThe Steering Commi� eemanages the output from 4 other commi� ees involving the fi ve-year strategic plan for the GPPA. We are on track! A number of initiatives have been implemented, and we have ongoing initiatives in the area of education, publications, research, and general outreach to the medical and other communities. However, we really need more from you, our members, in terms of your willingness to be on commi� ees. Please step forward and help us ‘get on the map’ as an organization. In short - we need you! Help us help our organization fl ourish and realize our goals : that the GPPA is the authoritative voice of integrative medical psychotherapy in Canada; that the GPPA is the number one professional organization for physicians practicing psychotherapy; and, that the GPPA enables and fosters the highest levels of self care, collegiality and connection for its members. Contact me (contact information below) or Ted Leyton, Chair of the Steering Commi� ee ( 613-542-5663; [email protected]@sympatico.ca ) to have fun, earn CCI credits, and make things happen!

From the Board - April 2012 • By Muriel J. van Lierop, MBBS, MGPP

Applying to be a Third PathwayApplying to be a Third Pathwayas a recognized organization for CPD tracking with the College of Physicians and Surgeons of Ontario (CPSO) continues. On January 5, 2012, Dr. Howard Schneider and I met with Dan Faulkner, Director, Quality Management and Research, CPSO and Wade Hillier, Manager Government Programs, CPSO at the CPSO. We introduced the GPPA with a PowerPoint presentation. We also gave them a copy of our Policy and Procedure Manual and the Guidelines for the Practice of Psychotherapy by Physicians for them to review at their leisure. We believe this was an important step in the approval process.

At the CPSO Council on February 24, 2012, the Criteria for Continuing Professional Development Organizations were approved. It seems that the GPPA has what will be required but we need to wait for the application process to be fi nalized. We have been assured by the administration at the CPSO that we will be advised as soon as the process has been set up.

continued on page 2

Spring 2012GPGPpsychotherapist2 psychotherapist

Review of the new dra� CPSO Policy Statement on Medical Policy Statement on Medical Records. The GPPA was asked to review and comment on the updated Medical Records Policy of the CPSO. The members of the Guidelines Task Force, which includes the Professional Development Commi� ee members, reviewed these and submi� ed an excellent report to the Board which, with very li� le change, was sent on the CPSO.

Join a GPPA commi� ee.Join a GPPA commi� ee. This is a wonderful way to get to know your colleagues and also to obtain Continuing Collegial Interaction credits. There is a list of all commi� ees on the back page of the GP Psychotherapist, so please GP Psychotherapist, so please GP Psychotherapisthave a look. If we are approved

From the Board (cont’d)

as a Third Pathway, even Clinical Members will require 25 hours of Continuing Educational Credits (CE) and 25 hours of Continuing Collegial Interaction (CCI) credits. This will be required to obtain your medical licence from the CPSO, if the GPPA is approved and you want to use the GPPA as your pathway to accreditation. Seriously think about joining a commi� ee. To maintain Clinical Membership, 12 hours of each category will still be the requirement. If you wish more information about this do contact me at 416-229-1993 or [email protected]@rogers.com

Be sure and read the article GP Psychotherapy Practice Guidelines 2011 in the Ontario Medical Review.

GP PsychotherapistISSN 1918-381X

Editor: Howard [email protected]

Scientifi c Editor: Norman Steinhart

Contributing Editor: Vivian Chow

Production Editor: Maria Grande

General Practice Psychotherapy Association312 Oakwood Court

Newmarket, ON L3Y 3C8Tel: 416-410-6644,

Fax: [email protected], www.gppaonline.ca

The GPPA (General Practice Psychotherapy Association) publishes the GP Psychotherapist three times a year. GP Psychotherapist three times a year. GP PsychotherapistSubmissions will be accepted up to the following dates: Winter Issue - November 2Spring/Summer Issue - March 2Fall Issue - July 2

For le� ers and articles submi� ed, the editor reserves the right to edit content for the purpose of clarity. Please submit articles to: [email protected].

GPPA RETREAT

The Power of Self-care in Health Care: caring for ourselves as a foundation

for the care of others

Please join us for a rejuvenating and energizing retreat weekend

November 9-11, 2012at the Geneva Park resort in Orillia

Facilitators: Drs. Larry Nusbaum and Natasha Graham

Watch for �lyer in the mail and sign up quicklyWatch for �lyer in the mail and sign up quickly

psychotherapist Spring 2012 3GPGPpsychotherapist

a soul mate, they “should” have a fabulous career, etc. I like to ask them if that’s wri� en in stone somewhere and point out that there’s no law stating they have to have these things.

I’m a fi rm believer in keeping it simple. Instead of providing my patients with the a� ached list of ten cognitive distortions with sub-categories, I merely write down the fi ve distortions I’ve listed above. Not only is it easier for me to remember, but it’s also easier for my patients to remember and catch themselves making and hopefully correcting.

Please feel free to contact me at [email protected] if you have any questions or comments. have any questions or comments. have any questions or comments.

ReferencesBurns, David D., MD. 1989. The Feeling Good Handbook. New York: WilliamMorrow and Company, Inc.

David Burns (a student of Aaron Beck, the father of CBT), in his book The Feeling Good Handbook, The Feeling Good Handbook, The Feeling Good Handbookidentifi ed ten types of cognitive distortions. If you were to separate out the sub-categories, you would fi nd that there are actually twelve distinctive types of distortions. I fi nd this list to be rather long and hard to remember. From years of practice, I’ve managed to narrow the list down to fi ve common thought distortions, which I also refer to as “thought mistakes” to really emphasize the point.

I’ve a� ached a list of the David Burns distortions for your reference. Here is the list that I give my patients with examples:1. All or nothing/black or white thinking“I didn’t play perfectly, therefore I suck” or “I’ll never meet my soul mate” or “I always get burned.” The goal, of course, is to teach your patient to see shades of grey. Are things really that absolute? In the fi rst example, ask your patient how the rest of the concert/game/whatever went. Just because one small portion goes wrong, does not mean the whole thing is a write-off . Another eff ective way to deal with the patient is to repeat back the all or nothing word e.g. “Never?” Patients will catch themselves at this point and say “Well, okay, maybe it’ll just take a long time.” Already, things don’t seem as grim for them.

2. CatastrophizingThe a� ached list puts catastrophizing as a sub-category of maximizing or minimizing. However, I fi nd in practice, patients basically catastrophize. “It would just be so awful if I made

CBT Tips • By Vivian Chow, MD

Cognitive Distortions Thoughts, i.e. cognitions, are a key component of the basic Cognitive Behavioural Therapy model. Since thoughts can infl uence moods, identifying cognitive distortions is an eff ective method of helping a patient alter his/her thinking in order to improve the mood.

a mistake.” Simply asking the patient “Is it the end of the world?” usually gets them thinking and acknowledging their distortion.

3. Mind ReadingThis, too, is listed as a sub-category on the reference list, but I hear it so o� en that I’ve given it its own category. My patients seem to think they know what the other person is thinking or they imagine what others think they are thinking. For example, “My co-worker thinks I’m an idiot” or “My husband must think I’m mad at him.” “Really,” I ask, “and are you (or your husband) a mind reader?” This usually works but if not (because in close relationships there are always established dynamics which makes patients think they are mind readers), I also like to point out that they can choose not to mind read and that it benefi ts everyone in the end. Yes, your co-worker is rolling her eyes, but not at you, she’s looking at something on her computer.

4. Fortune TellingThis gets lumped with mind reading as “overgeneralization” on the a� ached list, but again because I hear it so o� en on its own, I use it as a companion to mind reading. “I’m going to have a bad time anyway, so I may as well not go to the party.” To which I respond: “Really, are you a fortune teller?”

5. Should-ingI haven’t emphasized this type of distortion in the past, but lately, with an increase in Generation Y patients, I’m fi nding there is more of a sense of entitlement than in previous generations. These patients think they “should” have

continued on page 4


CBT Tips (cont’d)

Cognitive Distortions

1. All-or-nothing thinking: You see things in black and white categories. If your performancefalls short of perfect, you see yourself as a total failure.

2. Overgeneralization: You see a single negative event as a never-ending pa� ern of defeat.

3. Mental fi lter: You pick out a single negative detail and dwell on it exclusively so that your vision of all reality becomes darkened, like the drop of ink that discolours the entire beaker of water.

4. Disqualifying the positive: You reject positive experiences by insisting they “don’t count” for some reason or other. You maintain a negative belief that is contradicted by your everyday experiences.

5. Jumping to conclusions: You make a negative interpretation even though there are no defi nite facts that convincingly support your conclusion.

a. Mind reading. You arbitrarily conclude that someone is reacting negativelyto you and don’t bother to check it out.b. The Fortune Teller Error. You anticipate that things will turn out badlyand feel convinced that your prediction is an already-established fact.

6. Magnifi cation (catastrophizing) or minimization: You exaggerate the importance of things (such as your goof-up or someone else’s achievement), or you inappropriately shrink things until they appear tiny (your own desirable qualities or the other fellow’s imperfections). This is also called the “binocular trick.”

7. Emotional reasoning: You assume that your negative emotions necessarily refl ect the way things really are: “I feel it, therefore it must be true.”

8. Should statements: You try to motivate yourself with shoulds and shouldn’ts, as if you had to be whipped and punished before you could be expected to do anything. “Musts”and “oughts” are also off enders. The emotional consequence is guilt. When you direct should statements toward others, you feel anger, frustration, and resentment.

9. Labelling and mislabelling: This is an extreme form of overgeneralization. Instead of describing your error, you a� ach a negative label to yourself: “I’m a loser.” When someone else’s behaviour rubs you the wrong way, you a� ach a negative label to him, “He’s a damn louse.” Mislabelling involves describing an event with language that is highly coloured and emotionally loaded.

10. Personalization: You see yourself as the cause of some negative external event for which, in fact, you were not primarily responsible.


About 4.4% of the adult population meets the screening criteria (Kessler 2006) for Adult ADHD (Attention-Deficit/Hyperactivity Disorder). It is a real disorder – one that results in signifi cant social and work impairment.

When you think ‘ADHD’, think ina� ention, impulsivity and sometimes hyperactivity. Some patients will present as having ADHD in childhood and wanting continuation of treatment now that they are adults. O� en, the adult presentation features less hyperactivity and more ina� entiveness. However, other Adult ADHD patients may present with comorbid mood disorders, with the features of a personality disorder, as a referral from a family doctor who found the undiagnosed ADHD, or essentially a self-referral from a patient who now recognizes the ADHD symptoms in himself/herself, o� en a� er a child has been diagnosed with ADHD.

The DSM-IV-TR tends to be child-oriented in its consideration of ADHD, although the patient should generally meet many of the criteria as applied to an adult. There is controversy as to the age of onset of ADHD symptoms (McGough 2006). The etiology of ADHD is beyond the scope of this article, but some cases of ADHD can be acquired. Some other useful assessment tools are:

Management of Adult ADHD • By Howard Schneider, MD, CGPP, CCFP Sheppard Associates, 649 Sheppard Avenue, Toronto, Ontario, Canada M3H 2S4

Adult ADHD is frequently comorbid with mood disorders, anxiety disorders, substance abuse disorders, learning disor-ders, and other psychiatric disorders. Management of Adult ADHD with and without comorbidities is discussed.

The ASRS-v1.1 (Adult Self-Report Scale) is available free of charge from the web link in the table above. The ASRS was developed by the World Health Organization and has been validated (Kessler 2007).

In the diagnosis of Adult ADHD, using an assessment scale is only the fi rst step. You want a good history of the current functional impairment. You want to also assess the developmental history and functional impairments during childhood and school years. You want to obtain a detailed psychiatric history – Adult ADHD is o� en comorbid with mood and anxiety disorders, with substance abuse, with learning disabilities, and with many other psychiatric disorders. In the family history ask about ADHD – it is very heritable.

A physical exam (o� en by the referring physician) and laboratory testing should be performed. As in other psychiatric disorders a ‘physical’ cause should be ruled out. Standard blood tests such as a CBC, chemistry (glucose, creatinine, lipids, etc), and TSH are warranted, as are additional tests if there is an indication from history.

Always ask about risk factors for sleep apnea – order a sleep study if there is an indication.

If you will be considering treatment with stimulants, you may want to consider ordering cardiac evaluations. We will discuss this in more detail below.

Neurocognitive testing will o� en fi nd defi cits on tests of a� ention, information processing speed and general and working memory (Aycicegi-Dinn 2011). However, there is debate as to the usefulness of neurocognitive testing in the diagnosis and subsequent management of ADHD, and due to its cost, it is not o� en done in practice. In my own practice, I fi nd it useful to quickly screen all patients with a MOCA test (h� p://www.mocatest.org/h� p://www.mocatest.org/). If any cognitive defi cits are found, retesting is useful to see if there is resolution with subsequent treatment of the ADHD and possible comorbid disorders. However, only certain aspects of the MOCA are sensitive to the neurocognitive defects found in ADHD, and even then, may not pick them up in patients functioning at relatively high levels.

continued on page 6

Adult Self Report ScaleASRS-v1.1

www.med.nyu.edu/psych/psychiatrist/adhd.html

Adult ADHD-IV Rating ScaleADHD-RS-IV

www.therapeuticresources.com(search for scale)

Barkley’s Current Symptoms ScaleSelf-Report Form

ADHD: A Clinical Workbook, 2ndnd ed, by Barkley and Murphy, ISBN 1-59385-227-4

Conners’ Adult ADHD Diagnostic Interview for DSM-IV – CAARS

www.mhs.com (search for product)

Weiss Functional Impairment Rating Scale Self-Report WFIRS-S

www.caddra.ca


To complete the diagnosis, you should obtain collateral confi rming histories from family members or supportive others.

There is considerable overlap between the symptoms of ADHD and other psychiatric disorders. For example, there is impulsivity in both ADHD and Borderline Personality Disorder. However, patients with Borderline Personality Disorder and impulsivity o� en have an intent to harm in addition to having selective distortions in their interpretation of the world around them, while the impulsivity in ADHD seems to be more random.

However, in addition to the issue of diff erentiating ADHD from other psychiatric diagnoses, there is also the reality that many other psychiatric disorders are comorbidwith Adult ADHD, ie, they both are there. Approximately three-quarters of patients with Adult ADHD , if not more, will also have at least one other comorbid psychiatric disorder (Marks 2001). To continue the example above, at the 2011 CADDRA (Canadian ADHD Resource Alliance) ADHD Conference, Alexandra Philipsen discussed an associative and potential causal relationship between ADHD and Borderline Personality Disorder (Philipsen 2011; Jain 2011).

Kessler 2006 found the following psychiatric disorders comorbid with Adult ADHD:

Unfortunately, there are relatively few psychopharmacological guidelines that take into account the full reality of comorbidity in Adult ADHD, so let’s start with a more straightforward case. A 40 year old businessman presents to your offi ce where a diagnosis of Adult ADHD is made. There are no associated comorbid diagnoses. The initial physical examination and lab screenings done above are all within normal limits. The patient has a number of important meetings and presentations coming up in the next few months, and thus would like treatment as soon as possible.

At the 3rd International Congress on ADHD in Berlin in May 2011, Laurence Greenhill of Columbia University gave a course on the psychopharmacology of ADHD across the lifespan. He did not feel that lab tests were required (and indeed, he participated later in the conference as a proponent in a plenary debate ‘The psychostimulant is not dangerous for the patients’). However, at the 2011 CADDRA conference David Coghill of the University of Dundee went through the adverse eff ects of stimulants, which do include cases of sudden death. In many cases of sudden death among children and adolescents, there is structural heart disease. A 2006 Health Canada Advisory advises against the use of ADHD treatments in patients with structural heart disease. In Adult ADHD, stimulants are well known to cause small but signifi cant increases in blood pressure as well as in heart rate. However,

Coghill points out that averaging in clinical studies hides the small proportion of patients where there can be much larger increases.

While the guidelines do not require an ECG for children, in my practice of treating adults where the risk of underlying cardiac disease is higher and increases with the age of the patient, I obtain an ECG as well as an echocardiogram prior to starting treatment. If the patient is 35 years or older, as in our example patient, I will also obtain a stress test.

In the case above, the patient’s cardiac tests come back negative. Greenhill advises that the initial treatment should be with an FDA- approved agent for ADHD. Both amphetamines and methylphenidate formulations are very eff ective for ADHD treatment, much more so than the other types of medications discussed below, and thus should be tried fi rst. If an amphetamine doesn’t work despite optimal dosing, then methylphenidate should be tried, and vice versa.

Amphetamines and methyl-phenidates are considered to be in the class of ‘stimulants’. Without going into the details of their mechanism of action, they essentially increase norepinephrine and dopamine activity in the brain. Increased dopaminergic activity in the dorsolateral prefrontal cortex is thought to improve a� ention, concentration, executive function and wakefulness. Increased dopaminergic activity in the basal ganglia is thought to

Management of Adult ADHD (cont’d)

Disorder Comorbid with Adult ADHDDisorder Comorbid with Adult ADHD Prevalence in Adult ADHD PatientsPrevalence in Adult ADHD PatientsAny Mood Disorder 38.3%Major Depressive Disorder 18.6%Dysthymia 12.8%Bipolar Disorder 19.4%Any Anxiety Disorder 47.1%Any Substance Abuse Disorder 15.2%Intermi� ent Explosive Disorder 19.6%

continued on page 7


improve hyperactivity. Increased dopaminergic and noradrenergic activity in the medial prefrontal cortex and other brain regions is thought to improve depression and fatigue.

In my practice, the treatment of ADHD begins with psychoeducation. CBT (Cognitive Behavioral Therapy), focused on the issues at hand, is also started. While sessions may be spent on the comorbid psychiatric disorders, they are also spent on time management, organizational skills and organizational technology (eg, using an agenda or an electronic smartphone or personal digital assistant). Solanto and colleagues (Solanto 2010) at Mount Sinai School of Medicine in New York City showed that CBT directed at time management, organization and planning skills gave very good improvements in reducing ADHD symptoms compared to a control group receiving supportive therapy (odds ratio 5.4). In terms of psychopharmacology, I will o� en start with a long-acting amphetamine (eg, lisdexamfetamine (Vyvanse brand name) or extended-release mixed amphetamine salts (Adderall-XR brand name)).

There are few occasions when there is true justifi cation for using short-acting amphetamines. Although an immediate-release form of amphetamine can be prescribed in the late a� ernoon to ‘top up’ the eff ect of the sustained-release amphetamine taken in the morning, I fi nd it be� er practice (less insomnia, less abuse, more focus on lifestyle changes and psychotherapy) to optimize the dose, timing and form of the sustained-release amphetamine than to add a second short-acting medication.

Lisdexamfetamine is a long-acting amphetamine with a much reduced potential for abuse. It is inactive until it has been absorbed

and converted to the active dextroamphetamine. It peaks in about 3 hours and its eff ect lasts about 12 hours, which will allow the patient in our case above to get through his business day. Typical side eff ects seen in adults taking lisdexamfetamine are dry mouth, insomnia, headache and possibly some anorexia. Weight loss in adults is not all that common, but can occur. Taking the medication in the morning and adopting a healthy lifestyle (ie, daily aerobic exercise) tends to minimize insomnia. To minimize worsening of anxiety and overstimulation, the dose should carefully be titrated to the patient.

It is hard to predict what dose of lisdexamfetamine (or other stimulant) will work well in a particular patient. There are a number of titration strategies that are employed by practitioners. One strategy, which a number of guidelines recommend, is to increase the dose of the stimulant until the goals of treatment have been reached. In theory this sounds fi ne, but in practice, it is hard to tell if the patient would benefi t or not from a slightly higher or lower dose. Thus, an alternative strategy is to evaluate the patient on diff erent doses of the stimulant and then chose the dose level that gives the best response with the fewest adverse eff ects. Stahl 2011 recommends starting lisdexamfetamine at 30mg AM and then increasing by 10mg each week. In my own practice, I tend to titrate a bit slower where possible and to see patients at biweekly intervals. However, in cases such as our example businessman who is in a rush to be treated, Stahl’s titration schedule is fi ne, and we will follow this strategy for our example patient.

We see our 40 year old patient and start off with lisdexamfetamine at 30mg AM. A week later, he is not sure that there has been any improvement. We continue to see

the patient each week and raise the dose of medication to 60mg AM. The patient reports that he has become more alert as the dosages have increased, but he doesn’t feel he really can concentrate all that much be� er and is still having diffi culties ge� ing his work done. As well, during the last dose increase to 60mg, his anxiety has go� en much worse. The maximum dose in Canada is generally considered to be 60mg. (In the USA it is 70mg.) Some patients may do be� er at slightly higher doses, but this aspect of treatment is beyond the scope of this article. In any case, we decide not go to any higher dosage in this patient. We thus taper the medication down over ten days, and stop it.

Following Greenhill’s recom-mendations, we then start a trial of methylphenidate. As for amphetamines, there are few occasions when there is true justifi cation for short-acting methylphenidates (eg, such as immediate-release Ritalin brand name) and they will not be discussed here. Sustained-release methylphenidate can also last up to 12 hours, which will allow the patient in our case above to get through his business day. It should also be taken, of course, in the morning (ie, within a few hours of waking).

A number of sustained-release versions of methylphenidate exist. The particular formulation of methylphenidate may have particular eff ects, due to the rate of delivery of the methylphenidate. Even within a particular formulation of methylphenidate, there can be signifi cant clinicaldiff erences between the brand name and the generic version due to diff erences in pharmacokinetics. A commonly used sustained-release methylphenidate in Canada is brand name Concerta, which is an”osmotic-release oral system” OROS ® methylphenidate. Given


continued on page 8


the reality of the diff erences in the formulations of methylphenidate, in the discussion below the particular formulation used is specifi ed, and for the sake of familiarity, the OROS formulation is used.

We start with a dose of OROS methylphenidate (Concerta brand name) of 18mg AM. We see the patient a week later, and he thinks he can concentrate a bit be� er at work. We increase the dose to 36mg AM. We see the patient a week later. He reports a defi nite increase in concentration at work and less impulsiveness in his home life. He says for the fi rst time in years he is caught up with his paperwork. We increase the dose to 54mg AM. (The maximum dose is generally considered 72mg, but some patients may do be� er at even slightly higher doses.) We see the patient the next week. He reports feeling more anxious, even dizzy at times. We take his pulse – 84 regular beats per minute. We take his blood pressure - 128/84. We lower the dose of the OROS methylphenidate back to 36mg AM. We see the patient a week later. He is doing great. Work is going well. His wife fi nds him much easier to get along with. He even fi nished a 700 page novel – something he hasn’t been able to do in decades. We thus continue the OROS methylphenidate at 36mg AM and agree to see the patient every three weeks for psychoeducation and cognitive behavioral therapy.

If the patient does not have a response to either amphetamine or methylphenidate, Greenhill then recommends a trial of atomoxetine (Stra� era brand name). Atomoxetine is a selective norepinephrine reuptake inhibitor, and like the stimulants, will also increase norepinephrine and consequently dopamine (which is inactivated by norepinephrine reuptake in the prefrontal cortex).

If the atomoxetine fails, then Greenhill recommends extended release guanfacine (brand name Intuniv – available in the USA). Guanfacine is actually an antihypertensive, non-stimulant, that acts as a central alpha 2A agonist, and may be acting on the postsynaptic alpha 2A receptors in the prefrontal cortex to produce improvement in ADHD. In the case of a patient with only a partial response to a stimulant, it is possible to sometimes add extended release guanfacine as an augmenting agent.

If all of the above fails to work, then Greenhill recommends a trial with bupropion (brand name Wellbutrin). Bupropion is a norepinephrine dopamine reuptake inhibitor, and thus will increase norepinephrine and dopamine activity in the brain. To minimize the risk of seizures, bupropion-SR or bupropion-XL should be used.

Greenhill notes that if there is a robust response to medication, then that, by itself, is considered satisfactory treatment. However, if response is incomplete, then add psychotherapy.

In my practice, I provide psychoeducation and psychotherapy to all patients with Adult ADHD, although, of course, if there is a robust response to medication, perhaps not as much psychotherapy. An inexpensive book that I fi nd useful to work through with patients is Taking Charge of Adult ADHD by Russell A. Barkley, PhD (Barkley 2010).

Lifestyle changes such as regular aerobic exercise can be especially helpful to patients with ADHD. As well, Omega3 EPA has been shown to be useful in the treatment of ADHD. A meta-analysis done at Yale (Bloch 2011) found that omega-3 fa� y acid supplementation showed a small (less than with stimulants) but

signifi cant eff ect in improving ADHD symptoms. There was a correlation between improvement and the dose of eicosapentaenoic acid taken.

Let’s continue with the case of the 40 year old businessman above. Psychoeducation, CBT, lifestyle changes and sustained-release methylphenidate have continued to work well for him. He has returned to his family doctor for further refi lls of the medication and counselling as needed. Since you have not heard from him in the last year, you have closed his chart. Now, his 38 year old sister presents to your offi ce, also wanting treatment for her longstanding ADHD symptoms.. Remember – ADHD is strongly inherited. You reassure yourself that her brother’s chart is closed and there is no confl ict of interest in taking her on as a patient.

The 38 year old sister is married and the mother of two young children. She used to work as an administrative assistant but found it too stressful to keep up with the demands of her job. She now stays at home and looks a� er her 4 and 10 year old children. She fi nds it hard to run the household – everything always seems in disarray. She also complains of feeling a bit sad and apathetic over the last year.

You do full ADHD screening and a history. Since childhood, she has had trouble concentrating in school and doing her homework. She was never considered a problem child, but o� en would “zone out” in class. However, her teachers liked her and she got by. The patient’s symptoms have persisted for much of her life and simply manifested again in the workplace and in the home. She meets the ADHD criteria of a variety of screening instruments. In the psychiatric history, you also note two previous Major


continued on page 9


Depressive Episodes. At present, she meets the DSM-IV criteria for a mild Major Depressive Episode.

Unfortunately, there are relatively few guidelines or studies considering the treatment of Adult ADHD comorbid with mood disorders. At the 3rd International Congress on ADHD in Berlin in May 2011 described above, Greenhill unfortunately did not even touch upon this subject. However, the next day, at another ADHD psychopharmacology course at the same conference, Margaret Weiss of the University of British Columbia, took the bold step of discussing the treatments she has been using in such comorbid cases. Dr. Weiss stated that “comorbidity is the rule in Adult ADHD” and that greater than 90% of Adult ADHD patients have other psychiatric comorbidities (Weiss 2011). Part of Dr. Weiss’ lecture has essentially been incorporated in a recently released “CANMAT task force recommendations for the management of patients with mood disorder and comorbid attention-deficit/hyperactivity disorder” (Bond 2012).

The above CANMAT recommendations include the following recommendations:

- If there is ADHD + Bipolar Disorder – to avoid mood destabilization with an ADHD treatment, fi rst prescribe a mood stabilizer before starting ADHD therapy

- If there is ADHD+ Moderate/Severe Major Depressive Disorder – the Major Depression should be the treatment priority

- If there is ADHD+ Mild Major Depressive Disorder – the ADHD can be the treatment priority

- First-line treatments for ADHD+ Major Depressive Disorder – bupropion, antidepressant + long-acting stimulant, or antidepressant + CBT

- Second-line treatments for

ADHD + Major Depressive Disorder – desipramine, nortriptyline, or venlafaxine

Continuing with the case of the 38 year old woman above who presents with ADHD plus a Mild Major Depressive Disorder, you obtain the results of a recent physical examination by her family doctor, and you order a set of blood tests and a cardiac evaluation. There are no ‘physical’ causes to treat, nor are there any contraindications to treatment with a stimulant.Management of this patient begins with psychoeducation. The patient is interested in ‘natural treatments’. As in the case of her brother, CBT focusing on the issues at hand, is started. However, psychotherapy will also be directed at the patient’s depressive symptoms. Lifestyle changes, particularly regular aerobic exercise, are recommended. Omega3 EPA (eicosapentaenoic acid) 1500mg per day is recommended. A number of ‘natural treatments’ exist, although questions regarding effi cacy remain. EEG-based neurofeedback training is one such approach to treating ADHD, and it has the advantage that it can be added to conventional ADHD treatments. Simplifying greatly, brain wave pa� erns seen on EEGs include:- Delta waves – 0.5-4 Hz waves,

seen in deep “slow wave sleep”- Theta waves – 4-8 Hz waves,

seen (sometimes) when a person is daydreaming

- Alpha waves – 8-12 Hz waves, seen in relaxed states

- Beta waves – 12-30Hz waves, seen in a� entive states

- Gamma waves – 30-100Hz waves, hypothesized to be involved in brain region communication (Hughes 2008)

Normally when we start focusing on a task (eg, reading a paragraph) beta waves will increase. In some ADHD patients, the theta waves

instead increase, ie, the theta/beta ratio is higher than it should be. Several dozen sessions of EEG-based neurofeedback are used to train ADHD patients to decrease the theta/beta ratio. If the patient inhibits theta waves and increases beta waves then the neurofeedback computer program will give the patient positive feedback. For example, in one such program a colorful fi sh jumps out of a lake on the computer screen. As sessions continue, the theta/beta ratio may decrease and the patient may experience diminished ADHD symptoms, and in some cases the improvements are long-term.

Unfortunately the applicability of neurofeedback to ADHD is not as specifi c or eff ective as we would like it be. Speaking at the 3rd International Congress on ADHD in Berlin in May 2011, Daniel Brandeis of the University of Zurich noted that some 40% of ADHD patients don’t show an increased theta/beta ratio, that the ratio decreases with age, and in any case there was li� le eff ect of theta on ADHD symptoms (Brandeis 2011). Writing in Current Opinion in Psychiatry this past summer, N. Skokauskas and colleagues at Trinity College in Ireland consider complementary medicine for young people with ADHD. They write that recent studies have not been successful in scientifi cally showing treatment eff ect of complementary treatments such as neurofeedback, rTMS or essential fa� y acids, and that “there is no proof that complementary medicine provides a be� er alternative for children who have ADHD than treatments that are currently available within multimodal therapy (Skokauskas 2011) .” Nonetheless, for some patients, neurofeedback may indeed provide improvement of ADHD symptoms. Gevensleben and colleagues at the University of Gö� ingen in Germany


continued on page 10


(Gevensleben 2009) looked at over a hundred children (8-12 years old) with ADHD, assigning one group to a computerized a� ention skills training control group and providing the other group with neurofeedback training consisting of theta/beta wave training and slow cortical potential training. (Training of slow cortical potentials can also help with ADHD symptoms – Leins 2007.) Both groups received 36 sessions. The children’s ADHD symptoms were then rated by parents and teachers, with the neurofeedback group showing a signifi cant superior improvement.

Not only is the cost of neurofeedback training prohibitive for our 38 year old patient, there is even less evidence that it is consistently eff ective in Adult ADHD patients. Therefore, we spend several sessions starting CBT, while the patient has started to make lifestyle changes. The patient now thinks that she is able to focus a bit be� er, particularly on the days she goes jogging. As well, the cognitive therapy has helped her depressive symptoms a bit. However, the patient’s life is still quite impaired by her ADHD symptoms, and she feels sad just about every day. A� er about two months, we collaboratively decide to start psychopharmacological treatment.

While a stimulating antidepressant such as bupropion has the advantage of acting as both an antidepressant and ADHD treatment, it is not as eff ective in treating the ADHD symptoms as a stimulant. In such a case where bupropion is used as initial treatment, later on, if a stimulant is required, I would prefer not to add a stimulant to an already dopaminergic antidepressant (although some practitioners will). As well, from a neuropsychiatric point of view, in some patients, when the function of the prefrontal

cortex is optimized by treatment, which generally includes the use of stimulant, the function of the limbic system seems to improve as well, ie, the addition of an antidepressant is not always required in cases of mild depression.

Following the CANMAT guidelines above, we begin psychopharmacological treatment of this patient with a long-acting stimulant, in this case choosing one that is working for her brother, OROS methylphenidate 18mg AM. We see the patient two weeks later. She thinks her concentration is actually be� er. The OROS methylphenidate (Concerta brand name) is increased to 36mg AM. Two weeks later when we see the patient again, she reports further improvement in concentration. She can read the newspaper now and remembers what she is reading without having to reread it over and over again. However, her depressive symptoms have not changed that much, except for a bit more energy. We increase the OROS methylphenidate to 54mg AM and see the patient two weeks later. She reports feeling a large increase in anxiety and that her concentration has actually gone down. We reduce the OROS methylphenidate back to 36mg.

We see the patient two weeks later. The anxiety has gone down, back to where it was before. Her energy and concentration are much improved. Her house is becoming be� er organized. However, she still feels sad, cries for no reason and has the same trouble sleeping she had before starting the OROS methylphenidate.

We continue the methylphenidate and CBT for a few more weeks. The depressive symptoms have not changed much. We thus add an SSRI antidepressant – sertraline (Zolo� brand name) 50mg AM to the methylphenidate. Combining

an antidepressant with a long-acting stimulant is within the CANMAT guidelines discussed above. As well, the combination of methylphenidate and sertraline has been found to be well tolerated and useful in treating ADHD combined with depression (Findling 1996).

We see the patient two weeks later. There is not much change in the depressive symptoms nor are there any adverse eff ects. We thus increase the sertraline to 100mg AM. We see the patient two weeks later. She says she is feeling much more optimistic, not crying anymore and not feeling as guilty as before. We consider increasing the sertraline but, in collaboration with the patient, we will continue the CBT (along with the methylphenidate and sertraline at the existing dosages) and wait and see.

We see the patient another two weeks later. She reports that all of her depressive symptoms have gone – she is “back to normal.” We consider whether we want to further increase the dose of the sustained-release methylphenidate (since the serotonergic action of the sertraline will cause a refl ex drop in dopaminergic activity), but the patient states that her ability to concentrate remains “great” and that she is more organized than ever before. We thus leave the dosages of the methylphenidate and sertraline unchanged.

We see the patient for a few more months and continue the CBT. Her depressive symptoms remain in remission and her ADHD symptoms continue to remain much improved. We continue the OROS methylphenidate 36mg AM and the sertraline 100mg AM. A� er the initial course of CBT is completed, we see the patient at longer intervals. Given that this is the patient’s third Major Depressive




Episode, we collaboratively agree to continue treatment for the next several years, at a minimum.

Treating Adult ADHD well requires skills in psychotherapy, psychiatry, psychopharmacology, and general medicine – skills that the medical psychotherapist possesses. Treatment can be very rewarding, for both patient and therapist alike – patients o� en do well and are able to signifi cantly improve the quality of their life.

Thanks to Dr. Maria Grande for helpful comments.

ReferencesAycicegi-Dinn, A. et al, Neurocognitive

correlates of adult a� ention-defi cit/hyperactivity disorder in a Turkish sample, A� en Defi c Hyperact Disord, 2011, Mar; 3(1):41-52.

Barkley, R.A., Taking Charge of Adult ADHD, Guilford Press, 2010, ISBN 978-1-60623-338-2 (paperback).

Bloch, MH and Qawasmi, A., Omega-3 fa� y acid supplementation for the treatment of children with a� ention-defi cit/hyperactivity/hyperactivity/ disordersymptomatology: systematic review and meta-analysis, J. Am Acad Child Adolesc Psychiatry, 2011 Oct; 50(10):991-1000.Bond, DJ, Hadjipavlou, G, Lam, RW, McIntyre, RS, Beaulieu, S, Schaff er, A and Weiss, M, The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid a� ention-defi cit/hyperactivity disorder, Ann Clin Psychiatry, 2012 Feb; 24(1):23-37.

Brandeis, D., Effi cacy of Neurofeedback Training, 3rd International Congress on ADHD, Berlin, May 2011.

Coghill, D., Managing Adverse Events in ADHD, CADDRA 2011 ADHD Conference, Toronto, October 2011.

Findling, R.L., Open-label treatment of comorbid depression and a� entional disorders with co-administration of serotonin reuptake inhibitors and psychostimulants in children, adolescents, and adults: a case series, J. Child Adolecs Psychopharmacol, 1996 Fall; 6(3):165-175.

Gevensleben, H et al, Is neurofeedback

an effi cacious treatment for ADHD? A randomised controlled clinical trial,Child Psychol Psychiatry, 2009 July:50(7):780-789.

Greenhill, L, Course: Psychopharmacology of ADHD, 3rd International Congress on ADHD, Berlin, May 2011.

Hughes, J.R., Gamma, fast, and ultrafast waves of the brain: their relationships with epilepsy and behavior, Epilepsy Behav, 2008 July;13(1):25-31.

Jain, U., Personality Disorders and A� ention Defi cit Hyperactivity Disorder, CADDRA 2011 ADHD Conference.

Kessler, R.C., Adler, L., Barkley, R., Biederman, J., Conners,C.K., Demler, O., Faraone, S.V., Greenhill, L.L., Howes,M.J., Secnik, K., Spencer, T., Ustun,T.B., Walters, E.E. and Zaslavsky, A.M. , The prevalence and correlates of adult ADHD in the United States, American Journal of Psychiatry, 2006; 163(4):716-723.

Kessler, RC et al, Validity of the World Health Organization Adult ADHD Self-Report Scale (ASRS) Screener in a representative sample of health plan members., Int J Methods Psychiatr Res, 2007:16(2):52-65.

Leins, U. et al, Neurofeedback for children with ADHD: A Comparison of Slow Cortical Potentials and Theta/Beta Protocols, Appl Psychophysiol Biofeedback, Appl Psychophysiol Biofeedback, Appl Psychophysiol Biofeedback2007 June; 32(2):73-88.

Marks, D.J. et al, Comorbidity in adults with adult a� ention defi cit/hyperactivity disorder, Ann NY Acad Sci, 2001; 931:216-238.

McGough, JJ and McCracken,JT, Adult A� ention Defi cit Hyperactivity Disorder: Moving Beyond DSM-IV, Am J. Psychiatry, 2006; 163:1673-1675.

Philipsen, A., ADHD as a risk factor for Borderline Personality Disorder, CADDRA 2011 ADHD Conference.

Skokauskas, N, McNicholas, F., Masaud, T, and Frodl, T., Complementary medicine for children and young people who have a� ention defi cit hyperactivity disorder, Curr Opin Psychiatry, 2011 July:24(4):291-300.

Solanto, MV et al, Effi cacy of meta-cognitive therapy for adult ADHD, Am J Psychiatry, 2010 Aug;167(8):958-968

Stahl, S.M., 2008, Stahl’s Essential Psychopharmacology: Neuroscientifi c Basis and Practical Applications – 3rd Ed, Cambridge University Press, ISBN 978-0-521-67376-1

Stahl, S.M., 2011, Stahl’s Essential Psychopharmacology: The Prescriber’s Guide – 4th Ed, Cambridge University Press, ISBN 978-0-521-17364-3

Weiss, M, Course: Treatment of Adult ADHD, 3rd International Congress on ADHD, Berlin, May 2011.



Many Canadians (9.5%) seek treatment for a mental disorder or addiction in a given year (Statistics Canada, 2003), and 3.7% of Canadians who are 15 years and older (i.e., over 1 million Canadians) saw a psychologist or psychotherapist in the past year (Vasiliadis et al., 2009). Similarly, 3.18% of Americans received outpatient psychotherapy in the past year (Olfson & Marcus, 2010). These rates of psychotherapy use have not diminished in over a decade despite the dramatic rise in the prescription of antidepressant medication during the same period (Olfson & Marcus). Clearly, a large number of Canadians turn to psychotherapy for their mental health and health needs, to reduce their suff ering, and to improve their quality of life. Despite the high use of psychotherapy and a large body of research that has consistently demonstrated positive outcomes of psychotherapy for a wide variety of disorders (e.g., Fonagy, 2002; Nathan & Gorman, 2007; Wampold, 2001) there remains a signifi cant research-practice divide (Beutler et al., 1995; Boisvert & Faust, 2006; Wilson et al., 2009). That is, psychotherapy outcome research or process research (i.e., research on the facilitative mechanisms of change such as those related to the therapeutic relationship) is

Psychotherapy Practice Research Network (PPRNet): Bridging the Gap Between Psychotherapy Practice and Research • By Giorgio A. Tasca, Ph.D. Chair in Psychotherapy Research, University of Ottawa and the Ottawa Hospital ([email protected])

Barriers to translating psychotherapy research into clinical practice include perceptions by clinicians that randomized controlled trials of psychotherapies are not representative of their clinical practice or relevant to the patients they treat, a lack of communication between clinicians and researchers thus resulting in a two-way translational gap between clinical trials and clinical practice, and the professional diversity of psychotherapy practitioners-- unlike many other areas of health care, psychotherapy is practiced by a broad array of professionals in a variety of se� ings and for a wide range of patient problems. Novel interventions to overcome these barriers include the development of practice-based research networks that have a long history in family practice. A similar approach to overcoming barriers to translating psychotherapy research into clinical practice for the fi eld of psychotherapy might involve conducting psychotherapy research in applied community and clinical se� ings in which clinicians inform research areas important to them and their patients. A Psychotherapy Practice Research Network (PPRNet) is one means of achieving this goal. In a PPRNet community-based clinical practitioners actively collaborate with researchers to defi ne research questions, design research protocols, and implement studies. This collaboration between practitioners and clinical researchers is devoted to the conduct of scientifi cally valid eff ectiveness research.

not always translated into clinical practice. The end result is that Canadians with mental health and addiction problems may not benefi t fully from nearly 60 years of psychotherapy research.

One can identify at least three barriers to translating psychotherapy research into clinical practice. First, clinicians may perceive that randomized controlled trials of psychotherapies are not representative of their clinical practice or relevant to the patients they treat. Psychotherapy researchers have been establishing an evidence base for their treatments for several decades, and several lists are available that defi ne specifi c treatments for specifi c mental disorders for which suffi cient effi cacy data exists (e.g., Fonagy et al., 2002; Nathan & Gorman, 2007). However practicing clinicians have tended not to embrace these lists of evidence-based psychotherapies (EBP) or incorporate the treatment manuals into their daily clinical practice (Addis & Krasnow, 2000; Becker et al., 2004; Cook et al., 2009; von Ranson & Robinson, 2006). One concern among practicing clinicians is that while EBPs are based on highly internally valid studies, these fi ndings may not generalize to the more diverse and heterogeneous real world

populations that clinicians indicate that they treat (Kendall & Chambless, 1998; Westen et al., 2004). As a result, researchers o� en complain that psychotherapy practitioners pay li� le heed to research fi ndings (von Ranson & Robinson, 2006), and practitioners counter that psychotherapy research is not always relevant to real-world practice (Westen et al., 2004).

A second related barrier to implementing psychotherapy research is a lack of communication between clinicians and researchers thus resulting in a two-way translational gap between clinical trials and clinical practice. Community-based clinicians may feel disconnected from research that is designed and implemented in health sciences centers (Beutler et al., 1995). On the other hand, researchers may place a lower premium on information gleaned from clinicians, and may not readily use this information to inform their research (Beutler et al.). Despite this, a recent survey conducted by members of our team indicated that Canadian psychotherapists are interested in research (Lau et al., 2010), and others report that clinicians’ practices change when they are made aware of research



relevant to their practices (Stewart & Chambless, 2007). Concurrently, there is now a small but growing group of psychotherapy researchers who are designing research protocols based almost exclusively on clinician input (Castonguay, 2011).

A third barrier to translating psychotherapy research into clinical practice is related to the professional diversity of psychotherapy practitioners. Unlike many other areas of health care (e.g., dentistry, optometry, medical specialties), psychotherapy is practiced by a broad array of professionals (e.g., psychologists, psychiatrists, GP psychotherapists, counsellors, social workers, among others) in a variety of se� ings (e.g., private offi ces, community clinics, rehabilitation centres, hospitals), and for a wide range of patient problems (e.g., addictions, anxiety disorders, depression, eating disorders, etc.). There are few opportunities for cross-disciplinary dialogue about psychotherapy, and so there is li� le apparent cohesion among the communities of practitioners. Training in psychotherapy and in the conduct and use of psychotherapy research also vary greatly. Further, diff erent regulatory colleges require diff erent standards of training, continuing education, and regulatory requirements; and diff erent professional organizations have diff erent criteria for accreditation.

Novel interventions to overcome these barriers include the development of practice-based research networks that have a long history in family practice in the US (Westfall et al., 2007). A similar approach to overcoming barriers to translating psychotherapy research into clinical practice for the fi eld of psychotherapy might involve conducting psychotherapy research in applied community and clinical se� ings in which clinicians

inform research areas important to them and their patients (Beutler et al., 1995). A Psychotherapy Practice Research Network (PPRNet) is one means of achieving this goal. In a PPRNet, community-based clinical practitioners actively collaborate with researchers to defi ne research questions, design research protocols, and implement studies. This collaboration between practitioners and clinical researchers is devoted to the conduct of scientifi cally valid eff ectiveness research. To date, despite the development of PPRNet in the U.S. and the U.K., PPRNet are only just emerging in Canada.

The time is right for such an innovative approach to psychotherapy research in Canada for a number of reasons. First, there are several new standards of training and professional practice that are being considered at the national and provincial levels. Second, PPRNet goals are consistent with the growing emphasis on interdisciplinary training and research in health care. Third, the PPRNet’s objectives are compatible with the Canadian Institutes for Health Research (CIHR) current emphasis on knowledge translation, action research, and knowledge user-informed research agendas, which place a premium on high impact research relevant to real-world clinical se� ings.

Our Canada-wide multi-disciplinary team recently was awarded a CIHR Planning and Meeting Grant to launch a PPRNet in Canada. To achieve this, we will start by a Conference aimed to defi ne psychotherapy research priorities based on clinician, knowledge user groups, educator, and researcher input. This will be a collaborative psychotherapy research priority se� ing process in which small break out groups will generate psychotherapy research agenda relevant to

clinical practice. Such priority se� ing methods are increasingly used to inform research agendas that infl uence knowledge users including educators, policy makers, and research funders. The Conference will be held in November, 2012 in O� awa and will include approximately 100 participants: multidisciplinary clinicians, knowledge user group delegates, educators, and researchers. The Conference and subsequent survey outcomes will inform overall research priorities and the Network development process. Priority themes that may emerge in order to improve outcomes and reduce drop-outs might include: managing breaks in the therapeutic alliance (Safran, et al., 2011), capitalizing on client expectations (Greenberg, et al., 2006), maximizing early response to treatment through feedback (Lambert & Shimokawa, 2011), and the role of therapist factors like empathy (Elliot, et al., 2011), among others. Research priorities identifi ed through this method will form the basis for future practice-based research conducted in PPRNet members’ clinical practices.

The PPRNet collaborative action research paradigm will ensure excellent uptake of research among psychotherapists, educators, and professional organizations, and will result in both training and professional practice being informed by the identifi ed research priorities. Be� er psychotherapy practice means improved health and mental health outcomes for a large number of Canadians. The psychotherapy research priorities identifi ed through the PPRNet will also inform future knowledge translation and result in practice-based research that is clinically meaningful, directly informed by clinicians, and therefore more seamlessly integrated into clinical practice.

PPRNet (cont’d)



For more information about joining the PPRNet please e-mail [email protected]

ReferencesArnow, B. A. (1999). Why are empirically

supported treatments for bulimia nervosa underutilized and what can we do about it? Journal of Clinical Psychology,55(6), 769-779.

Becker, C.B., Zayfert, C., Anderson, E. A survey of psychologists’ a� itudes towards and utilization of exposure therapy for PTSD. Behaviour Research and Therapy, 42, 277-292.

Beutler, L. E., Williams, R. E., Wakefi eld, P. J., & Entwistle, S. R. (1995). Bridging scientist and practitioner perspectives in clinical psychology. American Psychologist, 50(12), 984-994.

Boisvert, C. M., & Faust, D. (2006). Practicing psychologists’ knowledge of general psychotherapy research fi ndings: Implications for science-practice relations. Professional Psychology,37(6), 708-716.

Castonguay, L. G. (2011). Psychotherapy, psychopathology, research and practice: Pathways of connections and integration. Psychotherapy Research, 21(2), 125-140.

Cook, J.M., Schnurr, P.P., Biyanova, T., & Coyne, J.C. (2009). Apples don’t fall far from the tree: Infl uences on psychotherapists’ adoption and sustained use of new therapies. Psychiatric Services, 60, 671-676.

Ellio� , R., Bohart, A. C., Watson, J. C., & Greenberg, L. S. (2011). Empathy. Psychotherapy, 48(1), 43-49.

Fonagy, P., Target, M., Co� rell, D., Phillips, J., & Kurtz, Z. (2002). What works for whom?: A critical review of treatments for children and adolescents. New York: Guilford Press.

Greenberg, R. P., Constantino, M. J., & Bruce, N. (2006). Are patient expectations still relevant for psychotherapy process and outcome? Clinical Psychology Review,26(6), 657-678.

Kendall, P.C. & Chambless, D.L. (Eds.). (1998). Special section on empirically supported psychological therapies. Journal of Consulting and Clinical Psychology, 66, 3-167.

Lau, M.A., Ogrodniczuk, J., Joyce, A.S., & Sochting, I. (2010). Bridging the practitioner-scientist gap in group psychotherapy research. International Journal of Group Psychotherapy, 60, 177-196.

Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. Psychotherapy,48(1), 72-79.

Nathan, P. E., & Gorman, J. M. (Eds.). (2007). A guide to treatments that work (3rd ed.). New York: Oxford University Press.

Olfson, M., & Marcus, S. C. (2010). National trends in outpatient psychotherapy. American Journal of Psychiatry, 167(12), 1456-1463.

Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48(1), 80-87.

Statistics Canada (2003). Canadian community health survey mental health and well being. Retrived from h� p:h� p://www.statcan.gc.ca/pub/82-617-x/pdf///www.statcan.gc.ca/pub/82-617-x/pdf/4200064-eng.pdf4200064-eng.pdf.4200064-eng.pdf.4200064-eng.pdf

Stewart, R.E., & Chambless, D.L. (2007). Does psychotherapy research inform treatment decisions in private practice?

Journal of Clinical Psychology, 63, 267-281.

Vasiliadis, H.-M., Tempier, R., Lesage, A., & Kates, N. (2009). General practice and mental health care: Determinants of outpatient service use. The Canadian Journal of Psychiatry, 54(7), 468-476.

von Ranson, K. M., & Robinson, K. E. (2006). Who is providing what yype of psychotherapy to eating disorder clients? A survey. International Journal of Eating Disorders, 39(1), 27-34.

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and fi ndings. Mahwah, NJ: Lawrence Erlbaum Associates.

Westen, D., Novotny, C. M., & Thompson-Brenner, H. (2004). The empirical status of empirically supported psychotherapies: Assumptions, fi ndings, and reporting in controlled clinical trials. Psychological Bulletin, 130(4), 631-663.

Westfall, J.M., Mold, J., & Fagnan, L. (2007). Practice-based research: “Blue highways” on the NIH roadmap. Journal of the American Medical Association, 297,, 403-406.

Wilson, J. L., Armoutliev, E., Yakunina, E., & Werth, J. L., Jr. (2009). Practicing psychologists’ refl ections on evidence-based practice in psychology. Professional Psychology, 40(4), 403-409.

PPRNet (cont’d)


Dialectical Behavior Therapy was developed by Marsha Linehan in 1993 and is used to “strengthen a person’s ability to handle distress without losing control or acting destructively.” The word dialectic means “to balance and compare two things that appear very diff erent or even contradictory” - specifi cally, to balance the process of change AND to accept that which presently exists. DBT has been used primarily to help people with overwhelming emotions become more eff ective in inter- and intra-personal relationships in the present moment.

As elaborated in the subtitle to the workbook, Linehan’s critical DBT skills are: Distress Tolerance; Mindfulness; Emotion Regulation; and, Interpersonal Eff ectiveness. These four skills overlap and reinforce each other, which helps the individual to learn the skills more easily and to remember them more quickly. For this reason, the authors recommend that the chapters and the exercises contained therein be done in the order presented. This review, therefore, will present the information contained in the sequence in which it appears. The fi nal chapter in the workbook is about the integration of the learned skills and their regular application in day-to-day life. There are several components of this workbook that make it remarkable. For example, there are fi � een detailed exercises for a variety of core skills; each section contains leading, insight-oriented questions with specifi c answers - examples that are concise and do-able; there is acknowledgement of the humanness of the individual

Book Review: The Dialectic Behavior Therapy Skills Workbook - Practical Exercies for Learning Mindfulness, Interpersonal Effectiveness, Emotional Regulation and Distress Tolerance by: Matthew McKay, PhD, Jeffery C. Wood PsyD; Jeffery Brantley, MD New Harbinger Publications, Inc. 232 pages. 2007

• By Maria Grande, MD, CCFP, DOHS, BSc.

in the provision of clear, step-by-step instructions for creating emergency action plans for those recurrent, inevitable, diffi cult situations that will undoubtedly arise; fi � een checklists have been compiled that, as a whole, assess many of the possible coping skills or recurrent thoughts that occur to either assist or disturb us.

DISTRESS TOLERANCE : As physicians with strong interests in psychotherapy, we are aware that emotional and physical pain can co-exist and push some individuals into using self (and relationship) destructive coping skills. These can include various addictions, ruminations, violence, anger, eating disorders etc. The goal of mastery of this skill is to alleviate suff ering by teaching an individual to distract, relax and cope.

a) Distraction is not avoidance. When using distraction skills, there is an innate understanding that the off ending situation has to and will be faced. Pleasurable activities and memories, paying a� ention to someone else, leaving, doing a necessary task/chore, are just a few of the suggestions given.

b) Self soothing skills are meant to allow the intensity of the emotion to dissipate, clearer thinking to occur, allowing the recouping of one’s strength and thus, for relaxation to establish itself. Using our readily accessible senses of hearing, seeing, smelling, tasting and touching are ways of fi nding this peace.

c) Acknowledging a painful situation without judging the events, fi nding blame, ge� ing angry or criticizing yourself is radical acceptance. By learning about, practicing and using Radical Acceptance, a� itudinal changes will occur and improved coping results. Think “Serenity Prayer” in action !

MINDFULNESS : Jon Kabat-Zin began popularizing this non-religious meditation technique in chronic pain patients during the 1980s. His seven a� itudes that form the foundations of stress reduction are : nonjudging, patience, beginner’s mind, trust, non-striving, acceptance and le� ing go.

In the context of DBT, mindfulness is “the ability to be aware of your thoughts, emotions, physical sensations, and actions - in the present moment- without judging or criticizing yourself or your experience.” In DBT, there is another vocabulary used that mirrors and expands the original concepts of Kabat-Zin. Heartful A� itudes [kindness, compassion, spaciousness, stillness] and Aff ective Qualities [gratitude, gentleness, generosity, empathy, lovingkindness] are considered inherently imbedded in any mindful activity. For those who are not familiar with the concept-word “lovingkindness”, it is used to convey the wide dimensions of deep friendliness, welcoming, compassion, cherishing, forgive-ness and unconditional love that can protect us from the habits of judging and criticism.



Another term that may not be widely known and encompasses a large construct is that of wise mind. A wise mind is the “ability to make healthy decisions about your life based on both your rational thoughts and your emotions.” As you can see, there is a unique language in DBT that makes sense in terms of dealing with some of the underlying assumptions which contribute to the affl iction of overwhelming emotions. More components of this vocabulary will be discussed within the body of this article.

The workbook eff ectively teaches core DBT “what “ and “how” skills - being mindful of what you’re focusing on and how to be both mindful and nonjudgmental .

WHAT skills are primarily WHAT skills are primarily WHATobservational and naming exercises, which include: recognizing your own sense of time; using visualization for thought defusion; recognizing and describing signifi cant inner and outer experiences, then separating them; mindful breathing; building an emotional vocabulary; and, learning about the natural lifespan of emotions.

HOW skills are primarily focusing, HOW skills are primarily focusing, HOWnonjudging and defusing exercises regarding: your judgements; your gut feelings; your decisions; and, events and the associated emotions, thoughts and actions that arise.

Included in the workbook sections on mindfulness is the helpful pneumonic, FLAME:

Doing what’s eff ective implies “doing what’s appropriate and necessary in the present moment - to resolve a problem, cope with a situation, or reach your goal - even if what you do feels unnatural, uncomfortable or goes against what you are experiencing emotionally.”

EMOTION REGULATION SKILLSAs GP Psychotherapists, we are quite aware of the disruptive eff ect of very strong, overwhelming and/or very many simultaneous, fl ooding emotions. We also know that emotions begin in the brain as electrical and chemical signals which serve to inform us, consciously or not, of what’s happening in our bodies and minds. An initial reaction to an event is the primary emotion while secondary emotions are feelings about our feelings. In the la� er instance, sometimes we have so many reactive emotions that they cause a lot more suff ering and pain than the primary response!

Since you can’t always control what you feel but you can control how you react to those feelings, one of the most important dialectics is accepting yourself without judgement while simultaneously changing destructive behaviours in order to live a healthier life. The process of change begins with the realization that emotions, thoughts and behaviours are connected. Stronger emotions can lead to larger behavioural reactions. Behaviours are repeated because there is a reward, which reinforces the behaviour and makes them more likely to be repeated.

Emotional rewards that reinforce self-destructive behaviours have immediate short term gain in addition to long term damage. Cu� ing/self-mutilation releases endorphins to help heal the physical wound. Manipulating others allows the semblance of control, when their own life is out of control.

To control overwhelming emotional reactions, fi rst we need to slow down the emotional process so that it can be examined. Then, a� er it’s examined, it’s possible to make healthier decisions.

On page 124 of the workbook, nine emotion regulation skills are listed and then elaborated upon in the subsequent chapters. They are as follows: 1.Recognizing your emotions - a

series of questions are provided to increase awareness

2.Overcoming barriers to healthy emotions - possible obstacles and interventions are suggested

3.Reducing physical vulnerability - by healthy lifestyle ( nutrition , activity, sleep )

4.Reducing cognitive vulnerability - identifying and dealing with trigger thoughts that cause pain

5.Increasing your positive emotions - removing the fi lter that sees all events as negative

6.Being mindful of your emotions without judgment - simply watch and let them fl oat away

7.Emotion exposure - facing your emotions rather than avoiding them

8.Doing the opposite of your emotional urges - managing the facial, postural, verbal and physical actions that accompany each emotion


Book Review (cont’d)

Mindfulness is like a FLAME Focus and shi� your a� ention to be mindful of the present moment Let go of distracting thoughts and judgements Use radical Acceptance to remain non judgemental Use wise Mind to make healthy decisions Do what’s Eff ective in order to accomplish your goals


9.Problem solving - requires behaviour analysis to identify what prompts the emotion and how to develop alternative strategies to cope with emotion triggering events

I N T E R P E R S O N A L EFFECTIVENESS SKILLSEvery relationship consists of two people trying to get what they need. For a relationship to succeed, you must be able to:1.Know and say what you desire2.Notice or fi nd out what the other

person desires3.Negotiate and compromise to get

at least some of what you want4.Give what you can of what the

other person wants

Although initially seeming to be an ambiguous category, the DBT defi nition of interpersonal eff ectiveness skills is quite understandable: social skills training + assertiveness training + listening skills + negotiation skills = interpersonal eff ectiveness.

Social skills training is about noticing the other person’s feelings and reactions, understanding facial expressions, body language, tone of voice and choice of words. This process provides clues about the mood and state of the relationship. When there is something that is ‘hard to read’, being able to ask a clarifying question is vital.

Assertiveness training works to fi nd a unique middle ground between passive or aggressive behaviours. Passivity is an abandonment of your own needs, creating frustration and resentment which builds and then becomes so painful you have no choice but to: blow up, collapse into depression or run away. Aggression revolves around a strong sense of the way things SHOULD be and, hence, a need to control events, all of which serve to push others away. Another component of assertiveness is

the ability to say no in a way that protects the relationship by validating the other person’s needs and desires while se� ing fi rm boundaries about what you will and won’t do.

Listening skills are a corollary to assertiveness skills. In the la� er, the script is “ I think-I feel- I want”, In the former, it is “They think-they feel-they want” . Mindfulness is key to both. There are several signifi cant blocks to listening which bear listing: mind reading; rehearsing; fi ltering; judging; daydreaming; advising; sparring; being right; derailing; placating. In the spirit of thoroughness which characterizes this book, all these blocks are addressed.

Negotiation skills encompass the ability to manage confl ict and resistance. Five confl ict management skills are competently outlined on pages 215-219 and are skillfully condensed in the acronym RAVEN. Relax, accept confl ict calmly.

Breathe!Avoid the aversiveValidate the other person’s

concern Examine your values in the confl ict

and within the relationshipNeutral voice

Finally, we have Chapter 10, Pu� ing It All Together. Here, the recommendation is to insure that you have a 15 minute daily appointment with yourself. During this “personal time”, their suggestion for emotional health habits are:1.Mindfulness : breathing, wise

mind [everything depends on this ]2.Deep relaxation : visualization [ for distress tolerance]3.Self observation: thought de-

fusion, nonjudgmental emotion observation

[for emotion regulation]

4.Affi rmation : one per day [for emotion regulation]

5.Commi� ed action : to solve a problem, deal eff ectively with a diffi culty, strengthen awareness of a higher power [for interpersonal eff ectiveness]

CONCLUSIONThis workbook has the potential to transform your experience of living, making you believe in your own power for healing and enriching your life. It makes the phrase “being grounded” come into sharp focus: by using your physical senses, you can “ recognize and separate your judgements and fantasies from what’s really happening in the moment.” Teaching mindfulness, wise mind, radical acceptance, visualization and interpersonal eff ectiveness allows for an opportunity to learn new choices and behaviours.

I would like to share two images from this workbook that you might fi nd useful. Consider the metaphor of a human as an ocean, having thoughts, feelings and behaviours much like waves. Identifying with the waves causes a loss of connection to the ocean, to its depths and to the diversities therein. Also, choosing to focus only on the distressing elements of your life is like wearing dark sunglasses all the time. Take those glasses off and see the world in all its colours, light and details!

Thanks to Dr. Howard Schneider for his helpful comments.

Book Review (cont’d)


As medical psychotherapists, whether we prescribe or not, we are expected to be familiar with current psychopharmacotherapy. Psychopharmacologist Stephen M. Stahl of the University of California San Diego, trained in Internal Medicine, Neurology and Psychiatry, as well as obtaining a PhD in Pharmacology. Dr. Stahl has released a case book of patients he has treated (Stahl 2011). In this issue of the GP Psychotherapist (and where space permits, in future issues), I will take one of his cases, and in a compact fashion, try to bring out the important lesson to be learned. For readers more enthusiastic about the subject, I encourage you to purchase this so� cover book, and follow along in more detail.

Stahl’s rationale for his series of cases is: knowing the science of psychopharmacology is not suffi cient to deliver the best care. Many, if not most, patients would not meet the stringent (and, it can be argued, artifi cial) criteria of randomized controlled trials and the subsequent guidelines which arise from these trials. Thus, as clinicians, we need to become skilled in the art of psychopharmacology, which, according to Stahl, is “to listen, educate, destigmatize, mix psychotherapy with medications and use intuition to select and combine medications.”

In this issue, we will consider Stahl’s fourth case – “the son who would not go to bed.”

The patient is a 34 year old man who is referred to you for “paranoia”, largely at the insistence of his parents. The patient lives with his elderly parents, who are worried

Psychopharmacology Corner: Refractory OCD • By Howard Schneider, MD, CGPP, CCFP Sheppard Associates, 649 Sheppard Avenue, Toronto, Ontario, Canada M3H 2S4

The best evidence for treatment of OCD is with SSRIs, which can be augmented with other agents such as atypical antipsy-chotics. In refractory cases of OCD, if possible, consider obtaining plasma levels of medications.

about who will take care of their son a� er they are gone. The patient has had OCD symptoms (could not touch books without washing his hands) since age 5, and has been seeing psychiatrists since he was 15 years old. He has been considered totally disabled since 21 years of age with symptoms of obsessions, compulsions, anxiety, paranoia and depression.

At present, the most troublesome symptom is the patient’s inability to go to sleep. He has many rituals that occur throughout the day, and go into the nigh� ime as well. Before bed, he must turn off the light, think about Jesus while not thinking about the devil, swallow three times, think about a girl, then go to bed, then blink three times and then think of Jesus one more time. If he does the ritual perfectly, then it is ok for the patient to go to sleep, but, if there any mistakes, he must repeat the ritual until it is perfect.

During the daytime the patient is tired and o� en takes naps. The patient has paranoid symptoms as well – when he is with other people he strongly believes they are thinking about harming him. As a result, the patient stays home almost all the time and is quite isolated. The patient has been prescribed diff erent SSRIs over the years, with a variety of augmentation strategies that included buspirone, lithium and benzodiazepines. Fluoxetine had been increased to 80mg and citalopram up to 60mg – there had been no response but no adverse eff ects. Clomipramine had been increased up to 150mg – there had been no response nor was it tolerated. The patient thinks

there was a small improvement at fi rst with the medications, but he no longer thinks they help him at all. The patient has also had a variety of courses of CBT with diff erent therapists, lasting more than 6 months each time , also with li� le response.

In the medical history, you learn that the patient is overweight, has Type II diabetes, hypertension and elevated triglycerides.

In the family psychiatric history, you learn that there is depression in his maternal aunts and grandparents.

On mental status examination, the patient is coherent and there are no delusions, hallucinations, evidence of thought disorder or suicidal ideations.

Current medications include: • Paroxetine 40mg BID • Quetiapine 100mg TID • Risperidone 3mg BID • Trihexyphenidyl 2mg TID • Benzotropine 2mg TID • Gabapentin 3000mg BID • Bupropion-XL 300mg +

Bupropion-SR 150mg qD • Lamotrigine 100mg qD • Rosiglitazone maleate and

metformin for diabetes • Lisinopril for hypertension

Although blood levels of SSRIs and many other medications are not readily available, perhaps they should be. Speaking at the 2010 International Forum of Mood and Anxiety Disorders, G. Zernig of the University of Innsbruck, Austria (Zernig 2010), noted that for all antidepressants investigated, despite patients all receiving the same dosage, plasma



levels varied up to 20-fold among diff erent patients, and that it is the drug plasma level, not the dosage, that correlates best with clinical response. Stahl, however, did have access to medication levels, and the fi rst thing he did was to check for these plasma levels.

The patient is seen again at week 3. Even though paroxetine is being prescribed at 80mg each day its levels were only moderate. Similarly, even though 6000mg a day for gabapentin is a very high dose, its levels were only moderate. The levels for risperidone, quetiapine, bupropion and lamotrigine were even lower.

Although 80mg a day of paroxetine seems high, the plasma levels are not, and since the best evidence for treatment of OCD is with SSRIs, the paroxetine was increased to 120mg a day. However, while gabapentin can help with anxiety, it is not actually specifi cally approved for OCD, plus it causes sedation and the patient was sleepy during the day, so the daytime dose was reduced.

It is be� er practice to have one adequately titrated antipsychotic rather than two. Thus risperidone was stopped and quetiapine increased. There is li� le indication for the antiparkinsonian agents trihexyphenidyl and benzotropine and they were stopped also. Since there is no clear depression, and since neither bupropion nor lamotrigine have much evidence in the treatment of OCD, they were both stopped. Non-medication treatment options were also discussed with the patient. CBT could still be useful. However, perhaps a 1-3 month residential CBT program at a center specializing in CBT should be tried. Deep brain stimulation (DBS) was also discussed as an option for refractory OCD.

Medications at week 3: • Paroxetine 60mg BID • Quetiapine 800mg qD • Gabapentin 2000mg daytime +

3000mg HS • Rosiglitazone maleate and

metformin for diabetes • Lisinopril for hyptertension

The patient was next seen at Week 7. He was not interested in DBS. As well, his insurance would not pay for a residential CBT program. The change in medications did not seem to help his OCD symptoms, although it was noted that it can take up to 12 weeks for a properly dosed SSRI to work in OCD. However, there were no adverse eff ects, no weight gain, no increase in glucose and no increase in triglycerides.

The patient was next seen at Week 15. The change in medications still did not seem to help his OCD symptoms. However, there were no adverse eff ects, no weight gain, no increase in glucose and no increase in triglycerides. A shorter, less-expensive non-residential 3 week intense CBT program was available, albeit in another city. The parents said they could pay for it and the patient agreed. Medications would be le� unchanged.

The patient was next seen at Week 21, a� er completion of the 3 week CBT program. His rituals reduced during the program but now, back at home, the rituals were returning. The CBT program did not help the obsessions.

Unlike many of the other Stahl cases, this one does not resolve any further. Stahl notes that while the patient’s new list of medications is simplifi ed, it is not any more eff ective than before. Stahl also notes that, unfortunately, many patients with OCD are resistant to medication and have maladaptive behaviours that need multimodal treatment a� empts. Although not done in this case, DBS still remains

an option. As well, Stahl briefl y notes that perhaps intravenous clomipramine could be tried.

Generic Name Trade NameParoxetine Paxil Quetiapine Quetiapine Seroquel Seroquel Risperidone Risperidone Risperdal Risperdal Trihexyphenidyl Trihexyphenidyl generic onlygeneric onlyBenzotropine Benzotropine generic only (Cogentin)generic only (Cogentin)Gabapentin Gabapentin Neurontin Bupropion Bupropion Wellbutrin Lamotrigine Lamotrigine Lamictal Fluoxetine Prozac Citalopram Citalopram Celexa Clomipramine Clomipramine Anafranil Buspirone Buspirone Buspar Buspar Lithium carbonate generally genericgenerally generic

Medications discussed in this article

Thanks to Dr. Maria Grande for helpful comments.

ReferencesStahl, S.M., 2011, Case Studies: Stahl’s

Essential Psychopharmacology, 2011, Cambridge University Press, ISBN 978-0-521-18208-9.

Stahl, S.M., 2008, Stahl’s Essential Psychopharmacology: Neuroscientifi c Basis and Practical Applications – 3rd Ed, Cambridge University Press, ISBN 978-0-521-67376-1.

Zernig G., Therapeutic drug monitoring Therapeutic drug monitoring of antidepressants: controversies and of antidepressants: controversies and possibilitiespossibilities, , International Journal of Psychiatry in Clinical Practice, Vol, 14, Supp. 1, November 2010.

Psychopharmacology Corner (cont’d)

Spring 2012GPGPpsychotherapist20

Whom to Contact at the GPPAJournal – to submit an article or comments, e-mail Howard Schneider at [email protected]

Referral Line – to add your name or remove it from the online listing, contact the GPPA offi ce

To contact a member - look in the Membership Directory or contact the GPPA To contact a member - look in the Membership Directory or contact the GPPA To contact a memberOffi ce.

Listserv – Clinical, Certifi cant and Mentor Members may e-mail Marc Gabel to join Listserv – Clinical, Certifi cant and Mentor Members may e-mail Marc Gabel to join Listservat [email protected]

Questions about submi� ing educational credits – CE/CCI reporting – contact Deborah Wilkes-Whitehall [email protected] or call (905) 834-4546

Questions about the website CE/CCI system - for submi� ing CE/CCI credits, contact Muriel J. van Lierop at [email protected]@rogers.com or call 416-229-1993

REASONS FOR MEMBERS TO CONTACT THE GPPA OFFICE1. To notify changes of address, telephone, fax, or e-mail address. 2. Add/Remove your name from the Online Referral Service 3. To register for an educational event. 4. To put an ad in the Newsle� er. 5. To request application forms in order to apply for Certifi cant or Mentor Status.6. To join the GPPA

GPPA Offi ce, 312 Oakwood Court., NEWMARKET, ON L3Y 3C8Contact person: Carol FordTelephone (as before): 416-410-6644 Fax: 1-866-328-7974 E-mail: [email protected]@gppaonline.ca

2011/2012 GPPA Board of Directors

Muriel J. van Lierop, President, (416) 229-1993 [email protected] Schneider, Chair, (416) 630-0610 [email protected] Brown, Treasurer, (519) 856-0175 [email protected] Webb, Past Chair, (416) 724-7218 [email protected] Beintema, (416) 921-3961 [email protected] Davidson, (416) 229-2399 [email protected] Low, (613) 962-3353 [email protected]

CommitteesProfessional Development Commi� eeCatherine Carmichael, ChairKaryn Klapecki, Larry Nusbaum,Liaison to the Board – Christena BeintemaLiaison to the Board – Christena BeintemaLiaison to the Board

Certifi cant Review Sub-Commi� eePam Mc Dermo� , Victoria Winterton

Mentor Review Sub-Commi� ee

Education Commi� ee Elizabeth Parsons, Chair Will Irwin, Kathie Keefe, Julie Webb, William JacykLiaison to the Board – Julie WebbLiaison to the Board – Julie WebbLiaison to the Board

Membership Commi� eeDebbie Wilkes-Whitehall, Chair Leslie Ainsworth, Mary Alexander, Norman Lauzon, Louis Morisse� e, Helen Newman, Richard PorterLiaison to the Board – Muriel J. van LieropLiaison to the Board – Muriel J. van LieropLiaison to the Board

Finance Commi� eeJim Brown, ChairMuriel J. van Lierop, Peggy Wilkins Liaison to the Board - Jim Brown Conference Commi� eeCatherine Low, ChairAlison Arnot, Heidi Walk, Lauren Zeilig, Harry ZeitLiaison to the Board – Catherine LowLiaison to the Board – Catherine LowLiaison to the Board

ListservMarc Gabel, WebmasterEdward Leyton, Lauren ZeiligLiaison to the Board - Howard SchneiderLiaison to the Board - Howard SchneiderLiaison to the Board Journal Howard Schneider, ChairVivian Chow, Maria Grande, Norman SteinhartLiaison to the Board – Howard Schneider

5 Year Strategic Visioning Commi� ees5 Year Strategic Visioning Commi� ees

Steering Commi� eeEdward Leyton, ChairJody Bowle-Evans, Jim Brown, Catherine Carmichael, Muriel J. van LieropLiaison to the Board – Jim BrownLiaison to the Board – Jim BrownLiaison to the Board Outreach Commi� eeEdward Leyton, ChairDavid Cree, Muriel J. van Lierop, Lauren Zeilig

Allan Hirsh is a psychotherapist in North Bay. This cartoon is from his book

Relax For the Fun of it: A Cartoon and Audio Guide to Releasing Stress. View at www. allanhirsh.com.

The views of individual Commi� ee and Board Members do not necessarily refl ect the offi cial position of the GPPA.

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