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THINC-it is a new app that can help you track and measure your patient’s cognition. This episode includes a special patient edition from the Pocket Psychiatrist that walks patients through the app and offers tips to keep them motivated while they make behavioral changes to improve their cognition. Free download here.

Published On: 6/14/21

Duration: 23 minutes, 28 seconds

Transcript: 

KELLIE NEWSOME: Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.

DR. AIKEN: I’m Chris Aiken:, the editor in chief of the Carlat Psychiatry Report.

KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

It’s the first Monday of the month, and that means a new episode of Pocket Psychiatrist is out. That’s our companion podcast that features psychoeducation you can share with your patients. We’re going to play the new episode here. It teaches patients how to use THINC-it, a new app that measures cognition. The app features 4 tests that have been used in neuropsych testing for decades, like the trail-making test and the digit symbol substitution test, and THINC-it itself has been validated in have a dozen studies in depression, bipolar, and healthy volunteers. Here’s what those studies have found:

1. The test results correlate well with psychosocial and work functioning
2. It reliably distinguished the cognitive dysfunction of bipolar disorder from healthy controls
   And, most importantly
3. The test is sensitive to change, so you can use it to measure improvement in your patients.

You can learn more about THINC-it in our April issue. And now, the Pocket Psychiatrist….

KELLIE NEWSOME: If you have problems with memory or concentration – whether from depression, schizophrenia, ADHD, or just normal aging – then this episode is for you. Well, actually, the last episode was for you – so start there – that’s where we talk about the top things you can do to improve memory. To recap:

1. Aerobic exercise, like brisk walking 30 minutes a day
2. Good sleep, or, if you can’t sleep, at least keeping it dark at night and following the other steps in our February podcast on how to sleep.
3. Mediterranean diet, which doesn’t mean eating at Greek restaurants. It means lots of fruits, vegetables, nuts, beans, lean meats; swapping all your butter and oil for extra virgin olive oil and all your carbs for 100% whole grains; and cutting back on fast food, junk food, fried food, salty, sweet and processed foods.
4. Spending time in nature, or even putting some plants and letting in more sunlight where you work or study
5. Activities that require some dexterity like ping pong, musical instruments, wii sports, or actual sports, about 20-30 minutes a day
6. Brain training apps

But knowing what to do is not enough. You also need to motivation to do it. And if you’re suffering from a psychiatric disorder or just general zoom fatigue, we’re guessing you’re going to need some help with that. In this episode, we’re going to share 2 secrets to boosting your motivation, and show you how to use measure your cognitive abilities with a new app.

DR. AIKEN: That reminds me of a question a patient asked me last year.

KELLIE NEWSOME: And you’ve been thinking about this all year?

DR. AIKEN: Yea, well, the question really stumped me. It’s a tough one: “How do you do things when you have no motivation to do them?” It seemed like a simple question, and one that gets to the heart of what depression is all about. But I was speechless, helpless, paralyzed – I had no answer.

KELLIE NEWSOME: Sounds like you had a moment of depression there yourself.

DR. AIKEN: Sure did. One cause of depression is trying to solve an unsolvable problem, like a broken marriage that can’t be fixed, a parent with dementia that is not getting better, or grief. And trying to boost your motivation when you have none, or feel better when you’re depressed, is another one of those losing battles – it’s likely to make you even more demoralized.

KELLIE NEWSOME: Psychologist Edward Watkins calls that rumination. It’s when your mind gets stuck in a loop, trying to solve an unsolvable problem or answer an unanswerable question, like “Why am I so depressed,” or “Why can’t I get anything done,” or “How can I talk myself into having more motivation?” Try sitting with those questions for a few hours. Chances are you’ll end up feeling worse, no less foggy headed, and no more motivated. On second thought, do not try this at home. So Dr. Aiken you couldn’t come up with an answer in the moment for that question – how do I boost my motivation – but you’ve had a year to think about it. What did you come up with? Or did you just get depressed thinking about it.

DR. AIKEN:: No I couldn’t come up with an answer, so I had to change to question.

KELLIE NEWSOME: That’s what I tell my patients with depression – if you can’t solve the big problem you’re wrestling with, try solving something different.

DR. AIKEN: I can’t answer the question “How can I boost my motivation right now?” but I can answer “What can I do that will gradually lift my motivation?” There’s a lot of answers to that one, but for the purposes of this podcast I’m going to focus on one: Gamify it.

KELLIE NEWSOME: Gamify means to borrow from the stuff that make games and video games so fun (and addictive). Gamification is used by fortune 500 companies to improve work performance, and people are increasingly using it in their everyday lives to boost their physical activity with apps like MyFitnessPal and Pokeman Go. But you don’t need to be an app designer to gamify something. You only need one simple ingredient: Measurement. Once you have a score – a measurable outcome – and a way of keeping track of that score, you’ve got a game.

DR. AIKEN:: And one score you can track is a cognitive test called THINC-It. Just google Download THINC-it – that’s thinc-it. Yea, they misspelled think there. We put a link to the page in our podcast notes, https://progress.im/en/content/download-thinc-it%C2%AE-tool. You’ll see it’s byline is “A new diagnostic resource for use in depression” but this test is also useful for schizophrenia, bipolar, ADHD, head injury, and age-related cognitive decline. Although it’s an app, it’s best done on a lap top or iPad so you can see everything big and clear. It’s a little easier to use with a touch screen, but you can do it with a mouse as well.

THINC-it was released last year, but the tests it includes have been used for decades. The tests are timed, and they are brief – it takes about 5 minutes to complete them all.

KELLIE NEWSOME: In most towns, it’s difficult and expensive to get cognitive testing, and if your cognitive problems are caused by a psychiatric disorder then cognitive testing is not going to tell you very much except how bad the problem is. And that’s what THINC-it can do. If you’re having trouble completing tasks, staying on time, or remembering and organizing in your daily life then this test can help pinpoint where the problem is and give you a metric to track your recovery. THINC-it consists of 5 tests. The first is a question and answer test that lets you rate how bad your memory problems are, like how often you forget things in conversation or have trouble organizing or concentrating. Then we get to the timed tests. There are 4 of them.

1. First is Spotter, which measures reaction time. The test will flash arrows pointing left or right and you have to press the left or right arrow button on the screen – or on your keyboard – that matches the flashing arrow. Sounds easy, but I’ll tell you when the left arrow shows up on the right side of the screen it makes you think twice, and part of your score is based on how quickly you press the correct button – your reaction time. But if you push yourself to go too fast, you’ll make mistakes, which cuts down on your score.
2. Next is Symbol Check, which measures working memory. Working memory is the ability to hold information in your head while you’re multitasking. Here are some examples:
   1. Imagine your boss gives you a phone number to call, and then starts telling you what to say on the phone. You have to hold the phone number in your working memory while you’re listening to the instructions.
   2. Or, your friend is telling you a story about their trip to the Florida Keys, and it reminds you of a new seafood restaurant in town that you wanted to tell them about. But you don’t want to interrupt their story, so you have to hold it in your working memory while you listen. And if you’re like me, you know what happens when that fails, and they get to the end of their story and you say “Ehhh, there was something I wanted to tell you I just can’t think of it now.”

In Symbol Check, it’s a shape that you need to keep in your working memory. Random shapes move across the screen in a line, and when they get to the middle they disappear. That’s when you have to recall which shape disappeared. Was it a circle? A square? But while you’re doing that, the next shape – the one that’s about to disappear – is just to the right of the black hole in the middle, so you have to keep that one in your working memory while you’re recalling the current one. It’s a bit of mental juggling, and it isn’t easy. Dr. Aiken consistently scores at the bottom on this one.

DR. AIKEN:: But I keep trying. This Symbol Check test made headlines in 2008 when a study came out showing that people’s IQ improved when they practiced the test regularly. The study was published in the Proceedings of the National Academy of Sciences – which is kind of like the Academy Awards for research articles – and the reason it made it into that journal is that finding was so unique. Usually, practicing brain games and tests like these just makes people better at doing the brain game they practiced, but in this study the effects generalized to other cognitive skills. Practicing Symbol Check – which in psychology research is called the one-back test because you have to remember the symbol that’s one step back from the one you are testing on – improved people’s reasoning and problem solving skills, and it increased their IQ by 3-4 points. This was a surprising finding – how could a simple memory game improve IQ? People didn’t believe it at the time, so they did more studies, 20 of them – and the result held up. The most likely explanation is that Symbol Check helps people control their focus, and when you can control your focus you can accomplish a lot more.

KELLIE NEWSOME: We’re not recommending that you practice this test to improve your IQ though. In those studies, people did the Symbol Check test for 25 minutes a day for 1-2 weeks. But this does bring up an issue – what if you just get better at the tests on this app because you keep practicing them. That’s probably going to happen the first few times you do it. The first time I took the test I did pretty awful – I was just trying to figure out what to do. Then, over the next few trials, I got the hang of it and even developed a few strategies that improved my performance. So take the test a few times in a row until you feel comfortable with it, then test your performance on it about once a month. That way your results will reflect real changes in your brain function instead of just getting better with practice.

DR. AIKEN:: The next test is Code Breaker, which measures processing speed. Do you take longer to get things done than other people, like grocery shopping, reading, or paying bills? You might have slow processing speed. It’s not related to education or intelligence, but it does affect job performance and even social life. People with slow processing speed might stand silently for a few seconds before responding to someone in a conversation.

In this test, you will decode a series of symbols, translating them into numbers. The code is on the bottom, so a hexagon is 1, a square 2, an X is 3, and so on, but to keep it simple it only goes on to 6. A line of symbols moves across the top of the screen, and you have to decode each one as they appear.

KELLIE NEWSOME: The code breaker test has been used for over a hundred years in psychology research, where it’s known as the digit symbol substitution test. Not surprisingly, a cup of coffee improves performance, while a glass of wine makes people a little slower and more prone to error. But nothing worsens performance more than sleep deprivation. Psychiatric medications also affect performance – usually for the better – such as the antidepressants vortioxetine – brand name Trintellix – and duloxetine – brand name Cymbalta, and the wakefulness promoting medicines modafinil and armodafinil – Provigil and Nuvigil. All of these medications are indicated for specific conditions, like vortioxetine and duloxetine are used for depression – but not for bipolar depression, and the modafinils are used for shift work and sleep apnea. It’s when they are used in those conditions that they also improve processing speed.

DR. AIKEN:: The final test is Trails, known in psychology circles as the Trail Making Test. This is a connect-the-dots exercise where you have to connect alternating letters and numbers in order, so start with A, then 1, then B, then 2, then C, then 3…. These letters and numbers are scattered randomly on the screen and you have to connect them as fast as you can. This is the one test that benefits from a touch-screen computer, but if you don’t have one you can still connect the dots with your mouse, it will just take a little longer, but don’t worry – the whole point of THINC-it is to measure change over time.

The Trails test looks simple, but your brain has to be in tip-top shape to do it well. Like the other tests, it depends on processing speed, but it also measures something else – executive functioning. This is the ability to plan, organize, flexibly adapt to life, and to control your impulses. Those are essential skills for any job, but how does this simple test measure all that?

As you connect the dots, you’re always having to think 1-2 steps ahead, planning for the next number or letter in the sequence. Your impulse is going to be to go on to the next letter in the alphabet, like C to D, but no – you have to inhibit that impulse, flexibly switch gears, and connect the letter C to the number 3, then switch back and connect that 3 to the letter D.

KELLIE NEWSOME: Processing speed, reaction time, working memory, executive functioning. THINC-it measures a lot of brain function in short amount of time. At the end of the test, it will graph your results and save them under your name. The test doesn’t collect any data on you or ask for your email, which may make you wonder – what’s the catch? Why is this all free? The test was created by an international team of psychiatrists and psychologists, and their work was funded by the pharmaceutical company Lundbeck. Lundbeck makes vortioxetine, one of the medications that improved performance on the Symbol test, so they have a vested interest in this work. Neither myself, Dr. Aiken, or the Carlat Report which creates this podcast has received any funding from Lundbeck or any other pharmaceutical company for that matter.

DR. AIKEN:: And we’re not recommending a pharmaceutical approach to improving cognition. While some medications can improve concentration and memory, the best effects come from lifestyle changes like we discussed in last month’s podcast. But back to our original question – how do you get the motivation to make those lifestyle changes? The THINC-it app is part of that, but it’s not the main thing.

Here’s what we recommend:

Choose one or two lifestyle changes from the list. Then gamify it – track how well you stick with it. If you choose brisk walking, get a piece of graph paper and draw a line each day indicating how many minutes you brisk walked for. As you look at your results every day, your motivation to walk will increase. You’ll be training your brain to think about walking, and to want to get those graphs filled in so you have a steady line of 30 minutes a day.

Kellie Newsome: Or – even simpler – you could tell your cell phone to track it for you. If you keep your phone in your pocket most apple phones are tracking your steps without you even knowing it. Just go to the Apple Health app and check…. Hmmm… let me see… yes I definitely could improve on mine. The optimum to aim for is 10,000 steps a day, but don’t aim for that. Just check what your usual routine is and set a goal that’s a little bit higher, so if you’re walking 3000 steps a day, aim for 4,000, then

DR. AIKEN: Gamification works best when it’s directly linked to stuff that’s in your control. Walking, playing piano, eating fruits and vegetables – these are all in your control and you can measure them. If you don’t have the motivation to do them, just start measuring how much you’re already doing and you’ll find as you shift your attention there your motivation will grow. But back to the THINC-it test. This test is not directly in your control. You might walk 30 minutes a day for a month and still not see a change on the test. Maybe you need to try 3 months, or do more, or maybe you have significant depression that needs to be treated before you see a change on the test. If you do the things we recommended in the last podcast, or even just some of them, I think you will see changes on the test, and I do believe that tracking your objective outcome on the computerized test will help you stick with the plan. But the main thing you should be tracking is just whether you did the basics – exercise, Mediterranean diet, healthy sleep habits, nature, and dexterity games. That’s what is in your direct control, and tracking that is what will keep your motivation going day to tday. THINC-it is something you should test month to month, and it’s more of a big picture thing that will let you know if the changes you are making are working.

Kellie Newsome: Another way to use THINC-it is when you are starting a new medication. If the medication improves your mood, your sleep, or ADHD, it will probably improve your score as well. You can download or print out the results to bring to your doctor. In THINC-it, click on the TEST DATA button to see your results graphed over time. The test can be real useful when switching ADHD medications like stimulants. Those meds have very quick effects – they work the day you take them – so in those cases it may make sense to do the test every day at the different doses. But otherwise we recommend doing it once a week or once a month. Weekly if you are anticipating faster changes, like starting a new antidepressant, or monthly if you are adding in lifestyle changes that may take a while.

And now for the word of the day… Avoidant restrictive food intake disorder

Avoidant restrictive food intake disorder entered the DSM with the 5^th edition in 2013. Like patients with anorexia, these patients restrict food, but not out of body image concerns. Instead, the reasons for restriction tend to fall into 3 main categories:

• Fear of negative consequences of eating;
• Low appetite or disinterest in food;
• Avoidance of food based on sensory characteristics.

The official definition requires that the restriction cause at least one of the following:

Significant weight loss

Nutritional deficiency

Dependence on enteral feeding or nutritional supplements

Marked interference in psychosocial functioning

We’ll look at a case report of mirtazapine for Avoidant restrictive food intake disorder in next week’s podcast: 5 new findings on mirtazapine.

Follow our twitter handle @CarlatPsych for daily research updates. Today’s paper relates to Lybalvi, a new combo pill that pairs olanzapine with the opioid blocker samidorphan. This month, the FDA approved Lybalvi for to reduce weight gain from olanzapine in bipolar and schizophrenia, but the company also pursued an indication for alcohol abuse with the novel ingredient in Lybalvi: samidorphan. In 2018, Stephanie O’Malley and colleagues published a large randomized controlled trial of samidorphan in alcohol use disorders, but the results were mixed. It didn’t work on the primary measure of heavy drinking days, but it helped secondary measures of cravings and alcohol intake.

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