Dysphagia is a medical term that is used to refer to difficulties with swallowing. The level of dysphagia varies. Some people have problems swallowing certain foods or liquids, while others are completely unable to swallow. It takes more time and effort to move food or liquid from the mouth to the stomach. Difficulty swallowing may also be associated with pain. Persistent difficulty swallowing may indicate a serious medical condition requiring treatment.

The term “dysphagia” derives from the Greek root dys meaning “difficulty or disordered”, and phagia meaning “to eat”.

According to Medilexicon’s medical dictionary:

Dysphagia is “Difficulty in swallowing“.

Difficulty in swallowing can occur at any age, but is more common in older adults. The incidence of dysphagia is higher in the elderly, in patients who have had strokes, and in patients who are admitted to acute care hospitals or chronic care facilities. The causes of swallowing difficulties vary, and treatment depends on the cause. Dysphagia frequently arises as a complication of another health condition, such as a stroke, throat and mouth cancer or gastro-oesophageal reflux disease (GORD).

There are two types of dysphagia:

• Oropharyngeal or high dysphagia. Difficulties in swallowing are due to problems with the mouth or throat.
• Esophageal or low dysphagia. Difficulties in swallowing are due to problems with the esophagus.

Low dysphagia is often caused by a blockage in or irritation to the esophagus, and can often be treated using surgery.

High dysphagia is often caused by underlying problems with the nerves and muscles that help control the swallowing process.

Some degree of dysphagia is relatively common in elderly people staying in nursing homes.

Apart from the risk of malnutrition and dehydration, difficulties with the swallowing reflex mean that there is a chance that small particles of food can drop down into the lungs. That can trigger a serious and possibly fatal lung infection (aspiration pneumonia). Depending on the cause, possible treatments include physical therapy, diet modification, surgery, and the use of feeding tubes.

What are the signs and symptoms of dysphagia?

A symptom is something the patient feels and reports, while a sign is something other people, such as the doctor detect. For example, pain may be a symptom while a rash may be a sign.

Signs and symptoms that can be associated with dysphagia:

• Bringing food back up (regurgitation)
• Choking when eating
• Coughing or gagging when swallowing
• Developing repeated and frequent lung infections (pneumonia)
• Drooling
• Food or stomach acid backing up into the throat
• Frequent heartburn
• Hoarseness
• Inability to swallow
• Pain while swallowing
• Sensation of food getting stuck in the throat or chest, or behind the breastbone
• Unexpected weight loss

Signs and symptoms of swallowing difficulties in infants and children:

• Breast-feeding problems
• Coughing or choking during feeding or meals
• Food or liquid leaking from the mouth
• Inability to coordinate breathing with eating and drinking
• Lack of attention during feeding or meals
• Lengthy and prolonged feeding or eating times
• Recurrent pneumonia
• Refusing to eat foods of different textures
• Spitting up or vomiting during feeding or meals
• Tensing of the body during feeding
• Weight loss or slow weight gain or growth

Seek medical attention if:

• In children. If a child has trouble swallowing, seek medical help.
• Constant problems. Slight or occasional difficulty swallowing usually is not cause for concern or action. But difficulty swallowing can indicate a serious medical problem, such as esophageal cancer. Seek medical advice if there is difficulty swallowing or if difficulty swallowing is accompanied by weight loss, regurgitation or vomiting.

• Obstructions. If an obstruction interferes with breathing, call for emergency help immediately. If unable to swallow due to an obstruction, go to the nearest emergency department.

What causes dysphagia?

How swallowing works

It takes about fifty pairs of muscles and nerves to accomplish the simple act of swallowing.

There are three stages to swallowing:

• Stage one. The tongue moves the food around the mouth so that it can be chewed. Chewing helps to break food down into smaller chunks. It mixes it with saliva. Saliva makes the food moist and easier to swallow.
• Stage two. The tongue pushes food or liquid to the back of the mouth in the pharynx. The nervous system triggers the swallowing reflex. It activates the muscles that push the food down the throat towards the esophagus which is a tube running from the throat to the stomach. During this phase, the larynx (voice box) closes in order to prevent any food or liquid from entering the lungs.
• Stage three. Food or liquid enters the esophagus. Muscles quickly move the food or liquid through the esophagus and into the stomach.

Dysphagia can affect any of the nerves, muscles or passageways that are used during the swallowing process.

Esophageal dysphagia refers to the sensation of food sticking or getting stuck in the base of the throat or chest.

In the case of Oropharyngeal dysphagia, certain problems related to the nerves and muscles can weaken the throat muscles. This makes it difficult to move food from the mouth into the throat and esophagus (pharyngeal paralysis). A person may choke, gag or cough when attempting to swallow, or have the sensation of food or fluids going down the windpipe (trachea) or up the nose. This may lead to pneumonia.

Neurological causes. Brain damage and damage to the nervous system can interfere with the nerves that are responsible for triggering and regulating the swallowing reflex. This can lead to dysphagia. Some neurological causes of dysphagia include: stroke, cerebral palsy, Parkinson’s disease, multiple sclerosis, and motor neurone disease.

Obstruction. An obstruction or a narrowing of the throat and esophagus can make swallowing difficult. Some causes of obstruction and narrowing include: mouth or lung cancer, cleft lip and palate, radiotherapy causing the development of scar tissue which can narrow the passageway in the throat and esophagus, gastro-esophageal reflux disease when stomach acid can cause scar tissue to develop, and infections, such as tuberculosis or herpes simplex, that lead to the inflammation of the esophagus.

Muscular conditions. Any health condition that affects the muscles that are used to push food down through the esophagus and into the stomach can cause dysphagia.

Scleroderma. The immune system attacks healthy tissue. This leads to a stiffening of the throat and esophagus muscles. Acid is allowed to reflux into the esophagus and causes symptoms and complications.

Achalasia. The muscles in the esophagus become too stiff to allow food or liquid to enter the stomach. This can cause regurgitation of food not yet mixed with stomach contents.

Aging. As a natural consequence of ageing, the muscles that are used in swallowing can become weaker. This may explain why dysphagia is a relatively widespread condition among elderly people. Any persistent trouble swallowing needs to be evaluated medically. This condition is not necessarily a normal part of aging.

Diffuse spasm. This condition produces multiple, high-pressure, and poorly coordinated contractions of the esophagus usually after swallowing. Diffuse spasm is a rare disorder. The contractions often occur occasionally, and may become more severe over time.

Esophageal stricture. Narrowing of the esophagus causes large chunks of food to get caught. Narrowing may result from the formation of scar tissue, often caused by gastroesophageal reflux disease or from tumors.

Esophageal tumors. Difficulty swallowing tends to get progressively worse when esophageal tumors are present.

Foreign bodies. Sometimes, food, such as a large piece of meat, or another object can become lodged in the throat or esophagus. Older adults with dentures and people who have difficulty chewing their food properly may be more likely to have an obstruction of the throat or esophagus. Children may swallow small objects that can become stuck.

Esophageal ring. This thin area of narrowing in the lower esophagus can occasionally cause difficulty swallowing solid foods.

Gastroesophageal reflux disease. Damage to esophageal tissues from stomach acid backing up into the esophagus can lead to spasm or scarring and narrowing of the lower esophagus.

Eosinophilic esophagitis. This condition is caused by an overpopulation of cells called eosinophils in the esophagus. It may be related to a food allergy, but often no cause is found.

Neurological disorders. Certain disorders, such as post-polio syndrome, multiple sclerosis, muscular dystrophy and Parkinson’s disease, may first be noticed because of oropharyngeal dysphagia.

Neurological damage. Sudden neurological damage (from a stroke or brain or spinal cord injury) can cause difficulty swallowing or an inability to swallow.

Pharyngeal diverticula. A small pouch forms and collects food particles in the throat. This leads to difficulty swallowing, gurgling sounds, bad breath, and repeated throat clearing or coughing.

Cancer. Certain cancers and some cancer treatments can cause difficulty swallowing.

Dysphagia in infants and children

Swallowing difficulties in infants and children are often caused by:

• Cleft lip or cleft palate
• Problems in development due to premature birth or low birth weight
• Nervous system disorders, such as cerebral palsy or meningitis

Unexplained dysphagia

Some people experience unexplained swallowing difficulties:

• Difficulty taking oral medications. Some people cannot swallow pills or tablets, even though they have no other difficulty swallowing.
• Feeling a lump in the throat. Some people feel the sensation of a foreign body or lump in their throats. But in reality no foreign body or lump exists. Stress or excitement may worsen this sensation.

What are the risk factors for dysphagia?

A risk factor is something which increases the likelihood of developing a condition or disease. For example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is a risk factor for diabetes type 2. The following are risk factors for difficulty swallowing:

• Aging. Due to natural aging and normal wear and tear on the esophagus, older adults are at higher risk of swallowing difficulties.
• Premature birth. Babies born prematurely are more prone to developmental problems. These include gastrointestinal disorders that may cause difficulty swallowing.
• Certain health conditions. People with neurological or nervous system disorders are more likely to experience difficulty swallowing.

What are the complications of dysphagia?

Difficulty in swallowing can lead to:

• Malnutrition and dehydration. Dysphagia can make it difficult to take in enough food and fluids to stay adequately nourished. People with difficulty swallowing are at risk of malnutrition and dehydration.
• Respiratory problems. If food or liquid enters the airway (aspiration) when swallowing, respiratory problems or infections can occur. This can lead to frequent pneumonia or upper respiratory infections. Aspiration pneumonia is a lung infection that is triggered when a small piece of food enters the lungs.

People with oropharyngeal or ‘high’ dysphagia are particularly vulnerable to aspiration pneumonia because their impaired swallowing reflexes mean that their larynx does not close during swallowing, so their lungs are not protected.

The symptoms of aspiration pneumonia include:

• blue skin (cyanosis) due to a lack of oxygen
• chest pain
• fatigue
• fever
• shortness of breath
• wheezing
• coughing that sometimes produces foul-smelling phlegm and may contain traces of blood and pus

The symptoms of aspiration pneumonia can range from mild to severe. Severe cases require admission to hospital and treatment with intravenous antibiotics.

In the case of particularly vulnerable or frail people, there is a chance that the infection could cause their lungs to become filled with fluid, preventing them from working properly. This is known as acute respiratory distress syndrome (ARDS).

How is dysphagia diagnosed?

A physical examination is performed as well as a variety of tests to determine the cause of the swallowing problem. The aim is to determine the exact location of the swallowing problem (‘high’ or ‘low’ dysphagia) and to assess how the ability to swallow has been affected.

Recent medical history

The patient will be asked about the dysphagia symptoms: for how long the symptoms have been experienced, whether dysphagia has affected the ability to swallow solids, liquids or both, and whether there has been any weight loss.

Water-swallow test

This test can provide a good initial assessment of the patient´s swallowing abilities. The patient is given a glass of water and asked to swallow it as quickly as possible. The time it takes to drink all the water and the number of swallows that were required are recorded.

Barium Swallow Test or Videofluoroscopic Swallow Study (Fluoroscopy)

It is one of the most effective ways of assessing a person’s swallowing, and locating exactly where the problems are occurring. The test can often identify blockages or problems with the muscles that are used during swallowing.

The patient is asked to drink some barium solution. Barium is a non-toxic chemical that is widely used for testing purposes because it shows up on an X-ray. The barium coats the inside of the esophagus, allowing it to show up better on X-ray. It allows assessing of the muscular activity.

Endoscopy

A thin, flexible, lighted instrument (endoscope) is passed down the throat to view the esophagus. A test called a fiber-optic endoscopic evaluation of swallowing (FEES) can also be carried out. It uses a small lighted tube (flexible laryngoscope) placed in the nose. This allows the mechanisms during swallowing to be seen.

Esophageal muscle test. In this test, a small tube is inserted into the esophagus and connected to a pressure recorder. This allows measurement of the muscle contractions of the esophagus during swallowing.

What is the treatment for dysphagia?

Treatment depends on the particular type or cause of the swallowing disorder:

Oropharyngeal dysphagia or ‘high’ dysphagia

The patient will most likely be referred to a throat specialist or neurologist for further diagnostic testing and to a speech or swallowing specialist for therapy. Therapy may include:

• Exercises. Certain exercises may help coordinate the swallowing muscles or stimulate the nerves that trigger the swallowing reflex.
• Learning swallowing techniques. Learning simple ways to place food in the mouth or to position the body and head to help swallow successfully. There are also a number of physical techniques that can be used to make swallowing easier. For example, some people find that ducking their chin forward when swallowing helps to prevent any food from entering their airways.
• Dietary changes. A nutritionist can advise the patient about making changes to their diet, such as incorporating food and liquids that are easier to swallow while ensuring that they receive a healthy, balanced diet.
• Feeding tubes. They may be required in severe cases of dysphagia that put the patient a risk of malnutrition and dehydration.

There are two types of feeding tubes:

• Nasogastric tube, a tube that is passed down the nose and into the stomach.
• Percutaneous endoscopic gastrostomy (PEG) tube, a tube that is surgically implanted directly into the stomach. It passes through a small incision on the surface of the stomach, or abdomen.

Nasogastric tubes are designed for short-term use and last for 10 to 28 days before they need to be replaced. PEG tubes are designed for long-term use and last for up to six months before they need to be replaced.

Most people with dysphagia prefer to use a PEG tube because the equipment can be easily hidden under clothing. However, PEG tubes do carry a greater risk of complications than nasogastric tubes (tube displacement, skin infection, tube blockage, and tube leakage). Major complications of PEG tubes include internal bleeding, and infection.

There is an indication that people who use PEG tubes find it more difficult to resume normal feeding compared with those who use nasogastric tubes.

In the case of dysphagia caused by Parkinson’s disease medication is useful. While Parkinson’s disease cannot be cured, the symptoms of dysphagia can be controlled using medication.

Esophageal dysphagia or ‘low’ dysphagia

Treatment approaches for esophageal dysphagia may include:

• Esophageal dilation. In the case of a tight esophageal sphincter (achalasia) or an esophageal stricture, an endoscope with a special balloon attached may be used to gently stretch and expand the width of the esophagus or pass a flexible tube or tubes to stretch the esophagus (dilatation).
• Surgery. For an esophageal tumor or pharyngeal diverticula, surgery may be recommended to clear the esophageal path.
• Medications. Difficulty swallowing associated with GERD can be treated with prescription oral medications to reduce stomach acid after a stricture is dilated. These medications may need to be taken for an extended period of time.In the case of esophageal spasm but with normal esophagus and without GERD, patients may be treated with medications to relax the esophagus and reduce discomfort.
• Botulinum toxin. It can be used to treat achalasia which is a type of dysphagia where the muscles in the oesophagus become too stiff to allow food and liquid to enter the stomach. The toxin can be used to paralyze the stiff muscles that are preventing food from reaching the stomach.

Coping with the condition

Living with swallowing difficulties can be challenging. Dysphagia may affect interaction with friends and family, productivity at work, and overall quality of life.

Patients may find that talking to a counselor or therapist can help them cope with the effects of swallowing difficulties. They may find encouragement and understanding in a support group.

Support groups can be good sources of information. Group members often know about the latest treatments and tend to share their own experiences.

When the cause is neurological damage or disorders, swallowing difficulties cannot be prevented. The risk of occasional swallowing difficulty can be reduced by eating slowly and chewing food well.

Early detection and effective treatment of GERD can lower the risk of developing dysphagia associated with an esophageal stricture.

Written by Stephanie Brunner (B.A.)

But a first-of-a-kind study conducted by researchers at the Kaiser Permanente Center for Health Research, Wesleyan University and Rutgers University found that more than 63 percent of participants had stopped binging at the end of the program – compared to just over 28 percent of those who did not participate. The program lasted only 12 weeks, but most of the participants were still binge free a year later. A second study, also published in the April issue of the Journal of Consulting and Clinical Psychology, found that program participants saved money because they spent less on things like dietary supplements and weight loss programs.

“It is unusual to find a program like this that works well, and also saves the patient money. It’s a win-win for everyone,” said study author Frances Lynch, PhD, MSPH, a health economist at the Kaiser Permanente Center for Health Research. “This type of program is something that all health care systems should consider implementing.”

“People who binge eat more than other people do during a short period of time and they lose control of their eating during these episodes. Binge eating is often accompanied by depression, shame, weight gain, loss of self-esteem and it costs the healthcare system millions of extra dollars,” said the study’s principal investigator Ruth H. Striegel-Moore, PhD, a professor of psychology at Wesleyan University. “Our studies show that recurrent binge eating can be successfully treated with a brief, easily administered program, and that’s great news for patients and their providers.”

Binge eating has received a lot of media attention recently because the American Psychiatric Association is recommending that it be considered a separate, distinct eating disorder like bulimia and anorexia. This new diagnosis can be expected to focus more attention on binge eating and how best to treat it, according to the researchers. It also could influence the number of people diagnosed and how insurers will cover treatment.

This randomized controlled trial, conducted in 2004-2005, involved 123 members of the Kaiser Permanente health plan in Oregon and southwest Washington. More than 90 percent of them were women, and the average age was 37. To be included in the study, participants had to have at least one binge eating episode a week during the previous three months with no gaps of two or more weeks between episodes.

Half of the participants were enrolled in the intervention and asked to read the book “Overcoming Binge Eating” by Dr. Christopher Fairburn, a professor of psychiatry and expert on eating disorders. The book details scientific information about binge eating and then outlines a six-step self-help program using self-monitoring, self-control and problem-solving strategies. Participants in the study attended eight therapy sessions over the course of12 weeks in which counselors explained the rationale for cognitive behavioral therapy and helped participants apply the strategies in the book. The first session lasted one hour, and subsequent sessions were 20-25 minutes. The average cost of the intervention was $167 per patient.

All participants were mailed fliers detailing the health plan’s offerings for healthy living and eating and encouraged to contact their primary care physician to learn about more services.

By the end of the 12-week program 63.5 percent of participants had stopped binging, compared to 28.3 percent of those who did not participate. Six months later, 74.5 percent of program participants abstained from binging, compared to 44.1 percent in usual care. At one year, 64.2 percent of participants were binge free, compared to 44.6 percent of those in usual care.

Everyone in the trial was asked to provide extensive information about their binge eating episodes, how often they missed work or were less productive at work, and the amount they spent on health care, weight-loss programs and weight loss supplements. Researchers also examined expenditures on medications, doctor visits, and other health-related services.

The researchers then compared these costs between the two groups and found that average total costs were $447 less in the intervention group. This included an average savings of $149 for the participants, who spent less on weight loss programs, over-the-counter medications and supplements. Total costs for the intervention group were $3,670 per person per year, and costs for the control group were $4,098.

As expected, participants in the intervention group spent less on weight loss programs and over-the-counter medications and supplements.

“While program results are promising, we highly encourage anyone who has problems with binge eating to consult with their doctors to make sure this program is right for them,” said study co-author Lynn DeBar, PhD, clinical psychologist at the Kaiser Permanente Center for Health Research.

Study authors include: Lynn DeBar, John F. Dickerson, Frances Lynch and Nancy Perrin from the Kaiser Permanente Center for Health Research in Portland, Oregon; Ruth H. Striegel-Moore and Francine Rosselli from Wesleyan University; G. Terence Wilson from Rutgers, The State University of New Jersey; and Helena C. Kraemer from the Stanford University School of Medicine.

Source:
Emily Schwartz
GolinHarris International

A research article published on November 14, 2009 in the World Journal of Gastroenterology describes the responses of 26 ED patients to F-S provocation. The research team, including Professors Kellow, Abraham and Hansen from the University of Sydney, Australia, monitored gastrointestinal symptoms and breath hydrogen concentration (a marker of small bowel absorption) for 3 h following ingestion of 50 g glucose on one day, and 25 g fructose/5 g sorbitol on the next day. Responses to F-S were compared to those of 20 asymptomatic healthy females.

F-S provoked gastrointestinal symptoms in 15 ED patients but only in one healthy control. In contrast, only one ED patient displayed symptom provocation to glucose, which does not usually provoke gastrointestinal symptoms; this shows specificity of the F-S response. A greater symptom response was observed in the most underweight ED patients (BMI ≤ 17.5 kg/m2) compared to those with a BMI >17.5 kg/m2. There were no differences in psychological scores, prevalence of functional gastrointestinal disorders or breath hydrogen responses between patients with and without an F-S response.

The key findings of this study are that F-S provoked gastrointestinal symptoms in more than half of the female ED patients, a significantly greater proportion than that found in healthy individuals; the response was specific for F-S ingestion; and there was a greater symptom response in patients at lower BMI values. Consistent with this last finding, symptom provocation was more common in anorexia nervosa patients. Hence negative energy balance appears to play a role in F-S sensitivity in these patients. As fructose and sorbitol are likely to be commonly ingested by ED patients, representing a potential source of gastrointestinal distress that would impact negatively on their nutritional management, F-S provocative testing could prove valuable in identifying those patients with symptom sensitivity to these substances.

Reference: Friesen N, Hansen RD, Abraham SF, Kellow JE. Fructosesorbitol ingestion provokes gastrointestinal symptoms in patients with eating disorders. World J Gastroenterol 2009; 15(42): 5295-5299 http://www.wjgnet.com/1007-9327/15/5295.asp

Source: Jin-Lei Wang
World Journal of Gastroenterology

People with bulimia experience cycles of disordered eating behavior in which they overeat and then purge, often by self-induced vomiting or taking laxatives. Binge eating disorder includes bouts of overeating, but without purging, and researchers have linked it to obesity.

Eating disorders are most common in women, with bulimia affecting about 1 percent of women and binge eating disorder affecting 2 percent to 5 percent. Although bulimia rates appear stable, binge eating disorder increasingly is becoming common.

The review included 48 studies with 3,054 participants and strengthened earlier findings in favor of cognitive behavioral therapy. It found that 37 percent of people completely stopped binge eating when given CBT focused on binging while 3 percent of those assigned to a waiting list control group quit.

Other therapies were less successful than CBT, helping 22 percent of participants achieve abstinence from binging by the end of treatment. One approach called interpersonal therapy did achieve comparable results but took months longer to do so.

Lead author Phillipa Hay, M.D., is foundation chair of mental health at the University of West Sydney in Australia. “Cognitive behavioral therapy is really the treatment of choice,” she said. “It has far and away the best evidence. It hadn’t really been so definitively found in previous reviews.”

The review appears in the latest issue of The Cochrane Library, which is a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

Cynthia Bulik, Ph.D., is director of the University of North Carolina Eating Disorders Program at Chapel Hill. Bulik, who had no connection with the review, said the key findings are that “bulimia nervosa is treatable; that some treatment is better than no treatment; that CBT is associated with the best outcome for bulimia nervosa.”

The original intent of CBT was to treat depression. A modified type of CBT in the studies focuses specifically on binge eating disorder symptoms. Nonetheless, participants also experienced significant improvements in mood.

“Many people have problems with depression secondary to binge eating disorders,” Hay said. “They often feel anxious and guilty because of their binging so if the eating disorder improves, the depression improves as well. We did look at the effects of CBT [for binge eating] on depression and it does help depression significantly just in itself.”

Weight, however, did not change with treatment. “None of these psychotherapies really affect people’s weight, which is good thing for people with bulimia who are normal weight but for those who are overweight or obese, they will need weight-loss therapies as well,” Hay said.

Cognitive behavioral treatment of bulimia or binge eating disorder typically involves 15 to 20 outpatient sessions with a therapist over a five-month period. CBT works by helping patients change the way they think about their behavior.

“CBT rests on the premise that unhealthy thoughts lie at both the roots of bulimia nervosa and in the maintenance of unhealthy eating behaviors,” Bulik said. “The goals of CBT are first to have the patient become his or her own detective and via self-monitoring start to understand their patterns of binge eating and purging and recognize and anticipate the cues (triggers) for their unhealthy behaviors.” Once these patterns and the thoughts that drive them are identified, they can be challenged and addressed.

Hay gave the example of someone who, after binging, skips lunch and breakfast the following day. That can easily produce another binge because the craving caused by intense hunger is harder to resist. The therapist would help the patient see that eating healthy meals after a binge would break the cycle, even though fasting might initially seem like a better solution.

The review also compared CBT done in conjunction with a therapist to self-help using books that teach its techniques and tactics. While guided CBT was more effective, there was not much research on self-help and Hay says the approach is “promising” and that it should receive further study. There has been more research on bulimia than binge-eating disorder so more data would help clarify the best approaches to the latter.

Other studies have found that antidepressants can help fight bulimia and binge eating. While this review did not compare medication to psychotherapy, Hay says clinicians should try CBT first because more people stick with it. “The dropout rate is quite significantly higher with drugs,” she says.

“Some treatment is better than none,” Bulik said. “If you can’t find a therapist [who practices CBT for binge eating], don’t throw in the towel find another kind of therapist, pick up a self-help book, do something because the outcome will be better than doing nothing at all.”

The Cochrane Library contains high quality health care information, including Systematic Reviews from The Cochrane Collaboration. These reviews bring together research on the effects of health care and are considered the gold standard for determining the relative effectiveness of different interventions. The Cochrane Collaboration is an international nonprofit, independent organization that produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions.

Source: Health Behavior News Service