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By W. Marcus. Spertus College. 2019.

Once you start looking in on your thoughts you’ll probably notice that most of them seem to be about reliving the past order finasteride 5 mg with mastercard, or planning for/imagining the future discount finasteride 1 mg overnight delivery. When a thought pops up purchase 1mg finasteride, I want you to name the time period when it seems to be occurring. The future hasn’t happened and therefore doesn’t exist as yet and the past has already gone by and therefore also doesn’t exist in the here and now. The present, this very moment, is the only time that you have any real control over. If your thoughts tend, as most do, to the future or the past, you’re missing out on a lot of the right now. You’re generally not fully present to the beauty of the only moment in time that truly exists! Another aspect of thought is that it’s largely concerned with judging, comparing and criticizing. Your mind is constantly evaluating every external and internal situation that you encounter. This time you’re going to pick a word that basically describes what the thought is about as it happens. Say something to yourself like 14 • Mindfulness Medication criticizing, or planning, or worrying, or judging, or remembering. The more familiar you are with your own mind, the easier it will be for you to intervene in your stress responses. Now that you’re getting a bit more familiar with your own mind, let’s try a few more experiments. If a different thought arises, other than mentally watching your breath-cycles and counting them, then start right back at the beginning at one. It’s important that you really try to do all of the experiments and practice suggestions in this book. Give this breath exercise a try right now and then return to the book when you’re through. Sometimes I can’t get beyond one or two breath-cycles before another thought pops up! Your mind is constantly thinking and as amazing as it is, you probably can’t even maintain your concentration for ten breaths. It can be very difficult for you to develop the concentration to be mentally present and fully aware of what’s going on in the here and now. Your mind is like a little hummingbird, flitting from one sensation, thought or perception to the next. Your thoughts are very powerful and can easily pull you away from what you’re doing. You can get carried away into your various mental worlds at the drop of a hat, which leads us to the next concept. As it turns out, both Eastern and Western observations confirm that we all have the ability to focus attention on what’s happening in the present moment, right in the here and now, and that when we do so, it silences and calms the mind. Even if you only manage this present-focus for a short period of time, what time you do spend in the present, is time that takes away from the habitual thoughts of the past or future. Contemplating the past and the future also just happens to be where most of your stressful thoughts arise. You probably worry most about either what’s going to happen or what has already happened. What’s happening right now, in this very instant, is likely considerably less stressful. Let’s try an experiment to see if you can bring those pesky, flitting little hummingbird-thoughts back into the present. Close your eyes tightly and bring all of your focus to the sensation of tension around your eyes. Squeeze your eyes even more tightly closed and feel which of your muscles are tightening in your face, between your eyes and in your forehead. Give this exercise a try right now and then return to the book when you’re through. H 16 • Mindfulness Medication Try it again and really focus on scrunching your eyes closed and feeling the tension in your eyes as well as around them. When you fix your concentration on doing something like this, I think you’ll find that it pushes any other thoughts of yesterday or tomorrow right out of your mind. Is it skiing, dancing, cooking, painting, gardening, photography or playing hockey? At those times when you’re deeply engrossed in a favourite activity does time stand still, or do other thoughts come into your consciousness? When you’re totally present in what you are doing, the only thoughts that exist tend to be about the activity you are engaged in. You already have the ability to quiet your mind and make it focus and that just happens to be a characteristic of the human mind that you can put to use for reducing your stress. I know what you’re saying is probably something like, “So scrunching my eyes reduces stress? As you’ve no doubt noticed during the preceding exercises, thoughts come and go very frequently. Most of us normally do not have the ability to consistently maintain concentration on one thought. Even if you’re generally feeling sad, angry, or happy, within a short time your mind will still drift from thought to thought. If each thought is that important and meaningful why don’t thoughts stay around longer than they do? The tricky thing about any thought is that while you find yourself immersed in it, it feels permanent. However, if you wait it out, often just a little longer, that thought will actually pass and then you’ll have, at least temporarily, a break from it. If you can think of your thoughts as clouds that form and change, vanish and reform, rather than as things that are true, absolute and permanent, it may help you to de-stress. A lot of what you’re thinking Meet Your Mind • 17 when you’re stressed is just a string of hypothetical ‘what-ifs’. When you bring some awareness to a particularly stressful moment, you can let the natural inclination of the mind to move on, work to your advantage. Now I’d like you to really consider how long a thought actually tends to last for you personally and whether or not it’s something that’s permanent and unchanging. Specifically, observe how long they last, how they change or jump around and how sometimes they just pass away and another thought comes up to take their place.

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Pharmacokinetics is the study of how drugs enter the body purchase finasteride now, reach the site of action and are removed from the body purchase finasteride 5 mg mastercard, i order finasteride 1mg with amex. Elimination is defined as the process of removal of the drug from the body, which may involve metabolism and/or excretion. The pharmacokinetic aspects of a drug are obviously just as important as its pharmacodynamics, when considering therapeutic efficacy. For many drugs this occurs by simple diffusion of the unionized form across cell membranes (see Section 1. When drugs are given by iv administration, there is an extremely high initial plasma concentration and the drug may rapidly enter and equilibrate with well-perfused tissues such as the lung, adrenals, kidneys, liver and heart. Subsequently, the drug enters poorly perfused tissues such as skeletal muscle, connective tissue and adipose tissue. As the concentration of drug in the poorly perfused tissues increases, there is a corresponding decrease in the concentration in the plasma and well-perfused tissues. Many drugs show an affinity for specific binding sites on plasma proteins such as albumin and α1-acid glycoprotein, which results in a reversible association, with some important consequences in therapeutics: • Drug binding lowers the concentration of free drug in solution, and thus the concentration of drug available to act at the receptor. This can result in the need to use high doses to compensate for drug wasteage, which is expensive. Unwanted deposition may also result in toxicity problems, arising from drug action at non-target sites. Classic examples of toxic side-effects resulting from unwanted drug distribution are found in cancer chemotherapy. The chemotherapeutic agent, a cytotoxic poison, lacks specificity and has the potential to kill all cells, both normal and malignant. The drug exploits the difference in the turnover of cancer cells, which is very much greater than normal cells. However, rapidly dividing normal cells, for example the hair follicles, and the cells of the gastrointestinal tract, are also susceptible to attack. This gives rise to typical side-effects associated with cancer chemotherapy such as hair loss and acute gastrointestinal disturbances. In the early 1900s Paul Ehrlich (who has been described as the father of drug delivery and therapeutics) pioneered the idea of the “magic bullet” approach, whereby therapy “could learn to aim”. The inherent premise of this concept is to try to improve therapy by targeting the drug to the site of action, thereby removing unwanted toxic sideeffects and minimizing drug wastage. It generally involves the transformation of a lipid-soluble drug (which can cross membranes and thus reach its site of action) into a more polar, water-soluble compound which can be rapidly eliminated in the urine. Metabolic processes have considerable implications for successful drug delivery: • Metabolic activity may result in premature degradation of the active moiety, prior to its arrival at the active site. Metabolic activity may also constitute a considerable biochemical barrier to drug absorption. As described above, extensive enzymatic degradation of labile drugs in the gastrointestinal tract can severely limit their oral bioavailability. Specific tubular uptake processes exist for carbohydrates, amino acids, vitamins etc. Drugs may pass from the tubule into the plasma if they are substrates for the uptake processes, or if they are lipid soluble (this process is highly dependent on the prevailing pH, see Section 1. Depending on the drug and the disease state, the timing of therapy may be optimal as either zero-order controlled release, or variable release. Considerable advances in controlling drug release from delivery systems have been made; such systems are described in detail in Chapters 3, 4 and 16. By effective management of the dose size and the dose frequency, it is possible to achieve therapeutic steady-state levels of a drug by giving repeated doses. An example of the type of plasma profile obtained after repeated oral dosing of a drug is shown in Figure 1. However, multiple oral dosing is associated with disadvantages: • The drug concentration does not actually remain constant in the plasma, but fluctuates between maximum (peak) and minimum (trough) values (Figure 1. These fluctuations in plasma concentration may mean that drug levels may swing too high, leading to toxic side-effects; alternatively drug levels may fall too low, leading to a lack of efficacy. An alternative approach to overcome these limitations is to use a delivery system which provides zero-order controlled release of the drug (Figure 1. Zero-order controlled release offers the advantage of improved control over drug plasma levels: the peaks and troughs of conventional therapy are avoided and constant plasma levels are attained. The risk of side- effects is minimized since possible toxic peak drug plasma levels are never obtained and the total amount of drug administered is lower than with frequent repeated dosing. There is also a reduction in symptom breakthrough which can occur if plasma concentrations drop too low. Furthermore, patient compliance is also improved as a result of the reduction in the number and frequency of doses required to maintain therapeutic efficacy. For example, the problem of dosing through the night is eliminated since the drug is slowly released in vivo. A wide variety of drug delivery systems have been developed to achieve zero-order controlled release and are discussed further in the relevant chapters. Situations in which changing levels of response may be required include: Circadian rhythms Biological processes are frequently associated with rhythms of a predictable period. Some of these rhythms have periods of less than a second, others are ultradian (a period ranging from a few minutes to a 31 Figure 1. The intensity of the disease state and associated symptomatology may vary over a 24 h period. For example, in hypertension, blood pressure is lower during the night and increases early in the morning, therefore optimal therapy should facilitate maximum drug levels in the morning. Approximately 80% of insulin-dependent diabetics experience the dawn phenomenon, a rapid rise in serum glucose levels in the dawn hours. At this time interval, the insulin dose should be increased to meet the biological need. Variation in the pharmacokinetics of a drug may also occur (chronopharmacokinetics) which is directly related to the time of day that the drug is administered. The responsiveness of the biological systems (chronopharmacodynamics) may also vary depending on the time of day that the drug is administered, thereby possibly resulting in altered efficacy and/or altered intensity of side-effects. This in turn has created huge challenges, but also exciting opportunities for drug delivery. The goal is to tailor drug input to match these complex, newly defined time courses. There are already some examples of chronotherapeutics in the literature, including the timed administration of theophylline and corticosteroids to asthmatics, treatment of hypertension and, increasingly, the administration of cytotoxic drugs. However, this is still a new, and as yet, poorly understood area of study with much progress to be made. Fluctuating metabolic needs Insulin causes a decrease in blood glucose concentrations. Physiologically, insulin delivery is modulated on a minute-to-minute basis as the hormone is secreted into the portal circulation and requirements vary widely and critically with nutrient delivery, physical activity and metabolic stress. Ideally, an insulin 32 delivery system should be instantaneously responsive to these fluctuating metabolic needs. A variety of other drugs such as calcitonin and growth hormone also demand complex release requirements.

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You can observe thought production as a process occurring outside of your conscious control finasteride 1mg without prescription, like your heartbeat buy finasteride 1 mg line, or your fingernail growth generic finasteride 5mg without prescription. Notice if there’s a connection between your thoughts and return to this chapter after H you’ve finished. We all have deeply embedded 20 • Mindfulness Medication memories of our experiences and there are multiple, unconscious, mental connections that occur between these memories. Practice In an attempt to train your mind to start becoming aware of the nature of your thoughts on a more regular basis, here are a few more exercises that I suggest you set some time aside to do every day. Whenever a thought arises and you’re consciously aware of it, simply note to yourself the word ‘thinking’. Take five to ten minutes in the morning before getting up, or in the evening before going to sleep, to observe your mind and its thoughts. Sometimes this exercise is harder to do if you’re tired but see what works best for you. Observe how your thoughts arise spontaneously, are often connected to the preceding thought and are impermanent in nature. Focus on the idea that ‘your thoughts are not you, they are just passing through’. Pick something that will serve as a cue for you that occurs during your average day and use it as a reminder to simply observe your thoughts for a moment before you act on them, just as you’ve been doing throughout this chapter. Your cue could be as simple as sitting down to eat a meal, getting ready to go for a walk, picking up your phone to make a call, going into the bathroom, sitting in your car for a moment before driving, whatever works for you. Stick a Post-it note up somewhere to remind you that it’s your intention to focus on your thoughts in that situation. In this Ichapter, I’m going to have you take a look at how these thoughts can link together habitually in what becomes your own personal belief system. A belief system is really just a pattern of stories that you have been taught or have learned since childhood, or that you have developed in response to your own experiences. It’s how you frame and understand the things that you encounter in the world around you. You have created a personal belief system about everything you have ever come across, every new discovery, every interaction and every activity, in order to fit things in with what you already know. You never just experience something without also experiencing the story that you then create about the event, based on your personal belief system. This is part of how one thought leads to another in patterns that tend to repeat themselves. It’s a normal part of your brain’s functioning to try to make sense of the world by relating new things to what you’re already familiar with. However, what’s helpful to you in providing meaning and context for novel experiences can also be harmful to you if you have developed a belief system that encourages a stress response. For example, when you look at another person, you project your belief system onto him or her. This helps you to decide if someone is to be approached as a friend or feared as a threat. But your first impressions, your beliefs, your patterns and 23 24 • Mindfulness Medication your stories are not necessarily true. He’s a big man and a little scary looking, but you couldn’t ask for a nicer person. We all form immediate opinions about the people we meet based on prior experiences, our cultures, our previously formed opinions and our upbringings. We form judgments about people without even having talked to them and without knowing who they really are and those judgments could be incorrect. If your belief system encourages you to judge a person negatively, then of course your behaviour toward that person will reflect that judgment. You could be in immediate and stressful conflict with someone based on a habitual response pattern triggered by his or her clothing, smile, or hair color. Many times, if people are acting, or dressing, in ways that don’t fit with how you believe they should be behaving, or looking, then you most likely react negatively to them. However, what you’re actually doing is reacting to a behaviour that you see in those people that you reject or deny in yourself. For example, if you see someone who is dressed in what you feel is a sloppy manner; you may find yourself thinking negative thoughts about him or her. You’re really rejecting the idea of ‘being sloppy’ yourself and so, you reject the characteristic when you see it in another person as well. Your parents may have initially defined “sloppy” for you as a negative characteristic. When you see someone who is dressed in what you describe as a sloppy fashion, you’re really just reinforcing the idea that you reject that quality in yourself. An understanding of belief systems and patterns can allow you to see that judgments are more about your own history than about the person, event, or situation being judged. But these judgments are really just stories that extend beyond the actual reality of the event itself, or the new person that you’re meeting for the first time. These stories are simply your belief system at work trying to help you negotiate and understand your daily environment. Despite the fact that your belief system seems The Origin of Thoughts • 25 true for you at any given time, it’s really just a set of interpretations, or tales, that you tell yourself. You have internal and external sensations that are constantly demanding your attention, but what’s instantly created in response to these circumstances is a story… your story. Even your thoughts, as they pop up out of nowhere, are immediately captured and slotted into existing patterns. It remembers the conditioned, reactive story that you created around the initial event, sensation, or perception and that becomes your reality. You completely forget the original event and only see the situation from the perspective of your own story. Isn’t it fascinating that we all lead our lives through the ways in which we look at the world? We can only perceive it through the unique filters of our belief systems and the stories that those systems tell us. Let’s take a look now at how your mind reacts to the internal and external sensations that you’re receiving. I’m going to suggest various images for you to think about and I’d like you to just notice what stories occur for you in response to the original thought. Choose to think about someone that is very neutral to you, such as the newspaper delivery person, or the person at the checkout at the grocery store. When you look at someone you don’t like, your thoughts and stories about that individual will reveal characteristics like negativity, selfishness and aggression. Even just walking down the street, your belief system has something to say about almost everything and everyone. You might see someone with tattoos and/or body piercings and think about that person in a certain way.

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When considering consumers’ responses to medication best purchase for finasteride, interview data suggest that it may be beneficial for prescribers to consider the impact of side effects and effectiveness on consumers’ lives and their daily functioning buy finasteride 1 mg low cost, as opposed to adopting a purely biomedical perspective buy finasteride 1mg low cost. Similarly, previous researchers have reported that service providers need to recognise not only the physical side effects of medications, but the emotional ones as well (Carder et al. Furthermore, interview data supported an increased role for peer workers in assisting with adherence and helping consumers to manage their illnesses and treatment more generally. As previously mentioned, peer workers were frequently constructed as reliable, credible sources of support and information for consumers, due to their shared experiences. They were also occasionally positioned as sources of inspiration for consumers struggling with their illness and adherence. Consistently, literature has suggested that consumers who are living well act as positive role models for other consumers and service providers and have a heightened capacity for empathy and developing relationships with other consumers due to their experiences (Copeland, 2006; Glover, 2005). Furthermore, the peer workers who were interviewed reported enhanced satisfaction and empowerment associated with their roles. This phenomenon has been explored historically and was described as the “helper therapy principle” (Riessman, 1965). The principle posits that by taking on socially valued roles, consumers are no longer bound to the passive role of a “patient”, who is reliant on expert advice. Rather, they serve as role models, who provide feedback and assistance to others, which can have a positive impact on self-concepts and lives. The principle was noted in some 1970s psychiatry journal articles which reported that helping others was beneficial for helpers in a variety of contexts, such as tutoring for younger children. There is an international trend towards greater involvement of mental health consumers to support fellow consumers as part of the shift towards more recovery-based services (Lawn, Smith & Hunter, 2008), however, it is uncertain whether this is purely an ideological shift yet to have translated into practice and research. The peer workers involved in the present study were employed by community centres. Common forms of peer support identified in the literature include naturally occurring mutual support programs (such as groups run at community centres whereby consumers can share experiences), consumer-run programs, and employment of consumers as providers within clinical and rehabilitative settings (Davidson et al. Peer workers could feasibly have a role in promoting open dialogue about adherence and non-adherence experiences, as well as strategies to assist with adherence. Whilst such dialogue may not necessarily translate into positive outcomes in terms of improved adherence rates amongst consumers, it may prepare consumers for adherence and non-adherence experiences, 295 potentially rendering them better equipped to manage adverse responses. Peer workers could also potentially facilitate communication between service providers and consumers and may have even a role in assisting service providers to gain empathy for consumers. Whilst the present findings support the benefits of peer worker services to consumers, particularly in relation to adherence, further exploration of the role that peer workers could have in assisting with adherence is required, particularly given that there is an absence of research in this specific area. In particular, although the present study’s interview schedule contained broad, general questions, it is acknowledged that these questions may have facilitated the emergence of some codes. For example, interviewees were asked specifically about their experiences of the benefits of medication, which tended to elicit talk related to the effectiveness of medication in treating symptoms and avoidance of relapse and hospitalisation. Furthermore, my interview style and my interpretation of information provided by interviewees guided the interview process. Additionally, whilst the analysis attempted to remain as close to the interview data as possible, the coding and selection of extracts as well as the analysis inevitably involved subjective interpretation and, thus, other interpretations may also exist concurrently. There are also several limitations in relation to the transferability of the results of the present study to other populations, particularly in relation to the service-related factors. This is because the service model differs 296 between states and territories within Australia, as well as internationally. Furthermore, it is highly likely that consumers’ experiences of services in rural South Australia may differ from those of consumers in urban areas. Additionally, the results of the present study may only be relevant to outpatients. More qualitative research needs to be undertaken in various contexts similar to, and different from, the present research that involves participants similar to, and different from, those involved in the present research in order enhance understanding about the factors that influence medication adherence and how these factors do so, and interact with one another. Schneider (2010), for example, successfully conducted participatory action research involving consumers with schizophrenia to explore issues affecting their lives including housing and interactions with healthcare staff. It additionally affirms that experience can be a basis of knowing and that experiential learning can lead to a legitimate form of knowledge that influences practice (Baum et al. Although consumers provided the data for the present study, future research in the area could 297 benefit from involving consumers in all processes of research, including data collection, analysis, literature reviews and the identification of research questions. Consumers may be more receptive to research that involves peer workers given that in the present study, interviewees frequently positioned peer workers as more relatable and more credible sources of information than healthcare professionals, who lacked experience with medication. Additionally, peer workers may be better equipped to interview consumers as they may ask more relevant questions due to their shared experiences, which may also lead to more open communication between the interviewer and interviewee. Rather, it was constructed as a process, central to which is experiential learning, highlighting the benefits of both adherence and non-adherence experiences for consumers. Results are consistent with previous findings: Adherence is related to factors including insight, side effects and the therapeutic alliance; however, as expected, adherence is a complex phenomenon, influenced by additional factors, which may change over time. Amongst these additional factors were the reflection on experiences and peer worker codes, which have not previously been established as separate influences on adherence in the literature. In most cases, the reasons for adherence and non-adherence were 298 linked to multiple factors rather than one specific cause, providing support for service providers to tailor treatment to consumers and contraindicating the effectiveness of generalised interventions. Whilst the benefits of adherence are not disputed, it is proposed that greater acceptance of non- adherence in the healthcare setting is required. Additionally, peer workers appear to have a positive influence on consumers and may be able to play important roles in assisting with adherence, however, further exploration of what peer support might entail is required. Recovery from mental illness: the guiding vision of the mental health service system in the 1990s. A prospective study of risk factors for nonadherence with antipsychotic medication in the treatment of schizophrenia. Journal of Clinical Psychiatry, 67, 1114-1123 Australian Institute of Health and Welfare (2011). The health and welfare of Australia’s Aboriginal and Torres Strait Islander people: an overview. Poor compliance with treatment in people with schizophrenia: causes and management. Neuroleptic compliance among chronic schizophrenia out-patients: an intervention outcome report. The quest for well- being: A qualitative study of the experience of taking antipsychotic medication. Treatment non-adherence among individuals with schizophrenia: risk factors and strategies for improvement. Schizophrenia and Mood Disorders: The New Drug Therapies in Clinical Practice (pp. Factors associated with medication non-adherence in patients suffering from schizophrenia: a cross-sectional study in a universal coverage health-care system. Depot antipsychotic medication in the treatment of patients with schizophrenia: (1) Meta-review; (2) Patient and nurse attitudes.