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CPAP adherence patterns are often established very early in the course of therapy. Our objective was to quantify patients' perception of CPAP therapy using a 6-item questionnaire administered in the morning following CPAP titration. We hypothesized that questionnaire responses would independently predict CPAP adherence during the first 30 days of therapy.
We retrospectively reviewed the CPAP perception questionnaires of 403 CPAP-naïve adults who underwent in-laboratory titration and who had daily CPAP adherence data available for the first 30 days of therapy. Responses to the CPAP perception questionnaire were analyzed for their association with mean CPAP adherence and with changes in daily CPAP adherence over 30 days.
Patients were aged 52 ± 14 years, 53% were women, 54% were African American, the mean body mass index (BMI) was 36.3 ± 9.1 kg/m2, and most patients had moderate-severe OSA. Four of 6 items from the CPAP perception questionnaire— regarding difficulty tolerating CPAP, discomfort with CPAP pressure, likelihood of wearing CPAP, and perceived health benefit—were significantly correlated with mean 30-day CPAP adherence, and a composite score from these 4 questions was found to be internally consistent. Stepwise linear regression modeling demonstrated that 3 variables were significant and independent predictors of reduced mean CPAP adherence: worse score on the 4-item questionnaire, African American race, and non-sleep specialist ordering polysomnogram and CPAP therapy. Furthermore, a worse score on the 4-item CPAP perception questionnaire was consistently associated with decreased mean daily CPAP adherence over the first 30 days of therapy.
In this pilot study, responses to a 4-item CPAP perception questionnaire administered to patients immediately following CPAP titration independently predicted mean CPAP adherence during the first 30 days. Further prospective validation of this questionnaire in different patient populations is warranted.
A commentary on this article appears in this issue on page 207.
Balachandran JS; Yu X; Wroblewski K; Mokhlesi B. A brief survey of patients' first impression after CPAP titration predicts future CPAP adherence: a pilot study. J Clin Sleep Med 2013;9(3):199-205.
The prevalence of obstructive sleep apnea (OSA) has been well documented1 and is expected to increase as the prevalence of obesity increases.2 Untreated OSA is associated with not just increased cardiovascular3 and metabolic risks,4 but also with myriad comorbidities including decreased quality of life,5 depressed mood,6 decreased cognitive function,7 increased risk of motor vehicle and occupational accidents,8,9 and increased risk of pregnancy complications.10 Though continuous positive airway pressure (CPAP) therapy is highly efficacious11 and is associated with decreased cardiovascular morbidity and mortality12,13 and metabolic morbidity,14,15 treatment effectiveness depends largely on patient adherence, which is often suboptimal.16 Moreover, long-term patient adherence is typically established within the first week of CPAP therapy.17–19
Certain factors have already been associated with poor adherence to CPAP therapy: lack of sleep specialist consultation prior to polysomnogram (PSG),20,21 African American race,20,22 low socioeconomic status,23–25 reduced nasal airway caliber,26 and mask leak,27 to name a few. Social factors, such as living with another person,28 spousal involvement,29 and participation in educational support groups30 are associated with improved CPAP adherence. Other factors, including OSA severity, body mass index (BMI), and the presence of daytime sleepiness, have been studied, and there are conflicting data on their association with adherence to CPAP therapy.31,32
Current Knowledge/Study Rationale: CPAP therapy effectiveness for OSA depends on adherence to therapy. Since CPAP adherence patterns are often established early in treatment, and since interventions exist to improve adherence, there is value in developing simple methods to assess patient attitudes to therapy, ideally at the point of CPAP therapy initiation.
Study Impact: This study demonstrates that a brief assessment of patient perception on the morning after CPAP titration predicts 30-day CPAP adherence, and it extends our current understanding of early assessments of CPAP therapy by examining a female- and African American-predominant patient population. Prospective validation of our brief questionnaire in a larger, more varied population is warranted.
Not surprisingly, patient health belief models, perceptions of OSA risk, expectancies of CPAP therapy and therapy self-efficacy have been shown to be important early predictors of adherence.33,34 At present, most of the existing literature on evaluations of these beliefs and attitudes include lengthy questionnaires33–36 and serial assessments,37 which are useful in a research model but may not be practical in a clinical setting.
Several interventions have been shown to improve CPAP adherence, including cognitive behavioral therapy programs38 and bi-directional telecommunications programs.39–41 Being able to predict a patient's "risk" for poor CPAP adherence early, ideally at the point of CPAP therapy initiation, may be useful in targeting "high-risk" patients for these interventions.
Because patient attitudes are strong early predictors of CPAP adherence, and because targeted interventions exist to improve CPAP adherence, there is a value in developing ways to assess patient attitudes in a simple way. Lewis et al. demonstrated that a single question asked on the morning following CPAP titration predicted CPAP adherence at one month in a cohort of 70 patients in the United Kingdom.28 However, it remains unclear how applicable and generalizable their findings are in populations of different cultural and racial backgrounds, particularly in African Americans. Along these lines, our sleep laboratory had developed a 6-question quality-improvement tool to assess patients' perception of CPAP therapy on the morning following an in-laboratory CPAP titration. Our goal in developing this tool was to have a short questionnaire which could be completed by patients and which could aid in quality improvement in our sleep laboratory. After using this tool for several years, we designed a retrospective pilot study to quantify patients' perception of CPAP therapy based on the responses to the 6-item questionnaire. We hypothesized that responses to these questions would independently predict mean CPAP adherence during the first 30 days of therapy.
We retrospectively evaluated the medical records of 1,126 consecutive, CPAP-naïve adults who were referred to the University of Chicago Sleep Laboratory for their first in-laboratory PSG because of clinical suspicion for OSA between July 2007 and June 2008, and who completed our 6-item questionnaire on the morning following their PSG. Exclusion criteria for these analyses included previous CPAP use, requirement for bilevel positive airway pressure or adaptive servoventilation, central sleep apnea, or lack of adherence data because of a lack of a wireless modem transmission device or faulty wireless modem transmission. The institutional review board of the University of Chicago approved the study, and ethical standards were observed during the investigation. Given the retrospective chart-review nature of the study, the need for informed consent was waived.
Patients underwent either an in-laboratory full-night PSG followed by a full-night CPAP titration or a single split-night PSG. Split-night PSGs were performed on patients who had 2-3 h of baseline sleep with an apnea-hypopnea index (AHI) ≥ 30 events/h, if there were at least 3-4 h of titration time remaining. Patients diagnosed with OSA and referred for CPAP therapy had CPAP set up in their homes by a durable medical equipment (DME) provider. PSGs were scored according to the standards issued by the American Academy of Sleep Medicine.42 A hypopnea was scored if the magnitude of ventilation signal decreased by ≥ 50% of the baseline amplitude of the nasal pressure transducer for ≥ 10 sec associated with either an oxygen desaturation ≥ 3% as measured by finger pulse oximetry or a microarousal.
On the night of the PSG, patients completed a routine questionnaire which included demographics, medical history, sleep history and self-reported habitual sleep duration, Epworth Sleepiness Scale (ESS),43 and the Center for Epidemiologic Studies Depression (CES-D) Scale.44 Self-reported race was categorized into African American and non-African American. Self-reported education level was categorized into "high school degree or less" and "more than high school degree." Age, gender, and medical insurance type were obtained from the medical record. Medical insurance was categorized into Medicaid and non-Medicaid. We categorized patients into 2 groups based on the specialty of the physician ordering the PSG: non-sleep specialists or board-certified sleep-specialists.
Upon awakening in the sleep laboratory, patients were asked by the sleep laboratory technicians to complete a 6-item questionnaire to quantify overall perception of their first experience with CPAP therapy after a night of titration (Appendix). The questionnaire was developed and implemented as part of a quality improvement initiative in our sleep laboratory to assess patient experiences during their CPAP titration PSGs. These questions were answered on a Likert-type visual analog scale ranging from 1 (no difficulty/no discomfort/positive attitude toward CPAP) to 10 (significant difficulty/significant discomfort/ negative attitude towards CPAP). The questions included: (1) How much difficulty did you have tolerating CPAP? (2) How uncomfortable was the mask? (3) How uncomfortable was the CPAP pressure? (4) What is the likelihood of you wearing the equipment at night almost every night? (5) How beneficial do you think CPAP is going to be for your health and sleep? (6) What is your attitude towards CPAP therapy?
CPAP adherence was determined objectively via wireless modem technology that enabled remote daily downloading of data from the CPAP unit during the first 30 days of use. Only 2 DME providers performed CPAP set up in patients' homes. During the first 30 days of treatment, only the DME providers performed education on CPAP set up and any troubleshooting. The data obtained from each CPAP unit included hours of usage per night at the prescribed pressure, residual daily AHI, and average mask leak.
Each of the 6 questions was subjected to bivariate analyses testing the correlation between question response and 30-day CPAP adherence (mean CPAP usage in minutes over the 30 days). Only questions that were significantly correlated to CPAP adherence were pooled. To validate the internal consistency of the questionnaire, we calculated Cronbach α.45 Factor analysis (principal component analysis) was performed to investigate the dimensionality of the scale.46 The sum of the pooled question responses was used in the analysis after the normality of the score distribution was assessed.
We performed a univariate analysis to evaluate associations between mean CPAP adherence during the first 30 days and important covariates such as the specialty of the physician ordering the PSG, age, gender, race, BMI, education level, insurance status, ESS score, CES-D score, AHI, and the CPAP perception score from the night of in-laboratory titration. We then performed a stepwise linear regression model to identify independent predictors of mean CPAP adherence during the first 30 days of therapy. We included the following variables in the stepwise regression model: specialty of the physician ordering the PSG, age, gender, race, BMI, OSA severity, education level, ESS, CES-D score, insurance status, and the CPAP perception score. The backward selection method was used, as the stepping method criteria variables with p-value ≤ 0.05 were kept in the model and variables with p-value > 0.10 were removed.
As a secondary analysis to evaluate changes in CPAP adherence over time and to confirm the findings of the primary analysis, random-effects regression was used with each patient contributing 30 days of data. Patients were categorized based on the CPAP perception score above or below the mean. Both linear (nightly CPAP usage in minutes) and logistic (nightly CPAP usage ≥ 4 h) models were fit. Lowess smooth curves were added to summary plots to aid in assessment of trends.
A p-value ≤ 0.05 was considered statistically significant. All analyses were performed using PASW Statistics (v.18.0, SPSS, Inc, Chicago IL) and Stata Version 12 (StataCorp., College Station, TX).
Of the 1,126 consecutive patients evaluated, 786 (70%) underwent CPAP titration. Data on CPAP adherence for the first 30 days were available for analysis in 403 of these patients (Figure 1). Demographic data are summarized in Table 1. The majority of the cohort was obese, African American, middle-aged, with "more than a high school degree" of education, and more than half were women. Medicaid was the only health insurance coverage in 21% of patients. Severe OSA (defined as AHI ≥ 30 events/h) was present in 58% of patients. Mean 30-day CPAP adherence was 236 ± 162 min per day (Table 2). Split-night PSG was performed in 41% of patients. Full-night PSG followed by full-night in-laboratory CPAP titration was performed in 59% of patients. There was no significant difference in mean 30-day CPAP adherence between patients undergoing split-night PSG vs. full-night PSG (p = 0.52). Due to a lack of a wireless modem transmission device or faulty wireless modem transmission, 383 patients were excluded from the final analysis because of lack of CPAP adherence data. These patients did not differ significantly with respect to any demographic category, sleep history, medical history, or PSG characteristic (data not shown).
Study flow diagram illustrating how the final cohort of patients was obtained
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Demographic variables for the entire analytic cohort
Polysomnographic, CPAP titration, and CPAP adherence data
In order to simplify the questionnaire and to identify the most important items, we tested the correlation between each individual question response and mean 30-day CPAP adherence. Only questions 1, 3, 4, and 5—regarding difficulty tolerating CPAP, discomfort with CPAP pressure, likelihood of wearing CPAP, and perceived health benefit—were significantly correlated with CPAP adherence (Pearson correlations and p values: Q1 = -0.122, p = 0.017; Q2 = -0.098, p = 0.057; Q3 = -0.143, p = 0.005; Q4 = -0.160, p = 0.002; Q5 = -0.122, p = 0.020; Q6 = -0.040, p = 0.444). Cronbach α for these 4 questions was 0.73, suggesting good internal consistency. Unidimensionality was confirmed with factor analysis with the first factor accounting for 55% of the total variance. Since each of the 4 question responses had a range of 1 to 10, the sum of responses to these 4 questions (referred to as the CPAP perception score) ranged from 4 to 40. A higher score represented more difficulty with and discomfort tolerating CPAP and a more negative attitude towards CPAP therapy. The mean CPAP perception score was 16 ± 7. The mean CPAP perception score among excluded patients was slightly higher (18 ± 8, p = 0.013). The CPAP perception scores were normally distributed.
Stepwise linear regression analysis demonstrated that the CPAP perception score significantly predicted mean 30-day CPAP adherence, even after adjusting for specialty of the ordering physician and race (p = 0.007). Other variables considered were dropped from the model due to non-significance, including age, gender, BMI, education, OSA severity, ESS score, CES-D score, and insurance status (Table 3). The unstandardized beta-coefficient for this relationship was -3.3 minutes, suggesting that each point increase in the CPAP perception score was associated with an adjusted reduction in average nightly CPAP use of approximately 3 minutes. This means that all factors being equal, a patient with the maximum score of 40 (indicating the poorest CPAP perception) would be predicted to have approximately 108 minutes less nightly CPAP use than a patient with the minimum score of 4. In addition, in the stepwise linear regression model, only 2 other variables remained significant predictors of mean 30-day CPAP adherence: specialty of the ordering physician and race (Table 3).
Stepwise linear regression model of mean CPAP adherence over the first 30 days of therapy
In our cohort, variables that were not predictive of CPAP adherence in the stepwise linear regression analysis were age, gender, BMI, OSA severity, ESS score, CES-D score, education level, and insurance status. Moreover, there was no significant interaction between race or physician specialty and the CPAP perception score. We fit additional stepwise regression models that also included self-reported habitual total sleep duration, type of PSG (split-night versus full-night), DME provider, and average leak as estimated by the CPAP devices; these did not have an impact on the 3 significant variables (CPAP perception score, race, and physician specialty; data not shown).
We used the mean CPAP perception score to create 2 categories of patients: poor CPAP perception (scores > 16) and good CPAP perception (scores ≤ 16). Although there was a significant decrease in mean daily CPAP usage over time in both groups (p < 0.001), higher CPAP perception scores were associated with decreased mean daily usage (p = 0.001), and this relationship did not vary significantly over time (p = 0.40 for the time by CPAP perception score interaction) (Figure 2A). Similarly, there was a significant decrease over time in the percentage of patients using CPAP ≥ 4 hours each day (p < 0.001). Higher CPAP perception scores were associated with a decreased likelihood of patients using CPAP for ≥ 4 h each night (p < 0.001), and this relationship did not vary significantly over time (p = 0.15 for the time × CPAP perception score interaction) (Figure 2B).
The mean CPAP perception score was used to create two categories of patients: poor CPAP perception (scores > 16) and good CPAP perception (scores ≤ 16). Higher scores on the CPAP perception score were associated with decreased nightly CPAP usage (A) p = 0.001. Similarly, higher scores on the CPAP perception score were associated with a decreased percentage of patients using CPAP ≥ 4 hours each night (B) p < 0.001. Lowess smooth curves were added to summary plots to aid in assessment of trends.
CPAP perception score predicts nightly CPAP use and percentage of patients with ≥ 4 hours nightly CPAP useThe mean CPAP perception score was used to create two categories of patients: poor CPAP perception (scores > 16) and good CPAP perception (scores ≤ 16). Higher scores on the CPAP perception score...
The main finding of our pilot study is that responses to a brief CPAP perception questionnaire administered to patients immediately following an in-laboratory CPAP titration predicts CPAP adherence during the first 30 days, even after adjusting for important covariates. This suggests that a brief, clinical evaluations of patient attitudes regarding CPAP therapy can have important predictive value.
Prior studies have demonstrated that long-term CPAP adherence patterns are often established within the first week of therapy.18,19,36 Moreover, measures of the experience with and benefit perceived from CPAP therapy after just the first night of CPAP titration have been shown to be important factors in determining long-term adherence.28,47 Therefore, assessing this initial night of therapy would be helpful in determining which patients are "at risk," particularly since effective interventions such as education and support programs exist for increasing CPAP adherence.38–41
Tools for assessing patient perceptions and beliefs about therapy already exist and are very useful for developing a multidimensional understanding of factors related to CPAP adherence.19,33,35 However, most of these assessments are lengthy and may not be practical in a busy clinical setting. Notably, Lewis et al. demonstrated that even a single question on the morning following CPAP titration may predict adherence.28 In this study, the patients were asked a closed-ended simple question: "Have you encountered any problems during this first night of CPAP?'' with two possible responses: "yes" or "no." Their study, however, included only 70 patients with significant underrepresentation of women (n = 4) and ethnic minorities. In contrast, our pilot study included significant numbers of African Americans and women and demonstrated that a four-question assessment provides a brief and simple method of assessing CPAP therapy perception and significantly predicts mean 30-day CPAP adherence. It is important to note that there are significant similarities between the single closed-ended question asked by Lewis et al. and two of the questions included in our CPAP perception questionnaire that were answered on a Likert scale: "How much difficulty did you have tolerating CPAP?" and "How uncomfortable was the CPAP pressure?" Therefore, our results confirm the findings of Lewis et al., that reporting problems after the first night of CPAP use is an important predictor of poor CPAP adherence.
We initially evaluated responses to six brief questions; of those, two questions—"How uncomfortable was the mask?" and "What is your attitude towards CPAP therapy?"—were not significantly predictive of CPAP adherence. The lack of association between the second question—"How uncomfortable was the mask?"—and CPAP adherence was observed despite the fact that the range of responses to this question was broad. Reasons for this remain unclear, but could be related to subsequent intervention and adjustment of mask fit by DME providers during the first 30 days of therapy. The lack of predictive value with the sixth question—"What is your attitude towards CPAP therapy?"—could be related to patients' unwillingness to voice a negative attitude towards potential therapy. Alternatively, the question may have simply been too vague.
Our group has previously reported that African American race and a non-sleep specialist ordering the PSG and home CPAP therapy were also predictive of decreased CPAP adherence, even after adjusting for relevant covariates.20 Lower CPAP adherence in African Americans has been reported by other groups as well.18,22,48,49 Whether this finding is related to other factors not captured by education level or insurance status, such as socioeconomic status, health literacy, or health beliefs surrounding CPAP therapy, requires further study. Although it is plausible that CPAP adherence is lower in African Americans because of shorter habitual sleep duration, the impact of race on CPAP adherence remained unchanged when we introduced self-reported habitual sleep duration into the model.
Regarding our finding that a consultation with a sleep specialist prior to undergoing a diagnostic PSG was predictive of increased 30-day CPAP use, it is possible that contact with a sleep specialist may have led to improved patient education, better awareness about OSA and its implications, and emphasis on the importance of CPAP therapy. Other investigators have reported that patients managed by accredited sleep centers have a reduced risk of discontinuing CPAP therapy.21 In spite of this, response patterns to the fifth question—"How beneficial do you think CPAP is going to be for your health and sleep?"—were not different when comparing patients referred by sleep specialists to those referred by non-sleep specialists. This question may not have been sufficient to capture the impact of sleep specialist consultation on patients' CPAP perception.
Our study had several limitations. First, a number of patients were excluded from our analysis due to a lack of objective CPAP adherence data. In all of these cases, the adherence data were missing due to either lack of or malfunction of wireless modem devices. Although there were no significant differences in baseline characteristics of included and excluded patients (suggesting a lack of systematic bias), the mean CPAP perception score was higher in the excluded cohort (18 ± 8 vs. 16 ± 7, p = 0.013). The clinical significance of this difference remains unclear given that the CPAP perception questionnaire has a scale of 4 to 40. Second, ours was a single-center study which limits the generalizability of our findings. Importantly, however, our study did include a substantial proportion of African Americans and women, two patient populations frequently under-studied with respect to CPAP therapy adherence. The retrospective nature of our study may also limit the conclusions that can be drawn about the reported associations. Our findings will therefore need to be validated prospectively in different patient populations.
It should be noted that our questionnaire was developed out of a longstanding quality-improvement initiative to assess patient perception of CPAP therapy after CPAP titration, a practice that is employed in many sleep laboratories. Our findings demonstrate the clinical utility and predictive power of a practical and simple questionnaire for post-CPAP titration assessment of patients' perceptions.
In summary, our pilot study demonstrates that 30-day CPAP adherence can be predicted by a brief assessment of patients' experiences and beliefs performed on the morning after an in-laboratory CPAP-titration. Those patients with scores suggesting an increased risk of non-adherence can then be targeted for interventions designed to improve adherence. Prospective validation of our questionnaire in a larger, more varied population is warranted. In addition, it would be intriguing to assess the utility of this questionnaire in predicting adherence when administered not just on the morning following CPAP titration but also on outpatient follow-up.
This was not an industry supported study. The authors have indicated no financial conflicts of interest.
Support for this study was provided in part by NIH Grant HD057796.
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Means MK, Ulmer CS, Edinger JD, authors. Ethnic differences in continuous positive airway pressure (CPAP) adherence in veterans with and without psychiatric disorders. Behav Sleep Med. 2010;8:260–73. [PubMed]
Joo MJ, Herdegen JJ, authors. Sleep apnea in an urban public hospital: assessment of severity and treatment adherence. J Clin Sleep Med. 2007;3:285–8. [PubMed Central][PubMed]
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Christmas day Menu
4 Course Set Menu | £74.99
Available on 25th December
Eat, drink and be merry this Christmas Day with our specially designed menu. Enjoy Christmas together with the tastiest roast of the year designed to help spread Christmas cheer.
Oak-Smoked Salmon & Pan-Fried Scallops†
Scottish salmon served with bubble & squeak, watercress and a dill & lemon dressing
Mushroom & Truffle Soup (v)
Topped with sautéed mushrooms, chopped chives and a swirl of cream, served with a cheese puff pastry twist
Caramelised Winter Vegetable Soup (Ve)
Topped with roasted winter vegetables and served with bread and chopped chives
Goat's Cheese Roulade (V) (N)
Goat's cheese with a walnut crumb, served with a whole roasted fig and a beetroot & watercress salad, topped with a balsamic dressing
Chicken, Confit Duck & Plum Terrine
Served with toasted bread and butter, whole roasted fig, watercress, crispy shallots and a fig, cranberry & date chutney
Hand-Carved Roast Turkey and Honey-Roast Ham^
Served with goose fat roast potatoes, dauphinoise potatoes, pig-in-blanket, sausage meat stuffing,
Yorkshire pudding, seasonal vegetables and gravy
Trio of Seafood†^
Roasted sea trout topped with pan-fried scallops, served with bubble & squeak, samphire, fine green
beans, green cabbage, watercress and mussels in a shellfish bisque
Beetroot Wellington (Ve)
Roasted beetroot & butternut squash with cranberry sauce, encased in puff pastry, served with roast baby potatoes, seasonal vegetables and vegan gravy
Fillet Steak Rossini^
7oz* fillet steak served on a toasted crouton with chicken liver parfait, roasted red onion
and sautéed mushrooms. Served with goose fat roast potatoes, Yorkshire pudding, seasonal
vegetables and a rich beef dripping gravy
Christmas Nut Roast (V) (N)
Butternut squash, cashew & walnut roast topped with Croxton Manor Brie and cranberry sauce.
Served with roast baby potatoes. a Yorkshire pudding, seasonal vegetables and gravy
Clementine Tart
Served with a raspberry sorbet and coulis, shortbread crumb, with a white chocolate mousse,
fresh raspberries and a marbled chocolate pencil
Prosecco Sorbet and Forest Fruits (Ve)
A refreshing Prosecco sorbet, served with black cherry compote, fresh strawberries and raspberries
Chocolate & Salted Caramel Choux Bun
A large choux bun filled with mascarpone cream, served with clotted cream ice cream, topped with
a salted caramel sauce and warm chocolate sauce
Christmas Pudding (V)
Served with redcurrants and a Drambuie® & clotted cream sauce
Cheese Board
Cheese and Biscuits
Croxton Manor Brie, Stilton® and mature Cheddar, served with grapes and a fig, cranberry & date chutney
Enjoy complimentary festive petit fours as the perfect way to finish your meal. Vegan petit fours available.
Deposit Information
Please note that a deposit of £10 per adult and £10 per child (up to the age of 12) is required to secure your booking.
Booking Information
Please note that a non-refundable deposit of £10 per adult and £10 per child (up to the age of 12) is required to secure your booking .
Can't see the date and time you're looking for? Give us a call on 01787 378494 and we will do our best to accommodate you.
Please note that to receive your £15 gift your deposit must be paid in full by the 31st October. Your £15 gift will be sent via email to you on the 2nd January 2020.
Terms & Conditions
(V) Suitable for vegetarians. (Ve) Suitable for vegans. (N) Dish contains nuts. † Fish dishes may contain bones and or shell. ^ Dish contains alcohol. *All weights are approximate before cooking. We aim to make our food enjoyable for as many people as possible, so we have a great range of vegetarian, vegan and dietary specific dishes.
Our menu descriptions do not list all ingredients. Some dishes may contain alcohol which may not be listed on the menu. Please advise the team of any dietary requirements before ordering. All of our dishes are prepared in kitchens where nuts and gluten are present as well as other allergens; therefore, we cannot guarantee that any food item is completely free from traces of allergens, due to the risk of unexpected cross contamination. Please be aware the allergen information for our dishes may change between the date of booking and the date of your visit. We would advise all of our guests contact a member of the team on the date of their visit to confirm the allergen information of our meals. All products subject to availability on a site-by-site basis. If booking for Christmas Day menu (available
exclusively on the 25th December 2019) this will require a £10 per person deposit. No booking is confirmed until a deposit is received.
Full Payment and menu choices for Christmas Day bookings are required by the 17th November 2019. If booking after this date, full
payment and your menu choices will be required within 48 hours of booking. If you need to cancel your booking please contact us ASAP as any meals not taken on the day may be charged unless 48 hours notice is given. Management reserves the right to withdraw/
change offers (without notice), at any time. All service charges, cash and credit/debit card tips are paid in full to our team members.
Promoter: Greene King Brewing and Retailing Ltd, Sunrise House, Ninth Avenue, Burton upon Trent, Staffordshire, DE14 3JZ.
Stilton® and Drambuie® are registered trademarks.
To be eligible to receive a voucher, you must make an online booking on one of our Festive menus for a minimum party of four guests. The online booking must be made and a deposit paid in full by 17th November. £15 gift vouchers are valid from 2nd January to 31st May 2020 - excluding Valentine's Day 14th February 2020, Mother's Day 22nd March 2020, Easter weekend 10th to 13th April 2020 and May Bank Holiday's 8th & 25th May 2020. Only one gift voucher will be accepted per transaction. No cash alternative. The voucher may only be used in a single transaction and no change will be given. At least £5 of the total voucher value must be spent on food, including at least one main meal, which can include breakfast and sharers. Voucher cannot be used against the balance of the Festive booking. Voucher cannot be used against the purchase of gift cards. The voucher cannot be used in conjunction with other discount vouchers or Greene King employee vouchers including friend & family vouchers – but can be used against promotion (e.g. daily deals or set menus). Greene King reserves the right to withdraw or amend the offer at any time. Gift vouchers are not available to Greene King employees or those under 18 years old. Vouchers will be delivered electronically by email on 2nd January 2020 (if you have provided a valid email address as part of your online booking and have opted-in to receive our marketing communications). Gift vouchers are redeemable at participating Pub & Dining pubs. To redeem, please present your unique voucher code within the email you receive at the till. Enjoy responsibly. Proof of identity may be requested. Age restrictions apply to certain products, serving times and locations. If you are under 18, please check with your pub in advance. Cash value of this voucher £0.00000001. This voucher is not transferable. Online booking subject to availability. Offer subject to availability. We reserve the right to cancel, amend or withdraw this offer at any time. Promoter: Greene King Brewing and Retailing Limited, Sunrise House, Ninth Avenue, Burton-Upon-Trent, Staffordshire.
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subset: commoncrawl


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Nutrition Facts
Ingredients and Preparation
- Heat oven to 200°F. Wrap pita rounds in aluminum foil and warm in oven about 10 minutes.
- Meanwhile, heat oil in a large nonstick skillet over medium-high heat. Add eggplant and onion, and sauté 9 minutes. Stir in garbanzo beans, cumin, lemon juice, and tomato, and cook 3-4 minutes, until beans are heated through. Add 2 tablespoons reserved garbanzo bean liquid, stir in parsley and 2 tablespoons feta, season with salt and pepper, and remove from heat.
- Cut warmed pita rounds in half. Spoon eggplant mixture into each half, top with remaining 2 tablespoons feta, and serve.


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For reasons that have eluded people forever, many of us seem bent on our own destruction. Recently more human beings have been dying by suicide annually than by murder and warfare combined. Despite the progress made by science, medicine and mental-health care in the 20th century — the sequencing of our genome, the advent of antidepressants, the reconsidering of asylums and lobotomies — nothing has been able to drive down the suicide rate in the general population. In the United States, it has held relatively steady since 1942. Worldwide, roughly one million people kill themselves every year. Last year, more active-duty U.S. soldiers killed themselves than died in combat; their suicide rate has been rising since 2004. Last month, the Centers for Disease Control and Prevention announced that the suicide rate among middle-aged Americans has climbed nearly 30 percent since 1999. In response to that widely reported increase, Thomas Frieden, the director of the C.D.C., appeared on PBS NewsHour and advised viewers to cultivate a social life, get treatment for mental-health problems, exercise and consume alcohol in moderation. In essence, he was saying, keep out of those demographic groups with high suicide rates, which include people with a mental illness like a mood disorder, social isolates and substance abusers, as well as elderly white males, young American Indians, residents of the Southwest, adults who suffered abuse as children and people who have guns handy.
But most individuals in every one of those groups never have suicidal thoughts — even fewer act on them — and no data exist to explain the difference between those who will and those who won't. We also have no way of guessing when — in the next hour? in the next decade? — known risk factors might lead to an attempt. Our understanding of how suicidal thinking progresses, or how to spot and halt it, is little better now than it was two and a half centuries ago, when we first began to consider suicide a medical rather than philosophical problem and physicians prescribed, to ward it off, buckets of cold water thrown at the head.
"We've never gone out and observed, as an ecologist would or a biologist would go out and observe the thing you're interested in for hours and hours and hours and then understand its basic properties and then work from that," Matthew K. Nock, the director of Harvard University's Laboratory for Clinical and Developmental Research, told me. "We've never done it."
It was a bright December morning, and we were in his office on the 12th floor of the building that houses the school's psychology department, a white concrete slab jutting above its neighbors like a watchtower. Below, Cambridge looked like a toy city — gabled roofs and steeples, a ribbon of road, windshields winking in the sun. Nock had just held a meeting with four members of his research team — he in his swivel chair, they on his sofa — about several of the studies they were running. His blue eyes matched his diamond-plaid sweater, and he was neatly shorn and upbeat. He seemed more like a youth soccer coach, which he is on Saturday mornings for his son's first-grade team, than an expert in self-destruction.
At the meeting, I listened to Nock and his researchers discuss a study they were collaborating on with the Army. They were calling soldiers who had recently attempted suicide and asking them to explain what they had done and why. Nock hoped that sifting through the interview transcripts for repeated phrasings or themes might suggest predictive patterns that he could design tests to catch. A clinical psychologist, he had trained each of his researchers how to ask specific questions over the telephone. Adam Jaroszewski, an earnest 29-year-old in tortoiseshell glasses, told me that he had been nervous about calling subjects in the hospital, where they were still recovering, and probing them about why they tried to end their lives: Why that moment? Why that method? Could anything have happened to make them change their minds? Though the soldiers had volunteered to talk, Jaroszewski worried about the inflections of his voice: how could he put them at ease and sound caring and grateful for their participation without ceding his neutral scientific tone? Nock, he said, told him that what helped him find a balance between empathy and objectivity was picturing Columbo, the frumpy, polite, persistently quizzical TV detective played by Peter Falk. "Just try to be really, really curious," Nock said.
That curiosity has made Nock, 39, one of the most original and influential suicide researchers in the world. In 2011, he received a MacArthur genius award for inventing new ways to investigate the hidden workings of a behavior that seems as impossible to untangle, empirically, as love or dreams.
Trying to study what people are thinking before they try to kill themselves is like trying to examine a shadow with a flashlight: the minute you spotlight it, it disappears. Researchers can't ethically induce suicidal thinking in the lab and watch it develop. Uniquely human, it can't be observed in other species. And it is impossible to interview anyone who has died by suicide. To understand it, psychologists have most often employed two frustratingly imprecise methods: they have investigated the lives of people who have killed themselves, and any notes that may have been left behind, looking for clues to what their thinking might have been, or they have asked people who have attempted suicide to describe their thought processes — though their mental states may differ from those of people whose attempts were lethal and their recollections may be incomplete or inaccurate. Such investigative methods can generate useful statistics and hypotheses about how a suicidal impulse might start and how it travels from thought to action, but that's not the same as objective evidence about how it unfolds in real time.
The inscrutability of suicide has not kept most psychologists who study it from theorizing about why people kill themselves. Nock, however, tends to approach theories from a different angle. "I think it's easy to generate explanations," he said recently. "It's much harder to test out these different explanations and see whether the data support them or not." At first, the stress of combat seemed to be the obvious reason for the jump in military suicides — until researchers realized that the rate has also risen among soldiers who were never deployed. Public-health experts have speculated that the uptick in suicides among the middle-aged is linked to modern tensions like the troubled economy, the stress of caring for elderly parents and insolvent children, and unprecedented access to prescription drugs. Nock, conversely, tends to point to a graph showing how the suicide rate for 45-to-64-year-olds has dipped and risen over a longer period of time — the rate today is similar to what it was 20 years ago. The graph tells a more complicated story. "My thought is that we've had theories of suicide for a long time and no data," he said. "So we want to work from the other end."
Indeed, Nock has started from scratch by searching for a way to precisely measure suicide risk. Three years ago, he and his team published a paper suggesting that they had found, for the first time, an objective test that could predict a psychiatric patient's likelihood of a suicide attempt better than the patient or his clinician could. Nock is now running it and other tests on hundreds of people — those who have tried to kill themselves, those who have had suicidal thoughts and those who have not — to see how the initial scores differ from one group to another and whether those scores will end up having forecasted, beyond what current methods can, who will try to kill themselves in the future.
Each data point Nock collects moves him one step closer to his ultimate goal: to be able to give people a series of tests that could tell them — and their psychiatrists or primary care physicians or school nurses — how high their risk of suicide is at any given moment, much the way cardiologists can use blood-pressure and cholesterol readings combined with weight and height to calculate a person's risk of heart disease.
Each data point is also a person whose impossibly complex conscious and unconscious thoughts — about who they are, what they want, what's possible and tolerable — highlight both why such tests are needed and why it is so surprising that they might actually work.
When Melissa was growing up in Southern California, her playmates included six imaginary princesses. One of them was always getting captured, and Melissa, a princess herself, would save her, she told me. We were in a teashop on a February afternoon in Harvard Square, where the clattering dishes, the hiss of steaming milk and the wash of voices cocooned our conversation the way she preferred. Melissa, who asked to be identified only by her middle name, wore a thin, white-checkered coat. She was 18, petite and pale, with faint freckles and auburn hair collected in a silver clip. Last November, she tried to kill herself in her college dorm room with an overdose of pills. Now, three months later, she had completed a residential treatment program at McLean Hospital in Belmont, Mass., and was living in a transitional house in Cambridge for psychiatric patients. She was taking classes at a local extension school; to return to her former college, a liberal-arts academy in another state, she would need to reapply. I first met Melissa in Nock's lab and was impressed by her cinematic memory. But even for her, trying to recreate the progress of her suicidal thoughts was like trying to trace a breaking wave back out to the ocean. Her parents, her doctors and even Melissa herself had not known the wave was coming until it hit. Now all of them were hoping to turn back future danger without knowing exactly what to look for.
In seventh grade, Melissa said, she sometimes wrote "goodbye notes" in her head in the shower. That year, she started feeling excluded by her friends, and because she was later than other girls to hit her growth spurt, she said, she looked like an outsider too. The notions she had about ending her life were mostly fantasy. "It was never something that I talked about, but it was always kind of there," she said. She hadn't considered herself "brave enough" to really do it, though she now thought "brave" was a weird word to use.
Melissa talked about her high-school years with animation, doing goofy voices to narrate the naïve thoughts of her younger self. She recalled mean messages her classmates had posted about her on a popular online forum, even as she sympathized with what she saw as their desire to fit in. Early on, she started drinking regularly and smoking pot. She starved herself. She fought with her parents. Her grades dropped. The summer after her sophomore year, Melissa told her parents that she felt suicidal and needed to go to a hospital; doctors there held her for five days and prescribed medication that her father, a neurobiologist, and her mother, a biochemist, refused because they felt it was far too strong for her, her mother told me. Eventually afraid to leave her alone for even a few minutes, they enrolled her in an inpatient program for substance abuse and mental illness. Melissa felt the counselors there punished her for her behavior instead of helping her learn how to change it, and they held her beyond the month she expected. "They said I was resisting treatment," she said. "Really the only thing that it taught me was that I have to get myself out of here. To leave, I had to explain why I was manipulative, passive-aggressive, how I relate to boys by expressing my sexuality." These assumptions offended her, and she didn't believe they were true. Ultimately, however, she told her doctors what she thought they wanted to hear, and they let her go.
Melissa saw a psychiatrist, who prescribed medication for depression and anxiety, and she went through several outpatient programs with better results. She transferred to a new school for her junior year, which eased her social stress; she was a competitive athlete, acted in plays and raised money for impoverished children in India that she delivered in person. She was accepted by her first-choice college. The summer before she left home, at a ceremony at a treatment center, she told me, the mother of another girl said to her, "I don't understand why you would be here in the first place, because it seems like you have everything figured out." Outwardly she accepted the remark as a compliment, though it startled her to realize that she seemed to have everyone fooled. "At that exact point in time," she said, "I was thinking about anything except being alive."
Her parents, worried, stipulated that they would pay her college tuition only if she attended weekly therapy sessions at the school's health-services center, which would report missed attendance to them. But Melissa wanted to start over. She skipped sessions and stopped taking her medication — despite the potentially dangerous side effects of quitting abruptly — saving the pills in a baggie instead. Her mother told me she flew out to check on her, but Melissa didn't want to see her. She was 18 by then and in charge of her own health care. At the teashop, Melissa described how she decorated her new dorm room, putting up a Harry Potter poster she brought from home and making the bed with blue sheets her mother bought for her when she was 13 and scared to go to sleep. She found friends, began drinking and doing drugs again and fell behind in her classes. About a month into the semester, she said, a painful episode between her and a boy she was seeing became campus gossip, making her feel heartbroken and exposed. She couldn't say exactly how or when she formed a plan to use the pills she had saved as "an emergency-exit measure."
She tugged at a pink hair tie on her wrist. "I'm having a hard time explaining this," she told me. "It wasn't one specific moment. It was just everything."
I asked her if the therapists she saw ever questioned whether she had suicidal thoughts. "They always asked," she said. "And the answer I always gave was yes, I had thoughts, and that it was nothing I would act on. It was sort of a robot answer, and it wasn't really true, but I wasn't in a position that I could say, 'No, I love my life,' and I wasn't in a position where I could say, 'Yes, I spend my subway rides planning out my goodbye note.' "
On the evening after Halloween, Melissa was hung over and wearing most of her angel costume from the night before, when she and her roommate, dressed as a devil, went to a campus party. A week earlier, she revived the relationship with the boy who hurt her. Now she received a text from him telling her to stop being so needy. She recalled feeling as if everyone would be better off if she disappeared; she wasn't making the world a better place and didn't deserve to be in it. Sitting on her bed, she wrote a goodbye letter in her favorite notebook while her roommate and a few of their friends listened to music and did homework. When Melissa's friends asked if she wanted to go to the dining hall for ice cream, she declined. After they left, she swallowed the pills. She woke from a coma in intensive care, intubated. Paramedics had scissored off her clothes, revealing "Do not resuscitate" scrawled on her forearms in red Sharpie. She didn't remember writing it.
Melissa found it hard to say why she tried to kill herself when she did — how that night differed from others when she had felt wounded or sad. "Everything just kind of hit me all at once," she said. "I was behind in my classes. I felt like my friends were embarrassed by me. And, I don't know, I just felt like I had screwed up my life so badly that this was the only way out."
Nock didn't plan to devote his career to researching self-harm. The son of an auto mechanic, he grew up pumping gas and learning to fix cars at the service station his parents own in Basking Ridge, N.J., while also taking other jobs: tuxedo-rental clerk, ice-rink guard, windshield repairer. He was the first member of his family to graduate from college and expected to use his degree in psychology to become a clinician and work with patients. But the more time he spent with people who hurt themselves, the more he worried about treating their behavior. His first internship, while an undergrad at Boston University, was in a psychiatric unit for violent patients prone to severe self-injury: one man pulled out his eyeball, another arrived with deep gashes in his arms. Nock, who rarely mentioned his own feelings even when I asked him personal questions, said he grew close to the youngest patient on the unit, a man about his age. "When he was in treatment, moodwise he was pretty stable, pretty happy guy, pretty upbeat guy," Nock said. "We'd talk a lot about hip-hop and soccer." When he was released, around the time Nock's internship was ending, he killed himself. He was the first person Nock knew who died by suicide, and Nock had not foreseen it. He went on to get a doctorate in psychology from Yale, and instead of joining a clinical practice, he turned to academia and research.
Nothing in medical literature suggests a reliable method for accurately identifying suicidal patients. The earliest known reference to suicide is a poem, written on papyrus in Egypt 4,000 years ago. From then until the 1700s, artists, philosophers and religious figures, rather than doctors or scientists, were the only ones to wrestle with the subject, according to George Howe Colt's comprehensive history, "The Enigma of Suicide." It was a sociologist, Émile Durkheim, who offered the first unified theory of suicide, "Le Suicide," which has underpinned suicide science ever since it was published in 1897. Durkheim argued that suicidal feelings occur in response to a person's relationship with society: not being part of a community and sudden disruptions in the fabric of daily life are potential triggers. Freud put suicide in the same category as masochism, which he attributed to an aggressively critical superego turning on the self. Recent psychological theories posit that suicide is driven by intense mental pain: hopelessness, a yearning for escape, a sense of not belonging, feelings of burdensomeness.
But suicidal behavior also appears to run in families, suggesting it has biological roots. "We think that there are many genes — there might be hundreds, there might be thousands, each of which might contribute a tiny amount individually" to heightened risk, says Jordan Smoller, a psychiatric geneticist at Massachusetts General Hospital who has collaborated with Nock. Gustavo Turecki, the director of the McGill Group for Suicide Studies, has also shown that one major risk factor linked to suicide, having suffered abuse in childhood, can cause changes in the receptors of brain cells that regulate the stress hormone cortisol, leaving the brain in a chemical state of increased alertness that causes a person to overreact to stress. "Our emotions are all somewhere coded in our brains," Turecki told me, and identifying what mechanisms drive suicide could one day enable scientists to tailor drug therapies to reduce risk. Right now, though, Nock's tests appear to offer our best hope for a diagnostic tool that could work on anyone, no matter what complex social and biological factors are prompting suicidal thoughts. They also offer a way of seeing how such thinking operates, which could help us understand why it happens.
In 2003, during his first year teaching at Harvard, Nock approached his colleague Mahzarin Banaji with a proposal. Banaji had helped develop the Implicit Association Test, which was introduced to social psychology five years earlier and has become famous for its ability to measure biases that subjects either don't care to acknowledge or don't realize they have on topics like race, sexuality, gender and age. Nock wondered if the I.A.T. could be configured to measure people's bias for and against being alive and being dead, and Banaji thought it was worth a try. They experimented with several versions in Nock's lab and at the psychiatric-emergency department at Mass General. Then they put their best one on a laptop and offered it to Mass General patients, many of whom had recently threatened or attempted suicide; 157 agreed to take it. Hunched in plastic waiting-room chairs or propped up in cots as they waited for a clinician to admit or discharge them, they were often grateful for a distraction.
Balancing the computer on their thighs, the patients held their pointer fingers over left and right keyboard keys. The heading "Life" appeared in the upper left corner of the screen, "Death" in the upper right. In the center, words associated with one of the headings popped up one at a time. Patients jabbed the left key to link "alive," "survive," "breathing," "thrive" and "live" with "Life"; the right key matched "funeral," "lifeless," "die," "deceased" and "suicide" with "Death." The researchers asked the volunteers to do this as quickly as they could. Each word had a correct response. If patients put "thrive" with "Death," for instance, a red X appeared, and the test paused until they hit the proper key. The sorting continued as the words reappeared randomly. After about a minute, the headers switched sides, and the process repeated. Then new rubrics popped up — "Me," "Not Me" — along with new words to sort: "self," "I," "myself," "my," "mine," "other," "theirs," "they," "them," "their." Again the headers flipped places, and the sorting continued.
Once the patients had established a rhythm, the test began to measure bias. The headers doubled up: "Life" above "Me" and "Death" above "Not Me," forcing test-takers to hit the same button to group "thrive" and "breathing" with "self," "my" and "myself." "Die" and "funeral" went with "theirs," "they," "them." Theoretically, the faster the patients were and the fewer mistakes they made on this part of the test, the more they associated themselves with living.
Then "Life" and "Death" switched places, swapping the associations; the same key grouped "myself" and "my" with "funeral," "suicide," "die," "deceased." Agility on this part of the test would suggest an association with dying.
Doctors of all kinds, including psychologists, do no better than pure chance at predicting who will attempt suicide and who won't. Their patients often lie about their feelings to avoid hospitalization. Many also appear to mislead by accident, not realizing they are a risk to themselves or realizing but not knowing how to say so. Some 90 percent of young people who kill themselves have visited their primary-care doctors within a year; nearly 40 percent of adults have within a month. The opportunity to help them seems enormous, if only there were a way to see past appearances and identify an inclination they might be hiding — perhaps even from themselves.
The Mass General patients and their clinicians rated on separate scales how likely they thought they were to try to kill themselves in the future. When researchers checked on each patient six months later, they discovered that, as expected, clinicians had fared no better than 50-50 in their predictions. Patients themselves, it turned out, were only slightly more accurate. The I.A.T., to everyone's surprise, bested them both. People who sorted words more quickly when "Death" was paired with "Me" than with "Not Me" proved three times as likely to try to kill themselves as people who sorted words more quickly when "Life" was paired with "Me." The I.A.T., it seemed, was picking up a heightened signal of suicidal tendencies that the most commonly used method for assessing risk — a clinical interview — had been powerless to detect.
On an unseasonably warm morning in January, a McLean Hospital van dropped Melissa off at Nock's lab, where one of his postdoctoral researchers, Cassie Glenn, was running the I.A.T. and two other tests on volunteers from 12 to 19 years old. She had advertised for subjects on Craigslist and Twitter and through fliers in hospitals. About eight test-takers came in the past month, often on Sunday afternoons, in pink zip-up hoodies or jeans with holes in the knees, wearing Red Sox caps or glitter eye shadow. I met one girl who was giggly and two boys who were shy. Two volunteers were not yet 18 and brought their mothers. Glenn, a cheerful Roller Derby player with a colorful tattoo beneath each wrist, gave them a permission form they could sign to let me watch them take the tests or interview them. Protective of her subjects, she always asked that I wait out of sight so that they wouldn't feel any pressure. Melissa was the fourth to sign on to meet me. When Glenn introduced us, Melissa held out her hand, listing slightly toward a purse with cartoon animals stitched on its side, slung over her opposite shoulder. "Would it be possible to take a break?" she asked Glenn. "Could I go downstairs and smoke a cigarette?" Glenn said yes, as long as she went with her. "You can come, too," Melissa told me, "if you want to ask me questions."
Outside, she perched on a bike rack, packing Marlboro Red 100s against her palm. I asked her why she volunteered for the tests, and she told me that in college, she took a psychology class in which she read about famous case studies. At McLean, curious about what it would be like to be a research subject, she asked her doctors how to become one. "I've always been interested, from an observer's point of view, in what they would say about me," she said. She paused, took a drag and gazed off down the street as she exhaled, playing the part of a tragic ingénue while making it clear that she knew she was onstage — that a real part of her was vulnerable to my opinion. Nock had told me that talking with people about their past suicide attempts does not increase the odds that they will try again. But I still worried about asking Melissa to revisit her experience. I wanted to know that she wouldn't hurt herself again, but I couldn't. I was afraid that if she did, I would feel responsible. It was, I realized, the same anxiety I heard from clinicians and researchers and family and friends who are involved with people thought to be at heightened risk for suicide. There was nothing I, or anyone else, could do to be absolutely certain she stayed safe.
We took the elevator back upstairs. In a tiny yellow room, Glenn settled Melissa in a wooden chair facing an ancient-looking P.C. Glenn and I watched through a tinted square window behind her. The first test was the Stroop, which psychologists use to identify words that are especially meaningful to the test taker. In Nock's version, words appear on-screen in blue or red type, and as fast as possible the test-taker pushes one key if the word is red and another key if it's blue. People who are contemplating suicide, knowingly or not, appear to take a fraction of a second longer to push the button when the word on the screen is related to suicide than when it is a neutral word like "engine" or "museum." As Melissa hit the keys, the words barely registered as more than bursts of color: "happy," "funeral," "suicide," "alone," "museum," "dead," "pleasure," "paper," "pleasure," "paper," "rejected."
Next came the I.A.T. On-screen, the words appeared and vanished like a time-lapse koan: "deceased," "die," "myself," "breathing," "self," "thrive," "my," "funeral," "suicide," "other," "deceased," "breathing," "thrive," "theirs," "die," "myself."
"I missed some," Melissa said apologetically when the test ended and Glenn opened the door. "Don't worry," Glenn said, "I miss some, too."
Nock and his team are currently running the I.A.T. and Stroop at local and military hospitals as well as in the lab. They are also experimenting with other measures. Glenn later gave Melissa headphones and attached electrodes underneath her eye to measure how much a muscle there contracted when she heard a burst of noise meant to startle her. The noise was coupled with a series of pictures, some of which were related to suicide without being too graphic, like a man standing in front of a train. Glenn's hypothesis is that teenagers have to overcome a fear of death to attempt suicide and that the less startled they are when looking at suicide-related imagery, the more likely they may be to try to kill themselves in the future. Nock's plan is ultimately to combine four or five tests that measure slightly different cognitive processes into a single diagnostic tool that could deliver a risk score. But the scores Melissa and others get now will take on fuller meaning only over months and years of work — as researchers analyze them together in light of what the test-takers go on to do: become more or less depressed, start or stop having suicidal thoughts, hurt themselves in other ways or attempt suicide. Glenn would call Melissa in six months and again in a year to ask how she was doing and add those responses to her file.
If these data lead to reliable diagnostic tests, researchers could use them as a measuring tool to design studies of suicide that mirror the Framingham Heart Study, which has guided how we treat and prevent cardiovascular disease: 65 years ago, researchers began tracking the habits of and compiling regular medical workups on 5,209 residents of Framingham, Mass. It wasn't initially clear what the data they were collecting meant. But over decades, as some people developed heart disease and others didn't, their earlier test results and behavior began to reveal how high blood pressure and cholesterol, smoking, obesity and lack of exercise had helped cause it, how those factors could be entered into a calculator to determine risk and what would drive that risk down; once these insights led to treatments, the rate of deaths from heart disease nationwide, which had been steadily increasing since the turn of the century, began a steep decline.
Cognitive tests, of course, are not as fail-safe as a blood test. Nock says it is possible for patients taking the I.A.T. or the Stroop to adjust the speed of their keystrokes if they wish to hide their thoughts. "But it's much more difficult to change the way you report on the test than to change the way you report verbally to someone." Nock said. "It's really easy to say: 'I don't want to kill myself. I'm totally fine.' " Anyone can choose not to reveal what he's really thinking about. It's much harder, Nock said, to trick the tests.
But even if the tests could offer a suicide-risk score right now, clinicians and researchers still have questions about how they would use the number to treat patients. "One of the things I wonder is what do you do if somebody tests positive on one of these things and they deny that they're suicidal," says David A. Brent, who holds an endowed chair in suicide studies at the University of Pittsburgh School of Medicine. "Admittedly I'd rather have the information than not. But it's an interesting thing, you know, to say, 'Look, according to this you are thinking about suicide.' And would you be able to keep somebody in the hospital because of that? Would you change your treatment? I'm just not really sure."
Nock's refusal to accept any wisdom that can't be tested, including the seemingly logical notion that simply getting more suicidal people into treatment would solve the problem, has put him at odds with clinicians who believe their methods work and that questioning those could cost lives. In January, in partnership with Ronald Kessler, an epidemiologist at Harvard, he published a study showing that about one in eight American teenagers reported experiencing serious suicidal thoughts. Strikingly, more than half of them were getting therapy before or during the period when they became suicidal. Some clinicians e-mailed Nock to express anger that he would make such statistics public. Their position, he said, was that if you tell people treatment's not effective, they'll stop coming. "But I think there's a balance here," Nock said. "Yes, we want people to get treatment. But at the same time, we want to make sure the treatment they are getting is effective." Marsha Linehan, a psychology professor at the University of Washington, has shown that intensive therapy designed to change patterns of thinking and behavior can reduce the risk of attempted suicide among highly impulsive patients with severe emotional problems. This was the treatment Melissa received at McLean. Preliminary evidence suggests that other existing interventions might work too, but — largely because of how difficult it is to tell who is suicidal and when — a majority of people at high risk aren't getting them.
A major investment of money and manpower from the Army is set to revolutionize the scope of collecting data on suicidal behavior. Nock and his team are participating in the Army Study to Assess Risk and Resilience in Servicemembers, which got under way in 2009 and is the most comprehensive investigation of suicide ever undertaken. The Army's access to thousands of volunteers who lead comparable lifestyles and excel at following instructions offers a unique laboratory for Framingham-scale longitudinal studies. Nock envisions, for instance, one day beaming the I.A.T., Stroop and other tests to servicemembers' phones daily — a technological feat unthinkable a decade ago. Those scores might reveal suicidal thoughts in real time. They might also offer a way to monitor patients known to be at high risk and call them if they seem to be entering a dangerous frame of mind.
"Right now, we ask people if they're suicidal," Nock said. "And if they say yes, we give them medication to try and make them less depressed or less anxious or less psychotic or to have a more stable mood. And then we talk to them. We do talk therapy. And essentially talk them into not being suicidal anymore. And this over all as a strategy for many people does not seem to be curative." But if doctors could see which patients are suicidal at a given moment, they might be able to retrain their self-destructive thinking based on their test scores. If, as the I.A.T. seems to suggest, associating yourself more with dying than with living increases your risk for suicide, breaking that association might decrease it. To find out, Nock is developing computer tasks that he hopes could help get people, through rote practice, to identify more with being alive than dead. His researchers are also starting to test whether training people to think more positively about the past and the future makes them less likely to attempt suicide. Nock often talks about "turning levers," as if he were a railroad-switch operator manning an existential junction. "Can we think of suicide as resulting from problems with memory or cognition or attention?" he said. "And if so, can we then turn levers on those things to make people less likely to think about suicide? So, it's not giving a pill; it's giving a training."
Before I met Nock, I wondered what someone whose research requires constantly delving into the grief of others must be like. I imagined he would be solemn and weary. But he is a mechanic by background and temperament. His search for solutions is Socratic, not quixotic. He is an optimist. "It's a complex problem," he told me once, in his reasonable fashion, "but there are answers to it." At this point in his career, he has asked hundreds of people why they tried to kill themselves. More often than not, their responses have fueled rather than dulled his curiosity.
One evening in his office in January, I asked him if he'd ever gotten an answer that did make sense to him. It was a school holiday, and most of the building was empty. Nock, working late, was wearing a tracksuit top and trying to kick a five-cups-a-day coffee habit by sipping a mug of apple cider. Outside, far below in the dark, snowflakes were slicking the roads.
Nock began to talk about pain. He imagined the building was on fire and that leaping from the window was the only way out. He evoked piercing ear infections that no drug could touch. He said he knows what it is like to be in intense pain and have an urgent need for it to stop, though he has never been suicidal. But he knows from his research that in most cases, feeling suicidal — for whatever reason — is a state that comes and goes. This is what drives him to turn levers, to keep asking people who attempt suicide, "Why?" As individual as their responses are, they tend to share at least one detail. "Virtually all of them," he said, "say, 'I'm glad I didn't die.' "
Everyone wishes life could be different; no one's first choice is to be dead. Melissa wants to be an actress or a writer. It upsets her, she told me, to think about the anguish her suicide attempt caused her family and friends, and she is working on building a life she can feel is worth living. But she has said there are also times when she faces an impulse to hurt herself again. She was always matter-of-fact when she talked about trying to kill herself — it felt, she said, like telling a story about somebody else. On the afternoon we met in the square, she seemed weary of rehashing the past and eager to get to class. She traced a wet mark along the table and spoke softly about what she euphemistically called her goodbye note. "The word 'suicide' kind of freaks me out," she said, "so I try not to say it."


text:
When prescription drugs are no longer needed, there's a risk that they could end up being abused by people other than those for whom they were prescribed. The environmentally concerned also point out that drugs are considered hazardous waste and flushing drugs or throwing them into the trash can contaminate groundwater.
So what's a responsible person to do?
By using the secure medication drop box in the Pullman Police Department lobby, your discarded drugs will be incinerated at a facility approved by the EPA and Washington Department of Ecology.
There are no restrictions on the type of drugs that can be put into the collection box. However, the Pullman Police Department is unable to accept sharps or bio-hazardous waste for disposal. Please contact Pullman Disposal's Medical Waste Service at (509) 334-1914 or the Whitman County Health Department at (509) 332-6752 to arrange for the safe disposal of needles, syringes, lancets, or any other sharps or medical waste.
According to state law, when transporting prescription drugs, they must be in the original prescription containers with the labels attached. It is illegal to possess prescription drugs outside of the original container or to possess prescription drugs that are prescribed to someone else. (RCW 69.50.309: A person to whom or for whose use any controlled substance has been prescribed, sold, or dispensed by a practitioner, and the owner of any animal for which such controlled substance has been prescribed, sold, or dispensed may lawfully possess it only in the container in which it was delivered to him by the person selling or dispensing the same.)
The prescription labeling can be removed at the police department or the drugs can be
placed in plastic zipper bags that are provided by the department. If placed in a bag, the name of the drug should be written on the bag.
The Pullman Police Department drop box is accessible 24 hours a day, 7 days a week, in our main lobby.
Please note that the Pullman Police Department drop box is not intended for use by physician's offices, pharmacies, veterinarians or other professional producers of drug waste. A pharmacy may transfer controlled substances to a DEA registered reverse distributor for disposal of controlled substances.
The Pullman Pullman Department drop box is funded by a Washington State Attorney General Prescription Drug Abuse Grant negotiated by Sigrid Gauger of Palouse River Counseling and is part of the Whitman County Prescription and Over-the-Counter Drug Disposal Plan.
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Carmelo Anthony's wife, Lala, on numerous reports that the Nuggets star is leaving: 'None of it is true.'
Carmelo Anthony to New York. Carmelo Anthony to Houston. To New Jersey. To the L.A. Clippers. To Chicago.
His wife, Lala, says she has learned to shrug all the reports off and laugh. Speaking to the Morning Show on KS1075 today, Lala said 'none' of what has been reported through sourced stories throughout the summer about Anthony's whereabouts after this season is true.
"In the beginning it was stressful because you would hear so many things," she said. "I used to take it seriously, but now we've turned it more into a joke because literally every day, more than four times a day, we have moved or are moving to a different place. So, at that point it's just funny that how one minute we're here, five minutes later we're there… and none of it is true.
"You just kind of laugh and go through with it. Whenever anything is going to happen, if it is going to happen, we'll deal with it at that point. But right now, he's happy to be Denver Nugget. That's where my home is and where my mind is right now."
On the subject of moving out of Denver and the Anthonys putting their house up for sale, Lala stayed matter-of-fact but left the door ajar on the possibility we are witnessing his last days in Denver.
"I still live there," she said. "There's so much speculation out there. We did (the) George Lopez (Show) two days ago, and Melo made it clear: He's still a Denver Nugget. So no matter what you might hear or speculate, he is a Denver Nugget. He's been committed to that team and that city for seven years now. You've got to cut him a little bit of slack… He hasn't made a move yet.
"As of now, the plans are to report back to Denver for training camp. So let's just see how this plays out."
As for their wedding, which took place on July 10 in New York, Lala said it was Anthony's idea to make it huge; that she preferred a much smaller celebration.
"I said let's just go to Vegas and do it and be done with it," she said. "He was the one who wanted a big wedding and to invite everybody. And when it was all said and done we had about 385 guests there. So, it was definitely a big wedding."
Chris Dempsey: email@example.com


text:
get down(redirected from get someone down)
get (one) down
To cause someone to feel saddened, depressed, discouraged, or dejected. The thought of working for a faceless corporation really gets me down. His rejection from Harvard has really gotten Stephen down.
get (something) down
1. To be or become proficient at (doing) something. I know the music is difficult to play, so you just have to keep practicing until you get it down. After years of working in data entry, I've got Excel spreadsheets down.
2. To eat or drink something. I'm just going to get this burger down before I head out the door. Here, get this tea down. It will help your nerves. I don't know how I managed to get that medicine down, it tasted awful!
3. To commit something to writing; to write something down. Here, get my number down. You can call me anytime you like. I always try to get my dreams down as soon as I wake up, or else I forget them altogether.
get someone or something down (from something)
to bring someone or something down from a higher place. See if you can get my cat down from the tree. Please get down the sugar from the top shelf.
get someone or something down somethingand get someone or something down
to manage to put or force something downward. We finally got her down the stairs, but it was a struggle. Don had to push and push to get his laundry down the chute.
get someone down
to depress a person; to make a person very sad. My dog ran away, and it really got me down. Oh, that's too bad. Don't let it get you down.
get something down (in black and white)and get something down (on paper); get something down*
Fig. to record some important information in writing. (Alludes to the black of ink and the white of paper.) Be sure to get his statement down in black and white. I'm glad we have agreed on a price. I want to get it down in black and white. Get down every word of it! This is important. Please get it down on paper.
get down (from something)
to get off something; to climb down from something. Please get down from there this instant! Get down before you fall!
get down (on all fours)
to position oneself on one's hands and knees. He got down on all fours and played with the children. Mary got down and walked around like a dog.
get down
1. Sl. to lay one's money on the table. (Gambling.) Okay, every body get down. Get down, and let's get going!
2. Sl. to concentrate; to do something well. I'm flunking two subjects, man. I gotta get down. Come on, Sam, pay attention. Get down and learn this stuff.
3. Sl. to copulate. Hey, let's get down! All Steve wants to do is get down all the time.
get down
1. Descend; bring down; also, swallow. For example, He's getting down from the ladder, or Can you get the cat down from the tree? or I can't seem to get this pill down. [Late 1500s]
2. get down to. Give one's attention to, as in Let's get down to work, or It's time we got down to business. [Late 1800s] For the most important variants, see under get down to brass tacks.
3. get down on. See down on.
4. get someone down. Discourage or depress someone. For example, Don't let Mary's troubles get you down, or Day after day of rain really gets me down. [c. 1930]
5. Describe in writing, as in Can you get down all he's saying?
6. Lose one's inhibitions, enjoy oneself fully. For example, At our reunion we got down with all our old friends. [Slang]
get down
1. To descend or climb off of something: He got down off the table and stood in the middle of the kitchen. Get down off the roof before you fall!
2. To cause someone or something to descend or climb off of something: I tried to get the cat down from the tree.
3. To lower oneself by crouching or lying, especially on the ground or the floor: When the thieves started shooting, we all got down and covered our heads.
4. Slang To exhaust, discourage, or depress someone: The awful heat was getting me down.
5. To swallow something: I got the pill down by taking it with a large glass of water.
6. To master something: I finally got my Latin vocabulary down, and I'm ready for the test.
7. To put something in written form; to write down: I couldn't get down her name before my pen broke. The teacher spoke so fast that the students couldn't get it all down.
8. get down to To begin putting effort into something: We need to get down to work.
9. get down to To begin focusing attention on something: Let's get down to the basic facts and find out what really happened.
10. Slang To lose one's inhibitions; enjoy oneself wholeheartedly: Let's just get down and enjoy the party.
11. Slang To start dancing with great gusto and style: After they ate, the guests got down and boogied.
get down
1. in. to lay one's money on the table. (Gambling.) Get down, and let's get going!
2. in. to concentrate; to do something well. Come on, Sam, pay attention. Get down and learn this stuff.
3. in. to copulate. All Steve wants to do is get down all the time.
4. in. to dance. Whenever I hear that band, I really want to get down.