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Common Mental Health Disorders: Identification and Pathways to Care.2COMMON MENTAL HEALTH DISORDERS2.1. INTRODUCTIONThis guideline is concerned with the care and treatment of people with a common mental health disorder, including depression, generalised anxiety disorder (GAD), panic disorder, phobias, social anxiety disorder, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD). It makes recommendations about the delivery of effective identification, assessment and referral for treatment in primary care. The guideline will also be applicable to secondary care, and relevant (but does not make specific recommendations) for the prison service and non-NHS services such as social services, and the voluntary and independent sectors. A particular purpose of this guideline is to integrate existing NICE guidance on the identification and assessment of common mental health disorders and to provide recommendations to support the development of local care pathways for these disorders.The purpose of this introductory chapter is to provide an overview of the epidemiology and treatment of the common mental health disorders, and to highlight important issues related to identification and assessment of the disorders and the relevant local care pathways within the NHS.This guideline does not cover interventions to treat the disorders and should be used in conjunction with other relevant NICE guidelines, which give evidence of the effectiveness of interventions for the specific disorders, including drug treatments and psychological therapies:Self-harm: the Short-term Physical and Psychological Management and Secondary Prevention of Self-harm in Primary and Secondary Care (NICE, 2004c; NCCMH, 2004b).Obsessive-compulsive Disorder (NICE, 2005a; NCCMH, 2006).Post-traumatic Stress Disorder (PTSD) (NICE, 2005b; NCCMH, 2005).Antenatal and Postnatal Mental Health (NICE, 2007a; NCCMH, 2007).Depression (NICE, 2009a; NCCMH, 2010b).Depression in Adults with a Chronic Physical Health Problem (NICE, 2009b; NCCMH, 2010a).Generalised Anxiety Disorder and Panic Disorder (with or without Agoraphobia) in Adults(NICE, 2011a; NCCMH, 2011a).Self-harm: Longer-Term Management (NICE, 2011c; NCCMH, forthcoming). A NICE guideline on social anxiety disorder is expected in 2013.Go to:2.2. THE DISORDERSThis guideline covers the following common mental health disorders in adults (18 years and older):depression (including subthreshold disorders)anxiety disorders (including GAD, panic disorder, phobias, social anxiety disorder, OCD and PTSD).The guideline will also cover, where relevant, issues relating to comorbidity; however, as no separate NICE guideline addresses comorbid presentations of common mental health disorders, this will not be a key topic of the guideline. Groups not covered include adults with subthreshold mixed anxiety and depression, adults with psychotic and related disorders (including schizophrenia and bipolar disorder), people for whom drug and alcohol misuse are the primary problem, people with eating disorders, and children and people younger than 18 years old.2.2.1. Symptoms and presentationDepressionDepression refers to a wide range of mental health problems characterised by the absence of a positive affect (a loss of interest and enjoyment in ordinary things and experiences), low mood and a range of associated emotional, cognitive, physical and behavioural symptoms. Distinguishing the mood changes between clinically significant degrees of depression (for example, major depression) and those occurring ‘normally’ remains problematic and it is best to consider the symptoms of depression as occurring on a continuum of severity (Lewinsohn et al., 2000).Commonly, mood and affect in a major depressive illness are unreactive to circumstance remaining low throughout the course of each day, although for some people mood varies diurnally, with gradual improvement throughout the day only to return to a low mood on waking. In other cases a person's mood may be reactive to positive experiences and events, although these elevations in mood are not sustained with depressive feelings often quickly re-emerging (Andrews & Jenkins, 1999).Behavioural and physical symptoms typically include tearfulness, irritability, social withdrawal, an exacerbation of pre-existing pains, and pains secondary to increased muscle tension (Gerber et al., 1992). A lack of libido, fatigue and diminished activity are also common, although agitation and marked anxiety can frequently occur. Typically there is reduced sleep and lowered appetite (sometimes leading to significant weight loss), but some people sleep more than usual and have an increase in appetite. A loss of interest and enjoyment in everyday life, and feelings of guilt, worthlessness and deserved punishment are common, as are lowered self-esteem, loss of confidence, feelings of helplessness, suicidal ideation and attempts at self-harm or suicide. Cognitive changes include poor concentration and reduced attention, pessimistic and recurrently negative thoughts about oneself, one's past and the future, mental slowing and rumination (Cassano & Fava, 2002).Generalised anxiety disorderThe essential feature of GAD is excessive anxiety and worry (apprehensive expectation), occurring on more days than not for a period of at least 6 months, about a number of events or activities. The person with GAD finds it difficult to control the anxiety and worry, which is often accompanied by restlessness, being easily fatigued, having difficulty concentrating, irritability, muscle tension and disturbed sleep (Brownet al., 2001).The focus of the anxiety and worry in GAD is not confined to features of another disorder, for example having panic attacks (as in panic disorder) or being embarrassed in public (as in social anxiety disorder). Some people with GAD may become excessively apprehensive about the outcome of routine activities, in particular those associated with the health of or separation from loved ones. Some people often anticipate a catastrophic outcome from a mild physical symptom or a side effect of medication. Demoralisation is said to be a common consequence, with many individuals becoming discouraged, ashamed and unhappy about the difficulties of carrying out their normal routines. GAD is often comorbid with depression and this can make accurate diagnosis problematic (Wittchen et al., 2002).Panic disorderPeople with panic disorder report intermittent apprehension, and panic attacks (attacks of sudden short-lived anxiety) in relation to particular situations or spontaneous panic attacks, with no apparent cause. They often take action to avoid being in particular situations in order to prevent those feelings, which may develop into agoraphobia (Breier et al., 1986).The frequency and severity of panic attacks varies widely. Situational triggers for panic attacks can be external (for example, a phobic object or situation) or internal (physiological arousal). A panic attack may be unexpected (spontaneous or uncued), that is, one that an individual does not immediately associate with a situational trigger.The essential feature of agoraphobia is anxiety about being in places or situations from which escape might be difficult, embarrassing or in which help may not be available in the event of having a panic attack. This anxiety is said to typically lead to a pervasive avoidance of a variety of situations that may include: being alone outside the home or being home alone; being in a crowd of people; travelling by car or bus; being in a particular place, such as on a bridge or in a lift.Obsessive-compulsive disorderOCD is characterised by the presence of either obsessions or compulsions, but commonly both. An obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person's mind. Obsessions are distressing, but are acknowledged as originating in the person's mind and not imposed by an external agency. They are usually regarded by the individual as unreasonable or excessive. Common obsessions in OCD include contamination from dirt, germs, viruses, body fluids and so on, fear of harm (for example, that door locks are not safe), excessive concern with order or symmetry, obsessions with the body or physical symptoms, religious, sacrilegious or blasphemous thoughts, sexual thoughts (for example, of being a paedophile or a homosexual), an urge to hoard useless or worn out possessions, or thoughts of violence or aggression (for example, stabbing one's baby) (Lochner & Stein, 2003).Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, or a covert mental act that cannot be observed. Covert compulsions are generally more difficult to resist or monitor than overt ones because they can be performed anywhere without others knowing and are easier to perform. Common compulsions include checking (for example, gas taps), cleaning, washing, repeating acts, mental compulsions (for example, repeating special words or prayers in a set manner), ordering, symmetry or exactness, hoarding/collecting and counting (Foa et al., 1995). The most frequent presentations are checking and cleaning, and these are the most easily recognised because they are on a continuum with everyday behaviour. A compulsion is not in itself pleasurable, which differentiates it from impulsive acts such as shopping or gambling, which are associated with immediate gratification.Post-traumatic stress disorderPTSD often develops in response to one or more traumatic events such as deliberate acts of interpersonal violence, severe accidents, disasters or military action. Those at risk of PTSD include survivors of war and torture, of accidents and disasters, and of violent crime (for example, physical and sexual assaults, sexual abuse, bombings and riots), refugees, women who have experienced traumatic childbirth, people diagnosed with a life-threatening illness, and members of the armed forces, police and other emergency personnel (Foa et al., 2008).The most characteristic symptoms of PTSD are re-experiencing symptoms. People with PTSD involuntarily re-experience aspects of the traumatic event in a vivid and distressing way. Symptoms include flashbacks in which the person acts or feels as if the event is recurring; nightmares; and repetitive and distressing intrusive images or other sensory impressions from the event. Reminders of the traumatic event arouse intense distress and/or physiological reactions. As a result, hypervigilance for threat, exaggerated startle responses, irritability, difficulty in concentrating, sleep problems and avoidance of trauma reminders are other core symptoms. However, people with PTSD also describe symptoms of emotional numbing. These include inability to have any feelings, feeling detached from other people, giving up previously significant activities and amnesia for significant parts of the event.Two further common mental health disorders, social anxiety disorder and specific phobias, are briefly described below. However, because no NICE guidelines currently exist for these disorders they will not be discussed in detail in the remainder of this chapter.Social anxiety disorderSocial anxiety disorder, also referred to as social phobia, is characterised by an intense fear in social situations that results in considerable distress and in turn impacts on a person's ability to function effectively in aspects of their daily life. Central to the disorder is a fear of being judged by others and of being embarrassed or humiliated. This leads to the avoidance of a number of social situations and often impacts significantly on educational and vocational performance. The fears can be triggered by the actual or imagined scrutiny from others. The disorder often begins in early adolescence, and although an individual may recognise the problem as outside of normal experience, many do not seek help (Liebowitz et al., 1985).Social anxiety disorder is characterised by a range of physical symptoms including excessive blushing, sweating, trembling, palpitations and nausea. Panic attacks are common, as is the development of depressive symptoms as the problem becomes chronic. Alcohol or drug misuse can develop because people use these substances in an attempt to cope with the disturbing and disabling symptoms. It is also often comorbid with other disorders such as depression (Kessler et al., 1999).Specific phobiasA specific phobia is an unwarranted, extreme and persistent fear of a specific object or situation that is out of proportion to the actual danger or threat (Humphris et al., 1995). The fear and anxiety occur immediately upon encountering the feared object or situation and tend to lead to avoidance or extreme discomfort. The person with a specific phobia recognises that the fear is excessive, unwarranted or out of proportion to the actual risk. Specific phobias result in significant interference with the activities of daily life; they are usually grouped under a number of subtypes including animal, natural environment, blood-injection-injury and situational.2.2.2. Incidence and prevalenceEstimates of the prevalence of common mental health disorders vary considerably depending on where and when surveys are carried out, and the period over which prevalence is measured.The 2007 Office for National Statistics (ONS) household survey of adult psychiatric morbidity in England found that 16.2% of adults aged 16 to 64 years met the diagnostic criteria for at least one disorder in the week prior to interview (McManus et al., 2009). In the three ONS surveys carried out so far, the proportion of adults meeting the criteria for at least one disorder increased between 1993 and 2000 but did not change between 2000 and 2007 (15.5% in 1993, 17.5% in 2000 and 17.6% in 2007). The largest increase in the rate of disorders found between 1993 and 2007 was in women aged 45 to 64 years, among whom the rate went up by about one fifth (McManus et al., 2009).More than half of the adults identified with a common mental health disorder in the ONS survey presented with a mixed anxiety and depressive disorder (9% in the past week). The 1-week prevalence for the other common mental health disorders were 4.4% for GAD, 2.3% for a depressive episode, 1.4% for phobia, 1.1% for OCD and 1.1% for panic disorder (McManus et al., 2009).In the US, Kessler and colleagues conducted the National Comorbidity Survey, a representative household interview survey of 9,282 adults aged 18 years and over, to estimate the lifetime (Kessler et al., 2005a) and 12-month (Kessler et al., 2005b) prevalence rates of mental disorders classified using theDiagnostic and Statistical Manual of Mental Disorders (4th text-revision version; DSM-IV-TR) of the American Psychiatric Association (APA, 2000). A summary of their findings can be seen in Table 1. Of the 12-month cases in the US National Comorbidity Survey, 22.3% were classified as serious, 37.3% as moderate and 40.4% as mild. Fifty-five per cent carried only a single diagnosis, 22% two diagnoses and 23% three or more diagnoses. Latent class analysis identified three highly comorbid classes representing 7% of the population, and the authors concluded that, although mental disorders are widespread, serious cases are concentrated among a relatively small proportion of people with high comorbidity (Kessler et al., 2005b).Table 1Summary of prevalence rates for common mental health disorders.In summary, at any given time common mental health disorders can be found in around one in six people in the community, and around half of these have significant symptoms that would warrant intervention from healthcare professionals. Most have non-specific mixed anxiety and depressive symptoms, but a proportion have more specific depressive disorder or anxiety disorders including panic disorder, phobias, OCD or PTSD.The location, time and duration of the survey are not the only factors to influence prevalence rates. A number of demographic and socioeconomic factors are associated with a higher risk of disorders, including gender, age, marital status, ethnicity and socioeconomic deprivation. These will be discussed below.GenderDepression and anxiety disorders tend to have a higher prevalence in women. Prevalence rates of depression have consistently been found to be between 1.5 and 2.5 times higher in women than men (Waraich et al., 2004). In the ONS survey (McManus et al., 2009) women were more likely than men to have a disorder (19.7 and 12.5%, respectively), with rates significantly higher for women across all categories of disorder except for panic disorder and OCD. The greatest difference between genders was among South Asian adults where the age-standardised rate among women (34.3% of South Asian women) was three times that of men (10.3% of South Asian men). Reasons cited in the 2007 ONS survey (McManus et al., 2009) include the impact of having children (Bebbington et al., 1991), exposure to domestic or sexual violence (Patel et al., 2006), adverse experiences in childhood and women's relative poverty (Patel et al., 1999; Piccinelli & Wilkinson, 2000).AgeIn the 2007 ONS survey (McManus et al., 2009) rates varied by age, with those aged 75 years and over least likely to have a disorder (6.3% of men and 12.2% of women). In women, the rate peaked among 45- to 54-year-olds of whom 25% met the criteria for at least one disorder. Among men, the rate was highest in 25- to 54-year-olds (14.6% of 25- to 34-year-olds, 15.0% of 35- to 44-year-olds and 14.5% of 45- to 54-year-olds).Marital statusWomen across all marital-status categories were more likely than their male counterparts to have disorders in the 2007 ONS survey (McManus et al., 2009), except for divorced people in whom the prevalence for men and women was very similar (26.6% for women and 27.7% for men). Among men, those currently divorced had the greatest likelihood of having a disorder, but variation by other marital status categories was less pronounced. For women the rate of disorder was high for divorced women, but even higher for separated women (33.0%). Men and women who were married or widowed had the lowest observed rates of disorder (10.1% of married men and 16.3% of married women; 10.4% widowed men and 17.4% widowed women).EthnicityIn the 2007 ONS survey (McManus et al., 2009), after age-standardisation of the data, there was little variation between white, black and South Asian men in the rates of any disorder. However, among women rates of all disorders (except phobias) were higher in the South Asian group. The number of South Asian women in the sample was small, so while the differences were pronounced they were only significant for disorders as a whole for GAD and panic disorder.Socioeconomic factorsIn the 2007 ONS survey (McManus et al., 2009), people living in households with the lowest levels of income were more likely to have a disorder than those living in the highest income households. A number of socioeconomic factors significantly affected prevalence rates in the 2000 ONS survey (Singleton et al., 2001): those with a depressive episode were more likely than those without a disorder to be unemployed, to belong to social classes 4 and below, to have no formal educational qualifications, to live in Local Authority or Housing Association accommodation, to have moved three or more times in the last 2 years and to live in an urban environment.An illustration of the social origins of depression can be found in a general practice survey in which 7.2% (ranging 2.4 to 13.7%, depending upon the practice) of consecutive attendees had a depressive disorder. Neighbourhood social deprivation accounted for 48.3% of the variance among practices. Other variables were the proportion of the population having no or only one car and neighbourhood unemployment (Ostleret al., 2001). The evidence therefore overwhelmingly supports the view that the prevalence of common mental health disorders, however it is defined, varies according to gender and social and economic factors.Learning disabilitiesThe rates of common mental health disorders in adults with learning disabilities are generally considered to be higher, but limited data and methodological problems (Smiley, 2005) mean that precise estimates are often not available and so uncertainty remains. In contrast, there is clearer evidence that other mental disorders such as problem behaviour have a higher rate of learning disabilities (Cooper et al., 2007). Rates of mental disorders may vary with the severity of the learning disability, being higher in more severe disability (Whitaker & Read, 2006), and challenges in assessment and diagnosis are considerable especially for those with more severe learning disabilities (Smiley, 2005; Whitaker & Read, 2006). However, some indication of the possible differential incidence of common mental health disorders can be obtained from the following studies. Richards and colleagues (2001) report a four-fold increase in the rates of affective disorders for people with mild learning disability. Rates of problems may also vary with the disorder; for example, Collacott (1999) reports a higher rate of depression in adults with Down's syndrome than in adults with other causes of learning disability. With regard to anxiety disorders, Cooper (1997) reports a rate of 2.5% for OCD in adults with a learning disability, which is higher than in the general adult population.2.2.3. AetiologyThe aetiology of common mental health disorders is multi-factorial and involves psychological, social and biological factors. Many of the common mental health disorders have similar aetiologies. For example,King and colleagues (2008) identified five immutable risk factors for depression. These were younger age, female gender, lower educational achievement, previous history of depression and family history of depression. Brewin and colleagues (2000) and Ozer and colleagues (2003) identified similar risk factors for PTSD, including a previous personal or family history of anxiety disorders or affective disorders, neuroticism, lower intelligence, female gender and a history of previous trauma. The ONS survey (McManus et al., 2009) identified factors that may be associated with increased duration of an episode of depression or anxiety. These can be broadly defined as biological factors, social stresses and life events. These risk factors will now be discussed in general. For information regarding factors for specific disorders, please refer to the relevant NICE guideline (see Section 2.1).There is good evidence for biological factors in the development of many psychological disorders. Biological factors can be biochemical, endocrine and neurophysiological (Goodwin, 2000; Malhi et al., 2005) or genetic (Kendler & Prescott, 1999), and can interact with early trauma ultimately leading to psychological distress (Heim & Nemeroff, 2001).Support for this claim often comes from family-history studies (Angst et al., 2003). A family history of depressive illness has been linked with an increased chance of developing depression (Kendler et al., 2001). Similarly, the risk of GAD in first-degree relatives of patients with GAD was five times that of controls (Noyes et al., 1987). Although specific genes conferring vulnerability to GAD have not yet been reliably identified, the genes involved in the transmission of GAD appear to increase susceptibility to other anxiety disorders such as panic disorder and agoraphobia as well as major depression (Hettema et al., 2001 and 2005; Kendler, 1996). There is some evidence to suggest that personality traits such as neuroticism may have a role in the development of common mental health disorders. Personality traits such as neuroticism have been identified as risk factors for both depression (Fava & Kendler, 2000) and GAD (Hettema et al., 2004). However, the specific role of neurotransmitters and other chemical mediators in the aetiology of common mental health disorders is currently unclear.According to a stress-vulnerability model (Nuechterlein & Dawson, 1984), it is not only biological factors that can trigger the development of a common mental health disorder. Social triggers may also play an important role (Harris, 2000). The ONS survey (McManus et al., 2009) identified perceived financial strain (Weich & Lewis, 1998a), work stress (Stansfeld et al., 1999), poor housing (Weich & Lewis, 1998b) and social isolation (Bruce & Hoff, 1994) as key factors that can influence the development of common mental health disorders. In the UK, an influential study found that social vulnerability factors for depression in women in Camberwell, south-east London, included: having three or more children under the age of 14 years living at home; having no paid employment outside the home; and not having a confiding relationship with another person (Brown & Harris, 1978). The importance of a confiding relationship has been further reiterated by Patten (1991) who found that a lack of such a relationship was a strong risk factor for depression.Negative life events, particularly those relating to health, can also impact on the development of depression and anxiety, although vulnerabilities will vary between individuals (Harris, 2000). The ONS survey identified poor physical health and problems with alcohol use as predictors of anxiety and depression (Salokangas & Poutanen, 1998), while King and colleagues (2008) found that current poorer physical and mental health functional status, based on the 12-Item Short Form Health Survey (SF-12) questionnaire, was linked to the development of depression. However, it is also important to note that depression may lead to secondary disability that compounds, and is difficult to distinguish from, the depression itself.Early life experiences as well as current social stressors must also be considered. A poor parent–child relationship, marital discord and divorce, neglect, and physical and sexual abuse almost certainly increase a person's vulnerability to depression in later life (Fava & Kendler, 2000) and can play a vital role in the development of GAD. Barlow (2000) reported that good parenting experiences are important in providing children with a secure base from which to explore the world. Problems in child–parent attachment have been linked to feelings of diminished personal control of potentially threatening events (Barlow, 2000), which can in turn increase susceptibility to psychological illness.However, when considering the importance of life events it is important to remember that events may not have a causal impact on the development of symptoms. Instead, they may act as a trigger among people who are biologically or psychologically predisposed to a disorder, for example OCD (Gothelf et al., 2004; Khanna et al., 1988). The authors of the ONS survey make the point that although these risk factors are associated with disorders and tend to increase the duration of episodes it is not clear whether or not they cause the onset of an episode.2.2.4. Development, course and prognosisFor many people the onset of common mental health disorders occurs in adolescence or early adult life, but the disorders can affect people at any point. Earlier onset is generally associated with poorer outcomes. Kessler and colleagues (2005a) reported an estimated median age of onset for anxiety disorders of 11 years and for mood disorders of 30 years in their US National Comorbidity sample. Half of all lifetime cases had started by 14 years and three quarters by 24 years. Many anxiety disorders also have a chronic course. This chronic course may be associated with a considerable delay in presenting to services, with consequent significant personal and social impairment. Therefore, Kessler and colleagues (2005a) concluded that interventions aimed at prevention or early treatment needed to focus on young people.DepressionThe average age of the first episode of major depression is the mid-20s and although the first episode may occur at any time, from early childhood through to old age, a substantial proportion of people have their first depressive episode in childhood or adolescence (Fava & Kendler, 2000).Although depression has been understood to be a time-limited disorder lasting on average 4 to 6 months with complete recovery afterwards, it is now clear that incomplete recovery and relapse are common. The World Health Organization (WHO) study of mental disorders in 14 centres across the world found that 50% still had a diagnosis of depression 1 year later (Simon et al., 2002) and at least 10% of patients have persistent or chronic depression (Kessler et al., 2003). At least 50% of people following their first episode of major depression will go on to have at least one more episode (Kupfer, 1991), and after the second and third episodes the risk of further relapse rises to 70 and 90%, respectively (Kupfer, 1991). Early-onset depression (at or before 20 years of age) and depression occurring in old age have a significantly increased vulnerability to relapse (Giles et al., 1989; Mitchell & Subramaniam, 2005). Thus while the outlook for a first episode is good, the outlook for recurrent episodes over the long term can be poor with many patients experiencing symptoms of depression over many years (Akiskal, 1986).Generalised anxiety disorderMost clinical studies suggest that GAD is typically a chronic condition with low rates of remission over the short and medium term. Evaluation of prognosis is complicated by the frequent comorbidity with other anxiety disorders and depression, which worsen the long-term outcome and accompanying burden of disability (Tyrer & Baldwin, 2006). In the Harvard-Brown Anxiety Research Program, which recruited patients from Boston hospitals, the mean age of onset of GAD was 21 years, although many patients had been unwell since their teens. The average duration of illness in this group was about 20 years and despite treatment the outcome over the next 3 years was relatively poor, with only one in four patients showing symptomatic remission from GAD (Yonkers et al., 1996). The proportion of patients who became free from all psychiatric symptomatology was even smaller, at about one in six. In patients who remitted from GAD, the risk of relapse over the next year was about 15% increasing to about 30% in those who achieved only partial symptomatic remission (Yonkers et al., 1996).The participants in the above study were recruited from hospital services and may not be representative of GAD in general. In a naturalistic study in the UK, Tyrer and colleagues (2004) followed up patients with anxiety and depression identified in psychiatric clinics in primary care and found that 12 years later 40% of those initially diagnosed with GAD had recovered, in the sense of no longer meeting criteria for any DSM-III psychiatric disorder. The remaining participants remained symptomatic, but only 3% still had GAD as the principal diagnosis; in the vast majority of patients, conditions such as dysthymia, major depression and agoraphobia were now more prominent. This study confirms the chronic and fluctuating symptomatic course of GAD in clinically-identified patients. It should be noted, however, that the majority of people with GAD in the community do not seek medical help for their symptoms (Wittchen & Jacobi, 2005) and the course of the illness in these circumstances is not established.Panic disorderPanic disorder comprises two main subtypes; panic disorder without agoraphobia and panic disorder with agoraphobia, with different presentations and often different courses. Panic disorder with agoraphobia (about one third of all presentations of panic disorder) is characterised by an avoidance of situations from which escape may not be possible or help not available in the event of a panic attack. Panic disorder with agoraphobia is also more common in women by a factor of approximately two to one. In contrast, panic disorder without agoraphobia is not situation-specific and symptoms may develop with no obvious or apparent cause (Weissman & Merikangas, 1986).The most common age of onset is from the mid-teens to the mid-20s; however, onset may occur at any time. Panic disorder often begins with occasional panic attacks that increase in frequency and which in time lead to a pattern of a generalised avoidance. The course of this disorder often follows a chronic pathway for many people with panic disorder, with agoraphobia likely to have an even more chronic course (Francis et al., 2007).Panic attacks commonly occur in many other disorders including specific phobias and social anxiety disorder, but they can also occur in GAD, drug or alcohol misuse, personality disorders and a number of physical disorders.Obsessive-compulsive disorderThe mean age of onset of OCD is in late adolescence for men and early 20s for women, although age of onset covers a wide range of ages. However, it may take individuals between 10 and 15 years or longer to seek professional help. There is often comorbidity with a range of disorders, especially depression (for example, Abramowitz, 2004; Abramowitz et al., 2003; Apter et al., 2003), and other anxiety disorders (for example, Biederman et al., 2004; LaSalle et al., 2004; Nestadt et al., 2003; Welkowitz et al., 2000).OCD may follow an acute, episodic or chronic course. In one of the largest follow-up studies, Skoog and Skoog (1999) conducted a 40-year prospective study and reported that approximately 60% of people with OCD displayed signs of general improvement within 10 years of illness, increasing to 80% by the end of the study. However, only 20% achieved full remission even after almost 50 years of illness; 60% continue to experience significant symptoms; 10% displayed no improvement; and 10% had deteriorated. A fifth of those who had displayed an early sustained improvement subsequently relapsed, even after 20 years without symptoms. This suggests that early recovery does not eliminate the possibility of very late relapse. Intermittent, episodic disorder was more common during the early stage of illness and predicted a more favourable outcome, whereas chronic illness predominated in later years. Worse outcome was predicted by early age of onset (particularly in males), experiencing obsessions and compulsions or magical thinking, poor social adjustment and early chronic course.Post-traumatic stress disorderThe onset of symptoms in PTSD is usually in the first month after the traumatic event, but in a minority (less than 15%; McNally, 2003) there may be a delay of months or years before symptoms start to appear. PTSD also shows substantial natural recovery in the initial months and years after a traumatic event. Whereas a high proportion of trauma survivors will initially develop symptoms of PTSD, a substantial proportion of these individuals recover without treatment in the following years, with a steep decline in PTSD rates occurring in the first year (for example, Breslau et al., 1991; Kessler et al., 1995). On the other hand, at least one third of people who initially develop PTSD remain symptomatic for 3 years or longer and are at risk of secondary problems such as substance misuse (for example, Kessler et al., 1995). In the 2007 ONS (McManus et al., 2009) survey, screening positive for current PTSD declined with age, from 4.7% of 16- to 24-year-olds to 0.6% of adults aged 75 years or over.2.2.5. Impairment, disability, secondary problemsDepressionApart from the subjective suffering experienced by people who are depressed, the impact on social and occupational functioning, physical health and mortality is substantial. In fact, depressive illness causes a greater decrement in health state than major chronic physical illnesses such as angina, arthritis, asthma and diabetes (Moussavi et al., 2007).Depression is a major cause of disability across the world. In 1990 it was the fourth most common cause of loss of disability-adjusted life years (DALYs) in the world and by 2020 it is projected to become the second most common cause (World Bank, 1993). In 1994 it was estimated that about 1.5 million DALYs were lost each year in the West as a result of depression (Murray et al., 1994). Depressive disorders account for 4.4% of the global disease burden or the equivalent of 65 million DALYs (Murray & Lopez, 1997; WHO, 2002).Emotional, motivational and cognitive effects substantially reduce a person's ability to work effectively, with losses in personal and family income as well as lost contribution to society in tax revenues and employment skills. Wider social effects include: greater dependence upon welfare and benefits with loss of self-esteem and self-confidence; social impairments, including reduced ability to communicate and sustain relationships during the illness with knock-on effects after an episode; and longer-term impairment in social functioning, especially for those who have chronic or recurrent disorders. Some of the features of depression (such as lethargy) may impede access to appropriate healthcare.Depression can also exacerbate the pain, distress and disability associated with physical health problems, and can adversely affect outcomes. Depression combined with chronic physical health problems incrementally worsens health compared with a physical health problem alone or even combinations of physical health problems (Moussavi et al., 2007). In addition, for a range of physical health problems findings suggest an increased risk of death when comorbid depression is present (Cassano & Fava, 2002). In coronary heart disease, for example, depressive disorders are associated with an 80% increased risk both for its development and of subsequent mortality in people with established disease, at least partly because of common contributory factors (Nicholson et al., 2006).Suicide accounts for nearly 1% of all deaths and nearly two thirds are people with depression (Sartorius, 2001); putting it in another way, having depression leads to over a four-times higher risk of suicide compared with the general population, which rises to nearly 20 times in the most severely ill (Bostwick & Pankratz, 2000). Sometimes depression may also lead to acts of violence against others, and may even include homicide. Marital and family relationships are frequently negatively affected, and parental depression may lead to neglect of children and significant disturbances in children (Ramachandani & Stein, 2003).Generalised anxiety disorderLike major depression GAD is associated with a substantial burden of disability, equivalent to that of other chronic physical health problems such as arthritis and diabetes (Wittchen et al., 2002). There is evidence that comorbid depression and anxiety has a worse prognosis and more persistent symptoms than either depression or anxiety disorders alone (Kroenke et al., 2007). There is also evidence that, in the community, anxiety disorders are independently associated with several physical health problems and that this comorbidity is significantly associated with poor quality of life and disability (Sareen et al., 2006), and high associated health and social costs (Simon et al., 1995).Studies have shown that the presence of GAD is also associated with significant impairments in occupational and social functioning. For example, over 30% of patients with GAD showed an annual reduction of work productivity of 10% or more compared with 8% of people with major depression. The figure for people with comorbid GAD and depression was over 45% (Wittchen et al., 2000). A large part of the economic cost of anxiety disorders is attributable to the costs of non-medical psychiatric treatment. Patients with GAD have increased numbers of visits not only to primary care doctors but also to hospital specialists, particularly gastroenterologists (Kennedy & Schwab, 1997; Wittchen et al., 2002). This may be a consequence of the distressing somatic symptoms that many people with GAD experience.GAD also carries a considerable cost in personal suffering and difficulties. In the Harvard-Brown Program, one third of patients had never married and unemployment was higher than average (Yonkers et al., 1996). Suicidal ideation and suicide attempts are significantly increased in GAD, particularly in women, and this increase is still greater in the presence of comorbid major depression (Cougle et al., 2009).Panic disorderPanic disorder has considerable impact on the NHS, such as general practitioners (GPs), society as a whole (in terms of sickness and absence from work, labour turnover and reduced productivity), and individuals and families (Sherbourne et al., 1996). The impact in any of these spheres is difficult to measure accurately and there may be an underestimation of the impact, but it is still substantial. A person with panic disorder may experience severe and enduring physical sensations, which may lead them to think that they have a physical illness; it can be difficult for healthcare professionals to provide adequate reassurance that this is not the case, which may lead to multiple consultations. Their economic wellbeing may also be affected (Edlund & Swann, 1987).Obsessive-compulsive disorderOCD is ranked by the WHO in the top ten of the most disabling illnesses by lost income and decreased quality of life (Bobes et al., 2001). The severity of OCD differs markedly from one person to another. While some people may be able to hide their OCD from their own family, the disorder may have a major negative impact on social relationships leading to frequent family and marital discord or dissatisfaction, separation or divorce (Koran, 2000). It also interferes with leisure activities (Antony et al., 1998) and with a person's ability to study or work, leading to diminished educational and/or occupational attainment and unemployment (Koran, 2000; Leon et al., 1995). The social cost (that is the person's inability to fully function in society) has been estimated as US$5.9 billion in 1990, or 70.4% of the total economic cost of OCD (DuPont et al., 1995).Post-traumatic stress disorderSymptoms of PTSD cause considerable distress and can significantly interfere with social, educational and occupational functioning. It is not uncommon for people with PTSD to lose their jobs either because re-experiencing symptoms, as well as sleep and concentration problems, make regular work difficult or because they are unable to cope with reminders of the traumatic event they encounter while at work (Zatzick et al., 1997). The resulting financial problems are a common source of additional stress and may be a contributory factor leading to extreme hardship, such as home-lessness. The disorder has adverse effects on the person's social relationships, leading to social withdrawal. Problems in the family and break-up of significant relationships are not uncommon.People with PTSD may also develop further, secondary psychological disorders as complications of the disorder. The most common complications are:the use of alcohol, drugs, caffeine or nicotine to cope with their symptoms, which may eventually lead to dependencedepression, including the risk of suicideother anxiety disorders, such as panic disorder, which may lead to additional restrictions in their life (for example, inability to use public transport).Other possible complications of PTSD include somatisation, chronic pain and poor health (Schnurr & Green, 2003). People with PTSD are at greater risk of physical health problems, including circulatory and musculoskeletal disorders, and have a greater number of medical conditions than those without PTSD (Ouimette et al., 2004).The course and prognosis of all common mental disorders are affected by a range of social factors, a number of which have been already discussed above. However, a range of factors related to social exclusion have a specific effect on access to services. This means that a number of groups may have particular problems accessing services including: those involved with the criminal justice system; homeless or precariously housed people; travelling communities; some groups of younger people (including those who have been in care as children and adolescence); people who misuse drugs and alcohol; and those of uncertain immigration status.2.2.6. Economic costsThe ONS report (McManus et al., 2009) makes the point that although common mental health disorders are usually less disabling than major psychiatric disorders such as psychosis, their greater prevalence means that the cumulative cost to society is vast. Mixed anxiety and depression has been estimated to cause one fifth of days lost from work in Britain (Das-Munshi et al., 2008). Even before the recent expansion of the European Union, it was estimated that work-related stress affected at least 40 million workers in its then 15 member states and that it cost at least €20 billion annually. In the UK, it has been suggested that over 40 million working days are lost each year due to stress-related disorders (European Agency for Safety and Health at Work, 2000).Costs of depressionDepression is associated with high prevalence and treatment costs, and as stated above is considered one of the most important risk factors for suicide (Knapp & Illson, 2002). Furthermore, depression has a large impact on workplace productivity. As a result, depression places an enormous burden on both the healthcare system and the broader society.Depression has a major financial impact on health and social services and the wider economy. A review was conducted by the King's Fund in 2006 to estimate mental health expenditure including depression in England for the next 20 years, to 2026 (McCrone et al., 2008). The study estimated the total cost of services for depression in England in 2007 to be £1.7 billion, while lost employment increased this total to £7.5 billion. Based on the estimate that 1.45 million people would have depression in 2026, the authors estimated that the total service cost would be £12.2 billion when accounting for prescribed drugs, inpatient care, other NHS services, supported accommodation, social services and lost employment in terms of workplace absenteeism.One of the key findings from the cost-of-illness literature is that the indirect costs of depression far outweigh the health service costs. A study by Thomas and Morris (2003) suggested that the effect on lost employment and productivity was 23 times larger than the costs falling to the health service. Other studies have also supported these findings. Based on UK labour-market survey data, Almond and Healey (2003)estimated that respondents with self-reported depression/anxiety were three times more likely to be absent from work (equivalent to 15 days per year) than workers without depression/anxiety. Furthermore, a US-based study suggests that depression is a major cause of reduced productivity at work, in terms of ‘work cut-back days’ (Kessler et al., 2001). This reduced workplace productivity is unlikely to be adequately measured by absenteeism rates and further emphasises the ‘hidden costs’ of depression (Knapp, 2003). A recent study conducted by the the Centre for Economic Performance's Mental Health Policy Group estimated that the total loss of output (in terms of lost productivity, absenteeism from work or benefits received) due to depression and chronic anxiety is some £12 billion per year (Layard, 2006).Other intangible costs of illness include the impact on the quality of life of people with depression and their families and carers. Certainly, the cost-of-illness calculations presented here and in Table 2 show that depression imposes a significant burden on individuals and their families and carers, the healthcare system and the broader economy through lost productivity and workplace absenteeism. Furthermore, it is anticipated that these costs will continue to rise significantly in future years. Therefore, it is important that the efficient use of available healthcare resources is used to maximise health benefits for people with depression.Table 2Summary of cost of illness data for depression and anxiety.Costs of anxiety disordersAnxiety disorders place a significant burden on individuals as well as on the healthcare system. Although direct comparisons between studies are difficult to make due to variations in country, health services and year of interest, economic cost has been estimated at over US$40 billion (Andlin-Sobocki et al., 2005; see Table 2 for further information). Estimated costs are incurred by healthcare resource utilisation such as mental health services, medication, hospitalisation, nursing homes and outpatient visits, productivity losses and, to a lesser extent, by provision of other services such as criminal justice services, social welfare administration and incarceration, as well as family care-giving (0.8%) (Andlin-Sobocki et al., 2005).Total healthcare cost is not the only important outcome to consider when investigating cost. Marciniak and colleagues (2005) found that the total medical cost per person with any anxiety disorder was estimated at US$6,475 in 1999. More specifically, when looking at GAD alone, the figure increased to US$2,138 when controlling for demographics and other disease states. This increased cost may be due to factors such as increased outpatient mental health service use or medical specialist service use. Furthermore, people with anxiety tend to miss more days of work or have a short-term disability than controls (Marciniak et al., 2004).Anxiety disorders are associated with a wide range of comorbidities, which result in a substantial increase in the total healthcare costs. Souêtre and colleagues (1994) estimated the total direct and indirect costs incurred by people with GAD with and without comorbidities using data on 999 people participating in a French cross-sectional study. Controlling for confounding variables, the prevalence of healthcare utilisation in terms of hospitalisation, laboratory tests and medications, and the respective medical costs were found to be significantly higher in people with GAD and other comorbidities than those without comorbidities. Moreover, comorbidities were associated with increased absenteeism from work. In particular, comorbid depression (Marciniak et al., 2005; Wetherell et al., 2007; Zhu et al., 2009) and physical pain (Olfson & Gameroff, 2007; Zhu et al., 2009) have been found to have a significant impact on treatment costs incurred by people with GAD.Costs of post-traumatic stress disorderIn 2003 to 2004, social and welfare costs of claims for incapacitation and severe disablement from severe stress and PTSD amounted to £103 million, which is £55 million more than was claimed 5 years previously (Hansard, 2004). Therefore, PTSD presents an enormous economic burden on families, the national health services and society as a whole.Go to:2.3. TREATMENTA number of treatments exist for common mental health disorders. However, because this guideline is predominantly interested in the identification and assessment of these conditions, the treatments will only be discussed briefly. For more information, please see the relevant guideline (see Section 2.1).2.3.1. Pharmacological treatmentsDepressionThere is a wide range of antidepressant drugs available for people with depression. These can be grouped into tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors and a range of other chemically unrelated antidepressants (British National Formulary [BNF] 59; British Medical Association & the Royal Pharmaceutical Society of Great Britain, 2010).Generalised anxiety disorderPlacebo-controlled trials indicate that a wide range of drugs with differing pharmacological properties can be effective in the treatment of GAD (Baldwin et al., 2005). In recent years, antidepressant medications such as SSRIs have been increasingly used to treat GAD (Baldwin et al., 2005).Conventional antipsychotic drugs and the newer ‘atypical’ antipsychotic agents have also been used in the treatment in GAD, both as a sole therapy and as an ‘addon’ to SSRI therapy when the latter has proved ineffective (Pies, 2009). However, the greater side-effect burden of antipsychotic drugs means that presently their use is restricted to people with refractory conditions, with prescribing being guided by secondary care physicians.Panic disorderThere is evidence to support the use of pharmacological intervention in the treatment of panic disorder, in particular with SSRIs. When a person has not responded to an SSRI, other related antidepressants may be of benefit. There is little good evidence to support the use of benzodiazepines. In contrast to a number of other depressive and anxiety disorders, there is little evidence to support the use of pharmacological and psychological interventions in combination.Obsessive-compulsive disorderPharmacological investigations have demonstrated effectiveness in OCD, in particular with SSRIs and related antidepressants (Montgomery et al., 2001; Zohar & Judge, 1996) for moderate to severe presentations, especially if the problem has a chronic course; this may be in combination with psychological interventions.Post-traumatic stress disorderAt present there is no conclusive evidence that any drug treatment helps as an early intervention for the treatment of PTSD-specific symptoms (NCCMH, 2005). However, for people who are acutely distressed and may be experiencing severe sleep problems, consideration may be given to the use of medication. Drug treatments for PTSD should not be used as a routine first-line treatment for adults (in general use or by specialist mental health professionals) in preference to a trauma-focused psychological therapy. Drug treatments should be considered for the treatment of PTSD in adults when a person with the disorder expresses a preference not to engage in a trauma-focused psychological treatment. The SSRI paroxetine is the only drug with a current UK product licence for PTSD.2.3.2. Psychological treatmentsDepressionEffective psychological treatments for depression identified in the NICE Depression guideline (NICE, 2009a) include: cognitive behavioural therapy (CBT), behavioural activation, interpersonal therapy (IPT),behavioural couples therapy and mindfulness-based cognitive therapy. For moderate to severe disorders these are often provided in conjunction with antidepressants. For subthreshold and milder disorders, structured group physical activity programmes, facilitated self-help and CCBT are effective interventions.Generalised anxiety disorderCognitive and behavioural approaches are the treatments of choice for GAD. People who have moderate to severe disorder, particularly if the problem is long-standing, should be offered CBT or applied relaxation. For those with milder and more recent onset disorders, two options are available: facilitated ornon-facilitated self-help based on CBT principles and psychoeducational groups also based on CBT principles.Panic disorderCognitive and behavioural approaches are again the treatments of choice for panic disorder. People who have a moderate to severe GAD, particularly if it is longstanding, should receive between 7 and 14 hours of therapist-provided treatment over a 4-month period. For those with milder and more recent onset GAD, facilitated or non-facilitated self-help based on CBT principle are efficacious treatments.Obsessive-compulsive disorderCBT is the most widely used psychological treatment for OCD in adults (Roth & Fonagy, 2004). The main CBT interventions that have been used in the treatment of OCD are exposure and response prevention (ERP) (for example, Foa & Kozak, 1996; Marks, 1997), different variants of cognitive therapy (Clark, 2004; Freeston et al., 1996; Frost & Steketee, 1999; Krochmalik et al., 2001;Rachman, 1998, 2002 and 2004; Salkovskis et al., 1999; van Oppen & Arntz, 1994; Wells, 2000), and a combination of ERP and cognitive therapy (see Kobak et al., 1998; Roth & Fonagy, 2004). ERP and cognitive therapy have different theoretical underpinnings, but may be used together in a coherent package.Post-traumatic stress disorderGeneral practical and social support and guidance about the immediate distress and likely course of symptoms should be given to anyone following a traumatic incident. Trauma-focused psychological treatments are effective for the treatment of PTSD, either trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR). These treatments are normally provided on an individual outpatient basis and are effective even when considerable time has elapsed since the traumatic event(s).2.3.3. Current levels of treatment of common mental health disordersIt is concerning that, according to the 2007 ONS survey (McManus et al., 2009), only one quarter (24%) of people with a disorder were receiving any treatment for it in the week prior to interview. Treatment received by that 24% was mostly in the form of medication: 14% were taking psychoactive medication only, 5% were in receipt of counselling or therapy and 5% were receiving both medication and counselling/therapy.Use of healthcare servicesOf the people reporting a common mental health disorder in the ONS survey (McManus et al., 2009), 39% had used some type of healthcare service for a mental or emotional problem within the last year, compared with 6% of men and women without a disorder.Primary care servicesGeneral practice services were the most common healthcare service used in the ONS survey. A total of 38% of people with a common mental health disorder contacted their GP for help. Depression and phobias were associated with the highest use of healthcare services for a mental or emotional problem (both 67%), and mixed anxiety and depression was associated with the lowest use (30%) (McManus et al., 2009).Community care servicesAll respondents in the ONS survey (McManus et al., 2009), were asked about community and day care services used in the past year. Community and day care services were used less than healthcare services. Those with phobias made most use of community or day care services (49%), while mixed anxiety and depressive disorder was associated with the lowest rate of community or day care service use (12%).SummaryIn summary, common mental health disorders are associated with a range of symptoms that can lead to significant impairment and disability, and high costs both for the individual with the disorder and for society as a whole.Effective treatments are available that differ depending on the disorder. As a result, early detection, assessment and intervention are key priorities for any healthcare system. This guideline, which is focused on primary care, will provide recommendations on how to best identify and assess common mental health disorders and the key indicators for treatment in order to help improve and facilitate access to care, and the route through care.Go to:2.4. IDENTIFICATION, ASSESSMENT AND PATHWAYS TO CAREGoldberg and Huxley (1992) described a useful model within which to consider issues relating to the identification, assessment and pathway to psychiatric care for people with a common mental health disorder (see Figure 1). They identified five levels of care, with ‘filters’ between them relating to the behaviour of those with the disorders and the behaviours of the healthcare practitioners with whom they came into contact, emphasising that only a small proportion of people with a mental disorder receive specialist psychiatric care.Figure 1Levels and filters model of the pathway to psychiatric care (adapted from Goldberg & Huxley, 1992).The prevalence rates given above are taken from the original model and relate to proportions found in epidemiological surveys conducted before 1980. The Level 1 figures refer to all psychiatric disorders in the population, including psychotic and organic disorders, so the prevalence rates are somewhat higher than those given for the common mental health disorders in Section 2.2.2 above.For Filter 1 (the decision to consult a primary care physician), the key individual is the patient themselves. Level 2 refers to all psychiatric disorders in general practice, even if the GP has not diagnosed the disorder. Filter 2 refers to the detection and diagnosis of psychiatric disorder; Level 3 is ‘conspicuous’ or diagnosed psychiatric disorder within primary care. The third filter is the process of referral to secondary care, and Level 4 and Level 5 refer to the small proportion of patients with illnesses severe enough to need specialist secondary care.2.4.1. Increasing access to careThere are significant concerns about a number of barriers to access to care. These may include stigma (both cultural and self, and stigmatisation), misinformation or cultural beliefs about the nature of mental disorder, social policy or other approaches that limit access to services.Presentation of people with a common mental health disorder to primary careOf the 130 cases of depression (including mild cases) per 1000 population, only 80 will consult their GP. The stigma associated with mental health problems generally (Sartorius, 2002), and the public view that others might view a person with depression as unbalanced, neurotic and irritating (Priest et al., 1996), may partly account for the reluctance of depressed people to seek help (Bridges & Goldberg, 1987). The most common reasons given for reluctance to contact the family doctor include: did not think anyone could help (28%); a problem one should be able to cope with (28%); did not think it was necessary to contact a doctor (17%); thought problem would get better by itself (15%); too embarrassed to discuss it with anyone (13%); and afraid of the consequences (for example treatment, tests, hospitalisation or being sectioned under the Mental Health Act; 10%) (Meltzer et al., 2000).Most anxiety disorders are found more frequently in primary care than in the community except for social anxiety disorder and agoraphobia, both of which involve avoidance of public places such as doctors' surgeries (Bushnell et al., 2005; Oakley Browne et al., 2006; see Table 3). However, even when people with anxiety and depression do consult their GP, their disorder often goes unrecognised, partly because many do not present their psychological symptoms overtly.Table 3Twelve-month prevalence of anxiety disorders in New Zealand (Oakley Browne et al., 2006).Dowrick and colleagues (2010) carried out systematic reviews to identify groups for whom there are particular problems accessing mental health services, and to identify systems for promoting access. Poorer access to care has been found to be associated with lower social class, geographical location, ethnic minority groups, the presence of sensory or other impairments, the presence of learning difficulties, and particular demographic factors including age and gender (for example, older people or younger men).This guideline seeks to identify service developments or changes that may be specifically designed to promote access, both for the general population and for specific outreach groups (see Chapter 4). Particular areas include: community outreach; providing education and information concerning the nature of mental disorder; and new and adapted models of service delivery, which focus on the needs of black and minority ethnic (BME) groups and older people.2.4.2. IdentificationRecognition of depressionOf the 80 people with depression per 1000 population who do consult their GP, 49 are not recognised as depressed, mainly because most such patients are consulting for a somatic symptom and do not consider themselves mentally unwell despite the presence of symptoms of depression (Kisely et al., 1995). People who present with somatic symptoms are especially unlikely to be recognised (Kisely et al., 1995). GPs tend to be better at recognising more severe forms of the disorder (Goldberg et al., 1998; Thompson et al., 2001). With 50% of people with depression never consulting a doctor, 95% never entering secondary mental health services, and many more having their depression going unrecognised and untreated, this is clearly a problem for primary care.Recognition of anxiety disordersAnxiety symptoms are also often not recognised by primary healthcare professionals because, once again, patients may not complain of them overtly (Tylee & Walters, 2007). Cases of anxiety are especially likely to be missed when people frequently attend with multiple symptoms, despite reassurance. Instead, these symptoms are often characterised as possible symptoms of cardiovascular, respiratory, gastrointestinal, neurological or musculoskeletal disease (Blashki et al., 2007).For many people with a common mental health disorder, stigma and avoidance may contribute to under-recognition of their condition. Pessimism about possible treatment outcomes may further contribute to this. However, GPs themselves can contribute to the under-recognition of these conditions.Consultation skillsGPs are immensely variable in their ability to recognise depressive illnesses, with some recognising virtually all of the patients found to be depressed at independent research interview, and others recognising very few (Goldberg & Huxley, 1992; Üstün & Sartorius, 1995).The communication skills of the GP make a vital contribution to determining their ability to detect emotional distress, and those with superior skills allow their patients to show more evidence of distress during their interviews thus facilitating detection (Goldberg & Bridges, 1988; Goldberg et al., 1993).According to Goldberg and colleagues (1980a and 1980b), ten behaviours are associated with greater detection. These include factors such as making eye contact, having good interview skills, asking well-formulated questions and focusing on more than just a symptom count. Attempts to improve GP behaviour have been successful (Ostler et al., 2001; Tiemens et al., 1999), although results are mixed (Kendrick et al., 2001; Thompson et al., 2000) and interventions sometimes fail to impact on patient outcomes despite changes in clinician behaviour (Gask et al., 2004).Case identificationThe fact that common mental health disorders often go undiagnosed among primary care attenders has led to suggestions that clinicians should systematically screen for hidden disorders. However, general screening is not without its problems and is currently not recommended in most countries, including the UK. Instead, targeted case identification, which involves screening a smaller group of people known to be at higher risk based on the presence of particular risk factors, may be a more useful method of improving recognition of psychological disorders in primary care.Whooley and colleagues (1997) found that two questions were particularly sensitive in identifying depression:During the last month, have you often been bothered by feeling down, depressed or hopeless?During the last month, have you often been bothered by having little interest or pleasure in doing things?The current NICE Depression guideline (NICE, 2009a) recommends that GPs be alert to possible depression in at-risk patients and consider asking the above Whooley questions when depression is suspected. If the person screens positive, further follow-up assessments should then be considered. Currently, no equivalent Whooley questions have been recommended for anxiety.The view of the GDG for this guideline was that the development of separate case identification questions for each type of anxiety disorder would very likely be impractical and have no utility for routine use in primary care. The preference was to explore the possibility of a small number of case identification questions with general applicability for a range of anxiety disorders. A potentially positive response would then prompt a further assessment. This is dealt with in Chapter 5.2.4.3. AssessmentSince April 2006, the UK general practice contract Quality and Outcomes Framework Guidance for GMS Contract (QOF) has incentivised GPs for measuring the severity of depression at the outset of treatment in all diagnosed cases, using validated questionnaires (British Medical Association & NHS Employers, 2008). The aim is to improve the targeting of treatment of diagnosed cases, particularly antidepressant prescribing, to those with moderate to severe depression, in line with the NICE guidelines.A number of assessment tools have been identified as potentially useful for the assessment. The NICEDepression guideline (NICE, 2009a), for example, recommends the use of the nine-item Patient Health Questionnaire (PHQ-9) (Spitzer et al., 1999), the depression scale of the Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983) and the Beck Depression Inventory, 2nd edition (BDI-II) (Beck, 1996; Arnau et al., 2001). The rationale for using such instruments is that doctors' global assessments of severity do not agree well with valid and reliable self-report measures of severity in terms of cut-off levels for case identification (Dowrick, 1995; Kendrick et al., 2005; Lowe et al., 2004;Williams et al., 2002), which can result in over-treatment of mild cases and under-treatment of moderate to severe cases (Kendrick et al., 2001 and 2005).However, the QOF guidance, again in line with NICE guidance, also recommends that clinicians consider the degree of associated disability, previous history and patient preference when assessing the need for treatment rather than relying completely on the questionnaire score (British Medical Association & NHS Employers, 2006). This is especially important given that people with mental illness vary in the pattern of symptoms they experience, their family history, personalities, pre-morbid difficulties (for example, sexual abuse), physical illness, psychological mindedness, current relational and social problems and comorbidities – all of which may affect the outcomes of any intervention (for example, Cassano & Fava, 2002; Ramachandani & Stein, 2003).Currently, evidence exists that points practitioners in the direction of well-validated tools. As a result, this guideline will not attempt to recommend specific tools because preferences vary between practices. Instead, this guideline will focus on ways to improve the assessment process, specifically, how to assess the nature and severity of a common mental health disorder, factors that may influence referral for treatment, routine outcome monitoring (ROM) and risk assessment.2.4.4. Pathways to careGiven the complexity of healthcare organisations and the variation in the way care is delivered (inpatient, outpatient, day hospital, community teams and so on), choosing the right service configuration for the delivery of care to specific groups of people has gained increasing interest with regard to both policy (for example, see Department of Health, 1999) and research (for example, evaluating day hospital treatment [Marshall et al., 2001]). Research using randomised controlled trial (RCT) designs has a number of difficulties; for example, using comparators such as ‘standard care’ in the US makes the results difficult to generalise or apply to countries with very different types of ‘standard care’.Stepped careCurrently, much of the UK mental health system is organised around the principles of stepped care. Stepped care (Scogin et al., 2003) is a framework that is increasingly being used in the UK to provide a structure for best-practice clinical pathways to care. It is designed to increase the efficiency of service provision with an overall benefit to patient populations. The basic principle is that patients presenting with a common mental health disorder will ‘step through’ progressive levels of treatment as necessary, with the expectation that many of these patients will recover during the less intensive phases. High-intensity treatments are reserved for patients who do not benefit from low-intensity treatments, or for those who can be accurately predicted not to benefit from such treatments. Thus, stepped care has the potential for deriving the greatest benefit from available therapeutic resources (Bower & Gilbody, 2005) and has been recommended in a number of NICE guidelines including Depression (NICE, 2009a) and Generalised Anxiety Disorder and Panic Disorder (With or Without Agoraphobia) in Adults (NICE, 2011a).A potential disadvantage of a stepped-care approach is that patients who do not benefit from low-intensity treatments may still have to undergo such treatments before a successful outcome is achieved. To maximise the efficiency of care delivery, patients who can be predicted as unlikely to respond to less intensive treatments ideally should be referred straight to higher levels; that is, care should be ‘stratified’ to an extent (Bower et al., 2006). However, prognostic evidence to support such decisions is currently lacking.Improving Access to Psychological Therapies programmeIn 2004 the economist Richard Layard made the case for a major expansion in the availability of psychological treatments, which he suggested could bring a significant reduction in the welfare benefits bill and increased tax contributions of those helped back to work. In 2006 the government established the Improving Access to Psychological Therapies (IAPT) programme, based heavily on the stepped-care approach. Clark and colleagues (2009) reported on the initial success of two demonstration sites in Newham and Doncaster, and the IAPT programme proposes a phased national roll-out by 2013 (to date, over 50% of Primary Care Trusts have an IAPT service). Self-referral to IAPT services is also actively encouraged, with emerging evidence to suggest that it increases access for vulnerable groups, such as BME groups to psychological interventions (Clark et al., 2009). In addition, an analysis of the first full year of operation of the first wave of roll-out sites (October 2008 to September 2009) has recently been published (Glover et al., 2010). Anonymous patient-level data were collected from 32 sites with the aim of evaluating whether the ‘commitments relating to accessibility, the provision of NICE-approved therapies and detailed outcome monitoring were progressing appropriately’. The authors concluded that the large amount of outcome data collected is a remarkable achievement, although there are some limitations and shortcomings that need to be addressed. For example, the analysis suggests that the diagnostic coding frame needs to be extended to include panic disorder and more research needs to be conducted to establish how reliable diagnoses can be obtained. Furthermore, in terms of equality of access, the authors state that ‘older people and men appeared under-represented in relation to expectation based on the patterns of morbidity shown by the psychiatric morbidity survey. The position for people with disabilities is not recorded at all in most sites, making it difficult to see how commissioners and providers can discharge their responsibilities to promote access to services for disabled people under disability discrimination legislation.’ Also, ‘after allowing for all other relevant factors for which data were available, Black people were significantly less likely to receive any treatment or to recover on either the two-scale or the three-scale makers, Asians were less likely to receive high intensity treatment (CBT or counselling), and both were significantly less likely to receive CBT’. More generally, with regard to treatment received, there was evidence to suggest that more needs to be done to ensure that the treatment given for specific diagnoses is aligned to that recommended in NICE guidelines.

50 Ways Happier, Healthier, And More Successful People Live On Their Own Terms1. Stop consuming caffeineAlthough people think they perform better on caffeine, the truth is, they really don’t. Actually, we’ve become so dependent on caffeine that we use it to simply get back to our status-quo. When we’re off it, we under perform and become incapable.Isn’t this absurd?In his book, The Untethered Soul, Michael Singer argues that your energy should come from within — from your why — not from external stimulants. The scientific backing is substantial and unsurprising: intrinsic motivation destroys extrinsic motivation every day of the week.Motivation aside — healthy eating, sleeping, and intensive exercise produce higher quantities and quality of energy than caffeine ever could. A holistic approach to life is essential. Garbage in, garbage out.Give up the caffeine and see what happens. To avoid withdrawal headaches — which are mostly placebo — replace your caffeine with something else (another placebo). After a few days without caffeine, you’ll develop confidence in your ability to function without it.2. Pray or meditate morning, mid-day, and nightIn a recent interview at the Genius Network mastermind event, Joe Polish asked Tony Robbins what he does to get focused. “Do you meditate? What do you do?” Joe asked.“I don’t know that I meditate. I don’t know that I want to meditate and think about nothing,” Tony responded, “My goal is clarity.”Instead of full-on meditation, Tony has a morning routine that includes several breathing exercises and visualization techniques that get him to a state of clarity and focus. For me, I use prayer and pondering (my version of meditation) as the same vehicle.Whatever your approach, the goal should be clarity and focus. What do you want to be about today?What few things matter most during the next 24 hours?I’ve gotten the best results as:My morning prayer and meditation are motivationalMy afternoon prayer and meditation are evaluative and strategicMy evening prayer and meditation are evaluative and reflective3. Read 1 book per weekOrdinary people seek entertainment. Extraordinary people seek educationand learning. It is common for the world’s most successful people to read at least one book per week. They are constantly learning.I can easily get through one audiobook per week by just listening during my commute to school and while walking on campus. Taking even 15–30 minutes every morning to read uplifting and instructive information changes you. It puts you in the zone to perform at your highest.Over a long enough period of time, you will have read hundreds of books. You’ll be knowledgeable on several topics. You’ll think and see the world differently. You’ll be able to make more connections between different topics.Reference #19 on this list if you feel you’re “too busy” to read one book per week. There are methods to make this task extremely easy.4. Write in your journal 5 minutes per dayThis habit will change your life. Your journal will:Clear your emotions serving as your personal therapistDetail your personal historyEnhance your creativityIngrain and enhance your learningHelp you get clarity on the future you want to createAccelerate your ability to manifest your goalsIncrease your gratitudeImprove your writing skillsLots more…Five minutes per day is more than enough. Greg McKeown, author of Essentialism, recommends writing far less than you want to — only a few sentences or paragraphs at most. This will help you avoid burnout.5. Marry the person you love“For all the productivity and success advice I’ve read, shaped and marketed for dozens of authors in the last decade, I’ve never really seen someone come out and say: Find yourself a spouse who complements and supports you and makes you better.” — Ryan HolidayResearch done by economists have found — even after controlling for age, education, and other demographics — that married people make 10 to 50 percent more than single people.Why would this be?Being married gives you a higher purpose for being productive. You are no longer a lone ranger, but have another person who relies on you.Marriage also smacks you in the face with what’s really important in life. Sure, hanging out and partying are fun. But too many people get stuck in this phase and miss the meaning that comes from building a life with someone.You will never find a better personal development seminar or book than marriage. It will highlight all of your flaws and weaknesses, challenging you to become a better person than you ever thought possible.Said Thomas Monson, “Choose your love; love your choice.” After you’ve chosen the person you love, love them. You don’t marry to make yourself happy, you marry to make someone else happy. Said Frankl in Man’s Search for Meaning, “For success, like happiness, cannot be pursued; it must ensue, and it only does so as the unintended side effect of one’s personal dedication to a cause greater than oneself or as the by-product of one’s surrender to a person other than oneself.”6. Make a bucket list and actively knock items offMost people have it backwards — they design their ambitions around their life, rather than designing their life around their ambitions (see this free eBook on how to quickly create your ideal life).What are the things you absolutely must do before you die?Start there.Then design your life around those things. Or as Stephen Covey explained inThe 7 Habits of Highly Effective People, “Begin with the end clearly in mind.”A simple mental exercise that may be helpful is imagining you only have 30 days to live. What would you do in those 30 days?Now imagine you have 5 years to live. What would you do during those 5 years?Get to work. The death-bed mentality is the only way to live. Stop pretending you’ll live forever. As Professor Harold Hill has said — “You pile up enough tomorrows, and you’ll find you are left with nothing but a lot of empty yesterdays.”7. Stop consuming refined sugarIf you stop consuming sugar, your brainwill radically change. Actually, study after study is showing that refined sugar is worse for our brains than it is for our waistlines. According to Dr. William Coda Martin, refined sugar is nothing more than poison because it has been depleted of its life forces, vitamins and minerals.Refined sugar has now been shown to make us cranky, make us make rash decisions, and make us stupid.Again, like caffeine, if you stop eating refined sugar, you will experience some negative withdrawals. But, like any good habit, the effects of this will be seen in the long-run. What would your health be like a year from now (or five) if you were completely refined sugar-free?Said Albus Dumbledore, Headmaster of Hogwarts School of Witchcraft and Wizardry, “It is not our abilities that show what we truly are. It is our choices.”8. Fast from all food and caloric beverages 24 hours once per weekOne-day (24-hour) food fasts are a popular way to maintain health and vigor. Fasting leverages the self-healing properties of the human body. Radical health improvements occur when the digestive system is given rest and the organs get ample time to repair and heal themselves.A regular practice of fasting can:Improve digestive efficiencyIncrease mental clarityIncrease physical and mental vigorRemove toxinsImprove visionGive a general feeling of well beingLike all the other habits, fasting gets easier with practice. I’ve been fasting for years and it’s one of the best things I have done for my health.Fasting is also one of the most recognized techniques in religious and spiritual practices. I also use fasting to get spiritual clarity and refinement.Honestly, I could go on for hours about this one. Give it a try. You’ll never be the same.9. Fast from the internet 24 hours once per weekYour body gets an intervention when you fast. Your mind and relationships could use one too. Unplug yourself from the matrix.If you haven’t caught on already, human beings are highly addictive creatures. We love our coffee, sugar, and internet. And these things are all great. But our lives can be far more enhanced by using these tools in wisdom.The purpose of the internet fast is to reconnect to yourself and your loved ones. So, you probably shouldn’t do it the same day you do your food fast. Because eating is one of the strongest ways to form bonds.You’ll be blown away by how much more connected you feel to your loved ones when you can give them your undivided attention. It may even feel awkward for a while having a real-life conversation without looking at your phone every three minutes.10. Stop consuming the news or reading the newspaperAlthough the amount of warfare and deaths by human hands are reducing globally, you will not get that message watching televised news or reading the newspaper.On the contrary, these media outlets have an agenda. Their goal is to appeal to your fears by inflating extreme cases — making them seem normal and commonplace. If they didn’t do so, their viewership would plummet. Which is why Peter Diamandis, one of the world’s experts on entrepreneurship and the future of innovation has said, “I’ve stopped watching TV news. They couldn’t pay me enough money.”You can get high quality news curated from Google news. When you detox from the toxic filth that is public news, you’ll be startled as your worldview becomes radically more optimistic. There is no objective reality. Instead, we live in perceived realities and are thus responsible for the worldview we adopt.11. Do something everyday that terrifies you“A person’s success in life can usually be measured by the number of uncomfortable conversations he or she is willing to have.” — Tim FerrissBut you don’t have to constantly be battling your fears. Actually, Darren Hardy has said that you can be a coward 99.9305556% of the time (to be exact). You only need to be courageous for 20 seconds at a time.Twenty seconds of fear is all you need. If you courageously confront fear for 20 seconds every single day, before you know it, you’ll be in a different socio-economic and social situation.Make that call.Ask that question.Pitch that idea.Post that video.Whatever it is you feel you want to do–do it. The anticipation of the event is far more painful than the event itself. So just do it and end the inner-conflict.In most cases, your fears are unfounded. As Seth Godin has explained, ourcomfort zone and our safety zone are not the same thing. It is completely safe to make an uncomfortable phone call. You are not going to die. Don’t equate the two. Recognize that most things outside your comfort zone are completely safe.12. Do something kind for someone else daily“Have I done any good in the world today? Have I helped anyone in need?Have I cheered up the sad and made someone feel glad? If not, I have failed indeed. Has anyone’s burden been lighter today, because I was willing to share? Have the sick and the weary been helped on their way? When they needed my help was I there?” — Will L. Thompson (music and text)If we’re too busy to help other people, we’ve missed the mark. Taking the time to spontaneously — as well as planned — helping other people is one of the greatest joys in life. Helping others opens you up to new sides of yourself. It helps you connect deeper with those you help and humanity in general. It clarifies what really matters in life.As Thomas Monson has said, “Never let a problem to be solved become more important than a person to be loved.” That would truly be a failure.13. Go to bed early and rise earlyAccording to countless research studies, people who go to bed and rise early are better students. Harvard biologist Christoph Randler found that early sleep/risers are more proactive and are more likely to anticipate problems and minimize them efficiently, which leads to being more successful in the business.Other benefits of going to bed and rising early — backed by research — include:Being a better plannerBeing holistically healthier as individualsGetting better sleepMore optimistic, satisfied, and conscientiousWaking up early allows you to proactively and consciously design your day. You can start with a morning routine that sets the tone for your whole day. You show self-respect by putting yourself first. In your morning routine, you can pray/meditate, exercise, listen to or read inspiring content, and write in your journal. This routine will give you a much stronger buzz than a cup of coffee.14. Get 7+ hours of sleep each nightLet’s face it: sleep is just as important as eating and drinking water. Despite this, millions of people do not sleep enough and experience insane problems as a result.The National Sleep Foundation (NSF) conducted surveys revealing that at least 40 million Americans suffer from more than 70 different sleep disorders; furthermore, 60 percent of adults, and 69 percent of children, experience one or more sleep problems a few nights or more during a week.In addition, more than 40 percent of adults experience daytime sleepiness severe enough to interfere with their daily activities at least a few days each month — with 20 percent reporting problem sleepiness a few days a week or more.On the flip side, getting a healthy amount of sleep is linked to:Increased memoryLonger lifeDecreased inflammationIncreased creativityIncreased attention and focusDecreased fat and increased muscle mass with exerciseLower stressDecreased dependence on stimulants like caffeineDecreased risk of getting into accidentsDecreased risk of depressionAnd tons more… Google it.15. Replace warm showers with cold onesTony Robbins doesn’t consume caffeine at all. Instead, he starts every morningby jumping into a 57-degree Fahrenheit swimming pool.Why would he do such a thing?Cold water immersion radically facilitates physical and mental wellness. When practiced regularly, it provides long-lasting changes to your body’s immune, lymphatic, circulatory and digestive systems that improve the quality of your life. It can also increase weight-loss because it boosts your metabolism.A 2007 research study found that taking cold showers routinely can help treat depression symptoms often more effectively than prescription medications. That’s because cold water triggers a wave of mood-boosting neurochemicals which make you feel happy.To me, it increases my willpower and boosts my creativity and inspiration. While standing with the cold water hitting my back, I practice slowing my breathing and calming down. After I’ve chilled out, I feel super happy and inspired. Lots of ideas start flowing and I become way motivated to achieve my goals.Here’s a tip if you’re just starting out: start your shower warm, as usual. Let the warm water on your muscles allow you to stretch them out. After you’re stretched and washed, completely turn-off the warm and completely turn-on the cold. It really isn’t too bad at all. It feels incredible. Just do it for 60–90 seconds, then get out. You’ll be very pleased.16. Say “No” to people, obligations, requests, and opportunities you’re not interested in from now on“No more yes. It’s either HELL YEAH! or no.” — Derek SiversYour 20 seconds of daily courage will most consistently involve saying “no” to stuff that doesn’t really matter. But how could you possibly say “no” to certain opportunities if you don’t know what you want? You can’t. Like most people, you’ll be seduced by the best thing that comes around. Or, you’ll crumble under other people’s agendas.But if you know what you want, you’ll have the courage and foresight to pass up even brilliant opportunities — because ultimately they are distractors from your vision. As Jim Collins said in Good to Great, “A ‘once-in-a-lifetime opportunity’ is irrelevant if it is the wrong opportunity.”17. Say “Thank you” every time you’re served by someoneIt’s amazing when you meet someone who is expressively and genuinely grateful. It’s amazing because, frankly, it’s rare.I remember one day while working as a busser of a restaurant as a teenager. Every time I went by a certain table, whether I was refilling waters, bringing food, anything… the kid at the table (no more than 20 years old) graciously said “thank you.” I even heard him from close proximity saying it to all the other employees when they stopped by his table.This experience had a dramatic impact on me. It was so simple what he was doing. Yet, so beautiful. I instantly loved this person and wanted to serve him even more.I could tell by how he looked in my eyes when saying “thank you” that he meant it. It came from a place of gratitude and humility.Interestingly, one study has found that saying “thank you,” facilitated a 66 percent increase in help offered by those serving. Although altruism is the goal, don’t be surprised as your habit of graciously saying “thank you” turns into even more to be thankful for.18. Say “I love you” 3+ times a day to the most important people in your lifeAccording to neuroscience research, the more you express love (like gratitude), the more other people feel love for you. Sadly, people are taught absurd mindsets about being vulnerable and loving in relationships. Just this morning, my wife and I had to coax and prod our three foster kids to say one nice thing about each other, and to say they loved each other.It took several minutes for our 8 year old foster boy to muster the strength to say he loved his sister. Yet, all of our kids constantly berate and belittle each other.You know the feeling: when you want to say “I love you” but hold back. What a horrible feeling.Why do we hesitate to express our love?Why do we hesitate to connect deeply with others?This may be strange, but if you tell your friends and family you love them, they’ll be blown away. I once knew a Polynesian missionary who told everyone he loved them. It was clear he was sincere.I asked him why he did it. What he told me changed my life. “When I tell people I love them, it not only changes them, but it changes me. Simply by saying the words, I feel more love for that person. I’ve been telling people all around me I love them. They feel treasured by me. Those who know me have come to expect it. When I forget to say it, they miss it.”“The bitterest tears shed over graves are for words left unsaid and deeds left undone.” –Harriet Beecher Stowe19. Consume 30 grams of protein within the first 30 minutes of waking upDonald Layman, professor emeritus of nutrition at the University of Illinois, recommends consuming at least 30 grams of protein for breakfast. Similarly, Tim Ferriss, in his book, The 4-Hour Body, also recommends 30 grams of protein 30 minutes after waking up.According to Tim, his father did this and lost 19 pounds in one month.Protein-rich foods keep you full longer than other foods because they take longer to leave the stomach. Also, protein keeps blood-sugar levels steady, which prevents spikes in hunger.Eating protein first decreases your white carbohydrate cravings. These are the types of carbs that get you fat. Think bagels, toast, and donuts.Tim makes four recommendations for getting adequate protein in the morning:Eat at least 40% of your breakfast calories as proteinDo it with two or three whole eggs (each egg has about 6g protein)If you don’t like eggs, use something like turkey bacon, organic pork bacon or sausage, or cottage cheeseOr, you could always do a protein shake with waterFor people who avoid dairy, meat, and eggs, there are several plant-based proteins. Legumes, greens, nuts, and seeds all are rich in protein.20. Listen to audiobooks and podcasts on 1.5 or 2x speed, your brain will change fasterListening to audiobooks at normal speed is so three years ago. There is a going trend — particularly in Silicon Valley — to listen to audiobooks at 150 or 200 percent called “speed listening.”In 2010, the tech blog GigaOm suggested “speed-listening to podcasts” as an overall time-saving technique. Software called FasterAudio promises to “cut your audio learning time in half.”If you want to get hardcore, a particularly useful tool is Overcast — a podcast-playback app with a feature called Smart Speed. Smart Speed isn’t about simply playing audio content at 150 or 200 percent of the standard rate; but actually attempts algorithmically to remove fluff (e.g., dead air, pauses between sentences, intros and outros) that bulks up the play time of audio content.Use this technique and you’ll be consuming as much information as you once consumed caffeine.21. Decide where you’ll be in five years and get there in two“How can you achieve your 10 year plan in the next 6 months?” — Peter ThielThere is always a faster way than you originally conceive. Actually, goal-setting can slow your progress and diminish your potential if you rely too heavily upon it.In an interview with Success Magazine, Tim Ferriss said that he doesn’t have five or ten year goals. Instead, he works on “experiments” or projects for a 6–12 week period of time. If they do extremely well, the possible doors that could open are endless. Tim would rather play to the best possibilities than get stuck on one track. He says this approach allows him to go drastically farther than he could ever plan for.22. Remove all non-essentials from your life (start with your closet)“You cannot overestimate the unimportance of practically everything.” — Greg McKeownMost of the possessions you own, you don’t use. Most of the clothes in your closet, you don’t wear. Get rid of them. They are sucking energy from your life. Also, they are dormant value waiting to be exchanged for dollars.Getting rid of underutilized resources is like injecting motivation and clarity into your bloodstream. While all of that untapped energy gets removed, a new wave of positive energy comes into your life. You can use that energy in more useful and productive ways.23. Consume a tablespoon of coconut oil once per dayCoconut oil is one of the healthiest foods on the planet.Here are 7 reasons you should eat coconut oil every single day:It boosts HDL (good) cholesterol and simultaneously blocks LDL (bad) cholesterol buildupIt has special fats that help you burn more fat, have more energy, and maintain healthy weightIt fights aging and keeps you looking and feeling youngIt reduces fever and acts as an anti-inflammatoryIt is antibacterial and thus wards off possible illnessesIt improves memory and cognitive functioning (even for people with Alzheimer’s)It can boost testosterone for men and balance healthy hormones level for both men and womenCoconut oil is a healthy alternative to caffeine. Eating a small amount will give you a shot of energy without the side-effects.24. Buy a juicer and juice a few times per weekJuicing is an incredible way to get loads of vitamins and nutrients from fruits and vegetables. These nutrients can:Help protect against cardiovascular disease, cancer and various inflammatory diseasesGuard against oxidative cellular damage from everyday cellular maintenance and exposure to chemicals and pollution.There are several approaches you can take to juicing. You can reset your body by doing a 3–10 day juice “cleanse.” Or, you could simply incorporate juice into your regular diet. I do both from time to time.I always feel enormously better after juicing. Especially when I get lots of intense greens like kale into my system.25. Choose to have faith in something bigger than yourself, skepticism is easyIn the timeless book, Think and Grow Rich, Napoleon Hill explains that a fundamental principle of wealth creation is having faith — which he defines as visualization and belief in the attainment of desire.As Hill famously said, “Whatever the mind can conceive and believe, the mind can achieve.”If you don’t believe in your dreams, the chances of them happening are slim to none. But if you can come to fully know the things you seek will occur, the universe will conspire to make it happen.According to Hill (see page 49 of Think and Grow Rich), here’s how that works:“Faith is the starting point of all accumulation of riches!”“Faith is the basis of all ‘miracles’ and mysteries that cannot be analyzed by the rules of science!”“Faith is the element that transforms the ordinary vibration of thought, created by the finite mind of man, into the spiritual equivalent.”“Faith is the only agency through which the cosmic force of Infinite Intelligence can be harnessed and used.”“Faith is the element, the ‘chemical’ which, when mixed with prayer, gives one direct communication with Infinite Intelligence.”Like expressing love, in our culture, many have become uncomfortable with ideas like faith. Yet, to all of the best business minds in recent history, faith was fundamental to their success.26. Stop obsessing about the outcomeResearch has found that expectations in one’s own ability serves as a better predictor of high performance than expectations about a specific outcome. In his book, The Personal MBA, Josh Kaufman explains that when setting goals, your locus of control should target what you can control (i.e., your efforts) instead of results you can’t control (e.g., whether you get the part).Expect optimal performance from yourself and let the chips fall where they may. The organic output will be your highest quality work. Put most simply: Do what is right, let the consequence follow.27. Give at least one guilt-free hour to relaxation per dayIn our quest for success, many of us have become workaholics. However, relaxation is crucial for success. It is akin to resting between sets at the gym. Without resting, your workout will be far less than it could have been.Foolishly, people approach their lives like a workout without rest breaks. Instead, they take stimulants to keep themselves going longer and longer. But this isn’t sustainable or healthy. It’s also bad for productivity and creativity in the short and long run.28. Genuinely apologize to people you’ve mistreatedPeople make mistakes several times every single day. Sadly — and hilariously — much of the time we act like kids and blame our mistakes on external factors. Research has found that people who don’t openly and often apologize experience higher levels of stress and anxiety.You don’t need that pent-up energy in your life. Make amends and let it go. It’s not your choice if people choose to forgive you.29. Make friends with five people who inspire you“You are the average of the five people you spend the most time with.” — Jim RohnWho you spend time with is incredibly important. Even more fundamental is: what types of people are you comfortable around?Your comfort level is one of the clearest indicators of your character. Are the people you enjoy being around inspiring or degrading, hard-working or lazy?What kinds of beliefs do you friends have?What kinds of goals are they pursuing?How much money do they make?What does their health look like?All of these things dramatically impact you. And it is one of the most painful experiences in the world to become uncomfortable around people who have long been your friends. When you grow and evolve and long for more, you’ll begin seeking a different crowd to surround yourself with.Misery loves company. Don’t let them hold you back. Move on but never detach from the love you have for those people.30. Save 10 percent or more of your income“I would have saved 10 percent automatically from my paycheck by direct deposit into a savings account earning the best possible interest compounded daily. I would have also disciplined myself to deposit 10 percent of any additional money from gifts, refunds or other earned income. I would have bought a small house outright with the money I had saved (instead of renting an apartment for over 30 years). I would have found a job that I loved and devoted my life to it. At least you could be happy even if you were not where you wanted to be financially. Hope this helps someone out there.” — D. LorinserTithing yourself is a core principle of wealth creation. Most people pay other people first. Most people live above their means.In total, American consumers owe:$11.85 trillion in debtAn increase of 1.4% from last year$918.5 billion in credit card debt$8.09 trillion in mortgages$1.19 trillion in student loansAn increase of 5.9% from last yearThe U.S. Census in 2010 reported that there were 234.56 million people over the age of 18 years old, suggesting the average adult owes $3,761 in revolving credit to lenders. Across the average household, American adults also owe $11,244 in student loans, $8,163 on their autos, and $70,322 on their mortgage.Simply switching to home-brewed coffeewill save you an average of $64.48 per month (or $2 per day) or $773.80 per year. By putting the savings into a mutual fund with average earnings of 6.5% interest and reinvesting the dividends into more mutual funds over a decade, the $64.48 saved every month would grow into $10,981.93.My wife once took an accounting class from a world-renowned accountant. His words on the first day of class, “The most important thing you’ll learn in this class, which most people will never learn: spend less than you earn. If you do this, you’ll be financially free.”31. Tithe or give 10 percent of your income away“One gives freely, yet grows all the richer.” — Proverbs 11:24Many of the wealthiest people in the world attribute their healthy financial life and abundance to giving some of it away.Most people are trying to accumulate as much as they can. However, a natural principle of wealth creation is generosity. As Joe Polish has said, “The world gives to the givers and takes from the takers.”From a spiritual perspective, everything we have is God’s (or the Earth’s). We are merely stewards over our possessions. When we die, we don’t take our money with us. So why hoard it?As you give generously and wisely, you’ll be stunned by the increases in your earning potential. You’ll develop traits needed for radical wealth creation.32. Drink 64–100 ounces of water per dayHuman beings are mostly water. As we drink healthy amounts of water, we have smaller waistlines, healthier skin, and better functioning brains. Actually, as we drink enough water, it’s safe to say we’re better in every way.It’s a no-brainer. If you’re not drinking the healthy amount of water each day, you should critically assess your priorities in life.33. Buy a small place rather than rentUnless you live in a big city (which many of you do), I’m baffled how many people pay outlandish amounts on rent each month.When my wife and I moved to Clemson to begin graduate school, we did a lot of front end work to ensure we’d be able to buy a home. What’s shocking is that our mortgage payment is far less than most of our friend’s rent payments. By the end of our four years here in Clemson, we’ll have earned several thousand dollars in equity and even more in appreciation. Conversely, many of our friends are simply dumping hundreds of dollars into someone else’s pockets every month.Paying rent is like working hourly. You get money while you’re on the clock. When you’re not on the clock, you get no money. Earning equity is like having residual income. Every month you pay down your mortgage, you actually keep that money. So you’re not “spending to live” like most people do. You’re living for free while saving — often earning in appreciation.34. Check your email and social media at least 60–90 minutes after you wake upMost people check their email and social media immediately upon waking up.This puts them in a reactive state for the remainder of the day. Instead of living life on their own terms, they’d rather respond to other people’s agendas.Hence, the importance of having a solid morning routine. When you wake up and put yourself, not other people first, you position yourself to win before you ever begin playing. As Stephen Covey has taught in his book, Spiritual Roots of Human Relations, “Private victory always precedes public victory.”Make the first few hours of your morning about you, so that you can be the best you can for other people. My morning routine consists of prayer, journal writing, listening to audiobooks and podcasts while I workout, and taking a cold shower.After I’ve had an epic morning, and I’m clear on the direction of my day, I can utilize email and social media for my benefit rather than detriment.35. Make a few radical changes to your life each yearReinvent yourself every year. Novelty is an antidote to monotony. Jump into new pursuits and relationships.Try things you’ve never done before.Take risks.Have more fun.Pursue big things you’ve been procrastinating for years.In 2015, my wife and I went from having no kids to having three foster kids (ages 4, 6, and 8). I’ve started blogging. I quit my job and started writing full-time. I completely changed my diet. I’ve changed my entire daily routine.This year has been just as transformative as the last. It’s taught me that you can change your whole life in one year. I plan on changing my whole life for the better every year.Change freaks people out. It immediately pulls you from your comfort zone. Which is exactly what you need. You’ll often feel like a fraud. But impostor syndrome is exactly what you should be seeking. Do your best to always be the dumbest person in the room and you’ll improve rapidly.36. Define what wealth and happiness mean to you“Be everything to everybody and you’ll be nothing for yourself.” — John RushtonNo two human beings are the same. So why should we have one standard of success? Seeking society’s standard of success is an endless rat-race. There will always be someone better than you. You’ll never have the time to do everything.Instead, you recognize that every decision has opportunity cost. When you choose one thing, you simultaneously don’t choose several others. And that’s okay. Actually, it’s beautiful because we get to choose our ultimate ideal.We must define success, wealth, and happiness in our own terms because if we don’t, society will for us — and we will always fall short. We’ll always be left wanting. We’ll always be stuck comparing ourselves and competing with other people. Our lives will be an endless race for the next best thing. We’ll never experience contentment.37. “Change the way you feel, think, and act about money” — Steve DownMost people have an unhealthy relationship with money. It’s not necessarily their fault; it’s what they were taught.In order to change your financial world, you need to alter your paradigm and feelings about money.Here are some key beliefs the most successful people in the world have:In a free-market economy, anyone can make as much money as they want.Your background, highest level of education, or IQ is irrelevant when it comes to earning money.The bigger the problem you solve, the more money you make.Expect to make lots of money. Think BIG: $100,000, $500,000, or why not $1 million?What you focus on expands. If you believe in scarcity, you’ll have little.If you believe there is unlimited abundance, you’ll attract abundance.When you create incredible value for others, you have the right to make as much money as you want.You’re not going to be discovered, saved, or made rich by someone else. If you want to be successful, you have to build it yourself.When you develop a healthy relationship, you will have more. You won’t spend money on the crap most people waste their money on. You’ll focus more on value than price.38. Invest only in industries you are informed aboutWarren Buffett doesn’t invest in technology because he doesn’t understand it. Instead, he invests in banking and insurance. He’s not a tech guy. He invests in what he understands.Yet, so many people invest in things they don’t understand. I’ve made that mistake. I once invested several thousand dollars in an overseas rice distribution. Although the investment sounded incredible on paper, it’s turned out to be a disaster.I didn’t have the understanding to make an informed decision. I put my trust in someone else’s hands. And no one cares about your success more than you do.From now on, I’m going to responsibly invest in things I can make informed decisions on.39. Create an automated income source that takes care of the fundamentalsWe live in unprecedented times. It has never been easier to create automated income streams. No matter your skill-set and interests, you can put a business in place that runs 24/7 even while you’re sleeping, sitting on the beach, or playing with your kids.An entrepreneur is someone who works for a few years like no one will so they can live the rest of their life like no one else can.If you want to free up your time and energy for the things that matter most, either invest in stuff you’re informed on (e.g., real estate, businesses, mutual funds), or, create a business that doesn’t require you (e.g., create an online educational course about something you’re passionate about).40. Have multiple income streams (the more the better)Most people’s income comes from the same source. However, most wealthy people’s income comes from multiple sources. I know people with hundreds of income streams coming in each month.What would happen if you set things up so you were getting income from 5 or 10 different places each month?What if several of those were automated?Again, with a few short years of intentional and focused work, you can have several income streams.41. Track at least one habit/behavior you’re trying to improve“When performance is measured, performance improves. When performance is measured and reported, the rate of improvement accelerates.” — Thomas MonsonTracking is difficult. If you’ve tried it before, chances are, you quit within a few days.Research has repeatedly found that when behavior is tracked and evaluated, it improves drastically.It’s best to track only a few things. Maybe just one at a time.If you want to track your diet, a fun approach is taking a picture of everything you eat. Everything. This allows you the time to determine if you really want to put that in your body.So, your tracking can be creative. Do what works for you. Use a method you will actually do. But start tracking.As a consultant and executive coach, tracking and reporting behavior, daily, has been the number one factor in my client’s success. When you track something, you become aware of it. When you report something, you become accountable to it.Most of my clients simply send me an email at the end of their workday with a few bullet points (e.g., I did 4 hours of work on my startup, I made 3 sales, I didn’t check social media before noon). Accountability to a spreadsheet or app is not the same as accounting to a person — particularly one you trust and respect.42. Have no more than 3 items on your to-do list each dayWhen you shift your life from day-to-day reactivity to one of creation and purpose, your goals become a lot bigger. Consequently, your priority list becomes smaller. Instead of doing a million things poorly, the goal becomes to do a few things incredibly — or better yet, to do one thing better than anyone else in the world.“If you have more than three priorities, then you don’t have any.” — Jim CollinsSo, instead of trying to do a million small things, what one or two things would make the biggest impact?Dan Sullivan, founder of Strategic Coach, explains that there are two economies: The Economy of Hard Work and The Economy of Results.Some people think hard work is the recipe. Although this is completely true, the effort is often misplaced. Most people focus on the process or work first, and the result second. Conversely, those who determine the outcomes their seeking first can better discern which strategy will be most effective. Sure, that strategy may be out of your comfort zone, but as Tim Grover has said inRelentless, “When you crave the end result, the hard work becomes irrelevant.”Tim Ferriss, in his book, The 4-Hour Body, explains what he calls Minimum Effective Dose (MED), which is simply the smallest dose that will yield a desired result and anything past the MED is wasteful. Water boils at 100°C at standard air pressure — it is not “more boiled” if you add more heat.What is the fastest way to get your desired outcome?43. Make your bed first thing in the morningAccording to psychological research, people who make their bed in the morning are happier and more successful than those who don’t. If that’s not enough, here’s more:71 percent of bed makers consider themselves happyWhile 62 percent of non-bed-makers are unhappyBed makers are also more likely to like their jobs, own a home, exercise regularly, and feel well restedWhereas non-bed-makers hate their jobs, rent apartments, avoid the gym, and wake up tired.Crazy, right?Something so simple. Yet, when you make your bed first thing in the morning, you knock-off your first accomplishment of the day. This puts you in a mindset of “winning.”Do it! It only takes 30 seconds.44. Make one audacious request per week (what do you have to lose?)“Rainmakers generate revenue by making asks. They ask for donations. They ask for contracts. They ask for deals. They ask for opportunities. They ask to meet with leaders or speak to them over the phone. They ask for publicity. They come up with ideas and ask for a few minutes of your time to pitch it. They ask for help. Don’t let rainmaking deter you from your dream. It’s one of the barriers to entry, and you can overcome it. Once you taste the sweet victory of a positive response, you’ll not only become comfortable with it, you might even enjoy it. But making asks is the only way to bring your dream to life.” — Ben ArmentI got into graduate school way after applications were due because I asked.I’ve gotten free NBA tickets by asking a few players I saw at a hotel.I’ve gotten my work published on high tier outlets because I ask.Very few things in life are just randomly given to you as an adult. In most cases, you need to earn it and/or ask for it.Yet, there are many opportunities currently available to everyone if they would muster the courage and humility to ask.The entire crowdfunding industry is based on making asks.Start making bold and audacious asks. What’s the worst that could happen? They say “No”?What’s the best that could happen?When you don’t ask, you lose by default. And you’ll never know the opportunities you missed out on.Don’t sell yourself short. Ask that beautiful girl on a date. Ask for that raise or big opportunity at work. Ask people to invest in your idea.Put yourself out there. You’ll be blown away by what happens.45. Be spontaneously generous with a stranger at least once per monthLife isn’t all about what you can achieve or acquire. It’s more about who you become and what you contribute.Interestingly, research done at Yale has found that people are instinctively cooperative and generous. However, if you stall and think about being helpful or generous, you’re less likely to do it. And the longer you wait, the likelihood of you being helpful diminishes. This principle applies to other areas as well, like creativity. The longer you wait to do something, the less likely it is you’ll do it.So, be spontaneous. When you get the wild thought of buying the person’s food in the car behind you, just do it. Don’t think about it.If you’re driving down the road and see someone with car trouble off to the side, just do it. Don’t think about it.When you want to say “I love you,” to a loved one, just do it. Don’t think about it.Paralysis by analysis is dumb. And Malcolm Gladwell explains in Blinkthatsnap-decisions are often far better than well-thought out ones.46. Write and place a short, thoughtful note for someone once per dayThe messages of handwritten letters impact deeper and are remembered longer than electronic messages. There is no comparison to this traditional form of conversation. Handwritten messages are so powerful that people often keep these notes for a long time. Sometimes a lifetime.Jack Canfield has taught that writing 3–5 handwritten notes per day will change your relationships. In our email world, it can seem inefficient to hand-write and mail a letter. But relationships aren’t about efficiency.Not only will handwriting letters change your relationships, it will change you. Research has shown that writing by hand increases brain development and cognition more than typing can.Consequently, the things you write will be seared into your own memory as well, allowing both you and the recipient to reflect back on cherished moments.Writing handwritten notes spices up your relationships, adding an element of fun. It’s exciting placing kind and loving notes in random places for your loved ones to find. Put a note under the windshield wipers of your loved one’s car to find after a hard day’s’ work. Hidden, wait til they come out and watch them from across the street. You’ll see their eyes light up and smile spread.Other fun places include:In the fridgeIn the closetOn the computer keyboardIn their shoeIn their walletThe mail boxAnywhere that makes the experience a surprise…47. Become good friends with your parentsMany people have horrible relationships with their parents. I once did myself. Growing up can be tough and sometimes our parents make horrible decisions that negatively impact us.However, my parents have become my best friends. They are my confidants. I turn to them for wisdom and advice. They understand me like no one else. Biology is a powerful thing.Although I don’t see things the same way my parents do, I love them and respect their viewpoints. I love working out with my dad and talking about big ideas with my mom.I couldn’t imagine not being close to them.If your parents are still around, rekindle those ties or increase the flame. You’ll find enormous joy in those relationships.48. Floss your teethAbout 50 percent of Americans claim to floss daily. My guess is that’s a large over-estimate. Either way, the benefits of flossing are incredible.Doing so daily prevents gum disease and tooth loss. Everyone gets plaque, and it can only be removed by flossing or a deep cleaning from your dentist. Plaque buildup can lead to cavities, tooth decay, and gum disease. If left untreated, gum disease can be a risk factor for heart disease, diabetes, and a high body mass index.Yes, not flossing can make you fat.Not only that, but it greatly reduces bad breath.49. Eat at least one meal with your family per dayIf possible, eat a sit-down meal with your loved ones daily. It doesn’t matter if it’s breakfast, lunch, or dinner.We’ve become so high-paced in the world that everything we do is on the go. We’ve forgotten what it means to just be with our loved ones.Eating together creates a sense of community like nothing else.Teens who have fewer than three family dinners a week are 3.5 times more likely to have abused prescription drugs and to have used illegal drugs other than marijuana, three times more likely to have used marijuana, more than 2.5 times more likely to have smoked cigarettes, and 1.5 times more likely to have tried alcohol, according to the CASA report.50. Spend time reflecting on your blessings at least once per dayGratitude is the cure-all for all the world’s problems. It has been called, “the mother of all virtues,” by the Roman philosopher Cicero.When you practice gratitude, your world changes. There is no objective reality. All people perceive reality as they selectively attend to things that are meaningful to them. Hence, some people notice the good while others notice the bad.Gratitude is having an abundance mindset. When you think abundantly, the world is your oyster. There is limitless opportunity and possibility for you.People are magnets. When you’re grateful for what you have, you will attract more of the positive and good. Gratitude is contagious. It changes not only your world, but everyone else’s you come in contact with.Article Credit- @Benjamin P.HardySource- https://journal.thriveglobal.com/50-ways-happier-healthier-and-more-successful-people-live-on-their-own-terms-2dd13bb131c3

Because we believe this is so crucial to learn and understand, the Sales Hacker team came up with 260+ Sales Terms that EVERY saas seller should know!Check it out:260 Sales Terms From A - Z: The Updated Glossary of B2B Sales Definitions | Sales HackerFor your convenience, the full glossary of terms are also listed below :)AAB TestingAccountAccount-Based Everything / RevenueAccount-Based MarketingAccount-Based Selling / Sales DevelopmentAccount Development RepresentativeAccount ExecutiveAccounts PayableAccounts ReceivableAccredited InvestorAmortizationAnalyticsAnnual Recurring RevenueApplication Program InterfaceApplicant Tracking SystemArtificial IntelligenceAverage Contract ValueAverage Sale/Selling PriceAB Testing (or Split Testing) is an experiment involving two variants, usually for measuring and comparing market response to each. For example, you can measure visitor traffic or conversion rate on two different web pages having similar content and purpose.Account refers to a record of primary and background information about an individual or corporate customer, including contact data, preferred services, and transactions with your company.Account-based Everything (ABE) or Account-based Revenue (ABR) is a framework that entails full coordination of customized care and management of targeted customer accounts across all relevant units of your organization (such as marketing, sales, finance, and product development) as well as the entire customer life cycle from lead generation to after-sales support.Account Based Marketing (ABM) is a strategic framework that engages qualified individual prospects or customer accounts as unique markets in themselves, worthy of focused, hyper-personalized treatment by sales, marketing and other teams.Account Based Selling (ABS) or Account Based Sales Development (ABSD) is a primarily B2B selling framework that treats qualified or high value accounts as unique markets in themselves, where each account deserves dedicated resource allocation as well as hyper-personalized and multi-point engagement with different teams from your organization.An account development representative (ADR) is a sales specialist focusing on attracting, qualifying and securing new leads for further engagement, conversion and nurturing by account executives.An account executive (AE) is a sales specialist who has primary responsibility for one or more customer accounts (called a portfolio), commonly tasked not only to nurture and grow the company’s relationships with said accounts but sometimes also to convert qualified leads into paying customers.Accounts Payable refers to an accounting entry denoting the amount of short-term monetary obligation your company owes its suppliers, vendors and other service providers.Accounts Receivable refers to the amount of money yet to be collected from your customers who purchased a product or subscribed to a service.Accredited Investor – Legally, $200k+/yr (or 300 w/ spouse) take-home or 1M+ assets.Amortization – paying off debt on a fixed schedule or spreading a write-down over time.Analytics is the active study of different types of data with the aim of discovering meaningful patterns and translating these into insight (such as historical analyses and forecasts), or action (such as those intended to improve business performance).Annual Recurring Revenue (ARR) is the value of contracted, often subscription-based revenues normalized for one calendar year.Application Program Interface (API) is an accessible technical framework for exchanging data.Applicant Tracking System (ATS) is a giant fancy excel chart used to follow hiring.Artificial Intelligence (AI) refers to a system of computers, software, machines and processes that simulate certain aspects of human intelligence such as image perception, voice recognition and reasoning.Average Contract Value (ACV) is the average revenue you derive from a single customer in a given period. It is called Annual Contract Value (ACV) when annualized and Average Purchase Value (APV) when the revenue derived is not subscription-based.Average Sale/Selling Price (ASP) is a term that may refer to the average price of a product in a given market or channel or the price a certain class of products or services is commonly sold for.BB2BB2CB2C2BBase SalaryBaselineBASHO EmailBonusBookingsBusiness IntelligenceBusiness Development RepresentativeBuyerBuying IntentB2B is an acronym for Business-to-Business, a model for selling, relationship-building or engagement.B2C is an acronym for Business-to-Consumer, a model for selling, relationship-building or engagement.B2C2B is an acronym for Business-to-Consumer-to-Business, a model for selling, relationship-building or engagement.Base Salary refers to an agreed-upon amount of payment an employee received as compensation for work rendered.Baseline refers to a minimum level or starting point from which further measurements or comparisons can be made for analyses, forecasting, performance improvement or strategy formulation.BASHO Email is a customer engagement sequence using voicemail and email messaging aimed at increase the likelihood of a positive response from prospects.A bonus is a gift or additional compensation given on top of the standard pay or fee, often serving as a reward for outstanding performance or for achieving certain business targets.Bookings are the net new contracts signed, in dollar amounts (typically ACV or TCV).Business Intelligence (BI) refers to the interpretation of (primarily internal) data to inform product and market decisions.A business development representative (BDR) or sales development representative (SDR) is a sales specialist focusing on finding new prospects, establishing foundational relationships, and refreshing the sales pipeline with new leads for account executives.A buyer is an individual or organizational entity that purchases a product or subscribes to a service.Buying Intent refers to the apparent likelihood of a person or organization of purchasing a product or service as inferred from behavior such as online browsing, media consumption, document downloads, event participation.CCall for ProposalChallenger Sales ModelChampion/Challenger TestChannel PartnerChannel SalesChurnC-Level / C-SuiteClawbackClick Through Rate (CTR)ClientClosed WonCold CallCold EmailCommissionCompensationComplex SaleCompounded Annual Growth RateContentContent Management SystemConversionCost of Goods Sold (COGS)Cost per Click (CPC)Cost per Impression (CPI)CovenantCustomerCustomer Acquisition Cost (CAC)Customer Relationship ManagementCustomer SuccessCall for Proposal (also: RFP is similar) is the process by which a company asks for something to be sold to them. Competitors usually compete to win the client’s business.Challenger Sales Model is a sales framework that takes the disruptive approach to solution selling, where customers are pushed beyond their comfort zones to embrace new ideas for their business. It alludes to the Challenger, one of five sales representative profiles as classified by CEB (now Gartner). The five profiles are Challenger, Hard Worker, Lone Wolf, Problem Solver and Relationship Builder.Champion/Challenger Test is a testing approach for determining the best engagement strategy for a given market segment, wherein the Champion represents your current production/servicing paradigm while the Challenger(s) represent new or different ways of doing things.Channel Partner is a person or organization that offers services or products on behalf of another entity, mostly via a co-branding agreement.Channel Sales is a method of classifying and deploying your sales force into groups focusing on different distribution channels such as in-house sellers, retailers, dealers, and direct marketers.Churn is a term that describes the percentage of customers that leave or cancel a service or product within a given period of time.C-Level or C-Suite Executives (CxOs) are usually listed as Chief Executive Officer (CEO), Chief Technology Officer (CTO), Chief Marketing Officer (CMO), Chief Financial Officer (CFO).Clawback means contractual provision or an action involving an employer or benefactor taking back money already released to an employee or beneficiary.Click Through Rate (CTR) is typically expressed as a percentage and refers to the number of clicks on a link (usually an ad) divided by the number of times the page containing the link is shown.A client is an entity who pays another entity for products purchased or services rendered. Also called a customer.Closed Won is the status of an opportunity where the deal has been closed with the prospect/lead who is now considered a customer.Cold Call is an attempt to engage a prospect (via a personal visit or a voice call) who have no prior knowledge about or contact with the salesperson making the call.Cold Email is the use of email to engage a prospect who have no prior knowledge about or contact with the salesperson sending the email.Commission is the amount of money a sales professional earns for reaching a specific sales volume or for executing one or more business transactions.Compensation is the total payment and benefits an employee receives for rendering work — covering basic salary, allowances, commissions, bonuses, health insurance, pension plans, paid leaves, stock options, and other benefits.Complex Sale is a type of sale common in B2B markets involving multiple decision makers, custom service or purchase agreements, and relatively longer sales cycles.Compounded Annual Growth Rate (CAGR) is the measure of growth over different time periods. Consider it the growth rate that gets you from the initial investment value to the ending investment value – e.g. we grew 72% CAGR (not the same value as YoY).Content refers to a material or document released in various forms (such as text, image, audio, and video) and created to inform, engage or influence specific audiences.Content Management System (CMS) is a computer program or software application used to create, modify, store and manage digital content.Conversion is the process of turning a target consumer into a paying customer; or more generally, the point at which a user performs a specific action favorable to a marketer or a seller.Cost of Goods Sold (COGS) relates to the incremental cost of producing one good (e.g. one subscription.)Cost Per Click (CPC) is an advertising metric by which advertisers pay a bidding fee based on the number of people who click their ads. Commonly used in Google Adwords and Facebook Ads.Cost Per Impression (CPI) is an advertising metric by which advertisers pay a bidding fee based on the number of eyeballs that are exposed to their ads. Commonly used in Google Adwords and Facebook Ads.Covenant is a formal written promise stating that certain activities will or will not be carried out. Restrictive covenants include NDAs and non-compete agreements.Customer is an individual or an organization that purchases a product or signs up for a service offered by a business.Customer Acquisition Cost (CAC) is the cost that is required to acquire a new paying customer for a product or service.Customer Relationship Management (CRM) is a system, set of practices, and associated technologies used to record, manage and analyze customer data and interactions, with the aim of improving customer engagement and revenue.Customer Success is a proactive mindset, function, department or strategy commonly adopted by B2B companies to optimize business with customers, reduce churn rate, drive profits and increase the predictability of recurring revenue.DDarkDataDay Sales Outstanding (DSO)Days to Term SheetDeal ClosingDecision MakerDe-dupeDeferred RevenueDeliverablesDemand GenerationDevOpsDialerDirect MailDirect SalesDiscountDiscoveryDoing Business As (DBA)Double TriggerDrag Along RightsDraw on Sales CommissionDrip CampaignDark is a description for the state wherein a prospect have become unresponsive to calls, invitations, emails and other attempts at engagement (e.g., Mr.Brown has gone dark.)Data is a set of quantitative and qualitative facts that can be used as reference or inputs for computations, analyses, descriptions, predictions, reasoning and planning.Day Sales Outstanding (DSO) is the time after acquiring a client before actually getting paid.Days to Term Sheet is the time from first contact to signing – average is 37 days.Deal Closing (or Closing a Deal) is the process of completing a sales transaction wherein the prospect agrees to purchase a product or sign up for a service.Decision Maker in the context of sales, is a person who possesses the required expertise and authority in making purchase decisions.De-dupe (de-duplicate) is the process of eliminating duplicate data such as records, accounts, contact details and other information,Demand Generation is a marketing process that aims to build awareness and excitement about a company’s products and services, often used by businesses to promote new offerings or feature sets, reach new markets, generate consumer buzz and drive customer loyalty.Dialer is a computer software, application or electronic device that automates the process of making phone calls.Direct Mail is a communication channel where newsletters, catalogs, brochures, and other documents are sent via traditional postal services (such as the US Postal Service) that physically deliver parcels (also called snail mail).Direct Sales is the method of selling a product or service in a location other than the associated retail stores or offices, wherein the seller personally engages a prospect in a physical or face-to-face environment such as a home or a cafe.Discount means a promotional reduction in the cost of a product or service, commonly deployed to speed up sales.A discovery call (might be used interchangeably with a qualifying call) is the first call with a potential customer, designed to determine if they are a good fit — wherein the seller can start building rapport, set the tone for the relationship and gain deeper insight about the prospect’s challenges.Doing Business As (DBA) is simply a rebranding or sub-branding – meaning, the name under which they operate their business differs from its legal, registered name.Double Trigger is a clause that accelerates vesting when an employee is let go (without due cause) in an acquisition.Drag Along Rights allow a simple majority of investors to effect legal change (usually a sale).Draw on Sales Commission is a form of compensation for sales professionals that is released in advance against expected commissions or earnings. Also known as “Draw Against Commission” or simply “Draw.”Drip Campaign is an automated response email that is sent after a certain amount of time.EEBITDAE-CommerceEmployee EngagementEnd of Day (EOD)EngagementEnrichmentEnterpriseEntrepreneur in Residence (EIR)Enterprise Resource Planning (ERP)EOMEOQEOYEquityEBITDA (earnings before interest taxes, depreciation, and amortization) – the accounting standard that large companies use.E-Commerce is a field, platform, or environment where the buying and selling of goods and services are transacted online.Employee Engagement is the state, level, or process of building employee commitment to an organization, reflected in how much they strive to improve the company’s image, well-being and profitability.End of Day (EOD) also: Close of Business (COB)Engagement is the state or process of keeping a specific class of audience (employees, management, customers, etc.) interested about a company or brand and invested in its success because of its perceived relevance and benefits to the audience.Enrichment means the act or process of upgrading the value or improving the quality of something (such as a product, service or function) that induces the target beneficiary (customers, employees, etc.) to have a better experience, or derive a deeper meaning, connection and attachment to the product or function.Enterprise (in the context of sales) is a relatively large organization typically composed of multiple levels, locations, and departments which need multi-layer software systems that support collaboration across a large corporate environment.Enterprise Resource Planning (ERP) refers to software that seeks to centralize purchasing, inventory, shipping and fulfillment, product planning, HR, and more.Entrepreneur in Residence (EIR) refers to when a venture capital firm hires a successfully exited founder to do deal flow/diligence (see also: VCR – VC in Residence).EOM is an acronym for End of Month.EOQ is an acronym for End of Quarter.EOY is an acronym for End of Year.Equity means a common stock, preferred share or other forms of security that represent ownership interest in a company.FFair Market Value (FMV)FirmographicFiscal YearForecastingFortune 500Forward RevenueFair Market Value (FMV) is the price that a reasonably interested buyer would be willing to pay for a given asset or service. This is very difficult to compute, but used to value companies.Firmographic is a set of descriptive attributes of prospective organizational customers that can be used to classify firms into relevant or applicable market segments.Fiscal Year is a financial accounting period of one year (that may or may not coincide with the calendar year), which is used by governments and businesses for taxation, budget planning, performance assessment, strategy formulation and other purposes.Forecasting is a prediction or calculation of a trend or event likely to occur in the future based on qualitative, quantitative and historical data as well as emergent but relevant factors.Fortune 500 is a listing of the 500 largest companies in the United States based on revenue, compiled and published yearly by Fortune magazine.Forward revenue is recurring revenue projected for the next 12 months. Public SaaS co’s are valued based on this. The current median multiple is 5.0X forward revenue.GGatekeeperGeneral ManagerGlobal Business UnitGo-to-Market StrategyGross MarginGatekeeper is a person (e.g., an executive secretary), application (e.g., a subscription or authentication interface) or other entities that control access to a person or object with a desired attribute such as a premium feature in case of a software service, or the ability to make purchase decisions in case of a corporate executive.General Manager is an executive with varying levels of importance and range of responsibilities depending on corporate structure, but who generally leads a company unit or a branch, overseeing its performance, profitability and daily operations.Global Business Unit (GBU) is a semi-autonomous component of a multinational corporation that focuses on a specific industry vertical or a specific set of functions, products or services, operating on a global scale.Go-to-market (GTM) strategy or Go-to-market plan refers to a plan, set of actions or road map that a company formulates with the aim of optimizing marketing and sales resources to establish the value of a new (or re-branded) product or service for consumers and achievecompetitive advantage, using methods such as advertising, distribution, pricing, direct sales and social media engagement.Gross Margin refers to total sales minus the cost of goods sold (COGS). Median for true SaaS cos is 71%, but what are considered to be “good margins” varies in SaaS. If you are running a marketplace/transaction revenue business, be very clear about gross margin.HHorizontalHorizontal refers to a specific offering or market opportunity (e.g. buying all the other medical CRMs so you’re the only medical CRM provider)IIdeal Customer ProfileInboundInbound SalesIndependent Software Vendor (ISV)Infrastructure as a Service (IaaS)Initial Public OfferingInMail MessagesIVR SystemsIdeal Customer Profile (ICP) refers to a type or class of customer who possesses all the desirable attributes (such as gender, age, location, financial capacity, lifestyle, brand affinity, etc.) that increase the possibility of an opt-in or a purchase, (your perfect type of client).Inbound refers to interest (could be sales or marketing driven) that comes in – e.g. cold emails to you, submitted forms on your website, press inquiries, etc.Inbound Sales is a process, method or transaction wherein purchases occur as a result of customers directly approaching, engaging and embracing your brand, achieved by focusing on their needs and strategically leading them to your solution.An independent software vendor (ISV) is an organization specializing in making and selling software, designed for mass or niche markets.Infrastructure as a Service (IaaS) refers to a type of cloud computing that provides digital computing resources over the internet. IaaS is part of 3 main types of cloud services, along with Software as a Service (SaaS), and platform as a service (PaaS). Examples of IaaS are backend functions like Amazon Web Services (AWS), Zapier, , Docker, etc.Initial Public Offering (IPO) refers to the sale of stock issued by a private company and offered to the public for the very first time.InMail Messages are introductory email that are sent to another LinkedIn member you’re currently not connected with.IVR Systems – interactive voice recording systems.KKey AccountsKey Performance Indicators (KPIs)KickersKey Accounts are whale spenders or VIP customers prioritized by sales reps and customer success; churn from these clients would be a detrimental loss to the company’s revenue.Key Performance Indicators (KPIs) are the most relevant measurable values that help indicate whether an organization or individual has succeeded at achieving targets or a desired level of performance.Kickers are monetary bonuses or extra commissions offered to motivate sales professionals to exceed quota, showcase a specific service or product, or target a particular market segment.LLeadLead GenerationLead NurturingLead QualificationLead ScoringLifetime Value (LTV)LinkedInLoss AversionLow-Hanging FruitLead refers to a prospect or potential customer (who can be an individual or organization) that exhibits interest in your service or product; or any additional information about such entity.Lead Generation is a set of activities aimed at generating interest around a product or service through methods such as 1. content marketing (blogging, podcasts, free downloads); 2. advertising (PPC, banner ads, Yellow Pages, sponsoring an event); 3. referrals (recommendations from existing customers and other people); 4. outbound marketing (cold email, cold calling), and 5. partnerships (joint ventures, affiliate marketing).Lead Nurturing refers to the process of engaging and building long-term relationships with prospective customers through different marketing techniques that develop their preference for your product and services.Lead Qualification is the process of determining whether a potential customer has the characteristics of your company’s ideal client (such as sufficient purchasing ability and a higher likelihood of buying your product).Lead Scoring is the process of assigning a relative value to each lead based on different criteria, with the aim of ranking leads in terms of engagement priority.Lifetime Value (LTV) is the total value of a customer from a business perspective or in terms of revenue before they churn. MRR/churn %LinkedIn is a social network for the business community.Loss Aversion is a psychological effect whereby people feel more strongly (negatively) about losing a sum of money than they do (positively) from gaining the same amount.Low-Hanging Fruit refers to a class of prospective consumers or a market segment that requires the least level of effort to turn into paying customers.MMachine LearningMarketingMarketing Qualified LeadMaster Services Agreement (MSA)MessagingMetricsMid-marketMinimum Viable Product (MVP)Monthly Recurring RevenueMachine Learning is an aspect or type of artificial intelligence whereby a computer possesses the ability to learn various things by itself without explicitly being programmed to.Marketing is the field, set of actions, or practice of making a product or service desirable to a target consumer segment, with the ultimate aim of effecting a purchase.Marketing Qualified Lead (MQL) is a type of lead that has been evaluated — based on a given set of criteria — to have a higher likelihood of becoming a paying customer compared to other leads.Messaging is the process of communicating your brand’s value proposition, the benefits you offer, and the perceived meaning of such communication among your target audience.Metrics are quantities that are measured and used to:Assess a set of attributes such as a company’s profitability.Determine cost efficiency or an individual’s job performance.Implement corrections or remedial actions.Make accurate revenue forecasts.Formulate departmental or corporate strategies.Mid-Market is a classification of business organizations in terms of scale (revenue, number of employees, etc.), occupying the segment between the small companies and large multinational enterprises serving the same market.Minimum Viable Product (MVP) is a development framework by which a new product or website is built with bare minimum / basic features; just enough to satisfy early adopters. The point is to validate product-market fit and demand. This is usually a fast, crappy product thrown together to see if anyone will buy it. Speed of execution is the goal.Monthly Recurring Revenue (MRR) is the amount of reasonably regular and predictable income a company expects to receive every month, typically used in rental and subscription-based businesses. The formula for calculating MRR = ARR divided by 12.NNatural Language Processing (NLP)Needs AssessmentNegotiationNet Asset Value (NAV)Net New BusinessNet Promoter Score (NPS)Net XNatural Language Processing (NLP) is the crossroads of artificial intelligence and computational linguistics. This is where machines learn to interpret human language based on contextual meanings and use it to do things and obey commands (e.g. Amazon’s Alexa uses NLP to take what you say and run commands with it.)Needs Assessment is a process for analyzing a system, person, function or organization with the aim of determining what the entity lacks to achieve a desired state or outcome, usually involving the identification and classification of specific needs according to their level of importance.Negotiation is a strategic dialogue, discussion, or bargaining process between two or more parties with the goal of reaching a mutually acceptable agreement.Net Asset Value (NAV) refers to value per share in a mutual fund or ETF.Net New Business is a prospect that you have newly converted into a paying customer or an existing account that has been dormant for a long period but has been re-engaged and reactivated as a revenue-generating account.Net Promoter Score (NPS) is a rating used to gauge the loyalty or satisfaction of a firm’s customer relationships. This survey is typically administered on a scale of 1-10, with 9-10 considered as promoters, 6-8 as passives, and 1-6 as detractors.Net X indicates payment is to be delivered in X days (typical: Net 30 or Net 60).OObjectionOn Track Earnings / On Target Earnings (OTE)OnboardingOpportunityOptimizationOrg StructureOrganizationOutbound SalesObjection refers to a position, statement or view of a prospect which indicates reservation about or disagreement with a particular aspect or the entirety of your sales pitch, lessening the likelihood of a purchase.On Track Earnings / On Target Earnings (OTE) refers to a common sales pay structure composed of a base salary with an additional amount of commission. For example, this would refer to a sales rep’s take-home pay if they are meeting quotas and earning expected commissions. OTE is an estimation; over/under quota reps will make different salaries depending on performance.Onboarding is the process or act of introducing a new customer to your product or service; or integrating a newly hired employee into your workforce or team.Opportunity (also SQL, Sales Qualified Lead) is a lead that has been determined to have a higher likelihood of opting in, subscribing or making a purchase based on a set of criteria.Optimization is the process or act of altering a system, design, or procedure such that it 1) attains full functionality or efficiency, or 2) generates maximum output, benefit, or impact.Org Structure is a system by which the hierarchy, lines of authority, and interrelationships of teams, roles, responsibilities, and functions in an organization are defined.Organization is a cohesive group of people working together and formally bound by a shared identity (e.g., one team, company, club, etc.) and a common purpose (e.g., business growth, athletic victory, etc.).Outbound Sales refers to a process where the seller directly initiates contact with a prospect customer with the aim of closing a deal down the line using methods such as cold calling, cold emails and direct outreach on social media.PPlatform as a Service (PaaS)PlaysPoint of ContactPredictive AnalysisPresidents ClubPricing/PricePro rataPro rata rightsProcurementProductProduct Lifecycle Management (PLM)Product Qualified LeadProfessional Employer Organizations (PEO)ProfitabilityProof of Concept (PoC)Purchase Order (PO)Push CounterPlatform as a Service (PaaS) refers to selling either a lightweight product with tons of integrations/apps or just the marketplace (e.g. Salesforce, Slack, Zapier).Plays is an engagement strategy, set of actions, series of tactical steps, or an agreed upon selling approach developed to be repeatable and customized to deliver the highest likelihood of closing a deal with a specific group of prospective customers during a set period.Point of Contact (POC) is the person or unit representing an entity, typically tasked to facilitate decision-making and coordinate the flow of information to and from the entity.Predictive Analytics refers to the field or tool that uses historical data, statistical models, emergent trends and other information to formulate an informed forecast about the future, usually with regards to the performance, growth, or feasibility of a business.Presidents Club is a prestigious award – often the most coveted in a sales organization – given to elite performers for exemplary achievements. The award often involves generous prizes and time spent (vacation, dinner, etc) with the organization’s key executives.Pricing/Price is the amount of money needed in order to purchase the service or product.Pro rata is a Latin phrase that describes a proportional allocation of income, expenses, or other quantities to their component items based on these items’ original share of the total amount.Pro rata rights refer to the right of first refusal (ROFR) given to investors (typically institutional ones) that allow them to buy an equivalent amount of equity that they would ‘lose’ due to dilution in the round(s) after the one they originally invested in.Procurement is the process of finding and acquiring goods and services, usually involving demand assessment, bid reviews, approval requests and transaction logging.Product refers to anything (an idea, item, service, process or information) that meets a need or a desire and offered to a market, usually but not always at a price.Product Lifecycle Management (PLM) is the process of managing a service or product across its entire lifecycle — ideation, design, development, deployment, termination/disposal.Product Qualified Lead (PQL) is a potential customer who meets a set of predefined criteria and have used a benchmark product(s), indicating a relatively higher likelihood of making a purchase.Professional Employer Organizations (PEO) is a firm that provides business/administrative services that employers can outsource. Many services can be outsourced via PEOs – such as employee benefits, payroll and workers’ compensation, recruiting, risk/safety management, and training and development.Profitability is the potential, degree, metric, ability or relative efficiency of a business to yield financial gain (i.e., profits) after all relevant expenses and costs have been deducted.Proof of Concept (PoC) is a study, prototype, or demonstration attempting to prove that a business idea is feasible and has the potential to be successful.Purchase Order (PO) is a document issued by a buyer to a seller to indicate the services or products the buyer intends to subscribe to or purchase at the indicated cost.Push Counter is a dashboard tracker used in some CRM’s such as Salesforce to monitor the frequency at which closing an opportunity is being pushed/postponed from period to period.QQuarterQuotaQuarter is a three-month period in a company’s fiscal year commonly used to make comparative performance analyses, detect or forecast business trends, report earnings, and pay shareholder dividends.Quota is a predefined benchmark indicating the amount of sales a selling unit such as a sales rep or a regional sales team should achieve within a given period, often used as a measure of success, performance and eligibility for commissions and other rewards.RRamp upRecruiterReferralRelationship Business Management (RBM)Request for Information (RFI)Request for Proposal (RFP)Request for Quotation (RFQ)Request for Tender (RFT)Return on InvestmentRevenueRight of First Refusal (ROFR or RFR)Rule of ReciprocityRamp up may refer to 1) the state at which full productivity (such as quota attainment) has been achieved by a salesperson or team; 2) the effort or campaign to achieve such a state; or 3) the amount of time or the rate at which a salesperson or a team achieves quota. Also called “Ramp Rate” or “Ramp up Time”.Recruiter is a person or agency whose primary purpose is to find, assess, hire and onboard people as employees in a company or as members of an organization.Referral means the act, process, or technique of generating sales leads wherein a third party shares information about a new prospect.Relationship Business Management (RBM) refers to the process of transitioning customer interactions from a transaction-based paradigm to one of long-term subscription.Request for Information (RFI) is a business document that aims to gather textual information about the offerings and capabilities of business entities such as vendors. Less rigorous than RFPs.Request for Proposal (RFP) is a business document that requests vendors or service providers to submit a proposal or bid during a procurement process.Request for Quotation (RFQ) is a business document asking suppliers or service providers to give a comprensive quote/pricing for the purchase of an item(s) or the completion of a specific task.Request for Tender (RFT) is a formal process where suppliers or service providers are invited to submit a bid for the procurement of an item, commodity or service.Return on Investment (ROI) is a metric — commonly expressed as a percentage — that indicates the efficiency or profitability of an investment, computed by dividing the benefit (return) by the cost of investment.Revenue is the amount of money a business generates during a specific period such as a year or a quarter; also called sales.Right of First Refusal (ROFR or RFR) is a contractual right granting its holder the option to perform a specific business transaction with an entity before any such transaction is offered to a third party.Rule of Reciprocity is a sociological rule that compels a person to treat others positively with the expectation that the person will be treated the same way.SSaaSSales AccelerationSales AutomationSales CadenceSales ChampionSales CoachingSales CycleSales DemoSales Development RepresentativeSales DirectorSales EnablementSales FunnelSales KickoffSales LeadSales ManagerSales OperationsSales PartnershipsSales PipelineSales ProcessSales ProductivitySales ProspectSales ProspectingSales Qualified LeadSales TrainingSalesforce AdministratorSandler TrainingScrapingSegmentationSelling, General, and Administrative (SG&A)Sender Policy Framework (SPF)/Domain Keys Identified Mail (DKIM)Service Level Agreement (SLA)Serviceable Available Market (SAM)Serviceable Obtainable Market (SOM)Share Purchase Agreement (SPA)Shareholders’ Agreement (SHA)SignalingSiloedSmall and Mid-Size BusinessSmarketingSingle Sign On (SSO)Social SellingSoftware as a Service (SaaS)Software CapitalizationSolutionSolution SellingSpiffSPIN SellingStakeholderStatement of Work (SOW)Strategic Investment/Smart Money/Corporate Venture Capital (CVC)Structured dataSubject Matter Expert (SME)System of Record (SOR)SaaS is an acronym for Software as a Service.Sales Acceleration is the act or practice of speeding up the sales process using tools and technologies that improve the productivity and efficiency of sales professionals.Sales Automation is the act, practice or technique of using software to simplify, speed up or streamline the entire sales process or specific component activities such as customer tracking, forecasting, and inventory monitoring.Sales Cadence is the established sequence of activities (such as voice calls and emails) and the frequency at which your sales team engages a prospect or an account, as guided by data analytics.Sales Champion is a prospect with influence and authority who also deeply understands and likes your product to the point of advocating for its adoption and success.Sales Coaching is the process of helping sales professionals improve their performance, efficiency, and impact largely through behavioral changes and the development of new skills.Sales Cycle is a repeating process characterized by a predictable sequence of stages that a company undergoes as it sells its products and services to customers.Sales Demo is the act or process of showing the functions, benefits and value of a product or service as it relates to a particular audience, with the aim of leading the audience towards a purchase.Sales Development Representative (SDR) or Business Development Representative (BDR) is a sales specialist focusing on finding new prospects, establishing foundational relationships, and refreshing the sales pipeline with new leads for account executives.Sales Director is a senior-level executive who oversees an organization’s sales operations by 1) leading the formulation and execution of strategies, plans and policies for national or international sales 2) proposing and rationalizing departmental budgets; 3) supervising regional sales managers; and 4) ensuring continuous sales growth for the company.Sales Enablement is a strategic process that provides a company’s sales professionals with tools, technology, training and other resources that improve their performance at customer engagement and at generating value for all stakeholders in the sales process.Sales Funnel is a visualization of the sales process that defines the stages through which prospective customers go through as they are led by sales professionals towards a purchasing decision.Sales Kickoff is a major annual event for sales organizations, often held as a celebratory gathering where key achievements in the prior year are recalled, new revenue and organizational targets are set, and inspirational talks/strategy presentations/keynote speeches are given by guest dignitaries and top executives to galvanize the salesforce to deliver high performance in the coming year.Sales Lead is a potential consumer of your company’s product or service who have 1) expressed interest about your offerings, and 2) shared contact information.Sales Manager is an executive who leads a sales unit, team or department by setting goals and meeting targets, formulating plans and policies, designating tasks, and developing salespeople.Sales Operations is a collection of aligned business processes, strategic implementations and other activities aimed at achieving organizational goals, specially in the areas of sales revenue, market coverage and growth.Sales Partnerships is a formal collaboration between individuals or organizations aimed at bolstering the sales performance of a product or service for mutual benefit.Sales Pipeline is a type of visualization showing the status of each sales prospect in the customer life cycle or sales process.Sales Process is a series of strategic steps or a set of activities aimed at driving sales growth through the alignment of personnel, market insight, methodologies, relevant business units, and technology.Sales Productivity is a metric that indicates how efficient a sales unit is at closing sales and generating revenue for the company, based on sales volume, payroll expenses, level of personnel activity and other factors.Sales Prospect is a potential consumer of your product or service who meets a given set of benchmarks; typically a sales lead whose financial capacity, buying authority and willingness to purchase are found sufficient enough to qualify and be upgraded in the sales funnel as a prospect.Sales Prospecting is the process of finding, building and qualifying a pool of potential buyers or clients through networking, cold calling, advertising and other engagement methods.Sales Qualified Lead (SQL) is a potential customer that has already met the criteria for MQL and has further shown a higher likelihood of opting in or making a purchase. SQLs are flagged by sales development representatives and forwarded to quota-driven Account Executives (AE) for closing-level engagements.Sales Training is the process of improving the skills, behavior and mindset of sales professionals to upgrade their selling performance.Salesforce Administrator refers to an individual — usually a team leader or manager — tasked to maintain high employee productivity and engagement through technology, process improvements and other methods; also a person tasked to operate and maintain the Salesforce CRM.Sandler Training is an organization that trains professionals around the world on sales performance, management, and leadership.Scraping is the process or technique of extracting large amount of data from websites. Also called data harvesting, data scraping.Segmentation is the process of subdividing a large market into distinct partitions (or segments) based on demographics and other factors, with the aim of formulating and implementing separate strategies to better engage the consumers in each segment.Selling, General, and Administrative (SG&A) refers to non-production expenses that are often itemized in a company’s income statement under operating costs. These include business management expenses as well as costs incurred in the promotion, sale and distribution of the company’s products and services.Sender Policy Framework (SPF)/DomainKeys Identified Mail (DKIM) verification are online security processes that prevents email fraud, phishing, impersonation, spam, spoofing, and other malicious online activities.Service Level Agreement (SLA) is a contract between a service provider and a consumer that specifies the quality, availability, restrictions, and other aspects of the service.Serviceable Available Market (SAM) is the portion of the Total Addressable Market (TAM) that can be reached by a business based on its current capabilities or prior track record (i.e., how much of the market you could realistically reach).Serviceable Obtainable Market (SOM) is the portion of your Serviceable Available Market (SAM) that you can reasonably capture in the short term. This is the smallest of the three market scales (TAM, SOM, SAM).Share Purchase Agreement (SPA) is a contract between a company, its shareholders, and investors that sets the basic terms for the purchase and sale of shares. Also called Share Sale Agreement (SSA).Shareholders’ Agreement (SHA) is a contract among the shareholders of a company prescribing how the company’s operations should be conducted and stipulating the rights and obligations of shareholders.Signaling is a process in which a consumer conveys readiness to purchase your product or service as indicated by “signals” or triggers such as willingness to sign up, participation in events, asking questions about your solutions, etc.Siloed is a descriptive term for an organization whose units, teams or departments lack collaboration, coordination or synergy because they are run and managed as separate and exclusive bubbles, towers, or “silos”. A siloed team misses out on opportunities to benefit from interactions with other teams. Teams and individuals who prefer such arrangements are said to have a “silo mentality.”Single Sign On (SSO) a method that allows access to multiple but independent software systems using a single ID and password. Considered safer, both in cybersecurity and in enterprise permissioning.Small & Mid-Size Business (SMB) is a business organization that straddles the middle of the scale between an office/home office (SOHO) and large enterprises, having varying number of employees and revenue level depending on location. In some classifications, a small business has fewer than 100 employees while a mid-sized business has 100-999 workers.Smarketing is the process of closely aligning the sales and marketing operations of a business, with the aim of increasing revenues via a shared integrated strategy.Social Selling is the deliberate use of online social networks as sales channels, where sellers directly engage and develop relationships with prospects by probing their needs and providing relevant and valuable insight.Software as a Service (SaaS) is a software distribution model where customers access and use the software under a subscription agreement. Almost always, the service is accessed on the Internet using cloud and browser technologies.Software capitalization is an accounting method that treats expenses related to software procurement or development as fixed assets.Solution is a combination of ideas, strategies, processes, technologies and services that effectively helps an organization achieve its goals or hurdle its challenges.Solution Selling is a sales approach commonly adopted in a B2B environment where the salesperson probes the customer’s problem(s) and develops/proposes a solution using the seller company’s products or services.Spiff refers to a quickly awarded incentive – such as an immediate financial bonus, paid vacation, or non-cash prize – for meeting a milestone (e.g., first premium sale of the day) or performing a specified task (special quota attainment within a specified time frame). Employers, managers and other entities offer spiffs when introducing new products or hiking up production for a given period. Business people sometimes treat spiff as an acronym, ascribing the words “Sales Performance Incentive Fund” to form its meaning.SPIN Selling is an acronym for four types of questions (Situation, Problem, Implication, Need-payoff) a sales professional should ask a prospect to establish a customer-centric selling paradigm and increase closing rate.Stakeholder is an entity with an interest in a company, process, or product, and which is typically concerned about its wellbeing.Statement of Work (SOW) is a project management document that defines all the parameters — nature, scope, deliverables, activities, costs, schedule — of work being performed by a vendor for a client.Strategic Investment/Smart Money/Corporate Venture Capital (CVC) refers to investments made by venture capitalists (VC), angel investors and corporations in startups and businesses they deem promising. In addition to cash investments these types of investors also provide non-cash value such as market insight, customer networks, domain expertise, branding, and promotion.Structured data refers to highly organized information that can easily be added into, managed, and searched for in a databaseSubject Matter Expert (SME) is a person who is considered an authority or an expert in a particular domain, topic, or field.System of Record (SOR) is an information storage and management system that protects data integrity, and serves as the authoritative source for specific data items in systems where multiple sources of the same items exists.TTargetTemplateTenorTop Level Domain (TDL)Top of the Funnel (TOFU)Total Addressable Market (TAM)Total Available MarketTotal Value to Paid In (TVPI)TouchesTranchesTriggersTwitterTarget/Targeting refers to the specific group or subset of potential consumers a company plans to sell its product; or the process involving the strategic identification and engagement of such group.Template is a generic file with a framework showing the standard sections or features of a specific kind of document, used to create a new document of the same type faster and easier.Tenor refers to the period or amount of time left for fully settling a loan until the financial contract defining its terms and conditions expires.Top Level Domain (TDL) is among the highest ranking domain type in the hierarchical Domain Name System of the Internet (DNSI). Examples include the domain name extensions .com, .info, .net, and .org.Top of the Funnel (TOFU) refers to the top and biggest portion of a sales or marketing funnel where prospects enter a screening process until only the leads most inclined to purchase are left. It is also a descriptive term for prospects (raw leads) that have shown initial interest in a service or product as a result of inbound marketing and outbound customer engagements.Total Addressable Market (TAM) refers to the largest possible revenue opportunity for a specific business.Total Available Market (TAM) refers to the total revenue potential for a specific product or service, including its future market imprint.Total Value to Paid In (TVPI) refers to the ratio of distributed and undistributed investments in a fund to the amount of invested capital. It is a metric often used to measure fund performance.Touches are units of milestones or points of contact used to measure the marketing effort it takes to transform a prospect into a viable, qualified lead. Also called touchpoints.Tranches refer to slices or portions of debt or securities often released in sequence, based on a specified periods of time.Triggers are a set of signals or occurrences that meet certain criteria to be considered an opportunity to make a sale.Twitter is a free-to-join social network with a micro blogging service that allows the sharing of links, images and videos as well as the publishing of short posts called tweets.UUnique Selling Point/Proposition (USP)Unit EconomicsUp and to the RightUserUser Experience (UX)User Interface (UI)UnicornUnique Selling Point/Proposition (USP) is a marketing concept that refers to the distinct advantage (lowest price, highest quality, different component materials, or new service features, etc.) a business has over other businesses catering to the same market or audience.Unit Economics refers to the application of economic principles as they impact a single entity such as a business or a customer. Taken this way, quantities such as Customer Acquisition Cost (CAC) and Lifetime Value (LTV) become meaningful metrics that help a business tweak its operational model to achieve higher margins or levels of profitability.Up and to the right is a description of a good business or sales performance, referring to the portion of a line graph where positive growth over a period of time is usually positioned; also called hockey stick growth.User means a person who uses or consumes a product or a service, usually a digital device or an online service.User Experience (UX) covers all aspects that relate to a user’s interaction with a product, service, business, or brand, especially those factors that impact the user’s emotions, viewpoint, attitude, and behavior. In digital marketing, an excellent UX help drive excellent Call-to-Action (CTA) performance.User Interface (UI) refers to the all the elements that allow people to access, use and interact with appliances, software, digital devices and other machines. Web and mobile sites for example, use menus, buttons, and hyperlinks to enable users to navigate a web page or an app. Home appliances use knobs, touch screens, levers and other means to enable human interaction.Unicorn is a term used to describe a startup company valued at over $1 Billion.VValue PropositionValue StatementValue TriangleVerticalVice PresidentVideo ConferencingVirtual Machine (VM)Value Proposition is a statement or message that encapsulates the reasons — such as benefits and unique attributes — consumers would want to patronize a brand or purchase a product.Value statement is an official declaration that informs the customers and staff of an organization about the company’s top priorities and its core beliefs.Value Triangle is a concept in sales and marketing that describes the interrelationships of three factors: cost, quality and speed in the determining the value of a product or service.Vertical refers to a market where a business targets only a small subset of customers such as a specific industry, sector, profession, or niche. For example, manufacturers of jet plane engines cater only to companies that produce or maintain jet planes.Vice President (VP) is a senior executive in an organization who heads a specific operation or unit, oversees the achievement of strategic targets, and reports directly to the company president.Video Conferencing refers to the technology behind or the act of establishing a visual connection between two or more people positioned in different locations to facilitate remote communication.Virtual Machine (VM) is primarily a software-driven solution that emulates a complete and conventional computing environment, equipped with an operating system and a dedicated hardware.WWarm CallWarm EmailWarrantWhite HatWhite LabelWireframesWarm Call is the process or act of calling or visiting a sales prospect with whom the sales professional has had a prior contact such as during an event or via a referral.Warm Email is the process or act of emailing a sales prospect with whom the sales professional has had a prior contact such as during an event or via a referral.Warrant refers to a contractual right entitling the holder to purchase shares in the issuing company during a specified period for a fixed amount, called exercise price.White Hat is a descriptive term to denote good and lawful behavior, but came to also include legalized activities (including sanctioned hacking) that are otherwise illegal in a different context. Many companies pay for White hat hackers to stress-test their computer systems and expose vulnerabilities.White Label is a term describing a product or service that can be purchased by a business entity and legally re-sold, marketed, and distributed under the entity’s own brand or trademark. Most of these products are turnkey and lightweight.Wireframes are rough or low-fidelity representations of a service or a product that show how either is structured and organized. In web development, wireframes serve as one of three types of modeling, the other two of which are prototypes (a much detailed and interactive representation of a website), and mockups (the most visually-intensive representation to convey styling and visual appeal).