Garth Kroeker

Statistics in Psychiatry & Medicine

2012-02-13T13:14:00.000-08:00

This is a continuation of my thoughts about this subject.

Statistical analysis is extremely important to understand cause & effect! A very strong factor in this issue has to do with the way the human mind interprets data; Daniel Kahneman, the Nobel laureate psychologist, is a great expert on this subject, and I strongly recommend a fantastic book of his called Thinking, Fast and Slow. I'd like to review his book in much more detail later, but as a start I will say that it clearly shows how the mind is loaded with powerful biases, which cause us to make rapid but erroneous impressions about cause & effect, largely because a statistical treatment of information is outside the capacity of the rapid reflexive intuition which dominates our moment-to-moment cognitions.    And, of course, a lack of education about statistics and probability eliminates the possibility that the more rational part of our minds can overrule the reflexive, intuitive side. Much of Kahneman's work has to do with how the mind intrinsically attempts to make sense of statistical information -- often with incorrect conclusions. The implication here is that we must cooly calculate probabilities in order to interpret a body of data, and resist the urge to use "intuition," especially in a research study.

I do believe that a formal statistical treatment of data is much more common now in published research. But I am now going to argue for something that seems entirely contradictory to what I've just said above! I'll proceed by way of a fictitious example:

Suppose 1000 people are sampled, (the sample size being carefully chosen using a statistical calculation, to elicit a significant effect size if truly present with a small probability of this effect being due to chance), all of whom with a DSM diagnosis of major depressive disorder, all of whom with HAM-D scores between 25 and 30. And suppose they are divided into two groups of 500, matched for gender, demographics, severity, chronicity, etc. Then suppose one group is given a treatment such as psychotherapy or a medication, and the other group is given a placebo treatment. This could continue for 3 months, then the groups could be switched, so that every person in the study would at some point receive the active treatment and at another point the placebo.

This is a typical design for treatment studies, and I think it is very strong. If the result of the study is positive, this is very clear evidence that the active treatment is useful.

But suppose the result of the study is negative. What could this mean? Most of us would conclude that the active treatment is therefore not useful.   --But I believe this is an incorrect conclusion!--

Suppose, yet again, that this is a study of people complaining of severe headaches, carefully controlled for matching severity and chronicity, etc. And suppose the treatment offered was neurosurgery or placebo. I think that the results-- carefully summarized by a statistical statement--would show that neurosurgery does not exceed placebo (in fact, I'll bet the neurosurgery group would do a lot worse!) for treatment of headache.

Yet -- in this group of 1000 people, it is possible that 1 or 2 of these headache sufferers was having a headache due to a surgically curable brain tumor, or a hematoma. These 1 or 2 patients would have a high chance of being cured by a surgical procedure, and some other therapy effective for most other headache sufferers (e.g. a tryptan for migraine, or an analgesic, or relaxation exercises, etc.) would have either no effect or would have a spurious benefit (relaxation might make the headache pain from a tumor temporarily better -- and ironically would delay a definitive cure!)

Likewise, in a psychiatric treatment study, it may be possible that subtypes exist (perhaps based on genotype or some other factor currently not well understood), which respond very well to specific therapies, despite the majority of people in the group sharing similar symptoms not responding well to these same therapies. For example, some individual depressed patients may have a unique characteristic (either biologically or psychologically) which might make them respond to a treatment that would have no useful effect for the majority.

With the most common statistical analyses done and presented in psychiatric and other medical research studies, there would usually be no way to detect this phenomenon: negative studies would influence practitioners to abandon the treatment strategy for the whole group.

How can this be remedied? I think the simplest method would be trivial: all research studies should include in the publication every single piece of data gathered! If there is a cohort of 1000 people, there should be a chart or a graph showing the symptom changes over time of every single individual. There would be a messy graph with 1000 lines on it (which is a reason this is not done, of course!) but there would be much less risk that an interesting outlier would be missed! If most of the thousand individuals had no change in symptoms, there would be a huge mass of flat lines across the middle of the chart. But if a few individuals had a total, remarkable cure of symptoms, these individuals would stand out prominently on such a chart. Ironically, in order to detect such phenomena, we would have to temporarily leave aside the statistical tools which we had intended to use, and "eyeball" the data. So intuition could still have a very important role to play in statistics & research!

After "eyeballing" the complete setof data from every individual, I do agree that this would have to lead to another formal hypothesis, which would subsequently have to be tested using a different study design, designed specifically to pick up such outliers, then a formal statistical calculation procedure would have to be used to evaluate whether the treatment would be effective for this group. (e.g. the tiny group of headache sufferers specifically with a mass evident on a CT brain scan could enter a neurosurgery treatment study, to clearly show whether the surgery is better than placebo for this group).

I suspect that in many psychiatric conditions, there are subtypes not currently known about or well-characterized by DSM categorization. Genome studies should be an interesting area in the future decades, to further subcategorize patients sharing identical symptoms, but who might respond very differently to specific treatment strategies.

In the meantime, though, I think it is important to recognize that a negative study, even if done with very good study design and statistical analysis, does not prove that the treatment in question is ineffective for EVERYONE with a particular symptom cluster. There might possibly be individuals who would respond well to such a treatment. We could know this possibility better if the COMPLETE set of data results for each individual patient were published with all research studies.

Another complaint I have about the statistics & research culture has to do with the term "significant." I believe that "significance" is a construct that contradicts the whole point of doing a careful statistical analysis, because it requires a pronouncement of some particular probability range being called "significant" and others "insignificant." Often times, a p value less than 0.05 is considered "significant". The trouble with this is that the p value speaks for itself, it does not require a human interpretive construct or threshold to call something "significant" or not. I believe that studies should simply report the p-value, and not call the results "significant" or not. This way, 2 studies which yield p values of 0.04 and 0.07 could be seen to show much more similar results than if you called the first study "significant" and the second "insignificant."   There may be some instances in which a p-value less than 0.25 could still usefully guide a long-shot trial of therapy -- this p value would be very useful to know exactly, rather than simply reading that this was a "very insignificant" result. Similarly, other types of treatments might demand that the p value be less than 0.0001 in order to safely guide a decision.   Having a research culture in which p<0.05="significant" dilutes the power and meaning of the analysis, in my opinion, and arbitrarily introduces a type of cultural judgment which is out of place for careful scientists.

How long does it take for psychotherapy to work?

2012-02-07T13:46:00.000-08:00

There are various research articles done in the past which describe rates of change in psychotherapy patients, some studies for example describing a plateau after about 25 sessions or so. I find these studies very weak, because of the multitude of confounding factors: severity and chronicity are obvious variables, also the type of follow-up assessments done.

In the CBT literature, a typical trial of therapy is perhaps 16-20 sessions.

In light of our evolving knowledge of neuroplasticity, and our breadth of understanding about education & learning, it seems to me that the most important variable of all is the amount of focused, deliberate practice time spent in a therapeutic activity. Oddly, most psychotherapy studies--even CBT studies--do not look at how many hours of practice patients have done in-between therapy appointments. This would be like looking at the progress of music students based on how many lessons they get, without taking into account how much they practice during the week.

I have often compared psychological symptom change to the changes which occur, for example, with language learning or with learning a musical instrument.

So, I believe that a reasonable estimate of the amount of time required in psychotherapy depends on what one is trying to accomplish:

-Some types of therapeutic problems might be resolved with a few hours of work, or with a single feedback session with a therapist. This would be akin to a musician with some kind of technical problem who needs just some clear instruction about a few techniques or exercises to practice. Or it might be akin to a person who is already fluent in a foreign language, but needs a few tips from a local speaker about idioms, or perhaps some help with editing or grammar in a written text.

-Many more therapeutic problems could improve with perhaps 100 hours of work. This would be like learning to swim or skate competently if you have never done these activities before. Regular lessons ("therapy") would most likely speed up your rate of progress substantially. But most of those 100 hours would be practice on your own, unless you're okay with the progress taking place over a year or more. With the language analogy, think of how fluent you might become in a foreign language with 100 hours of focused, deliberate practice. For most of us, this would lead to an ability to have a very simple conversational exchange, perhaps to get around in the most basic way in another country.

-A much larger change is possible with 1000 hours of work: with music, one could become quite fluent but probably not an expert. With a foreign language, comfortable fluency would probably be possible, though probably still with an accent and a preference for the old language.

-With 5000-10000 hours of work (this is several hours per day over a decade or more) one could become an expert at a skill or a language in most cases.

In psychotherapy, another confound though is whether the times in-between "practice sessions" lead to a regression of learning. An educational analogy would be of practicing math exercises an hour per day with a good teacher, but then practicing another 8 hours a day with another teacher whose methods contradict the first. Often times, learning will still take place with this paradigm, but it might be much less efficient. Persistent mental habits, in the context of mental illnesses, can be akin to the "second teacher" in this metaphor, and unfortunately they do tend to plague people for many hours per day.

This reminds me of the evolving evidence about stroke rehabilitation & neuroplasticity: substantial brain change can happen in as short a time as 16 days--but it requires very strict inhibition or constraint of the pathways which obstruct rehabilitation. (note: 16 days of continuous "immersion" = 16*24 = 384 hours!) In stroke rehabilitation, the neuroplasticity effect is much more pronounced if the unaffected limb is restrained, compelling the brain to optimize improvement in function of the afflicted limb. Here is a recent reference showing rapid brain changes following limb immobilization: http://www.ncbi.nlm.nih.gov/pubmed/22249495

In conclusion, I believe that it is important to have a clear idea about how much time and deliberate, focused effort are needed to change psychological symptoms or problems through therapeutic activities. A little bit of meaningful change could happen with just a few hours of work. In most cases, 100 hours is needed simply to get started with a new skill. 1000 hours is needed to become fluent. And 5000-10000 hours is needed to master something. These times would be much longer still if the periods between practice sessions are regressive. In the case of addictions, eating disorders, self-harm, or OCD, for example, relapses or even fantasies about relapse will substantially prolong the time it takes for any therapeutic effort to help. Of course, it is the nature of these problems to have relapses, or fantasies about relapse--so one should let go of the temptation to feel guilty if there are relapses. But if one is struggling with an addictive problem of this sort, it may help to remind oneself that the brain can change very substantially if one can hold onto to quite a strict behavioural pattern for the hundreds or thousands of hours which are needed.

As a visual reminder of this process, start with an empty transparent bottle, which can hold 250-500 mLof liquid (1-2 cups), and which can be tightly sealed with a small cap. Add one drop of water every time you invest one hour of focused, deliberate therapeutic work. The amount of time you need to spend in therapy depends on your goal. If the goal is total mastery--then you must fill the entire bottle. If simple competence in a new skill is an adequate goal, then you must fill just the cap of the bottle. If there are activities in your day which contradict the therapeutic work, it would be like a little bit of water leaking out of your bottle. So you must also attend to repairing any "leaks." But every hour of your effort counts towards your growth.

Scopolamine for Depression

2012-02-06T17:43:00.000-08:00

Scopolamine is an acetylcholine-receptor blocker, which is usually used to treat or prevent motion sickness. Some recent studies show that it might be useful to treat depression. Here is some background, followed by a few references to research studies:

The old tricyclic antidepressants (such as amitriptyline) were shown over many years to work very well for many people. Unfortunately, they are laden with side-effect problems and a significant toxicity risk (they can be lethal in overdose). The side effects are due to various different pharmacologic effects, particularly the blockade of acetylcholine and histamine receptors. Newer antidepressants, such as those in the SSRI group, have very few such receptor blockade effects.

In some studies, however, the old tricyclics actually are superior to newer antidepressants, especially for severely ill hospitalized depression patients.

It is interesting to consider whether some of the receptor blockade effects which were previously considered just nuisances or side-effect problems, could actually be part of the antidepressant activity. Or, in some cases, drugs which primarily have receptor blockade side effects may actually be indirectly modulating various other neurotransmitter systems.

A clear precedent exists in this regard: clozapine is undoubtedly the most effective antipsychotic, but it is loaded with multiple side effects and receptor blockades. It may be --at least in part-- because of the receptor blockades, not in spite of them, that it works so well.

Another example of this effect, quite possibly, is related to what I call the "active placebo" literature (I have referred to it elsewhere on this blog: http://garthkroeker.blogspot.com/2009/03/active-placebos.html) The active placebos used in these studies usually had side effects due to acetylcholine blockade, and the active placebo groups usually improved quite a bit more than those with inert placebos. This suggests another interpretation of the "active placebo" effect: perhaps it is not simply the existence of side-effects that psychologically boosts a placebo effect here, it is that the side-effects themselves are due to a pharmacologic action that is actually of direct relevance to the treatment of depression.

Here are some studies looking at scopolamine infusions to treat depression:

http://www.ncbi.nlm.nih.gov/pubmed/17015814
This 2006 study from Archives of General Psychiatry showed that 4 mcg/kg IV infusions of scopolamine (given in 3 doses, every 3-5 days) led to a rapid reduction in depression symptoms (halving of the MADRS score), with a pronounced difference from placebo. Of particular note is that the cohort consisted mainly of chronically depressed patients with comorbidities and unsuccessful trials of other treatments. Surprisingly, there were few side effect problems, aside from a higher rate of the expected anticholinergic-induced dry mouth and dizziness.

http://www.ncbi.nlm.nih.gov/pubmed/20074703
This is a replication of the study mentioned above, published in Biological Psychiatry in 2010.

http://www.ncbi.nlm.nih.gov/pubmed/20736989
Another similar study, this time showing a greater effect in women; again a 4 mcg/kg infusion protocol was used.

http://www.ncbi.nlm.nih.gov/pubmed/20926947
evidence from an animal study that scopolamine --or acetylcholine blockade in general-- affects NMDA-related activity, in general antagonizing the effects of NMDA. This is consistent with a theory that scopolamine may work in a similar manner to the NMDA-blocker ketamine (which has been associated with rapid improvement in depression symptoms) but without nearly as much risk of dangerous medical or neuropsychiatric side-effects.

http://www.ncbi.nlm.nih.gov/pubmed/21306419
This article looks at the pharmacokinetics of infused scopolamine, and also gives a detailed account of side-effects. There are notable cognitive side-effects, such as reduced efficiency of short-term memory.

http://www.ncbi.nlm.nih.gov/pubmed/16719539
This study looks at dosing scopolamine as a patch. The patch is designed to give a rapidly absorbed loading dose, then a gradual release to maintain a fairly constant level over 3 days. My own estimation, based on reviewing this information, is that a scopolamine patch would roughly approximate the IV doses used in the depression treatment studies described above, though of course the serum levels would be more constant.

Transdermal scopolamine (patches) are available in Canada from pharmacists without a physician's prescription.

While this is an interesting--though far from proven-- treatment idea, it is very important to be aware of anticholinergic side effects, which at times could be physically and psychologically unpleasant. At worst, cognitive impairment or delirium could occur as a result of excessive cholinergic blockade. Therefore, any attempt to treat psychiatric symptoms using anticholinergics should be undertaken with close collaboration with a psychiatrist.

Mental health issues in the workplace

2011-12-22T14:55:00.000-08:00

A frequent source of unhappiness I see has to do with a psychologically unhealthy work environment. I am interested to survey the research literature on this subject, but for starters here are a few thoughts:

1) many businesses simply do not seem to value the idea of simply treating employees well. Instead, a short-sighted view is taken, of attempting to maximize the work output or efficiency of the workers, while minimizing costs. On a short term basis (perhaps confirmed by mathematical models composed by the recent business or commerce graduate who is now in a managerial position), this leads to more profit for the business with fewer expenses. On a longer-term basis, however, this pattern leads to poor morale, loss of good or talented employees, higher rates of absenteeism, lower productivity, lower worker loyalty, which in turn must undoubtedly be perceived or intuited by customers, all of which would severely dampen the prosperity of the business.

2) counter-examples exist, of particular businesses which treat employees very well, allowing them more autonomy, healthy scheduling, security, non-authoritarian leadership, even paid time to attend fitness activities, etc. I can think of a few examples like this in which the business and the employees are prospering together, with a very positive public image as well.

3) I have to wonder if the current educational system biases the business world to perpetuate these types of problems. University programs in commerce, economics, or business may have a variety of biases: a money or wealth-acquisition-oriented value system may be very frequent in students drawn to these areas. The programs themselves, I observe, may be dealing with subject matter that involves very interesting, complex, and subtle interactions between human motivations, emotions, and behaviours. Yet the programs tend to have very little instruction or requirement for students to study the obviously related fields of psychology, sociology, ethics, history, political science, etc. Unfortunately this may equip graduates, who may be involved in group leadership and policy-making decisions affecting thousands of people, with strong profit-optimization skills, but very little wisdom or education about human nature or a foundation in altruistic values.

4) In any case, I think many employer-employee interactions are like a dysfunctional family: the "parents" either too authoritarian or enmeshed, or too detached and uninvolved. Usually there are problems with communication. Unfortunately, it is usually very difficult for this type of "family" to come for group therapy: it seems more common for these types of group problems to become more entrenched with time.

The field of "corporate psychology" seems to address some of these issues. I will be interested to survey this literature in the coming months, and hopefully add to this post in a helpful way. Aside from therapeutic ideas to make beneficial changes in business group dynamics, I wonder if it could be a useful trend in the future to allow free economic forces to help things along: if one is considering being a customer or an investor in a business, how about checking out how happy the employees are? It would be a service to the community, in the name of public and individual mental health, to support businesses which provide a healthy community not only to the public, but to their own employees.

Antidepressants = Psychotherapy = Placebo ?

2011-12-22T14:19:00.000-08:00

Jacques Barber et al. have recently published the results of a randomized, controlled study conducted between 2001 and 2007, comparing antidepressant therapy, short-term dynamic psychotherapy, and placebo in a 16-week course of treatment for 156 depressed adults. Here is a link to the abstract: http://www.ncbi.nlm.nih.gov/pubmed/22152401

The bottom line in the study was that there was no significant difference between antidepressants, psychotherapy, or placebo. Response rates were 31% for medication, 28% for psychotherapy, and 24% for placebo -- which has a low probability of being statistically different. Remission rates were 26% for medication, 22% for psychotherapy, and 20% for placebo.

Critics trying to explain these findings might attempt to argue that the psychotherapy or the medication regime was not sufficient, etc. -- but I do not see this to be true. The medications (venlafaxine or sertraline) were given at quite sufficient doses for good lengths of time. The psychotherapy was not CBT (which has a larger research evidence base) but there is little reason, in my opinion, to believe that the therapy style was inferior.

The authors attempt to do some secondary analyses looking for explanations, but their conclusions seem quite weak to me (e.g. regarding race or gender). The fact that they spin these conclusions into a prominently framed set of "clinical points" seems quite inappropriate to me -- this is a negative study, there are no "clinical points" to be found here, unless they recommend placebos and cessation of other therapies!

There are a number of issues from this study that I do find very important to discuss:

1) despite a massive amount of data showing that various therapies (e.g. antidepressants or psychotherapy) are effective for various problems, there are examples of carefully-conducted negative studies, such as this one. These results cannot simply be explained away as statistical aberration: there must be a reason why one group of people responds to a treatment, while another does not. Many of these reasons are poorly understood. It may be that the diagnostic category of "major depressive disorder" is inadequate, in that it correlates poorly on its own with treatment responsiveness.

2) the subjects in this study had a high degree of comorbidity (e.g. substance abuse problems, anxiety disorders, and axis II problems). While the severity and chronicity of depression was not found to actually correlate with treatment responsiveness, I suspect that the comorbidities would substantially affect response to a relatively short-term course of therapy.

3) the subjects in this study were socioeconomically disadvantaged; while the effect of SES was also not found to "influence the initial findings," I believe that low SES is not necessarily a direct negative influence upon mental health; rather it is an indirect factor which for many people increases the likelihood of some profound mental health negatives (e.g. unemployment, lack of meaningful or satisfying employment, lack of healthy or safe community, lack of availability to do healthy or meaningful leisure activities, not enough money to eat healthily, etc.). I believe that the environmental adversities need to be looked at very closely in a study of this type.

This leads to what I believe is an obvious explanation for the findings here: there is no therapy for depression that is likely to help unless ALL contributing factors (including obvious environmental contributing factors) are addressed. By way of analogy, I believe it is pointless to treat insomnia using a powerful sedative if a person is sleeping in a room which is continuously noisy, cold, and prone to break-ins by violent intruders. The environmental issues need to be addressed first! Another analogy I have often used is of trying to repair a water supply system for a city: it is a waste of effort to pipe in more water from rivers, or to dig a deeper reservoir, if the walls of the reservoir and the pipes are leaking or bursting because of structural defects. In order for a therapeutic strategy to work, the "leaks" have to be repaired first. For a person with anemia, it is not an appropriate strategy to simply give a blood transfusion: while a transfusion may be necessary, it will not be sufficient--and could even make matters worse-- if the underlying cause of blood loss is not addressed and treated.

In the case of medications or psychotherapy, I believe these can be very helpful, but only if environmental adversity is also remedied. In some instances, of course, relief of a psychiatric symptom could help a person to improve the environmental circumstances. But in most other cases, I think the issue is broader, and could be considered a political or social policy matter.

Another related issue is that I do not believe "depression" can be treated on its own without addressing all psychiatric and medical comorbidities at the same time. Ongoing substance abuse, in my opinion, is often a powerful enough factor--psychologically as well as neurophysiologically--to completely dominate and dissolve the positive influences of psychotherapy or effective medication. In this study, 30-40% of the cohort reported substance use problems.

As a final thought, I think the "5 axis" model of diagnosis in the DSM system deserves some affirmation; many times, however, we only pay attention to Axis I (diagnoses such as depression or schizophrenia, etc.) or Axis II (personality disorder). I think that studies such as this one highlight the necessity to look closely at Axes III (medical illnesses) and IV (social, community, financial, and relational problems). It is likely that issues on these latter two axes can prevent any resolution of problems on the first two.

Worksheets

2011-12-10T21:51:00.000-08:00

Here's a good site that has many links to free therapy worksheets: http://therapyworksheets.blogspot.com/

Spending some focused time with a worksheet can be a healthy, useful, structured component of therapy or self-help. Worksheets can be especially useful if you want to build up healthy therapeutic habits, both in terms of inner reflection and external action, but find yourself in need of more clear structure to get started or to continue guiding you. I find this can be analogous to learning a subject at school, or a musical instrument, etc. : practicing is obviously important, but it can certainly help guide and discipline your practice efficiently to have a good textbook to work through.

Many thanks to the person who recommended this site to me!

Piracetam

2011-11-03T12:20:00.000-07:00

Piracetam is a so-called "nootropic" drug, a substance which supposedly helps improve cognitive functioning. It is available without prescription as a sort of supplement in many parts of the world. In Canada it is not illegal, but must be imported (such as by ordering over the internet from U.S. suppliers).

The mechanism of action is not clear. There is no obvious single receptor-mediated mechanism. There may be various effects on ion channels, cell membrane characteristics, etc. but of course such statements are quite vague.

It is quite clear that there are few side-effect problems or toxicity risks with this agent. Doses are typically 2-5 grams per day.

I became interested in this agent after encountering a case example of someone who reported quite a dramatic improvement in mood and overall functioning attributed to piracetam supplementation.

Here are the results of my survey through the research literature:

http://www.ncbi.nlm.nih.gov/pubmed/16007238 -- a 2005 review

http://www.ncbi.nlm.nih.gov/pubmed/1794001 -- a 1991 review looking specifically at its use in treating dementia; the data is really not impressive at all for dementia treatment.

http://www.ncbi.nlm.nih.gov/pubmed/11084917 -- a 2000 Japanese study affirming the effectiveness of piracetam combined with clonazepam for treating myoclonus (myoclonus is a neurological problem in which muscles are twitching involuntarily).

http://www.ncbi.nlm.nih.gov/pubmed/8914096 -- a 1996 study from Japan also showing benefit in treating myoclonus; there were also improvements in motivation, attention, sleep, and mood (possibly secondary to improvement in the movement disorder).

http://www.ncbi.nlm.nih.gov/pubmed/11346373 -- 2001 study from Archives of Neurology again affirming that piracetam is effective over 12 months of follow-up for treating myoclonic epilepsy.

http://www.ncbi.nlm.nih.gov/pubmed/10796585 -- this 2000 Cochrane review stated that the data on piracetam are inconclusive, with studies not being of good quality

http://www.ncbi.nlm.nih.gov/pubmed/10338110 - this 1999 article reviewed studies of piracetam for treating vertigo, concluding that it was useful for reducing frequency of recurrence, at doses of 2-5 grams per day.

http://www.ncbi.nlm.nih.gov/pubmed/17685739 -- this is a 2007 randomized placebo-controlled study from The Journal of Clinical Psychiatry, in which piracetam 4800 mg/d for 9 weeks led to substantial improvements in tardive dyskinesia, with large differences from placebo.

http://www.ncbi.nlm.nih.gov/pubmed/10338108 -- piracetam has some antiplatelet function, which could be used in managing or preventing recurrences of vascular disorders. This is a 1999 review of this subject.

http://www.ncbi.nlm.nih.gov/pubmed/8061686 -- this is a broad review of nootropics, published in 1994.

http://www.ncbi.nlm.nih.gov/pubmed/3305591 -- this 1987 study from The Journal of Clinical Psychopharmacology shows that children treated with piracetam may show improvements in dyslexia.
Doses were 3.3 grams daily x 36 weeks (dosed twice per day). However, as I look at the results, I see that there is a statistical difference, but the numbers really look very similar between placebo and piracetam. The placebo group improved substantially; the piracetam group improved only slightly more. For example, the raw scores in the Grey Oral Reading Test increased from 17.1 to 22.5 in the placebo group; in the piracetam group it increased from 14.8 to 22.9. It is true that the piracetam was well-tolerated, with minimal side-effect problems.

http://www.ncbi.nlm.nih.gov/pubmed/12394531
this is a 2002 study which attempted to show whether piracetam could prevent ECT-induced cognitive problems. The dose was 7.2 g/day for a 2-week loading phase, then 4.8 g daily for the remaining 2 weeks. They concluded that piracetam had no effect on cognition in this group; but the piracetam group did slightly better than the placebo group in terms of overall clinical improvement.

http://www.ncbi.nlm.nih.gov/pubmed/16878489
this 2006 study described anxiolytic effects of piracetam which were blocked by flumazenil (a benzodiazepine receptor blocker), suggesting that piracetam has some GABA-like activity.

http://www.ncbi.nlm.nih.gov/pubmed/12809069
a Hungarian study describing successful use of piracetam to treat alcohol withdrawal delirium

http://www.ncbi.nlm.nih.gov/pubmed/7906672
a 1993 Indian study showing that piracetam has anti-anxiety effects when administered on a longer-term basis in rats.

http://www.ncbi.nlm.nih.gov/pubmed/95599
a 1979 article from Journal of Affective Disorders describing anti-anxiety effects from piracetam similar to a benzodiazepine, but without sedation.

http://www.ncbi.nlm.nih.gov/pubmed/6415738
in this 1983 study, piracetam 2.4 g/day or 4.8 g/day was compared with placebo in treating 60 elderly psychiatric patients; the 2.4 g/day group showed increased socialization, altertness, and cooperation, and had some improvement on memory and IQ tests, compared to the placebo group.

http://www.ncbi.nlm.nih.gov/pubmed/360232
in this 1977 study, elderly psychiatric patients were given 2.4 g/day of piracetam or placebo, for 2 months. The piracetam group did not improve in any cognitive tests or mood symptom scores compared to placebo, but interestingly 52% of subjects in the piracetam group showed overall improvement (CGI) compared to only 25% in the placebo group.

http://www.ncbi.nlm.nih.gov/pubmed/11687079
a Cochrane review from 2001 concluding that there is evidence that piracetam may improve the course of aphasia after stroke; however, the evidence was found to be weak.

http://www.ncbi.nlm.nih.gov/pubmed/6128331
this 1982 study shows that 40 g of IV piracetam caused greater reduction than placebo in antipsychotic-induced Parkinsonian side-effects.

http://www.ncbi.nlm.nih.gov/pubmed/488520
a small 1979 study which showed that refractory depressed patients improved with the addition of 2.4 g piracetam.

http://www.ncbi.nlm.nih.gov/pubmed/10338106
a look at toxicity risk due to piracetam, when given in higher doses (12 g/day) for 12 weeks, to stroke patients. The paper concludes that there is no significant toxicity risk at this dose for this population.

In conclusion, piracetam appears to be clearly effective for a few uncommon conditions, such as myoclonus. There is possible effectiveness for some other problems such as tardive dyskinesia. The evidence for effectiveness as a "cognitive enhancer" appears to be quite shaky, but not absent.

I am particularly interested in some of the evidence which suggests that it could be useful as a safe, well-tolerated adjunct to treat depression or anxiety. Some of the studies quoted above appear to support this possibility. This theme also intersects with my recent thoughts about considering cognitive function in chronic mood, anxiety, ADHD, or personality disorders. A weakness in working memory capacity or executive functioning could substantially interfere with recovery from psychiatric illness; I suspect that a treatment which could specifically help with cognitive function could be a unique angle to augment treatments for these other psychiatric problems. (see my previous post, which discusses an association between rumination & working memory dysfunction: http://garthkroeker.blogspot.com/2011/08/chronic-pain-rumination.html). Here's another link about this: http://www.ncbi.nlm.nih.gov/pubmed/21742932)

I do think it would be worthwhile for research groups to consider doing some new, careful, large trials of piracetam as an augmentation for managing depression, anxiety disorders, etc.

Therapeutic approaches to irritability

2011-10-26T13:00:00.000-07:00

Irritability can be a challenging symptom, often present in a wide range of different clinical settings. Unipolar depression can present with irritable mood, as can the manic states of bipolar disorder. Irritability is also a common problem in borderline personality disorder, as well as in various other populations, such as in those with autism, dementias, brain injury, conduct or oppositional disorders, and addiction disorders. In some cases, arguably, irritability could be considered the primary problem for some people, which either exists on its own as a solitary symptom, or is the direct single cause of the person's other life problems (e.g. in relationships, employment, conflicts with the law, ability to work or study, etc.)

A variety of simple factors usually make irritability worse:
1) sleep problems. Insomnia or deliberate reduction of sleep hours will magnify irritability.
2) hunger. For some individuals especially, allowing a hungry state without eating healthily will magnify irritability.

In both cases above, a vicious cycle can arise, as greater irritability may prevent sleep or cause a further lack of appetite.

3) multiple environmental or medical irritants which are not improving: for example, crowding, noise, poor air quality, physical pains or discomforts

Therefore, in approaching irritability, it is essential to take steps to improve sleep, nutrition, pain, and environmental stimuli.

Further therapy for irritability should of course involve healthy lifestyle practices, such as exercise, relaxation, and meditative activity (if not formal "meditation" then something which accomplishes something similar, such as music listening or performance, biofeedback, hot baths, massage, etc.) Reduction of caffeine intake, etc. could be important to try. Developing healthy philosophical practices can be very useful; for example, some type of calm or peace-oriented religious or other community involvement may add to one`s ability to manage irritability, especially since there could be group-based support and healthy cultural activities.

Pharmacological treatment of irritability, if necessary, would depend on obvious underlying causes. In substance withdrawal states, for example, temporary appropriate sedation (e.g. with benzodiazepines, clonidine, or anticonvulsants such as gabapentin) could ease the irritability. In manic states, mood stabilizers, antipsychotics, and benzodiazepines which ease the manic symptoms, would be expected to ease the irritability. In major depression, an antidepressant of any sort, if it works for the individual, could dramatically improve the irritability. ADHD can be a cause of irritability, which--seemingly paradoxically--could improve with stimulant therapy.

In this post, I am particularly interested in looking at specific pharmacological treatments for idiopathic irritability, or irritability which has existed as a long-term emotional dynamic such as in those with borderline personality traits or disorder.

Here are a few pertinent links to abstracts in the research literature:

http://www.ncbi.nlm.nih.gov/pubmed/20010551
this 12 week randomized study shows modest benefits from divalproex to treat irritability in autistic children (ages 5-17)

http://www.ncbi.nlm.nih.gov/pubmed/18273430 gabapentin useful for borderline patients over a 6 month period

http://www.ncbi.nlm.nih.gov/pubmed/19283647 (this is a good article, but it's in German)-- review of anticonvulsant effectiveness in personality disorders. There is evidence in this paper to support trials of valproate, topiramate, and possibility also lamotrigine. They describe some data on carbamazepine as well. The level of evidence is such that I think these medications could be worth trying cautiously on an individual basis, particularly to target symptom domains such as irritability. However, I think expectations should be modest, due to there most likely being a lot of variability in an individual's response.

I am interested in the use of clonidine for irritability. This drug is effective for treating withdrawal states (including one of the most unbearable withdrawal states possible, from opiates), but has also been used for many years to treat ADHD. It can help with tic disorders as well, so could be a good choice for managing ADHD + tic comorbidity, a difficult problem often made worse by stimulants. Clonidine was originally developed as a treatment for high blood pressure. My main concern about clonidine is about how well its effects persist if taken continuously for more than a few months. Here is an article about treating borderline personality patients with clonidine:
http://www.ncbi.nlm.nih.gov/pubmed/19512980

Here's a study looking at treating children with conduct or oppositional problems with stimulants and/or clonidine: http://www.ncbi.nlm.nih.gov/pubmed/10660814

In conclusion, there are various options to try in the treatment of irritability from most causes. While the evidence base is limited, there is support for attempting a variety of different pharmacological treatments for idiopathic irritability, particularly anticonvulsant medications.

Parental behaviours associated with offspring personality traits

2011-10-03T12:21:00.000-07:00

Johnson et al. have published an interesting article in the August 2011 edition of The Canadian Journal of Psychiatry (pp. 447-456) in which they describe a nice longitudinal study of 669 families, correlating parenting behaviour with future personality traits in the offspring.

To some degree, studies of this type might seem to be re-examinations of the obvious -- that is, children of friendly, gentle, stable, involved parents are more likely to be healthy and stable themselves. The thing is, much of this effect is arguably due to heredity rather than parenting. The genetic factors which influence temperament, mood, personality, etc. are likely to be present in both parents and children--the impact of parenting behaviours themselves are therefore likely to be overestimated.

A good method to tease out these factors would be to study families with adopted children, provided there is good data about psychological characteristics of the birth parents. In general studies of this sort have led to the surprising conclusion that genetic factors are quite a bit higher than expected, and parenting factors quite a bit lower.

But this particular study is quite good. It was longitudinal, following parents and offspring at various ages during the offspring's childhood years (ages 6, 14, and 16), then following up in the offspring's young adulthood years (ages 22 and 33). Most importantly, the study carefully assessed parental psychological traits and symptoms, which in my opinion would help control for inherited traits confounding the results.

This article has some problems with lack of clarity in the writing. It was not exactly clear when the interviews were done (particularly the data from when the children were 6 years old). Also, in the tables, various items (such as "high praise and encouragement" in Table 2) are listed twice, with different numbers! I'm surprised that the writers and editors didn't address these things before publication.

In any case, the results show that various positive parental behaviours led to substantially reduced risk of future psychological problems in the offspring ("reduced aggregate offspring personality disorder symptoms levels" and "elevated aggregate offspring personality resiliency"). Here are a few examples (some of these things may seem like obvious truths -- but it is important to be reminded about just how important these are):
1) speaking kindly to child
2) being calm, not reactive with child
3) attention and dedication to child
4) raised child without reliance on punishment
5) lots of time spent with child
6) shared enjoyable activities with child
7) high affection toward child
8) good communication with child
9) high praise and encouragement

A few findings might be surprising to some. For example, "encouragement of offspring autonomy" from fathers actually was associated with a higher risk of offspring psychological problems.

Studies about parenting may seem to have limited relevance to those of us who are not parents, or who are not currently being parented. But I believe these findings can be generalized: in a psychodynamic sense, all relationships have at least a partial "parental" quality to them. We all also have a "parenting role" with ourselves! This role, and the behaviours or stance we take in this role, are undoubtedly coloured by the type of parenting we have experienced in our childhoods.

Findings of this type encourage us to change our "self-parenting":

1) Speak kindly to self!
2) Be calm and not reactive to self!
3) Be attentive and dedicated with yourself!
4) Be with yourself without reliance on punishment!
5) Spend lots of time with yourself!
6) Share enjoyable activities with yourself!
7) Have high affection toward self!
8) Communicate well with self!
9) And give self praise and encouragement!

10) If you are accustomed to "encourage autonomy in yourself" a lot, maybe you can give this one a rest.

Pregabalin for generalized anxiety

2011-09-30T11:34:00.000-07:00

There have been a variety of studies in the literature showing that pregabalin is effective for treating generalized anxiety.

The latest of such studies I have seen is published by Mark Boschen in the September 2011 issue of The Canadian Journal of Psychiatry (p.558-565).

This article is a meta-analysis, and shows generally that pregabalin is effective compared to placebo, and has similar, if not greater, effectiveness than other medication options for treating generalized anxiety, such as SSRIs, venlafaxine, and benzodiazepines.

The most common doses have been in the 600 mg/day range, which I consider quite high, particularly since a reasonable dose range for pregabalin could be around 75-300 mg/day.

The "limitations" admitted by the author include issues about dosing, and the fact that Pfizer has funded every published randomized study quoted in the article.

I believe that pregabalin could be a very useful option to try, if a medication trial is being considered for generalized anxiety treatment (of course, the first lines of therapy for generalized anxiety are CBT, relaxation-oriented therapies, meditation, exercise, etc.--but for many people these approaches are not sufficiently helpful). Pregabalin has the advantage of having a quite different--and generally mild--side effect profile compared to other medications, and a what appears to be a fairly low (but I do not think zero) risk of addictiveness/dependence problems, particularly compared to benzodiazepines.

However -- the most obvious limitation of the literature findings is only mentioned briefly in passing by the author in the discussion: it is hard to make a good conclusion about a treatment for anxiety when the duration of follow-up is only 4-8 weeks! I believe that a study for this problem needs to extend for a year or more. First of all, many treatments for anxiety can be acutely helpful, but then wear off substantially over time. Arguably, having a beer every 4 hours could reduce GAD scores over a 4-week trial--but obviously this is not an acceptable long-term treatment! (not only would there be multiple physical harms caused by this over a period of many months or years, but there would be substantial tolerance to anxiety reduction effects, which might only become apparent over many months; furthermore,there would be new psychiatric symptoms induced over a period of months and beyond).

It is not clear from the literature whether the acute benefits over 4-8 weeks from pregabalin would persist over a year or more, whether there would be tolerance, whether there would be longer-term emergent physical or psychiatric side-effects, dependence phenomena, trouble with withdrawal or discontinuation, etc.

Research of this type could be used --spuriously--to justify giving GAD patients benzodiazepines on a routine basis as well, despite the frequent and obvious problem of tolerance, dependence, cognitive problems, etc. Most benzodiazepine studies are of similarly short duration, hence have very limited value to guide us for the long-term treatment decisions which are most important.

Yet, I do think that pregabalin is promising, and could be worth a cautious try, particularly if other approaches are not working well.

Multi-dimensional nature of borderline personality symptom structure

2011-09-29T13:42:00.000-07:00

Chmielewski et al. have published an article in the September 2011 edition of the Canadian Journal of Psychiatry in which they show that borderline personality is better described as having several separate symptom dimensions.

The benefit of having several dimensions instead of one could be illustrated by way of analogy: suppose we are talking about heart disease.   One could simply describe all patients suffering a "heart attack" according to a single severity scale, perhaps including information of the amount of pain, degree of disability afterwards, etc. This scale could be quite useful, but it would obscure a great deal of information about the group, and reduce the efficiency of treatment. A multi-dimensional scale would instead look at several domains separately, such as perfusion abnormalities, rhythm abnormalities, and structural abnormalities. Abnormal perfusion might be treated specifically with bypass surgery, rhythm problems with a pacemaker, and structural problems with a valve replacement etc.   Thus the management could become more meaningfully specific.

The authors of this paper about borderline personality show that a 3-factor model fit well to describe symptoms in borderline patients; a 1-dimensional model fit much more poorly. The 3 factors are "affective dysregulation," "behavioural dysregulation," and "disturbed relations."    Affective dysregulation would refer to high intensity and lability of negative emotion, inappropriate anger, etc. Behavioural dysregulation would refer to self-injurious behaviour, excessive or out-of-control behaviours such as binge eating, or I might add any sort of chemical or behavioural addiction. Disturbed relations of course refers to interpersonal relationship problems.   One could see that these three domains would each influence the others, but part of a theoretical model is to consider to what degree problems in each domain could be considered primary. (similarly, a blocked coronary artery would be a primary perfusion problem, but could in turn cause a secondary rhythm and structural problem in the heart).

A particularly relevant remark from the authors comes in the discussion: "...the current pattern of associations suggests that the glue that holds the BPD construct together may largely represent the general dysfunction or misery common across all forms of psychopathology and not just BPD." So, the authors are hinting that we could perhaps do away with the BPD construct altogether, without any loss of insight, and instead simply describe in succinct terms what the core symptoms are. This makes sense to me.   I do believe that some of these core symptoms are extremely important to examine and address directly. "Affective dysregulation" would be almost automatically addressed in any therapy environment, and "relationship dysfunction" is perhaps the most frequent topic of discussion (and perhaps transferential work) done in therapy. But the "behavioural dysregulation"domain I think is not quite so well-addressed in much therapeutic work. I see this domain as the most common severe problem relatively more unique to those who fit into a "borderline personality" spectrum. It is my own view to consider this domain through a type of addiction-medicine lens, as a set of problems which are highly destructive and addictive behavioural habits, often engaged in to cope with other symptoms, but which become independent problems with time. This is similar to any other addiction; alcoholism, for example, may begin as alcohol consumption intended to calm nerves, deal with boredom, or to facilitate socialization, but in time becomes more and more a separate, self-contained behavioural and physiological addiction.

In my browsing through the literature as I was writing this post just now, I encountered a psychology master's thesis published online (by Edward Selby, M.Sc. 2007). Here's a link:
http://etd.lib.fsu.edu/theses/available/etd-07092007-164107/unrestricted/SelbyMastersThesisFinal.pdf
Selby makes the case well that negative emotional cascades leading to behavioural dyregulation are strongly fuelled by rumination. The events of behavioural dysregulation, such as self-injury, serve to distract one from the intense discomfort of rumination. Here is a quote from the conclusion:
"the findings of this study provide preliminary evidence for an
emotional cascade model of dysregulated behavior. In this model high levels of rumination may cause extremely intense states of negative affect, which result in dysregulated behaviors that distract from rumination and reduce that state of negative affect. This study specifically linked rumination to drinking to cope, binge-eating behaviors, reassurance seeking, and urgency, and it is likely that rumination is linked to a variety of other deregulated behaviors. "

Rumination, of course, is another phenomenon common to much "general dysfunction or misery." I am reminded how important it can be, as a practical therapeutic project with patients, to work on ways to move away from, or to let go of, rumination. (see my previous post on rumination: http://garthkroeker.blogspot.com/2011/08/chronic-pain-rumination.html)

"Anti-psychiatry"

2011-08-18T13:01:00.000-07:00

I'm just bumping up this post, originally from July 2008, because there have been some new comments.

There are a lot of strong opinions out there about psychiatry.

Some people are concerned that the practice of psychiatry has caused harm, perhaps by "over-medicalizing" issues that should be considered matters of personal challenge, character, individual choice & responsibility, spirituality, or normal human experience. Other concerns are that psychiatry is overly influenced by large pharmaceutical companies, whose agenda is to earn larger profits by selling more medication. Critics holding these concerns often consider the results of research studies to be biased, since they have often been sponsored by drug companies.

I think these concerns need to be heard and respected. There are specific examples about some of the concerns having some validity to them. In the history of psychiatry, as in the history of all other human endeavour, mistakes have been made. Small mistakes and large mistakes. On a systemic level, I think some of the core theories about psychiatry over the past hundred years have been laden with huge inaccuracies, despite the many nuggets of wisdom contained within them (Freud's ideas are one example). Many times, attempts at treatment have not helped, or perhaps have reduced a symptom at a very great expense to other aspects of the patient's life. There have been trends and fashions in treatment, such as the widespread use of anxiolytic drugs in past decades--while only later do we discover that these treatments can cause entrenched problems with addiction.

Conversely, there are some testimonial accounts of individuals who have had long histories of conventional psychiatric therapies, who have gone on to thrive once leaving all of these behind (perhaps pursuing alternative or naturopathic medicine, or making some other lifestyle change).
I think it is important to step back and examine the evidence closely, with a critical eye (in future posts I will refer to some of the evidence). I hold that there is a vast body of evidence about psychiatry to look at. And the evidence shows that the treatments are truly helpful. The evidence also shows that the treatments are not perfect, and that typically 30% of people do not have a good response from a given psychiatric treatment. The evidence also shows that up to 30% of patients respond to "placebo treatments". These facts lead to several criticisms about psychiatric treatment: first, there are many (perhaps in the first group of 30%) who have tried "conventional psychiatry" and have found that it hasn't worked for them. Second, there are those who have tried "non-psychiatric" treatments, and found that these HAVE worked for them (perhaps these people are in the 30% "placebo" group). Both of these groups may have a tendency to criticize psychiatry; yet there is another 40% -- a group whose ailments have resolved as a direct result of their psychiatric treatments.

This has always reminded me a bit of other areas of medicine, such as cardiology or oncology: the treatments in these specialties can be remarkably curative for some, only palliative for others, and may not work at all for others still.

I do agree that we must never "over-medicalize" any human ailment. It is rare for a problem to be truly cured by a pill. Usually, for any human concern or challenge, any therapy that helps has to be accompanied by holistic changes in lifestyle & behaviour. For the cardiac patient, this means rehabilitative exercise, healthy diet, no smoking, etc. For the mind, just as for the heart, there are many lifestyle habits that are healthy, restorative, and protective against recurrent illness.

Yet, very often people are too ill to be able to institute the "healthy lifestyle habits". The cardiac patient may require medication to control blood pressure and angina before being able to safely or comfortably exercise. Similarly, there are medical treatments in psychiatry that can hopefully provide enough symptom relief to allow the patient to energetically change their life for the better.

I have observed that the "anti-psychiatry" group can be very vocal. I could understand that the individuals among this group could have good reasons to hold such strong, forceful opinions. But I don't want this site to be a forum to spend a lot of time on this debate, I would rather focus on my own beliefs about ways to manage the mind's symptoms in the healthiest possible ways.

Chronic Pain & Rumination

2011-08-10T16:08:00.000-07:00

I was planning to write separate posts on chronic pain and on rumination; but I have found that these subjects are related to each other, so I thought I would combine them.

In this article, I am defining "rumination" as frequent, repetitive thoughts about symptoms or problems. Such recurrent thinking can consume so much time and energy, that little is left in the mind to permit quality of life. And the ruminations, while understandable in the context of troubling symptoms or problems, do not help to resolve the problems at all. Rumination can also refer to a gastrointestinal problem, which I am not discussing here.

Chronic physical pain obviously has a huge negative impact on quality of life. The presence of physical pain symptoms is a strong risk factor for suicide. (references: http://www.ncbi.nlm.nih.gov/pubmed/21668756 ; http://www.ncbi.nlm.nih.gov/pubmed/16420727 )

If physical pain and depression are combined, the severity of both problems is substantially elevated.

Treatment of chronic pain requires good comprehensive medical care. Investigation and treatment of underlying medical causes is obviously important. Coordinated involvement of a mutlidisciplinary team is ideal, though often lacking in many people's experience.

In the psychiatric realm, a variety of therapies can help:

1) mindfulness meditation. Jon Kabat-Zinn developed much of his work on mindfulness meditation with patients suffering from physical pain. In my opinion, meditation is extremely important, since it carries no risk, has a variety of possible and probable benefits, and is likely to help with both emotional and physical symptoms.

This study shows similar reductions in pain from a mindfulness program vs. a multidisciplinary pain program without a meditation focus:
http://www.ncbi.nlm.nih.gov/pubmed/21753729

This study shows improvements in various types of chronic pain conditions, with greater improvements in symptoms when subjects practiced more at home:
http://www.ncbi.nlm.nih.gov/pubmed/20004298

This study showed that mindfulness strategies probably work best for those who already have higher levels of mindfulness to begin with, as a type of character trait:
http://www.ncbi.nlm.nih.gov/pubmed/21254055

This study shows a slight advantage for a mindfulness meditation program to treat back pain:
http://www.ncbi.nlm.nih.gov/pubmed/17544212

An interesting study showing improvement in distressing intrusive thoughts and images following a meditation program. This shows that mindfulness exercises can substantially improve symptoms of rumination and even psychosis. In chronic pain, ruminations and intrusive thoughts about the pain itself are a very common feature, and an element of the vicious cycle of pain perpetuation and reduced quality of life. The study was of good quality, and the effect was quite substantial and robust:
http://www.ncbi.nlm.nih.gov/pubmed/19545481

Similarly, a study showing the mindfulness training specifically increases ability to "let go" (in this case, of OCD thoughts). "Letting go" of ruminations about pain is very helpful in managing chronic pain conditions:
http://www.ncbi.nlm.nih.gov/pubmed/18852623

Here's another study once again showing that mindfulness is specifically helpful to reduce rumination:
http://www.ncbi.nlm.nih.gov/pubmed/17291166

2) Cognitive-behavioural therapy
There is a significant research literature showing the effectiveness of CBT for managing pain conditions. Here are some research examples:
non-cardiac chest pain: http://www.ncbi.nlm.nih.gov/pubmed/21262413
chronic TMJ (jaw) pain: http://www.ncbi.nlm.nih.gov/pubmed/20655662
fibromyalgia: http://www.ncbi.nlm.nih.gov/pubmed/20521308
severe back pain: http://www.ncbi.nlm.nih.gov/pubmed/19967572
vulvodynia: http://www.ncbi.nlm.nih.gov/pubmed/19022580
back pain (here, active behavioural/physical therapy was necessary for optimal improvement in performance, as expected): http://www.ncbi.nlm.nih.gov/pubmed/16426449
chronic headaches: http://www.ncbi.nlm.nih.gov/pubmed/17690017

3) Medications
a) antidepressants:

Several antidepressant types could help with chronic pain: tricyclics such as amitriptyline have been used in this way for decades, with reasonable evidence-based support. Cymbalta (duloxetine) has been marketed for this, and is reasonable to try. However, venlafaxine (Effexor) is probably just as effective for pain symptoms.
There have been no studies comparing venlafaxine with duloxetine in pain patients; I suspect that there would be little difference. Currently, duloxetine is more expensive, so I do not believe it should be a first-line agent. SSRI antidepressants or bupropion appear not to be consistently helpful for treating physical pain.

Here`s an animal study showing a difference favoring a tricyclic over an SSRI or bupropion for pain management: http://www.ncbi.nlm.nih.gov/pubmed/20689938

Here`s a negative study on moclobemide for physical pain: http://www.ncbi.nlm.nih.gov/pubmed/7549169

This study shows equivalent benefits from amitriptyline and duloxetine, with over 50% of patients having good pain relief in diabetic neuropathy: http://www.ncbi.nlm.nih.gov/pubmed/21355098

This study shows benefits from duloxetine in fibromyalgia; again with over 50% of patients feeling much better, compared to about 30% with placebo: http://www.ncbi.nlm.nih.gov/pubmed/20843911

This study shows significant benefit in treating osteoarthritis pain with duloxetine; the pain relief was not related to any change in depression scores (which, in this population, were quite low and did not change very much with either duloxetine or placebo). I find this study quite significant, in that it is looking at a different variety of pain than most of the other research: http://www.ncbi.nlm.nih.gov/pubmed/19625125

This study shows relief attributable to duloxetine in depressed patients with idiopathic pain symptoms: http://www.ncbi.nlm.nih.gov/pubmed/18052564

Here, venlafaxine is shown to be an effective agent to prevent migraine headaches: http://www.ncbi.nlm.nih.gov/pubmed/15705120

Venlafaxine shown to be effective in treating functional chest pain:
http://www.ncbi.nlm.nih.gov/pubmed/20332772

A 2007 Cochrane review concluding that venlafaxine and tricyclics are effective for chronic pain:
http://www.ncbi.nlm.nih.gov/pubmed/17943857

b) anticonvulsants, e.g. gabapentin, pregabalin, carbamazapine, topiramate

A comparison of gabapentin, pregabalin, and amitriptyline in treating neuropathic cancer pain. All of these drugs clearly helped, with pregabalin probably the best. Aside from direct relief, these drugs resulted in lower doses of opiates being needed: http://www.ncbi.nlm.nih.gov/pubmed/21745832

A review of gabapentin treatment for neuropathic pain, affirming its usefulness, particularly at higher doses of 1800-3600 mg per day: http://www.ncbi.nlm.nih.gov/pubmed/12637113

This is a negative review article, showing that lamotrigine is unfortunately not likely to be useful in treating chronic pain: http://www.ncbi.nlm.nih.gov/pubmed/21328280

An interesting study showing that pregabalin can reduce postoperative morphine requirement acutely: http://www.ncbi.nlm.nih.gov/pubmed/21786524

This is an example, and a review article, part of the large literature showing that topiramate is an agent of choice to prevent or treat recurrent or chronic migraine. There is preliminary evidence at a case-report level that topiramate could help with other types of pain: http://www.ncbi.nlm.nih.gov/pubmed/19838625

c) opiates, such as codeine or morphine -- outside of the scope of this posting. These may have a role in managing non-malignant chronic pain, but supervision is needed from someone with experience prescribing opiates, a pain clinic, etc. Long-acting opiates such as methadone are being used more often in acute or chronic non-malignant pain conditions. Of course, there is a balance here between pain relief and addictive risk.

Here is a recent review, which basically affirms that the use of opiates for chronic non-cancer pain is an "iffy" practice, yet I do affirm that in some cases it may be necessary. In any case I think that experienced and specialized prescribers, such as those at a pain clinic, would be highly preferred:
http://www.ncbi.nlm.nih.gov/pubmed/21412367

d) Atypical opiate: tramadol. This is an interesting drug, for various reasons, including that it has antidepressant activity as well as being a physical analgesic. It is an opiate, but a significant portion of its analgesic properties come from non-opioid mechanisms, such as neurotransmitter reuptake inhibition. It does a potential for addictive problems, but the risk is clearly less than other opiates. For this reason, I think it is reasonable to think of using tramadol before using other opiates (such as codeine or morphine) in treating pain syndromes.

Chronic CNS effects of tramadol differ from those of morphine, supporting the evidence that tramadol has a smaller risk of inducing opiate dependence/addiction:
http://www.ncbi.nlm.nih.gov/pubmed/17401159

Tramadol can be identified subjectively as having opiate-like effects, but mainly at higher doses:
http://www.ncbi.nlm.nih.gov/pubmed/21467190

Here are animal studies using a mouse model of depression, suggesting effectiveness of tramadol.. However, I would want to see longer-term studies of this sort, as the acute beneficial action of any therapy does not necessarily prove that the benefits will last, in fact many acutely beneficial things can become harmful if used long-term (e.g. benzodiazepines):
http://www.ncbi.nlm.nih.gov/pubmed/9749830
http://www.ncbi.nlm.nih.gov/pubmed/12417248

An animal study suggesting that tramadol and anticonvulsants (in this case, specifically topiramate) can work synergestically (cooperatively) in relieving neuropathic pain: http://www.ncbi.nlm.nih.gov/pubmed/17532139

Treatment of refractory major depression with tramadol monotherapy: http://www.ncbi.nlm.nih.gov/pubmed/11305709

Rapid remission of ocd with tramadol:
http://www.ncbi.nlm.nih.gov/pubmed/10200754
http://www.ncbi.nlm.nih.gov/pubmed/9559288

Restless legs treatment with tramadol:
http://www.ncbi.nlm.nih.gov/pubmed/10221285

Treating catalepsy with tramadol:
http://www.ncbi.nlm.nih.gov/pubmed/14504345

Tramadol dependence : in general these articles show that tramadol dependence occurs, but is significantly less likely than with stronger opiates:
http://www.ncbi.nlm.nih.gov/pubmed/19827010
http://www.ncbi.nlm.nih.gov/pubmed/21467190
http://www.ncbi.nlm.nih.gov/pubmed/20589494
http://www.ncbi.nlm.nih.gov/pubmed/16716877

There is a risk of serotonin syndrome with tramadol, particularly if combined with other serotonergic drugs, such as SSRI antidepressants:
http://www.ncbi.nlm.nih.gov/pubmed/21147393

Other direct approaches to treat rumination:

Here is a study showing effectiveness using a modified form of cognitive therapy called competitive memory training. It basically involves teaching techniques to either accept, or become indifferent to, the themes of the rumination:
http://www.ncbi.nlm.nih.gov/pubmed/21784413

Here`s a similar recent study showing improved relief in chronic depression with a CBT style modified to target rumination:
http://www.ncbi.nlm.nih.gov/pubmed/21778171

An interesting study from the psychology literature which shows that rumination is associated with a type of cognitive deficit involving reduced ability to manage negative material in working memory. This suggests to me that cognitive exercises, ones which train working memory, could have a role in treating depression and rumination. Conversely, it suggests to me that practicing ways of "letting go" such as via CBT or meditation, could improve working memory (by freeing working memory space of irrelevant, ruminative, or intrusive negative material), and therefore improve intellectual functioning, academic performance, etc. http://www.ncbi.nlm.nih.gov/pubmed/21742932

Here's one of many articles discussing rumination as a risk factor for depressive relapse or chronicity. Clearly, tactics to help manage or prevent rumination are very important in both acute treatment and in prevention:
http://www.ncbi.nlm.nih.gov/pubmed/19899844

Another article discussing the role of rumination as a sort of emotional amplifier, which causes "impaired down-regulation of negative feelings" -- thus preventing the maintenance of positivity or relationship health after a stressor. Such a dynamic would be a recipe for life disappointments to consistently derail one's emotional life. Once again, practicing ways to manage rumination directly could therefore help with emotional resilience, and prevent a recurrent depressive cycle:
http://www.ncbi.nlm.nih.gov/pubmed/21432690

In summary, there are a variety of ways to treat or manage chronic pain and rumination. Rumination itself may be an important perpetuating factor in pain syndromes. Due to the presence of many symptoms in such syndromes, affecting both physical and emotional domains, it is important to have a cohesive, integrated treatment plan.   There is a risk of having multiple sources of therapy, each of which targeting only part of the symptom complex, which potentially could complicate or confound efficient treatment efforts. In physical pain, emotional pain, or rumination, it can be extremely valuable to practice ways of "letting go."

Optimal Sleep Duration

2011-07-27T16:11:00.000-07:00

The best study which examines the relationship between sleep duration and mortality risk was published in 2007 by Hublin et al in the journal Sleep. Here's a link to the abstract:

http://www.ncbi.nlm.nih.gov/pubmed/17969458

It is part of the Finnish twin study, which followed over 20 000 twins over a 22 year period. This is an extremely large cohort, and the study had very high response rates. The analysis was thoughtful and comprehensive.

They showed that mortality rates were lowest for those who sleep between 7 and 8 hours per day. For those sleeping less than 7 hours per day, or more than 8, the mortality rates were about 20-25% higher. The results were adjusted for the covariates of education, marital status, age, working status, BMI, social class, drinking behavior, physical activity, smoking, and life satisfaction. Interestingly, and unexpectedly, sleep quality was not shown to be associated with differences in mortality risk.

The argument could be made that average sleep duration has a non-causal association with lower mortality. That is, people who happen to be healthier in the first place are more likely to have average sleep length. But another part of this analysis suggests that this is more than a non-causal association: subjects who changed their sleep duration during the course of this 22 year follow-up also changed their mortality rate, after controlling for the measured confounding factors. I suppose it could still be true that some other mortality-increasing factor was the cause of the sleep duration change, and not the other way around.

In conclusion, this data supports the commonly held belief that 7-8 hours of sleep per night is a desirable goal. It may be that particular individuals have a different "set point" for optimal sleep, and for those individuals optimal health might result from more or less hours than this average. Yet I do not actually see firm evidence of this in the research I've seen.

A 2010 meta-analysis supports the same conclusion: http://www.ncbi.nlm.nih.gov/pubmed/20469800 but I think the authors understate their findings. In particular, while a lot of the data showing increased mortality in short sleepers defined short sleep to be under 7 hours, the authors state in their discussion that "consistently sleeping 6 to 8 h per night may therefore be optimal for health." I think there is a significant difference between 6 and 7 hours, particularly due to pressures in the culture where many people are sleeping only 6 hours because of a busy schedule, while really needing 7 or 8.

Knutson in 2007 published a good article showing that sleep deprivation causes impairments in glucose tolerance (similar to the changes which occur in the development of type II diabetes), and impairments in the hormones associated with appetite regulation: http://www.ncbi.nlm.nih.gov/pubmed/185162

Here's one of the articles in the literature showing that sleep deprivation leads to an increase in proinflammatory cytokines and abnormal immune activation: http://www.ncbi.nlm.nih.gov/pubmed/19240794

I think it is especially true that if one has signs or symptoms related to sleep duration (e.g. feeling sleepy in the daytime after sleeping only 6 hours per night) then this could be taken as strong evidence that sleep duration should be increased up to the average (7-8 hours), if circumstances permit.

Patterns of sleeping long hours (above average) could be approached similarly, but of course if the reason for the long sleeping duration is medical illness or medication effects, etc. it would not be healthy to force oneself into a shorter (average) sleep regimen.

Somatoform Disorders & CFS : a discussion

2011-06-27T14:45:00.000-07:00

Somatoform disorders could be considered clusters or syndromes of physical symptoms which have a psychological cause.

Here are some examples:
1) somatization disorder -- a syndrome of multiple physical symptoms--typically pain symptoms-- which have a psychological cause
2) conversion disorder -- typically there is a complaint of paralysis or loss of sensation (including blindness) despite an absence of neurological signs; the symptoms may be generated without conscious intent, but may be profoundly disabling. With modern examination techniques and tests, these symptoms are easily demonstrated to be of non-neurological origin.
3) somatic delusions, in the context of psychotic depression or schizophreniform disorders. These have a wide variety of manifestations, though are most commonly bizarre in nature. Arguably, cases of somatization or conversion could be treated as somatic delusions.
4) somatic manifestations of anxiety -- this is extremely familiar to us all: tremor, sweating, bowel problems, etc. can all occur as a direct obvious consequence of anxiety. At times this physical component becomes the dominant feature, leading to behaviours intended to relieve the physical complaint, leading in turn to worsened avoidance, withdrawal, and exacerbation of the underlying problem.

This whole subject requires a lot of care, in my opinion. I believe that somatization is very common, and exists in a wide range of extremity--from minor symptoms to syndromes that can be almost totally disabling--yet it is also true that undiagnosed medical ailments of non-psychological origin can often be misdiagnosed as psychosomatic or somatoform. Therefore, thorough physical medical assessment and care is needed as a multidisciplinary strategy to manage these problems. These types of problems do indeed tend to be handled poorly by the conventional medical system--either through excessive and harmful medical interventions (e.g. in Munchausen's Syndrome), or through the dismissive neglect of a frustrated caregiver.

I think it is fair to say--and an observation I certainly find consistently in my experience--that physical symptoms of any cause ALWAYS have a psychological component as well. Often times, the psychological component is simple and direct: recurrent migraine headaches, malignant chronic pain, recurrent seizures, etc. (among hundreds of different causes of physical symptoms) cause a disruption to daily life & function, and their unpredictable patterns can leave one in a nearly constant state of anxiety. It can be hard to plan activities, time for relationships, work schedules, etc. when symptoms may come at any moment. So there is obvious direct psychological stress. This stress understandably can cause a feedback loop which may exacerbate the underlying medical condition.

Other times, I believe that the psychological effects of medical conditions can be more subtle or indirect. Chronic conditions can come to have a lot of power to redefine one's sense of self, often in a way which pronounces one to be more disabled than the medical problems necessitate.   Some types of symptom clusters may be sufficiently common as to allow a community of fellow sufferers to form. While this may permit the supportive care of a community, it may also consolidate or entrench the aspects of the phenomenon which have to do with identity. The relief that one may find in a group of people experiencing something similar may sometimes be so compelling that entrenched factitious beliefs about disability are deepened, at the expense of therapeutic growth.

Some currently unexplained diagnostic entities, such as chronic fatigue syndrome (CFS), may in some cases be examples of complex somatoform illness. I acknowledge that in other cases--perhaps even in the majority--there may well be some as yet unexplained physical pathology driving the symptoms.    A physiologic disposition towards fatigue may cause a cascade of behavioural changes (including withdrawal from activities), leading to a further cascade of cognitions about illness,   mood change (which can often present itself, for many people, in a further somatized set of symptoms), and perpetuating of underlying symptoms. The worldwide network of fellow sufferers may lead to perpetuation of symptoms, rather than relief, because the group consolidates some of the beliefs and identity formation which individuals may have about the condition, and also may agitate against what is seen as a dismissive or ineffectual medical system. The group dynamics may also foster the spread of various spurious alternative therapies, whose evidence base would often consist of glowing testimonial accounts rather than careful randomized data. Factitious therapies could sometimes be quite effective for factitious illnesses, since the therapeutic effort would permit the sufferer a psychological opportunity to move away from the illness symptoms, and attribute the improvement to something external, rather than to psychological change. Such is, in my opinion, the basis for most stories of so-called "faith healing" which have been around for millenia.

It is helpful to have observed extreme examples of somatoform illness. Case examples include individuals who have had recurrent factitious seizures (pseudoseizures), often leading to dangerous and harmfully inappropriate medical interventions. Many persons with a history of pseudoseizures also have neurologically-based epilepsy as well: somatized, factitious, or conversion symptoms often co-exist with their non-psychiatric counterparts. Other case examples include situations where individuals are delusionally convinced that they are paralyzed (due to a conversion disorder) causing them to have lived in a wheelchair for years. Such individuals often have networks of people in their lives who support them in their paralyzed role; such supporters often include physicians and other caregivers. Yet, it has been an amazing experience for me to witness cases of this type--cases where there has never been any objective sign of neurologic disease, but where the impact of the problem has been extreme; if a very careful neuropsychiatric evaluation is done, with strongly structured psychiatric and rehabilitative therapy, I have seen situations where the previously "paralyzed" person leaves the hospital on their own two feet.

But cases like these are inevitably complex. If a person has lived in a certain way for years, the behaviours themselves, and the associated thoughts, become integrated into identity. If you live as a paralyzed person for many years, it will not be so easy to get up and walk, even if you are neurologically healthy. There are physical barriers, but obvious psychological and social ones as well.

I believe this is a theme which epitomizes our understanding of brain function: repeated behaviour entrenches neural pathways. If "illness behaviour" exists despite "no illness", the brain learns to function "as if" a physical injury were present. It is just like language learning--with immersive experience over a course of months or years, the brain will speak the new language with ever greater fluency. It is a difficult task for the brain to "unlearn" such experience.

But this suggests a therapeutic imperative: for all cases of this type, immersive physical rehabilitation is necessary. In every single case I have ever seen of severe conversion, for example, the cure required intensive, prolonged, structured involvement of physiotherapists, in addition to whatever medications (typically antidepressants and antipsychotics) and psychotherapeutic work the person needed.

I believe this theme crosses over into the realm of ALL chronic disease, regardless of cause. Management of chronic disability or chronic diseases is greatly assisted by physical rehabilitation. In the language of narrative therapy, if we consider the illness or symptom to be like a negative character in our lives, that character is constantly telling us to do less and less--part of the therapy to challenge this is to find a structured and safe manner in which to do more and more, or to optimize our fitness so that we can do the most despite the limitations imposed by the disease.

Another interesting modality of therapy for conversion, one which can illustrate very compellingly the existence of a structure of drives and defenses first suggested by Freud, is the so-called "amytal interview." In the version I have seen, a patient with a conversion syndrome (following informed consent, of course) is given a dose of ritalin (which allows more amytal to be given without loss of consciousness), followed by intravenous sodium amytal (a barbiturate), with the supervision of an anesthetist in a well-equipped medical setting. The dose is titrated just to the point before the patient loses consciousness. The effect of the medication is to cause disinhibition. In this condition, the psychological forces necessary to continue the conversion symptom are weakened, so for example a person describing paralysis of an arm can be guided to raise the paralyzed arm in the air, and flex it, etc. This event can be videotaped. When the effects of the drug wear off, the person may not remember the scene, but when presented with the video footage (of the non-paralyzed limb in action), the person's psychological defense of conversion will be substantially weakened. As a result, often times a strong emotional reaction takes place, usually the overt emotions or affects consistent with a severe underlying depression which had previously shown itself through "paralysis."   In this way, "conversion" operates as a psychological defense, a way in which the brain deals emotionally or behaviourally with a painful symptom. These defenses can be vital ways to survive in the world, but sometimes--as in conversion disorders--the defense system goes awry, and becomes the core problem.

A negative study on vitamin d supplementation

2011-06-27T11:38:00.000-07:00

http://www.ncbi.nlm.nih.gov/pubmed/21525520
this 2011 randomized, controlled, prospective study from the British Journal of Psychiatry shows that vitamin d supplementation did not improve well-being in a group of over 1000 elderly women compared to a similar-sized control group.

This is a good study, with negative results. I don't think it means that vitamin d is of no use, but rather that it cannot be assumed to have obvious positive effects for everyone. Some of the effects measured in other vitamin d studies may be the result of non-causative associations (e.g. those with various healthier habits and health paramaters may be more likely to have higher vitamin d levels, but the vitamin d is not the cause of this healthiness, it results from it)

However, the data on this issue continues to evolve. There is some good positive data on vitamin d as well, though not enough in terms of randomized, prospective studies. It will be important, for example, to look at whether vitamin d could obviously be an effective adjunct to other therapies for treating depression. Or whether vitamin d alone has little effect, unless combined with other positive factors.

Meanwhile, I still believe that the standard recommended daily dose of 400 IU for vitamin D is too low, and that 1000-2000 IU per day is better.

See my previous post on vitamin d, http://garthkroeker.blogspot.com/2009/02/vitamin-d-other-vitamins.html

Music Therapy

2011-05-13T14:51:00.000-07:00

I believe that many creative modalities can be usefully included in a therapeutic relationship. There are times when spoken dialog can be more difficult, unwelcome, inhibited, or even frankly unhelpful. Other types of activities can be part of a therapeutic milieu, and work on non-verbal forms of communication, as well as other forms of positive experience in the therapeutic frame.

The use of music in therapy is well-established. Music therapy is a recognized profession, with a substantial academic literature behind it. I believe that music is under-utilized in therapy generally, perhaps considered outside the scope of experience or training of most therapists. Even therapists with a background interest in music may not share this with patients, for a variety of reasons. The predominantly oral tradition of psychotherapy can be so dominant sometimes as to view non-verbal activities as eccentricity.

Music -- listening, performing, learning, and coordinating -- can touch upon the following therapeutic themes:
1) emotional expression
2) performance anxiety / communicative inhibition
3) perfectionism
4) assumptions about capacity or incapacity to learn something new
5) focusing on an activity which is sufficiently engaging as to calm anxiety or agitation, or at least distract attention away from negative emotions or unwelcome thoughts
6) enjoyment
7) a sense of achievement
8) patterning the same learning schedule which leads to psychological change or skill acquisition of any sort -- some immediate progress in the moment--which needs to be enjoyable in itself-- but part of a process which can include thousands of hours of experience to grow substantially
9) a sense of trust and "harmony" with the therapist; possibility a modality which makes the therapeutic relationship stronger
10) on a sort of psychodynamic or developmental level, music could be understood as one of the individual's first experiences of emotional soothing (from the mother humming or singing to her infant), a modality which precedes verbal language. There might be deprivations or problems associated with this dynamic for some individuals, which could become a therapeutic theme if music was part of the frame of activities and discussion.
11) music preferences and interests are, of course, an element of identity expression. I believe that questions about music preference and experience are a useful part of a psychiatric history; often an understanding about this part of a person immediately deepens understanding, and offers a chance to connect in different ways, to build rapport and interested collaboration.

Many types of music therapy involve having the patient improvise on a simple instrument, etc., or perhaps listen to music. I think that doing cooperative musical exercises can be a valuable element, in which the therapist can act partly as collaborator or music teacher. The technical skill level is not relevant, in my opinion, and in fact could be considered a type of neutral transferential theme to be worked with in the therapy. Simply practicing a simple technical exercise on an instrument--even during a conversation--could be a tactic to help attain calm and relaxation, in the same way that many other physical skills can be relaxing (e.g. knitting, swimming, yoga).

Here is a review of some of the research literature on music therapy:

http://www.ncbi.nlm.nih.gov/pubmed/19269725
2009 meta-analytic review showing music therapy robustly effective for a wide range of problems in severe mental illness, including overall function, well-being, and symptom control. More sessions are more effective; 16-51 sessions associated with large effect sizes.

http://www.ncbi.nlm.nih.gov/pubmed/21474494
a 2011 article from the British Journal of Psychiatry, showing robust effects of music therapy in the treatment of depression. There was a "control group", but in this case the control group received "standard care" (medications + a few sessions of psychotherapy), while the active group received this same standard care plus up to 20 sessions of music therapy. So, in my opinion, the study did not control for the effect of simply spending time with the patients for 20 extra sessions. There should have been a control group which had 20 sessions of the same length of time as the music therapy group, but doing a "placebo" activity. Nevertheless, this does show that, at the very least, doing music activities with patients during therapy sessions is a supportable practice.

http://www.ncbi.nlm.nih.gov/pubmed/15846692
2005 Cochrane review showing that music therapy is an effective component of therapy for schizophrenia, leading to improved global state, as well as probable positive changes in various symptom clusters.

http://www.ncbi.nlm.nih.gov/pubmed/18254052
2008 Cochrane review showing that music therapy may be effective in the treatment of depression. 4 of 5 studies showed greater improvements in depressive symptoms in the music therapy group compared to standard care.

http://www.ncbi.nlm.nih.gov/pubmed/20614449
music therapy shown to be helpful to improve the rate of rehabilitation in brain injury or stroke

http://www.ncbi.nlm.nih.gov/pubmed/21292560
this is quite a cute study, showing that listening to Mozart's K.448 (sonata for 2 pianos) once nightly for 6 months leads to substantial reductions in seizures in children with refractory epilepsy. It's a weak study, of course, since there is no control group.

http://www.ncbi.nlm.nih.gov/pubmed/20129759
a similar study, but a bit stronger, since it shows that Mozart's K. 448 leads to an immediate change in EEG patterns, as long as the recording does not have prominent higher harmonics. I've noticed this myself, that tones with very strong higher-order harmonics above the fundamental tone can prevent focus on music performance, particularly for those with very strong ear skills, or could even be strident and unpleasant. Mozart himself was apparently very sensitive to this as a child. This leads to another issue, about sound level: the modern habit of listening to music at very high sound levels could sabotage not only one's hearing, but also the psychological benefits of the music.

http://www.ncbi.nlm.nih.gov/pubmed/21290852
a discussion of the role of music in non-suicidal self-injury.

I think some music may itself be self-injurious, or at least a consistent cue associated with self-injury; but clearly there is therapeutic potential, for music to be helpful in affect regulation or as a healthy substitute behaviour instead of self-injuring.

I'm curious as to the manner in which musical lyrics or the emotional tone in music affects "self-talk" or inner emotional tone. In a "Rogersian" sense, music with very depressive or hostile lyrical or tonal content may help a person to feel less alone--a type of empathic bond with the music--which may be therapeutic. But I believe that such a bond is much more therapeutic if it leads to a sense of resolution of the underlying problems, or offers a consistent message of hope or joy despite whatever empathic connections are made with sadness, anger, emptiness, etc. I think the greatest songs (present in all genres and eras) are those which suggest a resolution for problems of suffering or emotional pain, rather than simply evoking the negative emotion.

Alternative conceptions of "IQ"

2011-05-03T11:33:00.000-07:00

Standard IQ tests measure a particular set of intellectual skills. But this leads to a big question about what exactly is being measured. The notion of "IQ" implies that the test is measuring an innate, relatively fixed intellectual capacity.

But consider the following analogies:

-Suppose reading skill in English was being tested. Obviously, we could see that those who score very well in a test of rapid reading and comprehension would most likely be classified as more "intelligent." Yet, the test would have massive potential sources of bias or inaccuracy. Many people with excellent language skills would do poorly on an English reading test simply because of their lack of knowledge or experience with English. Others with excellent minds might not have had much reading education or experience of any sort, therefore they would not have acquired the skill to read or comprehend written language quickly.

-If "athleticism" was being measured, suppose the test involved having subjects shoot free throws on a basketball court. People who would score very highly on this test would most likely fit reasonably into a "high athleticism" category. But many very athletic people would score poorly on this test, simply because they had very little experience shooting basketballs. If a skill that was brand-new to all subjects was being tested one time (e.g. archery target practice), those who performed very well might well be more "athletic" but perhaps they had more experience in a similar type of skill in the past, or they just happen to be more calm with novel activities.

Acquisition of skills is a process that grows over a period of hundreds or thousands of hours of experience. If a test is measuring a skill, it may simply be measuring how many hours of experience that person has with a similar activity. Of course, an intrinsic strength in something is more likely to lead to a person spending more time developing the strength -- talent leads to passionate commitment; it facilitates and makes enjoyable the thousands of hours of work

So, an IQ test may be measuring--to a significant degree--the number of hours of experience the subjects have with similar types of activities (e.g. memory tasks, logic puzzles, arithmetic, etc.).

On a related note, recent findings have suggested that doing cognitive exercises such as brain-training video games does not really improve intellectual function significantly. But--the manner in which this conclusion was reached was testing subjects before and after using tests that did not directly relate to the cognitive games which were being played. Therefore, I believe the findings are spurious.

Here is my thesis on this issue:

"Intelligence" could be understood not as an absolute quantity of a skill (since this quantity would depend mainly on how many hours of practice or experience the person has had, which arguably should be viewed independently from the concept of "intelligence" as an innate trait). Rather, "intelligence" could be viewed as the RATE at which brand-new skills improve with a given period of practice. For example, the amount of improvement after 10 hours of practice of a brand-new activity would be a much better measure of "athleticism" than simply measuring the absolute performance one time. Even this type of measure would be influenced by a person's past experience: for example, a person with thousands of hours of experience learning different languages would probably be able to learn a completely new language more quickly with 10 hours of practice, compared to someone with very little past experience of this sort. The proviso that this be a "brand new" activity is important, because if a person has a very high level of expertise in a particular skill, then their rate of further improvement will be very low (since there is not much further improvement humanly possible).

So, for example, with athletic tests, it would seem a reasonable measure of "innate athleticism" to introduce a completely new sport or fitness activity, and to measure how quickly subjects could improve or master it with limited practice time.

Another complicating angle on this theme is that intellectual experience and focus in ANY area is likely to improve "innate intelligence." If you have practiced music for 10 000 hours, you will probably have strengthened a variety of other "innate" intellectual capacities. But this strengthening effect would not be obvious if measured conventionally.

Similarly, I suspect that "brain training" video games could have a significant effect of strengthening various intellectual capacities. But this positive effect would not be captured well by simply repeating single "before" and "after" skills tests. A much better measure would be the following:
1) "pre" test: subjects would have to put in 10 hours of practice learning a game having to do with verbal memory. The absolute scores, and the rate of improvement over the 10 hours, would be recorded.

2) Subjects would put in 100 hours of practice doing either a battery of memory-focused brain training games, or a "placebo" set of games not focusing on memory.

3) "post" test: subjects would put in 10 hours of practice learning a completely new game having to do with verbal memory. Once again, the absolute scores, and the rate of improvement, would be noted.

Here is my hypothesis about the findings of such an experiment:

1) The absolute scores at the beginning of the "pre" and "post" tests would be quite similar. This would be like testing the basketball skills of a group of volleyball players before and after volleyball training season. You would not expect any difference. This is the conventional type of assessment, which is bound to lead to the conclusion that there is no beneficial training effect.

2) What I would expect to be different is that the subjects who had done 100 hours of memory games would be able to much more rapidly IMPROVE their scores in the "post" test. In the athletic analogy, a group of people who have spent the summer in volleyball training would be able to much more rapidly learn soccer skills, compared to a group who spent the summer watching TV, even though both groups might have very similar soccer skills at the beginning of a 10-hour training period.

I believe my hypothesis is supported by observations of individuals acquiring expert skills, such as playing chess. While the absolute number of hours practicing chess correlates directly with performance, there are some individuals who advance more rapidly with the same number of hours of practice.
(see the following reference: http://www.ncbi.nlm.nih.gov/pubmed/17201516)
I believe it is this "rate of change" that is the most reasonable measure of "innate" cognitive ability. Even this "innateness" could be more malleable than the term implies, since I suspect that there could be a type of "meta-training" which could improve one's rate of skill learning or acquisition. This would involve practicing ways to use time more efficiently, and, most importantly, practicing ways to bring devotion, joy, and energetic attention to one's learning experiences.

Health effects of binge drinking

2011-05-02T15:59:00.000-07:00

In Canada, a "drink" or a "standard drink", as a unit of alcohol consumption, refers to a drink containing 13.6 grams of ethanol. This amount is present in a 12-ounce (355 mL) beer, or a 5-ounce (146 mL) glass of wine, or a 1.5 ounce (44 mL) shot of hard liquor such as whiskey or vodka. Reference: *

Binge drinking is defined as having 5 or more drinks on one occasion for men; or 4 or more drinks on one occasion for women. This pattern of consuming alcohol is a common cultural habit, with historic roots going back thousands of years.

There are various sources of epidemiologic evidence that light drinking may have health benefits. My review of the evidence suggests that the cut-off point for this would be no more than 2 drinks per 24 hours, with any episodes of greater alcohol consumption conferring a substantial health risk (both physical and psychiatric).

When it comes to binge drinking, I believe the health risks are very high. The immediate risks have to do with accidents & injuries, which are much more likely during a binge drinking episode. This risk also affects other people, such as passengers in a car or other drivers on the road.

In my opinion, the psychiatric risks of binge drinking can be divided into several categories:

1) Simple addiction. If heavy intoxication is associated with pleasure or relief, this may easily become an addictive process, such that relief or pleasure may only come with intoxication. As a result, other activities not involving intoxication become more subjectively boring and more prone to induce dysphoria rather than pleasure. I call this the "greying of the sky" phenomenon. The sky becomes less and less blue--figuratively speaking-- the more one repeats an addictive behaviour. It is so gradual as to often be unnoticable, until years later one may have the realization that the simple pleasure of gazing at the blue sky is no longer available.

2) Subcultural effect. In conjunction with simple addiction, binge drinking is likely to affect one's social network, such that one's friends will more likely also be binge drinkers. This makes it more difficult to leave the behaviour behind, since it would involve leaving one's social network. Also the subcultural effect tends to cause a subjective normalization of the behaviour, such that people could actually feel abnormal if they cut back or stopped binge drinking. Heavy drinking and its associated behaviour are a regular source of humour in our culture, which unfortunately may be another normalizing influence for those who are addicted.

3) Direct pharmacological effects during intoxication and withdrawal. Aside from the obvious effects during intoxication, I observe that binge drinking often leads to "mini-withdrawals" afterwards. While many people may normalize their once-weekly alcohol binge, they may not realize that the withdrawal effects during the rest of the week cause impaired sleep quality and heightened anxiety. Many young people are very resilient, so this may not be a problem, but if there is already a progressing problem with anxiety, depression, or other causes for insomnia, then binge drinking will make these problems much more difficult to treat.   I believe that the presence of binge-drinking behaviour makes antidepressant treatment much less likely to be successful.

My recommendation is never to binge drink. More than 2 drinks per 24 hours is harmful, causing adverse short-term and long-term health effects in all cases. If binge drinking is a significant part of recreational culture for any individual, then therapeutic work needs to be done not only to cut back on alcohol consumption, but to build a healthier cultural life, and probably a healthier social network.

Here is a review of some of the research literature on the subject:

http://www.ncbi.nlm.nih.gov/pubmed/21345624
binge drinkers have double the rates of depression; reductions of drinking subsequently associated with reduced depressive symptoms.

http://www.ncbi.nlm.nih.gov/pubmed/20858964
This is a very strong 2010 prospective twin study, showing that binge drinkers have double the risk of cognitive impairment (dementia); light drinkers have the lowest risk; abstainers in the middle. High alcohol intake is clearly a strong risk factor for dementia; binge drinking is a risk factor independent of total alcohol intake. That is, even if you don't drink a large volume of alcohol in a month, if you ever binge drink you will still be in a high risk group.

http://www.ncbi.nlm.nih.gov/pubmed/19556525
prospective study showing increased strokes and overall mortality in binge drinkers

http://www.ncbi.nlm.nih.gov/pubmed/19438420
Current binge drinking associated with increased depression 5 years later. This was strong data with a good effort to control for confounding factors. Heavy intoxications at least once a month, especially with associated phenomena (e.g. blackouts, hangovers), were associated with double to fourfold increases in hospitalizations due to depression.

http://www.ncbi.nlm.nih.gov/pubmed/19144978
binge drinking a stronger predictor of social harms (e.g. violence, loss of relationships) than total alcohol volume

http://www.ncbi.nlm.nih.gov/pubmed/21294995
2011, large epidemiologic study. 16% of men over 50 met criteria for binge drinking, 6% of women over 50.   Binge drinking behaviour strongly correlated with alcohol dependence (alcoholism).

http://www.ncbi.nlm.nih.gov/pubmed/20930706?dopt=Abstract
another major prevalence study

http://www.cdc.gov/mmwr/preview/mmwrhtml/su6001a22.htm
a concise review from the Centers for Disease Control and Prevention. Prevalence of binge drinking at least 20% for men, 10% for women; rates were higher still for young adults.

http://www.ncbi.nlm.nih.gov/pubmed/19538908
this study shows even higher binge drinking prevalences for college students; 40% of this population engaging in binge drinking in a one month period.

http://www.ncbi.nlm.nih.gov/pubmed/20407040
This is a very nice 2010 review article and discussion from JAMA , about the health impacts of alcohol consumption, particularly the question of whether light drinking might protect against cardiovascular disease. In the particular case discussion, it is concluded that light drinking could have a small but insignificant positive health impact, and it would be more a lifestyle choice than one rationally motivated by health variables. For other individuals, any drinking at all could confer substantial health risks (e.g. those with severe addictive disorders, high sensitivity to negative side-effects of alcohol, various medical diseases). Reasonable warnings are included, such as never to drink while pregnant, before driving, etc.

Vitamin B12

2011-04-13T13:35:00.000-07:00

A reader recently sent in a comment wondering about the possible role of vitamin B12 supplementation in psychiatry.

Here's a brief review of the literature:
http://www.ncbi.nlm.nih.gov/pubmed/21191533 --a small case report of b12-deficient individuals responding better to antidepressants after b12 supplementation.

http://www.ncbi.nlm.nih.gov/pubmed/20976769
--survivors of stroke who took folic acid 2mg/d, b6 25 mg/d, and b12 0.5 mg/d had slightly lower rates of depression; there was an impressive 7 year follow-up period

http://www.ncbi.nlm.nih.gov/pubmed/20716710
this cross-sectional study using a diet questionnaire found an association between dietary folate & b6 and lower rates of depression in a sample of over 6000 adolescents; no association was found regarding b12.

http://www.ncbi.nlm.nih.gov/pubmed/20519557
a study from the American Journal of Clinical Nutrition, which showed a relationship between higher folate and b12 levels, and lower rates of depression, over 7 years of follow-up.

http://www.ncbi.nlm.nih.gov/pubmed/19175490
another study finding an association between low b12 & folate levels and higher rates of depression. Here, the b12 association was specifically for women. Looking more closely at the data, I find that the results are not overwhelmingly strong or convincing; I suspect there could be many confounding factors influencing the association.

http://www.ncbi.nlm.nih.gov/pubmed/18854539
this is an important study from JAMA showing that high dose folate, b6, and b12 supplements did not improve the course of dementia. Furthermore, 28% of the vitamin group experienced depression, compared to 18% of the placebo group.

http://www.ncbi.nlm.nih.gov/pubmed/18557664this study from the Journal of Clinical Psychiatry showed very little protective effect of vitamin b6, b12, and folate supplementation to prevent depression in older men. However, I see the vitamin group did slightly better than the placebo group, but not well enough to meet criteria for statistical significance.

In summary, there is a little bit of evidence of benefits from b12 in psychiatry, but the results are not overwhelmingly strong unless there is evidence of deficiency. It is worthwhile to have B12 levels checked. It appears not to be dangerous to take supplements; I suppose it is reasonable to aim for the higher part of the recommended serum levels, and to adjust any supplementation accordingly. Having said that, I acknowledge the possibility that some individuals may have a more beneficial effect from b12 supplementation, perhaps there could be selected cases in which this could act synergistically or as an augmentation with other treatments for depression, or perhaps there could be cases of subtle deficiency.

B12 deficiency is not uncommon; this can occur due to malabsorption (as in pernicious anemia or bowel disease), or due to dietary deficiency (e.g. in vegans). If the cause of low b12 is malabsorption, is may be necessary to have b12 injections. Once again, it is important to have b12 levels checked, and make decisions about supplementation if the level is low.

Looking at affected body parts reduces pain

2011-02-15T21:13:00.000-08:00

Here's an interesting little study showing that acute physical pain is diminished in intensity when one is looking at the affected body part; if this body part is artificially made to look larger, then the subjective pain is reduced even further.
http://www.ncbi.nlm.nih.gov/pubmed/21303990

In applying this type of idea to psychological pain, I guess one could say that "looking at the affected body part" could translate to discussing the problem in a therapeutic dialog.

A limitation of the study, and with pain studies in general, is that a brief intervention for an acute pain may not necessarily be equivalently helpful as a prolonged intervention for a chronic pain. In fact, some effective physical treatments for acute pain potentially exacerbate a chronic or recurrent pain disorder (e.g. using opiates to treat mechanical back pain or migraine).

However, I believe that studies of this type do illustrate that simple, brief psychological techniques can be surprisingly powerful in modulating perceptions or sensation.

Working memory exercises for treating addictions?

2011-02-15T16:44:00.000-08:00

Here's a link to an interesting article from Biological Psychiatry this month:
http://www.ncbi.nlm.nih.gov/pubmed/20965498

It is based on the notion that the decision to engage in an addiction is often made based on a short-term, possibly impulsive, analysis of benefits and risks; consequently, longer-term risks or benefits associated with the behaviour are undervalued. This phenomenon is termed "delay discounting." Resistance to delay discounting could be considered a cognitive faculty that would help, on an intellectual level, with making a healthy decision in the face of strong impulses in the moment.

The authors note a relationship between addictive disorders and increased delay discounting. They also note a previously described relationship between delay discounting and reduced working memory function.

Based on these relationships, they did a controlled study of persons with stimulant addiction, in which the active group did a set of memory training exercises for 1-2 months. They found that the memory exercises led to improved (reduced) delay discounting.

This study does not show that memory exercises directly improve the course of addictive disorders; but it does present a promising therapeutic idea which I think is currently underutilized in the therapeutic community, not only for addictions but for other types of problems.

Cognitive exercises could have a variety of benefits for various psychological problems:
1) the improvement one would see with practice could help with self-esteem
2) arguably, the exercises would favourably alter the balance between executive function and visceral, limbic emotional drives (which could often be turbulent or disruptive)
3) the exercises could be an introduction to the various mental and physical disciplines required to effect psychological or behavioural change

In terms of the specific exercises used in this study, I do think that the number of practice sessions was far too small. I believe that most psychologically beneficial activities start to show substantial results after 50-100 hours of practice. This study used only a maximum of 15 training sessions. The memory practice itself could have been organized in a more engaging, game-like manner. I think of some quite unique working memory games from the lumosity.com website, which tap into a type of activity most people would rarely work on directly, but yet are quite entertaining and allow gradual progress.

In summary, this was an interesting article looking at the promising theme of using cognitive training exercises as part of the treatment of a psychological problem. This is a relatively new idea, showing up only a few other times so far in the research literature.

Omega-3 deficiency and low dietary omega-3 to omega-6 ratio may exacerbate depression and reduce neuroplasticity

2011-01-31T12:24:00.000-08:00

Here's an interesting update on the dietary fatty acid issue, as it pertains to mood disorders and neuroplasticity:
http://www.nature.com/neuro/journal/vaop/ncurrent/full/nn.2736.html

This article, published in Nature Neuroscience (January 30, 2011), is an example of some good research being done by a group at the University of Bordeaux in France. They demonstrate substantial negative neurophysiological changes in mice as a result of an omega-3 deficient diet. It is interesting to note that the brain's endocanniboid system is specifically affected by omega-3 deficiency, according to this research.

This is further evidence supporting the importance of attending to a healthy diet, in maintaining optimal mental health. Omega-3 fatty acids are one element of a healthy diet. While omega-6 fatty acids are also needed in the diet, these lipids behave to some degree competitively with omega-3. Therefore, the ratio of dietary omega-3 to omega-6 is is very important. Western diets tend to have an unhealthy ratio of these lipids, due to excessive omega-6.

An ongoing issue of debate has to do with whether plant sources of omega-3 (primarily ALA) are as useful as fish sources (DHA and EPA). Existing evidence shows that DHA and EPA are more important. ALA can be converted in the body to DHA and EPA, but the efficiency of this may vary from person to person.

Wikipedia has a nice review of this subject: http://en.wikipedia.org/wiki/Omega-3_fatty_acid
but some of the sources are less than ideal.

It is interesting to consider that the DHA/EPA issue is not a "micronutrient" issue. They could be considered "macronutrients." The solid mass of the brain consists mostly of lipids (60-80 % of the non-aqueous mass); DHA and EPA make up over 10% of this lipid mass, which is a very high concentration.

Here's a link to a paper which quantifies the high fractions of omega-3 lipids in brain mass:
http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=921064 --this paper also showed that dietary changes substantially altered the proportion of omega-3 lipids in brain tissue

"Outlier": The causes of high achievement

2011-01-24T16:51:00.000-08:00

Outlier by Malcolm Gladwell, is a brilliant book about the causes of success, outstanding achievement, and personal greatness.

Gladwell describes a variety of interesting life stories, of people with outstanding ability or outstanding achievement, then looks carefully at the factors leading to these successes.

He does not claim that "inborn traits" or hereditary factors are unimportant. But he shows quite convincingly that inborn talents correlate with achievement only to a certain point. Individuals with extreme talents tend not to achieve more than those with merely "sufficient" talents. A recurring theme in this book, shown through one example after the next, is that the simple stories many people might have, to account for a person's great achievements, are often appealing and believable, but are in fact often inaccurate or at the very least incomplete.

He shows that various situational biases can have a profound, snowballing effect on the course of successfulness in a person's life. A trite detail such as birthdate can lead to a cascade of advantages or disadvantages for athletes, which then accumulate over many years (his example is of successful hockey players being much more likely to have an early birthday--if you're born in December, this is an instant disadvantage, as you will be a little bit smaller and weaker on average compared to your teammates, therefore the older players will tend to outperform you, leading to a smaller chance of you being noticed or advanced to a more challenging team, or to be deemed "gifted" and given more ice time, etc.)

He emphasizes the role of thousands of hours of intensive practice being required to master a skill. Those who have 10 000 hours of practice under their belt early on in their lives--particularly if some serendipitous quirk of fortune allowed them to be one of the only individuals, or one of the first, to gain this experience-- have a strong chance of succeeding spectacularly in their fields. He gives examples such as Bill Gates, or the Beatles, or some of the most successful New York lawyers doing a particular type of law.

One of the psychologists cited in this book, who has studied the area of "exceptional achievement" is AK Ericsson, who generally argues that "extended, intense practice" is the primary determinant of elite performance, as opposed to inborn talent. The ability to do this type of practice, of course, requires or is greatly facilitated by, motivational resources as well as environmental opportunity, parental support, a culture which favours such as endeavour, etc.) Here are some references to articles of his:
http://www.ncbi.nlm.nih.gov/pubmed/17905932
http://www.ncbi.nlm.nih.gov/pubmed/17642130
I suspect that heredity is quite relevant, but may manifest itself in many ways aside from what many people might assume. Factors that could be considered at first glance to be a disadvantage, either hereditarily or environmentally, may, in the world of successfulness, end up being compelling advantages.

Guillermo Campitelli is another excellent researcher in this field; here's a reference to one of his recent papers: http://www.ncbi.nlm.nih.gov/pubmed/17201516. The evidence here, looking specifically at chess players as a model of acquiring expertise, affirms the extreme importance of thousands of hours of practice, but also recognizes that some players improve much more than others with the same amount of practice. This is probably the influence of inherited talent. Maybe there could be other hidden variables, including family or cultural factors. He suggests that the age at which the practice begins is another important variable.

It should be noted that, in this literature, "deliberate practice" refers to a type of activity which is specifically directed towards performance improvement, is adequately difficult, has feedback about performance, and which has opportunity to correct errors. This differs from "ordinary" work experience, which may be quite a bit less intense and much less geared towards improving skills. I suspect that the quality of "deliberate practice" may vary quite a bit, depending on the degree of immersion, concentration, energy, engagement, and meaningfulness there is in the action. I wonder if enjoyment of the practice is a major variable too, I would be interested to see if some of these researchers would look at this. If someone finds their 100 hours of practice meaningful and enjoyable, I have to wonder if they might advance much more than someone whose 100 hours were a drudgery.

Another excellent angle of discussion in Gladwell's book has to do with understanding a person's cultural background and childhood developmental history, as extremely important determinants of success. This leads to discussions about opportunity, pedagogical technique and policy, etc. Sometimes cultural or developmental factors cause individuals to lack a certain skill necessary to succeed, or put individuals at risk of recurrent severe problems or frustrations. Good examples are given, including the story of a profoundly gifted intellect who was never able to share his talents; and of highly trained pilots who were too quietly respectful of authority to be able to proactively use strong assertive social skills to prevent an aviation disaster.

I'll add to this post later on, to expand some thoughts about achievement and success. In the meantime, I think Outlier is a worthwhile and entertaining read.

Writing about worries can ease exam anxiety

2011-01-21T22:43:00.000-08:00

Here's another simple research finding, published recently in Science by Sian Beilock: students who spent ten minutes--immediately before a test--writing down their thoughts about what was causing them fear, performed substantially better on the test.

http://www.ncbi.nlm.nih.gov/pubmed/21233387

I'll have to review this paper in more detail to comment further, but I think it is another simple anxiety-management tactic for exam or performance preparation. A frantic review or a frantic bout of anxious rumination right before an exam is unlikely to help -- an anxiety-management exercise such as expressive writing is very much more likely to help, and a study like this is strong evidence of this.

The article shows that the effective action was specifically to write about negative thoughts and feelings during the ten minutes before the beginning of a stressful exam. A control activity--of writing about anything that comes to mind--was not effective. So the effectiveness of this technique was not simply due to distraction.

I would be interested to see the authors' opinions and/or research about whether specific journaling techniques could work particularly well, or less well, in various anxiety scenarios. Sometimes, purely "negative" journaling can end up being a somewhat ruminative activity which entrenches negative emotional states and attitudes (e.g. one can get worked up in a cynical, pessimistic rant, which could increase or magnify one's following cynicism or pessimism, or increase one's filtered attention to negative events in the day).
See the following references:
http://www.ncbi.nlm.nih.gov/pubmed/12173682
http://www.ncbi.nlm.nih.gov/pubmed/17120515
A "balanced" journaling style, which includes room for free discussion of thoughts and feelings, but also room for positively-focused or constructive discussion may prevent this risk of snowballing rumination or negativity from a journaling activity. One simple aspect of this experiment was that the journaling was immediately before a performance, and was very time-limited (10 minutes); these factors may reduce the potential for the journaling to be a negative or ruminative behaviour, and may increase the chance of the activity serving to process anxious emotion effectively.

Testing improves learning

2011-01-21T22:05:00.000-08:00

Here's another recent bit of research, published in Science, demonstrating the value of doing a test ("retrieval practice"), immediately after learning something. Those who did the tests, instead of other study techniques, had much better retention 1 week after learning something.

http://www.sciencemag.org/content/early/2011/01/19/science.1199327.abstract
This finding is consistent with my believe that a lot of study time is inefficient, because it encourages the studier to push forward to "get more reading done", before the reading which was just done has been consolidated well or reviewed. Even though "pushing forward" may seemingly cover more pages of text, it accomplishes less long-term learning. A much more efficient use of time is to pause, review, and do a test on the material at just the right interval. If the interval is too short, the tests will be too easy, and the review will also be an inefficient use of time. If the interval is too long, too much will have been forgotten already, the tests will be too hard, and it will make you have to go over the same material again, another inefficiency.

I don't believe findings such as this one necessarily contradict ideas about flexible or "constructivist" approaches to education. Nor do I believe it has anything to do with the controversial area of standardized tests for children or professional schools, etc. Standardized tests are not a mechanism for education, they are assessment tools (how good they are as assessment tools would be a subject for a good debate).

There are some instances in which pausing frequently to review could disrupt a larger thematic appreciation of a subject or experience--it would be like pausing a movie every ten minutes to answer questions about the plot or characters--so, of course, sometimes this technique would have to be set aside.

I think that flexible, personalized educational approaches are extremely important--but this evidence about the merits of retrieval practice testing can be applied to any such style. Its immediate value is in helping people use their time more efficiently for many study tasks.

A previous post also deals with the subject of study efficiency, and actually cites a more densely technical analysis showing more or less the same result, though it adds information about the frequency with which one should optimally pause to test oneself: http://garthkroeker.blogspot.com/2010/04/optimal-learning-training-schedules.html

Reading Exercises

2011-01-10T16:20:00.000-08:00

A common problem I find among university students is difficulty reading quickly or efficiently. Reading problems can also occur in conjunction with depression.

The best thing to do to improve reading skills is, of course, to read more. But a phenomenon which often happens when reading any text, but especially longer texts, such as novels, is that you can lose track of what you have just been reading. Whole sections of the text may end up being skimmed superficially, as part of your attention lapses or wanders, while still maintaining a basic pace of absent-minded reading. This leads to a lack of enjoyment or feeling of mastery with reading, dampened morale, sapped motivation, contributing further to any depression which had been present, and deterring further reading efforts.

An approach to this type of problem requires you to stop to reflect or answer questions frequently about what you have just read. Whenever you test yourself regularly, your learning and retention are greatly increased. Most good introductory university textbooks are set up this way. But not very much in the line of non-textbook reading.

So, I have been trying to find resources to help with reading skill, for adults. Elementary-school language textbooks or readers seemed like a reasonable thing to check. I certainly recommend that adults at least periodically read books which have been written for children or adolescents. The best things I've found online are from ESL (English as a second language) programs. Even if you are an advanced reader, or have spoken English all your life, I think that ESL exercises could be good for improving reading skill.

Cognitive-skills training websites tend not to offer very much in terms of language learning or improving reading fluency or retention. I wish that the cognitive skills website people could develop more along these lines: reading-oriented games don't seem very difficult to imagine or design, compared to other types of games.

Here's a list of a few sites I've found, where you can practice English reading skills:

http://web2.uvcs.uvic.ca/courses/elc/studyzone/
This is an excellent free resource from the University of Victoria (in BC). For the reading exercises, choose an "English language level" (beginner to advanced), then follow the links about reading.

Houghton Mifflin College
This site also offers timed readings with questions afterwards.

Quizzes Based On VOA Programs (ESL/EFL)

This link goes to a site where you have to read a text a sentence at a time, and fill in the blanks from a list of options, according to what makes sense or is grammatically correct. While some might find this type of exercise too easy, I think it is a nice way to remain more interactive with the text. If you do find it easy, you can just try to do it faster, and make it into a game.

Another useful thing to look for is an online book club which has discussion questions about the book you're reading. Some sites have questions for each chapter, which is the type of thing I'm recommending, so that you can pause frequently to review what you have just been reading. I haven't found a single site which has chapter-by-chapter questions for a wide variety of books, but here's an example of a specific site, giving questions about Great Expectations by Charles Dickens (a great book, by the way):
http://www.victorianweb.org/authors/dickens/ge/pva107.html

Tetris or sleep deprivation to treat or prevent PTSD?

2011-01-04T16:01:00.000-08:00

Here's a reference to an interesting 2009 study showing that playing tetris for 30 minutes can interfere with memory consolidation of upsetting visual imagery:
http://www.ncbi.nlm.nih.gov/pubmed/19127289

This is an example of evolving evidence that an important period for consolidation of memories occurs in the first 24 hours after an experience. A consolidated implicit association between the factual components of memory and strong negative emotions may also form most strongly during this initial post-exposure period.

The same group published a 2010 study showing that a game like tetris was more effective than a quiz-type game activity for reducing visual flashbacks following exposure to upsetting imagery:
http://www.ncbi.nlm.nih.gov/pubmed/21085661

I think the message here is not that tetris in particular has some kind of unique medicinal properties, but that a non-passive activity which requires continuous, intense visual attention is most effective at reducing consolidation of intrusive visual memory. A distracting activity lacking strong visual involvement may be less likely to interfere with this consolidation mechanism.

Other research has suggested that propranolol, a beta-blocking drug, can reduce post-traumatic memory consolidation, particularly the troubling implicit or emotional component responsible for psychological symptoms of PTSD. (see my other post, http://garthkroeker.blogspot.com/2009/02/beta-blockers.html)

Some of the standard psychological treatments in the immediate post-trauma period may be harmful, such as critical incident stress debriefing. If individuals are compelled to revisit details of their trauma in a group setting, during the sensitive 24-hour post-incident window, this may increase rather than decrease memory consolidation. I think this tactic is especially problematic if there is social pressure or overt prescriptive advice from professionals to do this, when the individual may not wish to talk about the trauma. This type of pressure may feel coercive rather than freely consensual, a dynamic which could be re-traumatizing.

In another recent study (http://www.ncbi.nlm.nih.gov/pubmed/20889142 ), sleep deprivation following exposure to upsetting visual stimuli was shown to reduce aspects of implicit memory consolidation. This is consistent with other evidence showing that sleeping facilitates learning, by helping to consolidate recently acquired memories.

In conclusion, I think it is useful to know some simple techniques which could reduce the harm which traumatic experience can immediately impose upon the brain's memory systems. Immediate distraction with an absorbing visual activity, such as tetris, could be helpful. Sleeping right away may not be helpful, and may actually increase consolidation of traumatic memory.

For consolidated symptoms of PTSD, and for longstanding troubling thoughts, memories, images, and emotions, etc. it is clear that therapeutic dialog can be very helpful, provided the setting is safe, non-pressured, comfortable, with a strong sense of trust. Such gentle dialog could begin the process of weakening the strong negative emotional grip that the traumatic experiences may have in daily life. The evidence mentioned above has to do with reducing the incidence of PTSD in the first place, through specific tactics to be undertaken immediately after the trauma.

We could infer, conversely, that engaging in distracting activities, such as video games, after doing an activity that you would want to remember vividly (such as studying, or some other pleasurable or meaningful event), could lessen retention of these positive experiences (so, you shouldn't distract yourself with an absorbing visual activity right after studying). Also, having a good sleep after a pleasurable event, or after studying, would be expected to make these experiences more permanent in your factual and emotional memory. So, it's important to be conscious of what you do, during, but also after, events of significance.

"The King's Speech"

2011-01-01T17:09:00.000-08:00

I recently watched this movie ("The King's Speech"), which I thoroughly enjoyed.

I found it to be a nice story about the potential benefits of therapeutic change, and about the ingredients required to achieve this.

The literal facts of the story were interesting, but like a plot of a play, are not important in themselves to appreciate the theme or message.

The story has to do with the relationship between Prince Albert--who would become King George VI--and a seemingly unconventional speech therapist he met to deal with his stuttering problem.

I see the stuttering/speech therapy angle of the story (and its implied psychodynamic underpinnings) to be more of a metaphor for psychological symptoms.   The facts about the causation of stuttering do not include a prominent role for psychodynamic factors or childhood trauma, etc.   But the therapy for any problem, irrespective of its cause, is often helped greatly through psychodynamic insights and focus, particularly if the context of the problem has affected relationships and sense of self.

The compelling message I found about therapy in general, was that symptoms in the mind can obstruct the attainment of greatness or satisfaction in achievement or character.    I see this often -- that there is tremendous potential in an individual, almost a sense that there is a special place or purpose for the person in the world, but this potential is obstructed and trapped because of symptoms, psychological injury, or illness.    For a therapeutic endeavour to be helpful, it requires trust, a safe and balanced therapeutic frame, and a good rapport. I like the idea that playfulness, spontaneity,   physical activity, and humour are essential elements of therapeutic benefit in this story. The other ingredient for therapeutic change--often under-emphasized in many stories--is that the work required needs to be very intense and disciplined. A good therapist can have the role of trusted confidante, listener, teacher, or advisor, but also of a behavioural coach, to help and encourage the long and difficult daily work involved to effect behavioural and psychological change.

Another great thing about this movie is the soundtrack, which includes some of my very favourite, wonderful and thematically relevant pieces by Mozart and Beethoven.

Psychiatry & Dentistry

2010-10-28T16:43:00.000-07:00

There could obviously be psychiatric issues in dentistry, such as phobias. A good dentist could be quite therapeutic in this regard.

But there are a other dental issues that have to do with psychiatry.

For example, having unhealthy gums probably causes increased transient bacteremia each time one eats; this is caused by the mechanical stimulation of gums with a high bacterial load leading to leakage of bacteria into the blood circulation. This would not be expected to cause a systemic infection, but it would stimulate an immune response. Some research suggests that this type of recurrent phenomenon causes heightened systemic inflammation, which in turn stresses the brain.
Here are some references which show a relationship between gum disease and systemic inflammation; this causative relationship is further associated with increases in the risk of various systemic diseases, and overall mortality.
http://www.ncbi.nlm.nih.gov/pubmed/20306866
http://www.ncbi.nlm.nih.gov/pubmed/20502435
http://www.ncbi.nlm.nih.gov/pubmed/18052701
http://www.ncbi.nlm.nih.gov/pubmed/19909639
http://www.ncbi.nlm.nih.gov/pubmed/17559634
http://www.ncbi.nlm.nih.gov/pubmed/20960226
http://www.ncbi.nlm.nih.gov/pubmed/19774803
http://www.ncbi.nlm.nih.gov/pubmed/20509364

The existing research shows a link between oral disease and increased risk for various other diseases, such as cardiovascular disease. We can hypothesize that any factor increasing risk for cardiovascular disease would also be deleterious to the brain, as it would affect the brain's very sensitive vascular system. Not much research clearly proves this risk. Here is a reference which starts a discussion on the subject:
http://www.ncbi.nlm.nih.gov/pubmed/19864654
Here's another, suggesting that controlling or preventing gum disease is a preventable risk factor for Alzheimer's Disease:
http://www.ncbi.nlm.nih.gov/pubmed/18631974

So, it is a relevant part of preventative mental health care to take good care of your teeth, including regular dental visits!

There are other overlaps between psychiatry and dentistry. Many people, when depressed, neglect daily dental care. Psychotic symptoms can arise over dental issues (e.g. believing there is a transmitter implanted in a filling). Various overvalued ideas can persuade people to seek arguably unnecessary dental procedures (e.g. regarding mercury amalgam filling removals). While mercury is likely to be of some risk, e.g. regarding the development of autoimmune reactions, it is likely that many people overestimate the degree of risk, or falsely attribute symptoms to the type of dental fillings they have. Therefore, a business may arise of expensive filling replacements which are medically unnecessary. Here are a few articles about this: http://www.ncbi.nlm.nih.gov/pubmed/16042501
http://www.ncbi.nlm.nih.gov/pubmed/16393137
http://www.ncbi.nlm.nih.gov/pubmed/18517065
http://www.ncbi.nlm.nih.gov/pubmed/16448848
Another dentistry/psychiatry intersection has to do with cosmetic dentistry, and orthodontics. Orthodontic treatment is associated with at least a temporary increase in self-esteem, and possibly even an improvement in motivation. (reference: Karen Korabik, "Self Concept Changes during Orthodontic Treatment", Journal of Applied Social Psychology, 1994, 24, 11, pp. 1022-1034). Korabik's earlier work showed that orthodontic treatment led to individuals being perceived in a more positive way by others, with regard to impressions of personality, intelligence, as well as appearance (even, for example, based on pictures in which teeth were not visible). (Basic and Applied Social Psychology 2, 59-66, 1981). This phenomenon illustrates a problem with human nature, that we would infer things about one another based on superficial factors. The power of such superficial phenomena, relationally, is usually also short-lived and superficial, yet I do think that simple esthetic practices, if available, could be at least a small positive in affecting interpersonal dynamics, and therefore be a small positive influence in maintaining a healthy mood.

Psychiatry and Linguistics

2010-10-27T13:58:00.000-07:00

The history of spoken and written language is a very interesting field of study. The manner in which languages evolve over time is similar, literally, to the way in which species evolve (languages do evolve much more rapidly than species). It is interesting to look at a kind of linguistic evolutionary tree, to see the parallels and differences alongside a genetic evolutionary tree, say of Indo-European languages in comparison to mitochondrial or Y-chromosome haplotype analysis in Eurasian groups.

Styles of language, and of word choice, etc. are certainly influenced by the culture of the day. It would be interesting to consider the degree to which word choices affect individual psychology. Some modern feminist thinking has certainly looked at the issue of language issues having important elements of psychological effects, particularly if the language itself is biased towards being sexist. This is a big area, one which I'd be interested to learn more about.

Another aspect of linguistics has to do with the multi-sensory nature of language perception. I find this very interesting, in expanding our understanding of the way the mind works in general: words on their own may be perceived or understood in different ways intellectually (this is an issue often discussed by literary scholars), but the manner in which words are perceived is also influenced very directly by core neurologic processes.

For example, I recently discovered the existence of a very powerful perceptual phenomenon called the "McGurk Effect." Here are a few examples from YouTube:
http://www.youtube.com/watch?v=DsdyE491KcM&feature=related
http://www.youtube.com/watch?v=aFPtc8BVdJk&feature=related
If you watch the video while listening to the speaker pronounce a syllable, it sounds completely different from when you close your eyes and just listen without watching. The phenomenon demonstrates how powerfully visual input changes how we perceive an auditory stimulus. I was surprised to find how overpoweringly strong the effect was, how difficult it is to somehow "over-ride" it.

Other linguistics research demonstrates that other sensory modalities, including tactile, also have strong effects on language perception.

As an extension to psychiatry, and to the general workings of the mind, I think it is true that many different perceptual and psychological inputs have very strong effects on the way we perceive other stimuli. In social exchanges, there may be a wide variety of inputs which we are not consciously aware of, which could be substantially affecting our experiences. In most cases, these other inputs assist us in understanding better. The purpose of having one sensory modality influence another is to bolster the input from both, so as to facilitate understanding. This is the foundation for how lip-reading works, for example. But if one input is, without our knowledge, giving opposing information compared to another input, then this could lead to a very problematic behavioural cycle.

I think such phenomena are likely to happen in many anxiety disorders, for example, in which the anticipatory anxiety, and resultant physical and emotional tension, are likely to cause one's perceptions of benign social stimuli to become exaggeratedly negative. This is happening not just on an intellectual level, but arguably on a core perceptual level, akin to the McGurk effect. Similar perceptual distortions are likely to happen in other psychological states, such as depression. The cognitive theory of depression centres around so-called "cognitive distortions," but I think it is important to expand this concept to admit that the phenomena could be powerful "cognitive-perceptual" distortions, which could require a lot of disciplined work to overcome. Without acknowledging the strength of this phenomenon, frustration could quickly set in, just as it would if you were to simply practice hearing McGurk-style syllables without knowledge of the McGurk effect.

Psychiatry and Economics

2010-10-27T13:17:00.000-07:00

I've alluded to the field of "behavioural economics" in other posts. I think this is a very interesting extension of social and motivational psychology.

I think that a broad analogy can be made between economics and psychiatry:
the phenomenon of an economy is similar to the mind, or to one's life, in a variety of ways:
1) there are engines which drive the economy, in the form of productivity. Economic productivity may be measured by goods or services generated by the population. Life productivity includes various tasks of developmental "work".
2) There is a relationship between "supply" and "demand" which changes the valuation and flow of productivity.
3) Currencies become symbolic short-cuts to exchange goods or services; emotional or behavioural "currencies" can be short-cuts in to obtain needs in the community or in relationships.
4) Problems in an economy could occur at many different levels in the system: productivity failure due to a technical, external problem (e.g. a natural disaster), a failure to exchange or trade freely, a symbolic or regulatory system which goes out of control despite integrity in the rest of the system (e.g. stock market crashes). In the economics of mind, there could be core external problems (e.g. a neurological disorder), but there could certainly also be problems "trading freely." Heightened neurotic defenses could be compared to a lack of "free trade," where healthy inner resources cannot be shared, not with other parts of oneself, nor with others. Such phenomena stunt an economy, even if the core capacity for productivity is strong. A "stock market" crash, similarly, could occur in the mind, if regulatory mechanisms in one's mind run wild, while losing touch with a moment-to-moment sense of self or present.
5) Borrowing could, one the one hand, be a powerful means to accomplish tasks that would otherwise be impossible (e.g. buying a house). Refusal to borrow limits capacity for growth. But if debt cannot be managed, it leads to an economic instability, reduced autonomy, and ultimate failure (bankruptcy). Similarly, in one's mind, risks need to be taken to grow, and one needs to borrow from others and from the community in order to develop oneself. Refusal to borrow limits what is possible. However, over-borrowing, and accumulation of social & emotional debts, leads to a cascade of chaotic effects.
6) Investing is a means of taking a risk of giving one's resources away, with the hope that the community will prosper as a result, and return the investment prosperously. Emotional and social investments are risks taken which, on the one hand, are immediately depleting, and which may cause permanent losses (e.g. with unfruitful actions are relationships) but which permit the possibility of substantial growth in one's own life, while also allowing resources for the community to grow (emotionally or socially) around you.

Much in the field of economics include sophisticated mathematical analysis of the energy dynamics in an economic system, accounting for the many variables at play. It would be interesting to apply some of this analysis to psychological dynamics. Behavioural economics is more psychology than economics, at this point. It would be curious to have more of the leaders in the study of mathematical economics apply some of their ideas to "psychological economics."

Psychiatry & Architecture

2010-10-27T13:09:00.000-07:00

This is the first in a series of posts in which I'd like to discuss figurative or literal comparisons and overlaps between psychiatry and other fields of study.

Architecture could be considered a science and an art--a field with many technical elements, but with an over-riding importance given to esthetics, expressiveness, and community relationships.

Ideas in psychiatry could be considered "architectural" in the sense that it is important to have an overall sense of a plan, with a clear sense of purpose. Even with good technical skills (e.g. to relieve a symptom), work in psychiatry, or in life progress, may be unsatisfying if there is no attendance to the larger sense of purpose in the life's structure. Part of the purpose is "esthetic," but part has to do with identity, interaction with community, originality, and expressiveness. This is similar to the architectural considerations involved in planning and developing a new physical structure.

As in architecture, many very good ideas could be generated to develop one's life, but the ideas must also be technically sound, and supported by good engineering. Many life plans have dangerous weaknesses in the foundation, so to speak, or may be hindered by untreated symptoms. So, a sound architectural plan in psychiatry or in life management must include both esthetic or artistic elements, as well as good structural support.

Making tasks fun improves motivation & self-control

2010-10-27T12:47:00.000-07:00

Juliano Laran and Chris Janiszewski recently published a study in Journal of Consumer Research (Vol. 37, electronically published Aug. 24, 2010, entitled "Work or Fun? How Task Construal and Completion Influence Regulatory Behavior."

It is an example of a simple research study in an evolving literature about self-control.

A prevailing notion is that the work involved in any self-controlling action is depleting; therefore, repeated difficult acts of self-control, even if successful, increase the chance of self-control failure shortly thereafter, because of the depletion of inner self-control resources.

The authors in this study hypothesize that there are several variables which affect the dynamics here:
1) individuals vary in their capacity for self-control
2) individuals who engage in actions which are inherently satisfying (fun) are not depleted by these actions, and do not experience a decrement in self-control afterwards
3) individuals for whom these same actions are merely work, and not fun, are depleted by their actions, and have less self-control afterwards
4) Activities which are incomplete have a neutral effect on subsequent self-control
5) Activities can be "reframed" as work, or as fun, and this reframing affects whether the activity is depleting or not.

The experiments described in this paper are, like many brief psychological studies of this sort, somewhat amusing to read about, and could certainly be criticized as somewhat shallow, cross-sectional portraits of a complex behavioural dynamic, with quite limited generalizability. The measure of "self-control," for example, involves measuring how much candy the subjects eat following a written exercise.

Yet, the results did support the hypotheses, allowing the following conclusions:

1) One's attitude towards a task has a very strong influence upon how the completed task will affect you afterwards. If tasks are perceived and experienced as work, as tedious, as unenjoyable, then they will leave you "depleted," and substantially more prone to unhealthy behaviours afterwards. If an attitude can be nurtured of tasks being enjoyable or fun, then the completion of these tasks leads to an increased sense of vitality, without any experience of depletion. .

2) While there may be mood or personality states or traits which influence these attitudes towards tasks, it is possible to reframe the activities in a beneficial way.

3) If some tasks cannot be reframed as "fun," than a neutral alternative could be to frame the activity as ongoing, and therefore never complete. Incompleted tasks, according to this study, have a more neutral effect upon self-control depletion. In the management of obesity, for example, nutrition management tactics, even if not subjectively enjoyable, would best be framed as a permanent lifestyle change, rather than a temporary "diet." An unpleasant "diet" is much more likely to cause regulatory failure after completion; this is certainly the almost invariable experience of all those who have managed their weight using spartan "diets." Yet, I would emphasize that something better than neutrality should be sought after, which, in the case of nutrition management, means that one's permanent nutritional habits should also be enjoyable, rather than simply a self-care chore.

Medications for ADHD: newspaper headline

2010-10-22T12:25:00.000-07:00

I have just looked at a front-page newspaper article by Carolyn Abraham in The Globe and Mail (Tuesday, October 19, 2010).

The article attempts to discuss the issue of whether medications are prescribed too often, for treating supposed attention deficit disorder, particularly in male children.

This is a very serious, important question. It warrants careful analysis of the issues, and a balanced evaluation of evidence.

Unfortunately, the article bothered me greatly, because of its bias. Here are some quotes from the article:

Boys: Fixing with a pill is easier than counselling [this was a heading]

There's a desire for the quick fix...the idea that - 'oh, we'll fix this with a pill' - rather than spend a few months in counselling, is pretty appealing. [this was a quote attributed to Gordon Floyd, the CEO of Children's Mental Health Ontario]

What are we drugging? Female teachers who don't understand boys like to run and jump and shout - that's what boys do. [this was a quote attributed to Jon Bradley, an education professor at McGill University]

Prescription rates for ADHD drugs, which like cocaine, are psycho-stimulants...

Mr. Floyd feels counselling stands a better chance of getting to the root of the problem with children, rather than using drugs for years to dull symptoms. Research shows, he says, that talk therapy can be very successful for kids with ADHD.

stimulant drugs may be dangerous for those with underlying heart problems - and those who do not actually have ADHD.

I have often wondered why no real connection has been made between the over-medicalization of our children and the increasing prevalence of illicit drug use in our society. When we give kids the message that they can be 'fixed' by popping a pill, it hardly seems surprising to me that they would later seek to solve their problems by using other available substances. [a quote attributed to Judy McGuire, a "Globe Catalyst"]

The article mentions important issues of concern, including the role of pharmaceutical marketing in changing medication prescription patterns. The diagnosis of ADHD, and the use of medications, appears to vary substantially from one locale to the next. The phenomenon of teachers coercing parents to seek medication treatment for their children is certainly problematic.

But the article did not give a balanced presentation of evidence.

It is more common, in my experience, to encounter young adults who have struggled with ADHD symptoms, without any medication treatment, all their lives.   Often times, they, or their parents, have been strongly opposed to the idea of taking medications. Many of these young adults are very intelligent, but often have been unable to sit through the intellectual tasks required to develop their intelligence. Therefore, they have often not been able to achieve the goals which are reasonably available to them. There is really no way around the fact that reading, for example, is necessary to develop one's mind in the modern world; reading requires one to sit still and focus for extended periods of time. A great deal of the discipline required to develop one's intellect requires prolonged focus, often with tasks that are initially perceived to be uninteresting (with discipline, intelligence, and imagination, any so-called "boring" subject can become interesting--but if individuals are unable to focus during the initial "boring" introduction to a subject, this deep interest and engagement may never be found).

Treating ADHD with medication does not increase substance abuse. Rates of substance use in an untreated ADHD population are substantially higher. Here is a reference to a research article demonstrating this: http://www.ncbi.nlm.nih.gov/pubmed/18838643 It is certainly my clinical experience, that subjects with untreated ADHD have much higher rates of substance use, including cigarettes, alcohol, cannabis, and harder drugs. The belief that treating ADHD with medications somehow increases risk for substance abuse, is simply unfounded--the opposite effect has been clearly shown. Exceptions exist, of course, in individual cases where adolescents may be abusing their medication, selling it, etc. Also, in many cases "ADHD" is not the only issue or problem; there may be antisocial behaviour, mood disorders, severe family or psychosocial problems, etc. which also obviously affect risks.

In terms of dangers or risks, it is of course important to examine negative side-effects or toxicity from stimulants. Such an analysis would fairly establish that risks are present, but of low incidence. For example, the risk of stimulants causing heart problems.

But a fair assessment of risk must include consideration of the risks of non-treatment! The obvious risks in an ADHD population are higher risks of accidental injuries, car accidents, sequelae from substance abuse, and reckless interpersonal behaviour. The risk pertains not only to those with untreated ADHD, but also to peers (for example, passengers in a vehicle). Here are a few references evidence about this:
http://www.ncbi.nlm.nih.gov/pubmed/19739058
http://www.ncbi.nlm.nih.gov/pubmed/18815438
http://www.ncbi.nlm.nih.gov/pubmed/10790000

It is also, of course, very important to consider whether counseling or other types of therapy could be helpful for ADHD symptoms. The prevailing evidence shows that there can be small effects with existing therapy styles--this is certainly worth pursuing--but counseling often doesn't work very well. In cases where there are multiple other problems going on (e.g. anxiety, mood, family conflicts, etc.) then of course some type of external counseling support would be preferable to simply obtaining a stimulant prescription. The notion that "a few months of counseling" would make much of a difference for most kids with ADHD symptoms is absurd, and entirely unsupported by any evidence.

The idea of accepting that "that's what boys do," etc. is important to consider. But imagine, as an adult reader, that you are transported to elementary school again. Would it be a pleasant and rewarding situation for you to be in a classroom where the attitude "that's what boys do" prevails?    Similar philosophies, in the adult world, have been used to justify various types of antisocial behaviour. The issue is not just about the individuals with so-called ADHD, but also about peers and community. Rambunctiousness need not be pathologized, but a desire for sustained attentiveness need not be pathologized either. Most people with ADHD histories have had serious difficulties not just in classroom settings, but in all spheres of life: home, friendships, community, work, etc. This issue is not just about artificially forcing people into the constraints of a boring, quiet classroom, although admittedly a sedate classroom environment could be a very unhelpful factor for some.

The article seems to suggest that male teachers would be preferable. What does this have to do with anything? Where is the evidence?! Is this claim not an insult to female teachers? And, in my memory, I don't remember male teachers being any better at managing a classroom of rambunctious kids, compared to female teachers. In fact, I can think of counterexamples, in which female teachers could have a gentle, maternal effect on hyperactive kids helping them to enjoy their day, so that their experience of a classroom could be more positive.

I do agree that there are learning or educational styles which could suit some individuals much better. And I agree that having opportunities to be physically active is extremely important--for everyone, not just for "ADHD kids." One of the authors in this article suggests that the decline of opportunities such as "wood shop" (the implication is, that these are mainly for boys) is part of the problem.   But, imagine as a wood shop teacher -- where you are in charge of a band saw, a lathe, and a few power nail guns -- that you have a few kids who are easily bored, highly rambunctious, and have difficulty paying attention. Band saw + ADHD! Do you see any problems there?

Some "alternative learning styles" could already begin to produce an unnecessary tier, sending kids with more ADHD symptoms away from a more scholarly focus, towards developing a more physical trade. I don't think there's anything wrong with this per se, unless the child with ADHD symptoms actually wants to develop scholarly pursuits, and/or has an undeveloped talent for the type of scholarship which requires intense focus, and doesn't really want to be "tiered" in this way.

I recognize that this is an important issue, and everyone's point of view needs to be considered to work out the best solutions for health policy and for helping individuals. But this article, in one of Canada's leading newspapers, was disturbingly one-sided, and in my opinion could contribute to many individuals feeling stigmatized or rejecting the possibility of medication therapy without a balanced understanding of the evidence.

One of the main issues to contemplate, and really the main helpful theme in this article, in my opinion, has to do with degree or magnitude: ADHD symptoms exist on a continuum, with everyone in the population having some measurable quantity of attentional capacity, physical restlessness, or impulsivity. These could be considered traits, and each of these traits could be considered useful, positive, and "normal" in some ways, as well as negative or deleterious in others. Medications or other therapies have the capacity to change the degree of symptoms or traits somewhat, for anyone (it is a myth that stimulants improve attention only in those with ADHD). The degree of environmental change required to help an individual escalates rapidly as the degree of symptoms increases. So, there will always be a gray area, of individuals who have more "ADHD symptoms" than the population average, but fewer than those with extreme and highly disabling symptoms. Determining how to help these individuals may be highly influenced by the whims of the local educational or medical culture, combined with the attitudes of the individuals and their families. There may be no absolute, fixed standard possible, to determine exactly when to use a particular form of therapy.

I believe that such decisions should be influenced by the following factors:
1) clear informed consent on the part of individuals and families considering medications or other therapies.   This involves having a balanced understanding of evidence, of the risks and benefits of treating and of not treating.
2) thorough assessment with careful attendance to family and psychosocial stresses--never an impulsive prescription of stimulants after a single 5-minute appointment!
3) Follow-up in all cases, with opportunities for talking therapies and behavioural therapy if desired.
4) A reasonable set of nationalized, standardized guidelines for assessment and treatment, to reduce the possibility that a person's geographic location, or the whims of teachers, doctors, journalists, etc. would be strong determinants of whether or not treatment of any kind is offered.

Atomoxetine for ADHD

2010-09-29T16:51:00.000-07:00

Atomoxetine (Strattera) is one of the pharmacological options for treating ADHD symptoms (attention or concentration problems, hyperactivity, impulsivity) in children and adults. I think it is a good drug, quite safe, quite effective. It is not likely to help with mood or anxiety symptoms. Its effect is probably not quite as robust, for most people, compared to stimulants, but it has the compelling advantage of working continuously throughout the day, instead of wearing off (as the stimulants do) after a few hours. It takes at least 2 weeks of daily dosing for it to work, which differs from the immediate effect of stimulants.

While it has only a 5-hour half-life in the body, it probably works just as well if dosed once-daily compared to twice-daily. Side-effects are usually quite mild, including possible dry mouth and reduced appetite.

It is quite expensive, and is not covered well by medication funding plans in BC.

Here is a brief survey of some of the research literature about atomoxetine that I found interesting:

http://www.ncbi.nlm.nih.gov/pubmed/20665133
This 2010 article demonstrates that once-daily atomoxetine is superior to placebo for treating adult ADHD symptoms, over a 6-month follow-up period. Treated patients typically had about a 30% reduction in their symptom scores. Doses were about 80 mg/day.

http://www.ncbi.nlm.nih.gov/pubmed/18448861
This is an important study, with 4 years of follow-up, treating adult ADHD patients on an open-label basis. The medication was tolerated well, again with ADHD symptom reductions of about 30%. Depression and anxiety symptoms were not affected. I tried unsuccessfully to find a clear statement about average doses used in the study; the dosing regime was similar to other studies, with a maximum of 160 mg/day. From the authors' previous paper on the interim results of this study, the mean dose was about 100 mg/day, the median about 120 mg/day. So these are higher doses than in some of the other studies, which typically had 80 mg/day dosing.

http://www.ncbi.nlm.nih.gov/pubmed/20070786
This was a 6-week open study, showing that adults with "atypical ADHD" showed improvement with atomoxetine treatment, doses averaging about 80 mg/day.

http://www.ncbi.nlm.nih.gov/pubmed/20051220
This is an important 2008 meta-analysis, comparing effect sizes of different therapies for adult ADHD. Short-acting stimulants were best; long-acting stimulants similar (no advantage--if anything, not quite as high an effect size compared to short-acting stimulants); non-stimulants such as atomoxetine significantly helpful, but not quite as large an effect size as stimulants.

http://www.ncbi.nlm.nih.gov/pubmed/17110824This study shows modest but significant improvement in quality-of-life ratings for adult ADHD patients treated with atomoxetine 80 mg/day for 6 weeks.

http://www.ncbi.nlm.nih.gov/pubmed/20642391
This study shows reduction in high-risk behaviours in adolescents treated with atomoxetine over a 40-week period. Looking quickly at the results, I see significant differences between atomoxetine and placebo, but the absolute differences were quite modest in size (typically about a 10% change). Also the study design has a variety of weaknesses.

http://www.ncbi.nlm.nih.gov/pubmed/17474814
This is one of many studies showing that atomoxetine does not help with depressive symptoms. In this case, it was used as an adjunct to an SSRI.

http://www.ncbi.nlm.nih.gov/pubmed/19358788
This study showed no improvement in cognitive function in patients with schizophrenia treated with atomoxetine over 8 weeks. There were no adverse psychiatric effects, however.   This is an important area to study, to determine if ADHD treatments such as atomoxetine are psychiatrically safe for those with other major mental illnesses, such as schizophrenia or bipolar disorder.

http://www.ncbi.nlm.nih.gov/pubmed/20679638
This 2010 article from Neurology shows that atomoxetine is not useful for treating depression in Parkinson Disease patients. I find this type of study useful, to look at psychiatric symptoms in medical illnesses. In such situations, the biological impact of the treatment often seems more clear to me, perhaps with fewer confounding psychological factors.    The study did find that patients treated with atomoxetine (target dose 80 mg/day) had significantly less daytime sleepiness, and significant improvement in "global cognitive function."

http://www.ncbi.nlm.nih.gov/pubmed/19025777
This similar study shows a possible improvement due to atomoxetine treatment--averaging about 90 mg/day--of executive dysfunction in Parkinson Disease patients. I note also that there was a reduction in other symptom domains, such as apathy and emotional lability; these problems can be difficult to address in those with mood disorders.

http://www.ncbi.nlm.nih.gov/pubmed/17900980
Here's another interesting study, using atomoxetine to treat sleep apnea patients, averaging about 80 mg/day over 4 weeks. The atomoxetine did not help reduce apnea, but it did significantly reduce subjective sleepiness.   There are only a couple of fragmentary mentionings of atomoxetine in treating narcolepsy, another disorder of excessive sleepiness; here is one case report: http://www.ncbi.nlm.nih.gov/pubmed/16268387 Excessive sleepiness is another challenging symptom I see a lot of in young adult depression; antidepressants often don't help with the sleepiness, and tolerance tends to develop for stimulants. So atomoxetine may be another useful option.

"Vitamin Water" and "Energy Drinks"

2010-09-16T13:20:00.000-07:00

Here's another exploitative marketing scheme going on, in the middle of university campuses:

A sugary drink, consisting of water with 23 grams (about 5 teaspoons) of sugar per 500 mL, sold in large, colourful bottles of 300 - 500 mL each -- is being aggressively marketed to young people, with many implied claims about healthfulness. There are funny, witty, ironic statements printed on the bottles, which I think would appeal to young adults, and consolidate the notion that these are actually healthy.

A similar drink, which also contains caffeine and a bizarre mixture of added chemicals, is also being aggressively marketed, with free samples being given out by smiling, athletic young people in decorated sports cars. Today I noticed the energy drink people occupying one of the university's athletic fields with three large garishly decorated vehicles, hip musical accompaniment blaring out as they handed out samples. It was a bothersome irony that an athletic field (another health-associated prop) had to be the setting for this.

It is not a healthy practice to consume sugary drinks. Aside from the risk of tooth decay, and the exposure to metabolically harmful simple carbohydrates, the habit of consuming these drinks conditions people to expect sweetness while they hydrate themselves. Ordinary, pure, free drinking water becomes bland and undesirable. Though the direct health effects of having a glass of sweetened water are not catastrophic, there are a variety of indirect harmful effects:

-because you are quenching your thirst, and hunger, with a solution containing glucose or fructose, you will have a smaller appetite, and less money, to obtain or consume a healthy meal.

-because of the advertising involved, you will become conditioned to believe that you are engaging in a healthy behaviour.

-you will be financially supporting one of the largest junk food manufacturers in the world; the magnitude of harm done to the world's population (directly and indirectly) by such companies would be staggering to calculate.

-by purchasing these products, you are contributing to the phenomenon of retailers stocking their shelves with "vitamin water" instead of with healthier choices. In one of my favourite local cafes, my favourite healthy, locally-made fruit juice is gone, replaced by rows of multi-coloured "vitamin water." The reason was economic -- the bright colours and the sugar make for a rapidly-selling product.

The presence of vitamins, minerals, amino acids, etc. in these products is, in my opinion, irrelevant. It is pure marketing. If you need extra vitamins in your day, you can take a daily supplement, or have a piece of fresh fruit. The other ingredients are largely placebo as well, just like the colouring.

The case is made by some that there is less sugar in these drinks, compared to other familiar soft drinks. The difference is actually not very substantial, it reminds me of cigarette companies manufacturing "light" cigarettes, to try to sell people on the idea that this is "healthier."

I consider this type of marketing to have little ethical difference from a hypothetical example of cigarette companies hiring athletic, charming young people to hand out free samples from a flashy new car.

What bothers me most about this issue is the use of healthy-sounding nutrition talk ("vitamins," etc.) to persuade people to buy an unhealthy product.

I do not support a puritanical view of food & eating though. I think there are many sweet, wonderful, decadent foods to be savoured (in moderation of course!) Generally, dessert vendors do not market their tastiest pastries by emphasizing their vitamin content! In any case, such foods can be enjoyed more richly, in smaller, healthier portions, if one is less conditioned to expect sweetness frequently through the day, such as in drinking water.

Here are a few references to some pertinent review articles:
http://www.ncbi.nlm.nih.gov/pubmed/20631477
http://www.ncbi.nlm.nih.gov/pubmed/20682226
http://www.ncbi.nlm.nih.gov/pubmed/18809264

One exception, in which a case could be made to supplement drinks with vitamins, could be in the management of chronic, severe alcoholism. There is a syndrome called "Wernicke-Korsakoff encephalopathy", in which severely malnourished alcoholics develop irreversible, catastrophic brain damage due to metabolism of carbohydrates without adequate vitamin B1. Adding vitamin B1 (thiamine) to hard liquor, could conceivably prevent some cases of irreversible brain damage in malnourished alcoholics who keep drinking. I'm not sure if thiamine would be chemically stable in an ethanol solution though--if anyone knows the answer to this one, please let me know. Anyway, I don't believe this consideration is relevant to health management on university campuses (!)

Conclusion: if you're thirsty, drink water!

Personality Tests

2010-09-15T15:16:00.000-07:00

Here's a site which has a good selection of free personality questionnaires:

http://similarminds.com/personality_tests.html

I find that questionnaires of this type rarely give any novel information that you wouldn't know about yourself already, and be able to describe in a short self-descriptive paragraph. Many such questionnaires are actually copyrighted, and one needs to pay a fee just to have a copy. I've always had a bit of a problem with this, as I think it exaggerates the importance of what is usually a simple set of questions, which in my opinion should usually be in the public domain. It is annoying to read a journal article about questionnaires (which are often referred to, in a somewhat aggrandizing way, as "instruments," as though we are talking about some kind of highly sophisticated engineering technology), where the copyrighted questionnaire is referred to in the article, but you can't actually see the questions!

But spending some time with these things can have a few positives:

1) a framework for reflection -- sometimes questionnaires can deal with questions or phenomena which are relevant, but rarely thought about or discussed. The questions can be a cue or a framework to contemplate issues. Some of these issues could be addressed in a therapeutic discussion.

2) entertainment -- it can be an interesting or possibly enjoyable activity to fill out questionnaires, and compare your results with others in the population.

It would be important to resist any tendency to be self-critical about your results; everyone will have a unique set of responses, some of which may change over time, or be mood-dependent, as well. Questionnaires are an imperfect way to measure any sort of characteristic anyway. But in any case, a questionnaire is a bit like a lens or a camera--it produces data which can be informative. Sometimes the information can be unique or interesting, like a clever snapshot of yourself from a camera; but other times the information may not be very unique or interesting at all (like a poorly-lit or blurry snapshot of yourself). Even if you may have issues with the way a particular questionnaire is constructed, it can be interesting to see how your responses compare on a percentile basis with others. You may find certain phenomena about yourself that you previously thought were quite extreme, are in fact really quite close to the population average. Or you might discover there are other phenomena which are farther from the mean. Any of these findings might be a subject of future therapeutic dialog.

Health Tips for the new school year

2010-09-08T14:01:00.000-07:00

Here are some suggestions for maintaining your health during the new school year:

1) Have a healthy study schedule. You will learn much more efficiently and enjoyably if you study regularly, in a disciplined schedule. I don't believe it is possible to master any subject, much less build up an enjoyment of it, by procrastinating or cramming. Each full-year course probably deserves about 200 hours of study, to be spread out as evenly as possible. Mastery of a specific field of study probably requires about 10 000 hours of work, which would be full-time for 5 years. Even if you can get good grades without working hard, I would emphasize to you that doing the bare minimum is an extremely harmful habit--the consequence is that your potential will remain unrealized, also your enjoyment and respect for your subject will never be fully developed.
2) Have a healthy leisure schedule. Time must be reserved for pleasure (outside of the hoped-for intrinsic pleasure of studying or working). A type of "meta-subject" at university is learning to have a pleasurable and healthy lifestyle, with a sense of friendship and community, in the midst of working hard.
3) Be physically active. Exercise & sports will help you maintain your strength, sharpen your mind, relieve stress, and offer potential sources of community & friendship. A common problem, however, is excessive exercise, which drains time and energy away from other activities, and which can cause an addictive pattern leading to a psychological dependence on fitness activities alongside a diminished capacity to manage stress in other ways.
4) Don't binge drink. There is an illusion that binge drinking is an essential part of university social culture. While it may be a common phenomenon, I think many people minimize its extremely negative health impact. Anything more than 2 drinks per 24 hours is, from an epidemiologic point of view, harmful to health.    For those dealing with anxiety, depression, trouble fitting in, etc., alcohol can lead to an illusory sense of relief or social belonging while insidiously deepening and entrenching the problems.
5) Eat well. It's easy to neglect this one, particularly if you're living on your own for the first time. Basic nutritional advice is not hard to find. Unfortunately, I think that unhealthy food choices are too easy to find on university campuses. I think that university cafeterias should not sell junk food, soft drinks, etc. (I also think such items should be taxed heavily, in the same way that cigarettes are). It's always disappointing to see soft drink companies or fast food restaurants as major food sponsors, with vending machines all over the place, including in hospitals and gyms, etc.   Two simple changes for most people would be to increase vegetables in the diet, and to eliminate junk food. Allowing oneself to go hungry, or to be carbohydrate-deprived, is likely to substantially impair academic performance, attention, and mood.
6) Make cultural choices with care. Developing personal culture is very important, and deserves time and energy. I don't think it is healthy to make a particular cultural choice (e.g. "let's go clubbing!") just because everyone else seems to be doing it. I see a lack of personal culture, with an ensuing lack of a sense of meaningful community, to be one of the leading problems driving loneliness and perpetuating depression on university campuses.
7) Seek medical help if you have symptoms. There are treatments and supports to be connected with, which can help address anxiety, mood problems, physical symptoms, etc. It can be better to connect with resources early, rather than wait for things to get worse.
8) Be wary of viral contagion. A single banal respiratory infection could substantially reduce your enjoyment and learning for a week or more at a time. The best preventative strategy is to wash your hands frequently, especially if handling objects which thousands of other people have handled or coughed on. It's important not to go overboard with this--which could be an obsessive-compulsive symptom-- but basic infection control techniques could save you a lot of headache.
9) If you tend to get tired or depressed in the winter months, consider trying a light box. This is an easy, safe physical treatment which can help with seasonal depression. Daylight is diminishing rapidly in September, so this is probably a good time to get out your light box.
10) Nutritional supplements. Women should have ferritin levels checked, and in general should take iron supplements if ferritin is below 50 ug/L. A daily multivitamin/mineral supplement is a good idea, especially if having abundant fruits and vegetables in the daily diet is not happening consistently. Harmless at worst. Extra vitamin D is indicated, I'd suggest 2000 IU extra per day. DHA/EPA supplements could be useful (omega-3 fatty acids, typically from fish oils). I have some references about this in other entries.
11) Addiction inventory. I'd encourage everyone to take an inventory of all addictive or compulsive behaviours, and take steps to stop or moderate them all. Alcohol or drug use are obvious examples, but other activities could include internet use, gambling, exercise, self-injury, phoning or texting, etc. Many habits consume so much time and attention, that there is much less time, energy, or enthusiasm left for other things that may be more deeply important to you.

Dopamine Agonists in Psychiatry

2010-07-16T11:45:00.000-07:00

The dopamine agonists pramipexole and ropinirole are drugs used in the treatment of Parkinson Disease.

These drugs are now well-established in treating restless legs syndrome (RLS) and periodic limb movement disorder of sleep (PLMS), which are frequent problems afflicting about 10% of the population, and which can negatively impact quality of life & mood symptoms.

There is a small body of evidence showing possible benefits of dopamine agonists in the treatment of depression.

Unfortunately, dopamine agonists can exacerbate addictive/compulsive behaviour: http://www.ncbi.nlm.nih.gov/pubmed/20484726

Here are some references about the role of dopamine agonists in RLS and PLMS:

http://www.ncbi.nlm.nih.gov/pubmed/20120624

Here's a good review article on the use of ropinirole to treat these conditions: http://www.ncbi.nlm.nih.gov/pubmed/20421915
Here's a recent review of dopamine agonists in general to treat RLS: http://www.ncbi.nlm.nih.gov/pubmed/20206780
Here's a 2008 meta-analysis comparing ropinirole with pramipexole for treating RLS. Pramipexole is shown to be slightly superior:
http://www.ncbi.nlm.nih.gov/pubmed/18226947

In this 2010 study, gabapentin was compared to ropinirole for treating RLS. While ropinirole was superior in reducing objective measures of periodic limb movements, subjects taking gabapentin had a higher subjective benefit:
http://www.ncbi.nlm.nih.gov/pubmed/20049491

Here's a case study showing remission of depressive symptoms with ropinirole used as an augmenting agent:
http://www.ncbi.nlm.nih.gov/pubmed/20188777

Here's a 2005 study looking at ropinirole augmentation in treating depression:
http://www.ncbi.nlm.nih.gov/pubmed/15999953
This 2010 review in Lancet showed a direct antidepressant effect of pramipexole in Parkinson Disease patients: http://www.ncbi.nlm.nih.gov/pubmed/20452823
Here's a rather weak but positive 2010 paper describing a group of patients with bipolar depression who appeared to benefit from longer-term pramipexole treatment; doses averaged about 1 mg/d: http://www.ncbi.nlm.nih.gov/pubmed/20425143

The side effects from these drugs include frequent nausea and dizziness, possibly some daytime sleepiness. Psychiatric adverse effects can include hallucinations, and increased compulsive or impulse-control problems.

In summary, I think dopamine agonists have a role in selected psychiatric conditions, particularly if there are restless-legs symptoms contributing to insomnia or nocturnal discomfort. They may help treat refractory depression, but there is a risk of causing impulse control problems or hallucinations in predisposed individuals.

Potential adverse effects of group therapy

2010-07-16T10:50:00.000-07:00

I encountered an article today about a subject I've often thought about: does group therapy actually have a risk of worsening underlying problems?

Here's a link to the article:
http://www.time.com/time/health/article/0,8599,2003160,00.html

The mechanism could typically occur in the treatment of addictions, which is the subject of this article. The same mechanism might operate in the treatment of behavioural problems, including conduct disorders, eating disorders, maybe even mood disorders.

Basically, the concern is that the individuals in the group might actually "teach" others in the group about tactics to engage more deeply in the problem behaviour. The social bonds formed in the group might expand a person's network to engage in addictive behaviours. If some members of an addiction treatment group are severely involved in the addiction, are perhaps ambivalently committed to therapy, and may be connected to convenient resources in the community to access their addiction, this may facilitate other less severely involved members of the group to broaden their access to addictions.

In eating disorders, members of the group might "compete" with each other to some degree with eating disorder behaviours. If there are social leaders in the group who are still highly involved in the eating disorder, this may cause a negative peer pressure on others who are starting out.

On the other hand, an opposing, positive force in group therapy is encountering others who have understanding and personal experience of similar problems. This can be especially important for problems where a person often feels judged or misunderstood. Also, members of the group can teach others tactics to deal with moment-to-moment manifestations of the addiction. In order for these positive forces to be manifest, the group itself needs to be composed of individuals who are probably similar in terms of problem severity, and where there are individuals members of the group who are progressing. This introduces a social learning effect, in which an individual can see and emulate another individual with similar problems who is starting to make progress. The similar problem severity among members of the group would hopefully reduce the likelihood of mildly afflicted group members being drawn into more severe illness behaviours.

Since progress through problems is always a dynamic, individualized process, it may be that involvements with groups ideally need to change dynamically as well. If individuals are moving quickly away from addictive behaviours, they may ideally need to nurture group connections which are similarly healthy.

This poses another problem for many with long histories of addiction or other socially dynamic health problems: relationships which have been strongly associated with the addiction may need to left behind, or at least boundaried very carefully.

Naturalistic study comparing quetiapine, ziprasidone, olanzapine, and risperidone

2010-06-10T09:36:00.000-07:00

This study caught my eye recently (here's a link to the abstract:)

http://www.ncbi.nlm.nih.gov/pubmed/20334680

It's a naturalistic study, published in BMC Psychiatry in 2010, prospectively following 213 patients with symptoms of psychosis, who were randomized to receive one of four antipsychotic medications (quetiapine, ziprasidone, olanzapine, or risperidone), then apparently followed for up to 2 years.

My prediction with such a study would be that all four medications would have similar effectiveness, with a slight edge in favour of olanzapine.

In fact, the results showed a slight edge in favour of quetiapine. There were no substantial differences in tolerability.

The problems with this study, though, include the following:

1) Most of the data was actually for patients who had only been followed up for 6 weeks (not 2 years!). Only 8 of the 213 patients were followed up for 2 years. Of these 8, 5 were taking olanzapine, 2 were taking ziprasidone, and 1 was taking risperidone. Perhaps one might be tempted to conclude that olanzapine is the drug that has the highest chance of being acceptable for long-term use.

2) The results were presented in a type of "refined" fashion, for example the changes in symptom scores for each drug over time were presented as graphs with a single straight line for each drug, plotted over a 300-day period. This type of graph omits a tremendous amount of relevant data: first of all, there were very few patients who were actually followed for 300 days, most of them were only followed for 6 weeks. A graph like this implies that there are strong data points stretching out over the entire period. Secondly, the linear plots do not show the degree of scatter in the data points. There were no direct reports of the raw data in the study, only refined statistical distillations. It would be much more informative to show all of the data points plotted out over time: then one could see the times where most of the data were derived, the various courses of symptom change for each individual in the study, etc. It would be a messier graph! -- but it would not mislead the viewer to immediately conclude that one medication is obviously better than the others.

In conclusion, the study really grabbed my attention when I first looked at it, but I found it to be much weaker than I thought, after reading it closely.

It does, however, provide a little bit of support for the idea that any one of these four antipsychotic medications are reasonable to try, in the treatment of psychotic symptoms. I agree that quetiapine is a reasonable first choice, though the others could be reasonable also, depending on personal preference, past experience, side effect risks, etc. I would still lean towards olanzapine for anticipated long-term treatment of severe symptoms.

A Learning Model of Psychological Change: the necessity of work & practice

2010-06-09T15:31:00.000-07:00

It requires a great deal of work to bring about psychological change.

The brain is a dynamic organ, its development influenced by genetic predisposition combined with environmental experience. Repeated environmental experience sculpts the brain, altering the strength of neuronal connections, neuronal activity, neurochemistry, and even neuronal growth or survival.

Various environmental adversities obviously predispose the brain to generate psychological symptoms, including specific incidents of trauma or neglect.

The manner in which adversity changes the brain is similar to the manner in which the brain changes in response to any other sort of experience: sometimes there is sudden, intense change which can happen in an instant (e.g. a traumatic brain injury), but most often the brain changes gradually, after many repetitions of similar stimuli or similar inner processes.

Some environmental adversities are repetitive over months or years. But often times the repetition which does further harm is generated by the brain itself: in response to a problem, the brain's repetitious analysis and revisiting of the problem ends up causing consolidated change and ongoing symptoms. A great deal of the harm caused by specific instants of trauma is caused by the brain's reaction months or years after the trauma is over. This reaction is akin to an autoimmune disease, in which the body's attempts to fight off disease end up causing inflammation, pain, and tissue damage.

A symptom, such as anxiety or depressed mood, once generated from any cause, may lead to a cascade of brain changes which perpetuate and intensify the symptom. The behavioural withdrawal which results from anxiety or depression changes the potential experiences the brain may incorporate in order to heal itself. Even without overt behavioural withdrawal, an anxious or depressive state may cause the brain to perceive normal or pleasurable stimuli as dangerous, negative, boring, or unpleasant. Each time this experience occurs, the brain changes further into a state of more deeply consolidated anxious or depressive disorder. The theory of cognitive-behavioural therapy insightfully recognizes the role of thoughts as part of a cascade of phenomena perpetuating psychological illness. Recurrent hostile, reflexively critical, cynical, pessimistic or negative thinking may at times have intellectual or philosophical validity; however, such thoughts, if highly recurrent, teach and sculpt the brain to make such a style of thinking an entrenched habit. Such habits of thought are obvious causes for depression and diminished quality of life.

My point here is to describe the brain as a "teachable" organ. It is changed and sculpted by experience. The source of this experience may be from the external environment or from the self-generated inner environment of the brain. The degree to which the brain is sculpted by experience depends on the intensity of the experiences, multiplied by the time or frequency the experiences repeat themselves.

In this regard, as I've stated before, the brain and its experiences are analogous to a growing garden, or a forest: changes require time, care, knowledge about requirements, and energy.

Therapeutically, it is very clear to me that much work must be done in order to effect significant, lasting brain change. Likewise, a growing garden requires frequent care, particularly if there are adverse conditions caused from within (e.g. depleted soil, weeds) or from without (e.g. harsh weather, vandalism).

The neurochemical environment can be an obstacle to brain change, in the same sense that abnormal soil chemistry may thwart the most earnest efforts of a gardener. The "abnormal soil chemistry" may itself have been caused by an imbalanced garden ecology over many years, perhaps by genetic predispositions of the plants, and may conceivably be remediated and prevented in the long term by healthy gardening practices, yet an immediate external aid could be an immensely helpful catalyst to help these changes occur more easily and quickly. Likewise, psychiatric medications can often be helpful catalysts for change.

But the key ingredient for brain change is experiential. The type of experience capable of changing the brain substantially must be strong enough (i.e. it must employ a significant degree of the brain's capacity for attention, thought, feeling, and sensation, rather than simply being a passive or background activity), and must be frequent enough (i.e. it must occur regularly over a long period of time).

These requirements for experiential change are, as I've claimed before, similar to the requirements needed for learning a new language, or a musical instrument.

Without daily practice, therapy experiences which involve only one, or a few, appointments per week, are unlikely to cause significant psychological change, for the same reason that a language or music class once or twice a week will not lead to much language or music learning without doing daily homework. The classes may be helpful or inspiring guides, but most of the change or learning will occur due to many hours of hard work, practicing, in-between classes.

Studies of different therapeutic strategies for treating psychological symptoms usually neglect to assess the most obvious and powerful source for change: the amount and quality of the practice done. It seems to me that most any style of therapy could work quite well (some slightly better than others, depending on the situation), provided that a great deal of disciplined work and practice takes place to learn new skills, and to effect change in the brain.

The analogy of musical practice leaps to mind again, in which quantity and repetition are important for learning, but also "quality." To practice something passively, carelessly, or inattentively is often ineffectual, or sometimes even counterproductive, since one may be inculcating an unwanted habit. Also, some types of practice may be excessively mechanical, or may be veering off a desired course too easily.

I am reminded of the "Suzuki" method of music education, which I think is wonderful, for the following reasons:
1) it encourages one to start young (i.e. at any age or level of ability)
2) it strongly encourages "playing by ear", listening frequently to recordings with strong attention to perceiving sound and tonal quality; this leads to a stronger and more rapidly developed appreciation for esthetics, as well as less dependency on external cues such as printed music.   The therapeutic analogy could be of inviting frequent indirect involvement from a therapist or therapeutic system, rather than doing all "homework" completely on ones' own.
3) it strongly encourages group practice & performance, right from the beginning. This teaches not only solo musicianship, but also following and playing well with others, enjoying others, cooperation, being in a leadership role, having confidence with performance, and sharing one's gifts with others. Also, practice is encouraged to be not just a solitary activity, but something which can be done with family or loved ones. Therapeutically, I think it is strongly desirable to incorporate psychological work into group, family, and community settings.
4) it emphasizes the importance of good posture. Therapeutically, I think a fairly strict and disciplined framework to practice psychological techniques is healthy and reduces the likelihood of acquiring unhelpful habits. On a literal level, I think a balanced exercise routine is psychologically healthy, including cardiovascular or strength training, sports, or a "postural" exercise such as yoga.
5) it emphasizes the need for a lot of repetition. Therapeutically, it may be necessary to practice techniques thousands of times, over a period of months or years, in order for them to become fluent.   Repetition should never be undertaken in a dull, mechanical way -- it needs to be infused with careful, reverent attention -- but it is absolutely needed in order to master anything.

I challenge all those wishing to change longstanding psychological problems to frequently renew commitments to work hard, and to translate these commitments into a disciplined schedule of daily practice. It may be that there are symptoms of tiredness, amotivation, apathy, or a very negative or painful reaction to a broad variety of daily life experiences; these symptoms can prevent engagement with commitments, and can hinder the capacity to engage in disciplined work habits. Also, the life stressors (work, money, relationship problems, etc) can take up so much time and energy that there is not much left to do regular psychological work. Perhaps part of the therapeutic process at this stage is to problem-solve around ways to reduce stresses, reduce some of the symptoms, bolster energy, etc. as prerequisites to establishing a work plan. Another view of this issue is that the "work" alluded to here could take place within any type of life stressor, it does not necessarily require a lot of extra time separate from other activities of daily living.

"Brain Training" ineffective?

2010-04-22T12:03:00.000-07:00

Adrian Owen et al. published a letter in Nature this week, summarizing the results of a study examining the effects of playing "brain training" computer games. Here is the link:
http://www.ncbi.nlm.nih.gov/pubmed/20407435

The format of the study is interesting, involving the BBC website, inviting mass public participation in ongoing on-line research projects (here's a link to that site, which has a variety of other entertaining surveys you can do: http://www.bbc.co.uk/science/humanbody/mind/index_surveys.shtml).

In this case, over 11 000 subjects did various types of computer games on-line, aimed at developing various cognitive skills. The subjects had to practice for at least 10 minutes per day, at least 3 days per week, for 6 weeks. Some subjects practiced much more than others.

The results are not very surprising to me: basically, they showed that the skills developed while practicing a computer game do not "transfer" : they do not lead to generalized improvement in cognitive ability. Even the subjects who practiced much more than the minimum requirement did not end up improving in a set of generalized cognitive tests afterwords.

Subjects improved significantly only in the specific tasks which were practiced. This is intuitively obvious. If you practice Tetris, you will become much better at Tetris, but are not likely to improve your mastery of French vocabulary! Practicing volleyball will not help your guitar skills very much -- in some cases, such practice may in fact interfere with other skills acquisition, because one is procrastinating or redirecting energy away from one skill while practicing another. Certainly it is true that computer games can be quite addictive: if someone is spending many hours per week playing computer chess, or some other game, instead of reading, then overall educational performance is likely to decline rather than improve.

For participants in this study, it may be true that benefits occurred in "process" which were not adequately measured by the benchmark tests administered before and after the 6-week trial. For example, playing a game which improves reflexes or visual memory might not immediately or directly "transfer" or lead to improved performance in another reflex-based or memory-based benchmark test--but it might cause improvement in the rate at which another reflex-based or memory-based test, task, or game would be learned or mastered. Analogously, if you have played a lot of volleyball, you might not immediately perform well in soccer--but you might learn to play and master soccer more quickly. Or, if you have learned French and Spanish, you might not immediately perform well in a German vocabulary test, but you might be able to learn German much more quickly. These types of benefits would not be picked up by the testing administered in this study.

Here are some further ideas:

1) Is it possible that some particular cognitive games are more useful or generalizable than others?

-I think this is very possible. I think that one should consider what type of gain is desired from the exercise you are doing.

A game which helps you practice learning and remembering faces and names could be quite helpful if such memory issues are problematic in your daily life. Such a game would be inherently generalizable, since the daily behaviour and experience outside of the game would be similar to the game challenges. Lumosity.com has examples of such games.

A game which helps you pay attention to reading texts closely, while monitoring and testing your speed, accuracy, memory, and comprehension of the text, could be very useful if you are having trouble reading or studying.

Games which teach and test general knowledge subjects could be obviously useful to gain general knowledge -- e.g. learning vocabulary, facts about nature, etc.

So, I think one should choose games carefully, with the knowledge that the game will train you to improve in a particular skill. Is that particular skill likely to be useful or generalizable in your daily life?

2) Is it possible that some of the specific games used in this study could be generally useful to some particular individuals, even though they were not helpful to the group as a whole?

-I think this is very possible as well. There are three main issues that leap to my mind about this:

First, the study looks at a large general population of volunteer subjects. A great many of these subjects were probably already in pretty good shape cognitively, and were motivated and enthusiastic to participate in such a research project. This would be like asking a bunch of fitness enthusiasts to do 10 minutes of calisthenics 3 times per week, and then checking to see if their overall fitness improved 6 weeks later. It would not be surprising to see an absence of any effect. However, if the participants were chosen because of having cognitive weaknesses, due to learning disabilities, dementia, other illnesses, or environmental deprivation, then perhaps there could have been a much more substantial and relevant improvement with such a regime. People with a lower fitness level would be expected to benefit much more substantially from a simple calisthenic routine than those already in good shape. Many people with depression might have low motivation or engagement with intellectual tasks -- in this case, games of this type might help people get their minds more active again, as a prelude to other types of learning or intellectual engagement.

Second, I am reminded of some other requirements for change in the brain: an immersive or highly intensive environment can be required for the brain's plasticity to be harnessed. This might require many hours per day, over many months. These hundreds of hours of training would contrast with the total of 3 hours' minimum training which this study evaluated.

Third, some of these game types could be useful, diagnostically, for evaluation or identification of particular cognitive or perceptual strengths and weaknesses. If these problems are identified, then a specific recipe for improvement could be mapped out.

I do wish the authors of this study, given their interest in computer-based learning & cognitive testing, would invent some games which could help people develop ability in reading, comprehension, general knowledge, etc. Also, there are game-like computerized exercises which can help people develop skills in recognizing emotions, empathizing, etc. (examples can be found at the BBC site). These exercises could be useful for dealing with social anxiety, relationship problems, Asperger's Syndrome, etc.

A good site for free cognitive training games

2010-04-19T14:07:00.000-07:00

I found this free site which offers exercises which you can use to practice memory, concentration, and reasoning skills:

http://www.cambridgebrainsciences.com/

There are a variety of basic memory exercises, mainly testing visual/spatial immediate memory. Many of the tests are on a timer, for 90 seconds to 3 minutes, so the exercises are designed to help develop speed and accuracy. Unfortunately, there is not much at this site for practicing verbal memory skills, verbal comprehension, calculation, longer-term memory, or other practical cognitive skills such as remembering faces or names. But for a free site, it is quite good. It also shows you a graph of your score improvement over time, which can demonstrate to you that your skills are improving with practice.

The authors of the site are two British professors who do research into web-based assessment and development of cognitive skills.

Optimal Learning & Training Schedules

2010-04-09T14:07:00.000-07:00

An interesting question I have often considered has to do with the most efficient way to use time, in order to prepare for something, or to learn. This is relevant in psychotherapy, in terms of helping therapeutic change progress at the most optimal pace.

To formalize the question, consider the following:

1) If you had 100 hours to learn something (e.g. to memorize a text; to learn a foreign language; to learn a musical instrument; to understand a set of complex ideas; to learn a new sports skill; or overcome a psychological symptom), how would you distribute these hours, so as to optimize the therapeutic change? Would it be 10 hours per day, for 10 days in a row? Or 1 hour per day, 100 days in a row? Or 1 hour twice per day, for 50 days? Or 1 hour per week, for 2 years (!?)

2) Another set of constraints on this problem would be this -- if you had 10 weeks to learn something, a maximum of 10 hours per week to learn it, and a maximum of 10 hours on a single day to spend, what would be the best way to work? Would it be 10 hours every Monday, for 10 weeks? Or 2 hours every weekday? Or 1 hour twice a day on weekdays?

It interests me to note that answers to this type of question come from different fields of research, from cognitive psychology to education to athletic training.

The most sophisticated piece of research I found regarding this issue is described in the following article:

Pavlik et al., "Using a model to compute the optimal schedule of practice," Journal of Experimental Psychology: Applied, v14 n2 p101-117 Jun 2008

The research shows that, in general, "spacing" is far superior to "blocking" in terms of time management or study scheduling. That is, if you have 10 hours to learn something, it is better to split the time up into short blocks, with rest periods in-between, rather than spending all 10 hours at once.

Pavlik's article includes a much more sophisticated analysis: for a memory task, items which were more difficult to remember were reviewed with a shorter interval, whereas easier or more well-learned items were reviewed with longer intervals. As each item became more well-learned, the spacing increased gradually. To review something too soon would not be using time well: not only could that moment be used more efficiently to review something more difficult, it also does not develop the longer-term memory of the item as well. It is most optimal to review something just as its memory is starting to decay. These memory decays take place over a longer and longer time, the more you have learned something. To review something with too long an interval between study trials would also be inefficient, as too much forgetting will have taken place, and an inefficient investment of time will need to be spent re-learning the same material.

Common practices in studying or practicing include the following:
1) familiar or easy material is revisited too much: it is often inefficient to review something you already know well, unless this causes you to develop some new insight about it.
2) unfamiliar material is reviewed in large blocks of time (cramming) -- this is profoundly inefficient, and does not allow for long-term learning.

Pavlik's experiment also confirms that high levels of accuracy should be sought, right from the beginning, so as to maximize efficiency.

In summary, Pavlik's work shows that one should space learning efforts. When just starting out, the spacing interval should be brief, with enough frequent review to master what you have just learned. With the material mastered on a short-term time scale, the spacing interval can be extended, just enough to make the review slightly challenging. This process continues, with gradual expansion of spacing intervals, until the material is permanently learned. Once the spacing interval extends for days, weeks, or months, the learning will probably be permanent.

The research is very incomplete on this matter, for a number of reasons:

1) the complexity of each individual learning task needs to be taken into account. For example, if one is trying to solve a complex physics problem, or to comprehend a difficult concept in philosophy, it may be necessary to invest many solid, continuous hours of effort in a "block." In this sense, each individual "trial" of learning takes place over many hours, rather than over seconds (as in memorizing a foreign-language word). So, for more complex tasks, fragmenting one's study time could decrease efficiency. But in a general sense, it will be extremely inefficient to try to "cram" in order to learn how to do complex physics problems. The "spacing" needs to take place generously, but with each space over a period of days--allowing you to complete individual problems--rather than hours.

2) It remains true that action is required in order to learn. If accuracy is valued so highly as a priority that action does not take place, than learning cannot occur. So, for example, in order to learn a new language, one must practice speaking it, or using it. If one is excessively meticulous about accuracy of vocabulary or grammar right from the beginning, and therefore one is silently contemplative in a conversational language class, then the action cannot proceed, and instead a stifling self-critical process will inhibit learning and engagement.

3) The existing research does not account for the powerful effects of "constraint-induced" neurologic change. Immersive processes may permit the brain to develop new pathways much more efficiently -- anything less than immersion allows a continuing neural pathway of least resistance. The Taubian ideas about stroke rehabilitation exemplify this phenomenon: neurological recovery may be much more complete if the brain is not allowed to by-pass or compensate for the disabled body part: in this way the brain's energy and capacity and plasticity may be directed towards regaining lost function. So, in this sense, a continuous "immersion" in a study process may be more effective than any sort of "spacing" regime. The immersive experience would be a "block" lasting months at a time, continuously. Of course, there could be smaller spacing effects within this. Addiction recovery requires similar "immersion" in an abstinence process. The neurological recovery from the addictive process could then proceed over months or years (typically a year being a significant milestone).

4) Sometimes, large blocks of time can be useful. Even though it is not the optimal schedule for using time, in terms of memory formation, it may be optimal on other levels, such as with developing the ability to maintain longer periods of attention in the subject matter, with developing deeper insights about patterns within the subject, or with developing a richer sense of community or identity around the activity. Thus, a "weekend retreat" experience of something can be educationally powerful, even if the same number of hours spread over several weeks might be a more optimal use of time, if simple memory is the only consideration.

Here are some references to other research which addresses this question:

http://www.ncbi.nlm.nih.gov/pubmed/19122053
Extinction more effective if spaced rather than in a block of time.

http://www.ncbi.nlm.nih.gov/pubmed/19831094
Variable practice (involving several versions of a skill) has advantage over constant practice

http://www.ncbi.nlm.nih.gov/pubmed/17326522
Random training in basketball has better retention after 1 year

http://www.ncbi.nlm.nih.gov/pubmed/12831284
Contextual interference improves learning skill

http://www.ncbi.nlm.nih.gov/pubmed/19093603
Blocked practice better for immediate acquisition, random practice better for retention (long-term).

http://www.ncbi.nlm.nih.gov/pubmed/17037668
blocked practice better for acquisition, random practice better for retention (long-term) --pistol shooting

http://www.ncbi.nlm.nih.gov/pubmed/16383091
variable practice better in tennis

http://www.ncbi.nlm.nih.gov/pubmed/1989009
knowledge of results (KR) -- more is not necessarily better. less KR improves results after a delay, especially if tested without KR

http://web.ebscohost.com/ehost/detail?vid=7&hid=3&sid=04efbc76-6010-4987-ab5f-353b00504841%40sessionmgr13&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=ehh&AN=26941729
shuffled practice of math problems vastly superior to standard blocked practice, when measured 1 wk later

http://web.ebscohost.com/ehost/detail?vid=7&hid=3&sid=3588cd73-af26-475d-81e9-6186d4241292%40sessionmgr10&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=ehh&AN=47668545
spacing better, in general; but if the learner prefers a block strategy, then spacing less advantageous

http://web.ebscohost.com/ehost/pdf?vid=3&hid=3&sid=902d9a70-de9b-4441-835b-2fddc6ff0698%40sessionmgr14
1988 psychology article reviewing spacing as optimal memory strategy

http://web.ebscohost.com/ehost/detail?vid=8&hid=3&sid=3588cd73-af26-475d-81e9-6186d4241292%40sessionmgr10&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=ehh&AN=37193344
1 day per week courses -- much inferior to 3 days per week

http://en.wikipedia.org/wiki/Spacing_effect

The Nature of Happiness - book review

2010-04-08T12:55:00.000-07:00

The Nature of Happiness by Desmond Morris, is a brief little book describing the author's beliefs about various types of happiness.

I think it's worth including in a list of books to read about happiness, though I find it to be quite a superficial opinion piece. There are a few interesting observations; some sound, simple advice; and a collection of nice quotations from famous authors, but otherwise the book really lacks substance. There is almost no reference to research; there are many sweeping statements, such as about evolutionary underpinnings of happiness-related behaviour, yet without a rigorous development of these ideas, and perhaps without a sense of understanding the voice or perspective of those to whom he is referring.

It is always surprising to me how a minor text of this type could warrant a glowing review from a major newspaper:
"At last, a highly intelligent, serious exploration of a subject as universal as it is mysterious...an illuminating and fascinating read." The Times

Antidepressant + CBT superior to either treatment alone for treating social anxiety

2010-03-19T16:41:00.000-07:00

Blanco et al. published this study in the March 2010 issue of Archives of General Psychiatry. Here's a link to the abstract:
http://www.ncbi.nlm.nih.gov/pubmed/20194829

Patients with social anxiety were divided into four groups in this randomized prospective 24-week study: placebo; cognitive behavioural group therapy; phenelzine medication; combined CBT + phenelzine.

CBT was modestly effective, phenelzine only slight more effective, but the combination of CBT + medication was substantially more effective, more or less additively so, particularly in terms of total remission rates. There was a very low placebo response.

Findings of this type are not surprising. An interesting aspect to this particular study is that it makes use of phenelzine, an old MAO inhibitor. This shows that sometimes these old drugs can still be quite useful.

This study does not necessarily demonstrate that CBT is the only form of psychotherapy which would work adjunctively to help social anxiety. I do think that components of CBT, such as emphasizing exposure to anxiety-provoking situations, and practicing social initiatives in a systematic way, are necessary. But, other forms of psychotherapy might adjunctively help the CBT to work better!

Omega-3 update

2010-03-19T13:09:00.000-07:00

Appleton et al. has published a recent review of evidence regarding the psychiatric effects of omega-3 supplementation.

Here's the link:
http://www.ncbi.nlm.nih.gov/pubmed/20130098

Basically, the conclusion is similar to my previous impression on this issue: there is more evidence coming out, generally supporting the possibility that omega-3 supplementation can be modestly beneficial for treating depression. But the existing evidence is somewhat shaky, heterogeneous, and probably influenced by publication bias.

The authors overstate some of the conclusions: for example, they claim that, based on the evidence, omega-3 supplements are unlikely to be useful to prevent depression in a healthy population. This is unfounded, since there were really no adequately long studies which aimed to show preventative effects.

Another of my usual complaints about the studies described is that they are of inadequate duration: many lifestyle changes or treatments that could affect depression (an illness with a periodicity which is often over years or decades) may require several years of disciplined adherence before significant benefits would become apparent. Most of the studies described were less than 3-6 months in duration.

Another study by Amminger et al. from the February 2010 issue of Archives of General Psychiatry (http://www.ncbi.nlm.nih.gov/pubmed/20124114) assessed subjects with signs of early psychotic disorder who were randomized to receive 4 capsules per day of fish oil (containing omega-3 fatty acids), or placebo daily, for 12 weeks. In the following year, substantially fewer individuals in the fish oil group, compared to the placebo group, went on to develop ongoing psychotic illness (5% vs. 28%).

I do encourage omega-3 supplementation, as it poses negligible risk, with a modest potential benefit, both with respect to mood and to some other areas of health.

Saturated fat not intrinsically harmful?

2010-03-19T12:50:00.000-07:00

I'm intending to start a series of posts reviewing articles that I found interesting from a selection of journals published in the first months of 2010.

Here is the first, from The American Journal of Clinical Nutrition, March 2010, Vol. 91, No. 3, pp. 533-546. Here's a link to the abstract:
http://www.ncbi.nlm.nih.gov/pubmed/20071648

The authors, Siri-Tarino et al., show via meta-analysis that saturated fat intake is not actually positively correlated with heart disease risk.

Rather, the more important issue is the ratio of polyunsaturated to saturated fat in the diet. Higher ratios are protective against heart disease.

The authors cite evidence that ingesting the same number of calories as carbohydrate instead of saturated fat actually increases the risk of myocardial infarction (heart attack).

With respect to nutritional behaviour for optimal physical and mental health, I return again to the recommendation that there be a balance which includes adequate fat, carbohydrate, and protein as dietary macronutrients. Saturated fat need not be excluded or avoided, but should be balanced by a more abundant intake of non-saturated fats.

In a separate article, the same authors recommend maintaining balanced dietary fat intake, but avoiding refined carbohydrate in the diet:
http://www.ncbi.nlm.nih.gov/pubmed/20089734

In my opinion, adequate dietary carbohydrates are very important for brain health, as I believe low-carb ketotic diets are hard on the brain. Complex carbohydrates, with a lower glycemic index, are preferable.

Intellectual Lineage & the Sources of Therapeutic Ideas

2010-03-12T12:54:00.000-08:00

It was hard to think of a title for this post; really, this is a bit of a philosophical ramble. It's the type of title I might sometimes poke fun at, it sounds like something you might find in an overly serious scholarly journal. To some degree this post is a sequel to my previous one.

Psychotherapy, while not religious in a dogmatic sense (unless there is some form of religiosity infused into an individual practioner's style), contains many ideas which are dealt with or contemplated by philosophers or theologians. Many ideas in psychotherapeutic styles are inspired by religious or literary metaphor, which can be rich sources of insight about the human condition.

If there are borrowings from any type of religious thinking, we could in turn say that the religions themselves "borrowed" ideas (such as regarding compassion, altruism, meaning, etc.) from other thinkers or cultural influences of the day. Most religions finally have quite similar values in this regard, with stylistic variations from one culture to the next (even within the same religion). Much theological writing and thinking in this era is, in turn, influenced by secular philosophy, including such pragmatic secular philosophies as contained in cognitive-behavioural therapeutic theory.

The history of human creativity is deeply rooted in borrowing, or referring to, creative ideas generated by others. Mozart or Beethoven did this with music. Einstein did this in physics. Shakespeare did this with language. New religions are substantially influenced by "borrowings" from other religions. Art, architecture, engineering, etc. are all imaginatively influenced by work (either whole pieces of work, or mere fragments of a whole) that others have done before. There is a type of "family tree" with respect to ideas, in which we can trace the lineage or ancestry of most any creative or intellectual work. The degree to which a new thinker ought to give overt credit to the ancestry of his or her ideas is open to some debate, I suppose. Sometimes the ancestry might not even be part of the conscious awareness of the author.

The very language I am currently using has its origins in a type of linguistic family tree, in the Indo-European family of languages. The shape of the letters of our alphabet derives substantially from Egyptian hieroglyphics (a delightful area to learn about, see http://webspace.ship.edu/cgboer/alphabet.html or http://www.usu.edu/markdamen/1320hist&civ/pp/slides/17alphabet.pdf or http://members.peak.org/~jeremy/dictionaryclassic/chapters/alphabet.php ): for example, various letters of our alphabet derived from symbols the ancient Egyptians used, which resembled animals or objects in the environment; the letter A comes from a picture of an ox head; the letter m from waves in water; the letter o from an eye; the letter D from a symbol representing a door, etc.

Yet I do not feel compelled to include footnotes referring to Egyptian hieroglyphics every time I use letters of the modern alphabet.

I find most styles of psychotherapy to be helpful in particular ways, and in particular situations. One has to acknowledge the strong evidence base showing that CBT, for example, is useful, particularly for the treatment of specific anxiety symptoms. I find these ideas to be highly recommended in approaching most any life difficulty. However, I have found CBT on its own to be very unsuccessful in helping people with chronic, treatment-refractory symptoms. Research studies generating empirical support for CBT are geared towards showing rapid symptom improvement in non-refractory disorders. In fact, the very lack of success of CBT can magnify the sense of hopelessness and despair in chronic, treatment-refractory conditions. Tangible benefits in treatment-refractory conditions may sometimes be measurable on mood questionnaires, but many tangible benefits may come from a broader evaluation of finding a reason to live despite unchanging symptoms; such questions about "reasons to live" are rarely present on questionnaires, or at least would often not be weighted highly. Yet such an issue is often the most integral daily question faced by a person with a severe chronic illness.

An approach to being present with unremitting symptoms, as a therapist or as a patient, without losing a sense of meaning or connection, is very important, in my experience. Stories from those who have endured such suffering are relevant in encouraging a hopeful or life-affirming attitude.

Man's Search for Meaning

2010-03-10T12:33:00.000-08:00

Man's Search for Meaning, by Victor Frankl, is one the great books of the past century.

Frankl (1905-1997) was an Austrian psychiatrist who developed a style of therapy which he called "logotherapy," a style which focuses upon the identification and nurturance of meaning as a primary therapeutic goal. While this style affirms the importance of symptom relief, it focuses on the idea that meaning is available even in the context of extreme unremitting symptoms or suffering.

The gravity of his ideas must be taken very seriously, because of Frankl's own personal experience between 1942-1945: he survived almost three horrific years in Nazi concentration camps including Auschwitz and Dachau. His parents and wife were killed in the concentration camps, and his only surviving immediate relative was one sister. So Frankl approaches these questions with the perspective of one who understands the extremity of suffering, profound loss, and domination by oppressive forces outside of one's control. In this way, Frankl has a deep empathic understanding of what it can be like to experience severe, torturously unremitting psychological illness.

The first half of Man's Search for Meaning is a description of life in the concentration camps. The second half is a brief description of the author's meaning-based psychotherapy style.

As a style issue, I do wish there was more attention to gender-inclusive language, as humans are always referred to as "man," and the pronoun "his" is always used instead of "her." But this is a very small complaint, given the profoundly moving, inclusive, and life-affirming nature of this writing.

This is another of the books I've read recently, which I really ought to have read 20 years ago...

Losing at the Olympics

2010-03-08T13:15:00.000-08:00

This subject has come up many times in conversation, over the past month.

The comments go something like this:

(referring to someone who has lost at the Olympics, and therefore did not get a gold medal, or any medal at all, etc.):

"What an incredible waste -- a waste of time, a waste of effort, to train all those years, to get all the way to the Olympics, to base your whole life on excelling in your sport, only to lose at the end!"

It seems to me that children or adults who have grown up being involved with athletics, and who have had good coaching over the years, have gained a good understanding of this issue (at best, I think athletic involvement can help considerably with personal growth). Their response might be something like this:

"It is a joy and an honour to participate in the sport. To play at all is meaningful. To train for something is an intrinsic joy. To be part of a community event, whether at a local community arena, or at the Olympics, is exciting, fun, and meaningful. The meaning of all those years of training does not depend on winning a medal (although a medal would be nice!) -- all that training was an act of love, my life has been better because of it, regardless of any medals."

Most of the Olympic competitors were very gracious and honorable in their wins or losses. The occasional individuals who were not gracious were really the only ones who "lost."

Of course, there are issues about financial compensation, future career opportunities, etc. which may depend on winning, in one form or another. And it could be deeply disappointing if a particular goal is not reached, and may not ever be reachable again (e.g. to make the Olympic team, to win a medal, etc.).

But psychological health cannot depend on such things. I don't believe that Olympic athletes experience significant depressions due to losing...because the joy & meaning do not depend on winning or losing, they depend on the process.

Few of us are Olympic athletes, but we all have analogous life pathways...many of us view life success as dependent on some external "win" such as getting high grades, getting into the right school or program, getting the best job, having money, car, house, relationship, being a certain body type or weight, etc.

Provided that an individual is not in an impoverished state (financially, nutritionally, neurophysiologically, psychosocially, etc.), I claim that success in life is dependent on process, not on winning anything. While the pursuit of excellence is itself a healthy and enjoyable process, it ironically cannot proceed if the pursuit of excellence becomes frozen into a pursuit of "winning." Winning will happen, on multiple levels, if a joy of process is nurtured.

Book Review: Mad, Bad and Sad

2010-03-03T11:30:00.001-08:00

Mad, Bad, and Sad: A History of Women and the Mind Doctors from 1800 to the Present, by Lisa Appignanesi (2007) is quite a good history of psychiatry, particularly regarding the period between 1800 and about 1950.

It was interesting and valuable to look at some of the life histories of individual women from previous eras, and to speculate about what helped them and what did not. Some of the biographical sketches are about famous women such as Sylvia Plath, Virginia Woolf, and Marilyn Monroe.

The author approaches the subject matter with a broad vision to include social and cultural context, and particularly feminist issues such as the role constraints and expectations imposed upon women by the prevailing culture, in communities, in families, and also in the therapeutic relationships (which often had a paternalistic quality, or one which reinforced restrictive cultural stereotypes about women).

Many of the stories are strong critiques against various elements of therapeutic philosophy and practice, especially biological psychiatry.

An important thesis is of the limitations of "therapy": her closing statement is

...the mind doctors--whether they're GPs on the front line, therapists of an increasing number of varieties, psychoanalysts, psychiatrists or psychopharmacologists -- trudge along, doing what they can, which is sometimes all that can be done. The danger, perhaps, comes when we ask them to do too much. (p. 484)

Certainly, through all the stories mentioned, the benefits of therapy were often tangible but limited--some compelling "success stories," others particularly tragic in their ending (e.g. Plath, Woolf, or Monroe).

An underlying thesis seems to be very supportive of psychoanalysis as an important form of therapy, which may nurture a sort of freedom in self-development and personal growth.

I find that she is excessively dismissive of cognitive-behavioural therapy. While I agree that such "shorter term" therapy styles may well be designed to improve symptom scores, such that an insurance company would be more willing to fund this therapy for a short time, then cut people off--I also think that many psychological ailments can be products of simple symptoms which can be treated in a very direct, matter-of-fact way, rather than through years of philosophical rumination on a psychoanalyst's couch. Panic attacks, OCD, social anxiety, etc. can be approached as symptoms which can be mastered through behavioural practice. It could be a tremendous disservice to individuals seeking "freedom" or "liberation" to neglect these practical and philosophically simple techniques.

I do agree that complex existential and relational issues can usually not be addressed in a shorter course of therapy, especially if the therapist is dogmatically attached to a particular style (e.g. in formal CBT, there may be no time to talk about any transferential issue or existential problem). Yet, many people may feel empowered to develop their existential and relational life on their own, provided that symptoms are not obstructing their efforts.

Some of her comments can be quite dismissive, for example:

But what young person doesn't feel depressed?--particularly perhaps after a week of student exams, or a split with a boyfriend, even after a little use of recreational drugs and forgetting to eat...A sense of hopelessness, a teenage irritability, may be a phase, even if one that lasts several years...One of the effects of such tools as the Beck's [sic] Depression Inventory and the DSM's chartable diagnoses is that they can produce the very results they are looking for. (pp. 468-9)

In response to this quote, I would say that we are dealing with semantics to some degree. Actually, most young people do not feel depressed after their exams. They do not have a sustained change in behaviour after relationship disappointments, do not have a prolonged sense of hopelessness, irritability, insomnia, weight loss, suicidality, etc. These feelings may well be "phases," but the question is, should we simply treat these as "normal," (which is a semantic construct itself), and therefore not "do" anything (i.e. not offer companionship, support, advice, mentorship, etc.)? I agree that labeling and medicalization may unreasonably guide people into reflexive and sometimes unhelpful or inappropriate treatments (e.g. if a certain Beck score or life disappointment would automatically necessitate antidepressant drug therapy without any opportunity for dialog).

The author appears to have a particularly narrow view of some psychiatric treatments, such as ECT, which she describes as "barbarism." (p. 480) Perhaps thoracic surgery could be judged barbaric as well--most types of medical treatment were truly barbaric in many previous points of history, and only became less so through understanding and careful research as to how to perform the treatments more safely. Undoubtedly, even today, many people have negative experiences with thoracic surgery--or ECT--but in order to evaluate the humane usefulness of such invasive procedures, we need to do careful research trials. In order to assess whether something is "barbaric" or not, perhaps it is important to examine the stories of those who have had a profound, life-saving experience of something, alongside the stories of those who have had ambivalent or negative experiences.

She attempts to be fair in her analysis of medication treatments, but I think most readers unfamiliar with the issue would read her analysis, and conclude that medications to treat depression are a dangerous sham perpetrated by drug companies, with the collusion of paternalistic and impatient physicians.

There is little discussion of vast areas of research about the human mind: the entire field of academic & research psychology is barely mentioned. This research is so very important in challenging the dogmas associated with various therapeutic theories. Psychoanalytic theorists may have been, and still are, very wise and very talented listeners or shamanic figures, but the theories themselves were, and are, often very weak if taken too literally, and sometimes cultishly dogmatic, with therapeutic gains or inferences being illusions caused by the primitive logic of association leading to an assumption of causation. Also, the field of neuroscience is barely mentioned. The author uses the term "Big Science" as a kind of pejorative epithet, alongside "Big Pharma", a kind of ad hominem style of argument which seems to suggest that research findings from "Big Science" must be biased, and that the lack of research findings which support her position must have to do with the scientists being inadequate, rather than her position in fact being weak. One piece of "Big Science"-style research she does cite, in support of psychoanalysis, is upon closer observation a single study, with no adequate control group, little critical review. Yet she seems to aggrandize these findings in a way similar to how I have seen "Big Pharma" reps market medications based on a single, fairly weak research study.

The strength of this book lies in the biographical stories of suffering individuals, and of the descriptions of how people attempted to help them. Some of the most effective strategies are clearly based on common sense: humane social and community support, minimizing iatrogenic harm, promotion of the greatest degree of freedom possible. She argues effectively that Freudian ideas were quite liberating, permitting discussion of subjects previously held under a veil of taboo in the Victorian era, such as the nature of sexual drives. Also, these Freudian notions tended not to pathologize the drives themselves, but rather considered the drives to be innately normal, hence inviting frank, uncensored dialog as a pathway to greater freedom. The book highlights, importantly, some of harms done to people by misguided therapists and theories. And the book highlights the fact that symptoms generated by the mind can present in different ways, according to cultural influences. She argues that classification schemes can follow a fashion, and that ailments may present to follow the classification scheme, rather than the other way around.

So, in conclusion, a book with some interesting biographical sketches of patients and therapists. And some good discussion about the dangers of over-medicalizing human nature. But she does not convey a good understanding of psychological or neuroscience research, and certainly does not lay out evidence in a balanced or comprehensive way.

Olympics & Psychiatry

2010-02-11T09:58:00.000-08:00

The Olympic games cost billions of dollars to prepare for, and to host. Therefore, it has been a subject of controversy, particularly because so many people (both globally, and in the local communities near the Olympic sites) are suffering with homelessness, poverty, lack of opportunities for therapy, education, recreation, healthy community, etc. There is understandable criticism that those billions could have been better spent addressing these serious social problems directly.

A few things in particular bother me about the Olympics: one main corporate sponsor is a soft-drink company; another is a fast food company. These companies, in my opinion, contribute to the health problems of millions of people. It is like having cigarette companies as sponsors. The Olympic torch was preceded by a truck with neon lights and dancers boisterously advertising soft drinks...I think this was contrary to the spirit of the event--certainly in bad taste-- and I hope future Olympic organizers can be more health-conscious in considering whom to allow as corporate sponsors.

Overall, however, my opinion is that the Olympics are very healthy, for the following reasons:

1) In these games we have an opportunity for nations of the world to display a type of excellence, and to come together in serious, spirited, but friendly competition. It is a model of sublimating competitive conflict through sport or play, rather than through war. And it is an opportunity for multicultural celebration, in a setting which encourages sportsmanship, generosity, and hospitality.

2) The ethical problem of spending extravagantly while many do not have basic needs met is a very serious one. Here are a few ideas about this:
-Almost any activity could be considered extravagant spending (in terms of money, time, or attention) : much university education does not address the needs of impoverished, displaced, or other suffering individuals. Much in medicine (e.g. transplantation surgery) could be considered expensive extravagance, benefiting a small number of people while others have inadequate basic health care. A great deal of scientific exploration (e.g. the space program) is very expensive, yet doesn't help directly with poverty or world hunger. Investment of time, attention, or money in the arts (e.g. music, theatre, literature, visual arts) could be considered wasteful, since it does not directly help with poverty or homelessness. People could be directed to stop spending time reading novels, going to plays, going jogging, having pets, etc. because they should better be volunteering to assist with dire social problems.
-Regarding the above examples, I think most would agree that these "extravagant" aspects of human endeavour are healthy...it is part of human nature to strive for excellence and for new frontiers (whether this be in space travel, advanced surgery, mathematics, theatre, or sports): it is part of healthy civilization that we allow our attention, time, and money to be invested in these activities. It would induce a type of global psychosocial impoverishment to suppress these activities. The development of a culture which is advanced in terms of arts, sciences, and sports, and which shares its advances with other cultures, is healthy. While these activities may not directly help with social problems, they are part of building a healthier society, which in turn can address its social problems with greater ease and morale.

This social issue has a metaphorical parallel, I think, in individual cases of depression, anxiety, or other psychological symptoms: in a depressed or anxious state, a much greater portion of energy may be invested to meet basic needs. Energy itself may be in short supply, and it may require most of this energy just to prepare food, or to make it through the day. It makes sense to budget energy in such a way that few "extravagances" are allowed. Yet, if this budgeting practice persists for years, it may lead to a perpetuation of a grey, depressed status quo. "Extravagance" may be a necessary part of energy budgeting in depressive states--this extravagance might take the form of energy expenditures which may not seem affordable (e.g. exercising, taking up a new activity, involving oneself in a new community, socializing, taking time away from a hard-to-maintain work schedule in order to volunteer, etc.)---and indeed, such extravagances may sometimes not work out (e.g. efforts to socialize may fizzle, the new activity doesn't work out due to depressive fatigue, etc.). But allowing for extravagances is a type of balanced risk that can permit growth from a depressive status quo.

Suppose a room-mate invites a whole bunch of people to your home, for a lavish celebration. Suppose you are very opposed to this event, perhaps in the context of your room-mate not having done his share of chores regularly for the past 4 years (etc.) ...But suppose also that the guests are themselves honorable, noble people who come from many lands, who are polite, respectful, talented, and interesting. Perhaps in this context it is healthier to set aside one's differences, and to welcome the guests with a spirit of hospitality and celebration.

I think it is great to have the Olympics in Vancouver: I wish all the athletes and spectators a happy, healthy, spirited few weeks of enjoying our community, of enjoying vigorous competition and good sportsmanship. Afterwards, I hope that all of us in the community may enjoy the resources constructed for the games, and that special effort may be made to include those in greatest need.

Sleep, Hormones, and Obesity

2010-02-10T10:34:00.001-08:00

Here are some excellent references about the interaction between sleep, hormones, and obesity. They were contributed by a reader (thank you very much!):

http://www.ncbi.nlm.nih.gov/pubmed/16459757

http://www.ncbi.nlm.nih.gov/pubmed/18591489

http://www.ncbi.nlm.nih.gov/pubmed/19056602

http://www.ncbi.nlm.nih.gov/pubmed/15531540

http://www.ncbi.nlm.nih.gov/pubmed/18564298

Lastly a good review paper and shows the basics (along with some fun diagrams)
http://www.jpp.krakow.pl/journal/archive/1205_s6/articles/01_article.html

Comments:

These references make it very clear that inadequate sleep increases the likelihood of obesity.

The last article was interesting, but oddly lacked any discussion of culture or psychology with respect to eating behaviours or obesity.

In terms of advising a fixed, early wake time, I believe this is entirely consistent with a plan to get adequate, optimal sleep. In fact, I believe that when individuals who are struggling with insomnia have a habit of sleeping in, the overall sleep quality diminishes, the insomnia pattern is exacerbated and perpetuated, and the health problems associated with inadequate sleep are likely to worsen.

Therefore, I believe that sleep quality and the restorative health benefits of sleep are most optimal if wake times are consistent and early. Possible exceptions to this could occur in adolescents, who probably need more sleep (but even then, it would be better for them to get that additional sleep by sleeping longer hours but getting up at the same time every day, rather than by sleeping in on weekends). Another exception could be in the setting of a physical illness, in which case one might need to stay in bed longer to recover.

Self-help books

2010-02-01T10:24:00.000-08:00

There are a lot of self-help books to choose from, dealing with almost anything including mood problems, anger, anxiety, body image, obesity, shyness, relationship or marriage problems, etc.

There are others that might aim to help a person develop creativity, or guide one with respect to some other life pursuit, such as building a sense of purpose, meaning, balance, simplicity, etc.

I think it is worthwhile to familiarize yourself with the self-help literature. I think it can be something like getting a textbook for a course at school...while some textbooks may not be very well-written, I think having a textbook at all can at least allow some extra tangible structure in therapeutic work.

Most self-help books have exercises to work through, often requiring you to write things out with pen and paper. I think it is important to actually do the exercises, as opposed to just leafing through the book, or thinking that you've done all those things in your mind before anyway. Working through exercises strengthens the mind, even if the exercises themselves are not very well-constructed. It is something like working through arithmetic or grammar problems. Even if the exercises are boring or trite, the earnest effort spent working through them will strengthen your ability and insight about the subject matter. Also, most self-help books, even if they are poorly written, can act as structures to develop your own personalized insights about the subject matter--the workbooks can be a frame to do the work, as opposed to being an intrinsic source of insight.

Many self-help books are organized with cognitive-behavioural ideas in mind. Once again, even if you don't care much for cognitive therapy, the exercises remain useful, provided you engage in them earnestly (it is possible to do these exercises in a half-hearted or sarcastic way, etc. -- which would minimize any possible benefit, just as with any other exercise in life).

What does evidence have to say about self-help books? So-called "bibliotherapy" (yes, someone had to designate an awkward piece of vocabulary to describe "reading") has an evidence base--here are a few references:

Gregory et al. published this 2006 meta-analysis showing cognitive bibliotherapy was effective for depression: Professional Psychology: Research and Practice 2004, Vol. 35, No. 3, 275–280. They concluded that bibliotherapy had an effect size of about 0.77, which is substantial, and comparable to effect sizes from medications and psychotherapy.

Here is a reference to a 2003 meta-analysis by Newman et al. showing that bibliotherapy was effective in the treatment of various anxiety disorders:
http://www.ncbi.nlm.nih.gov/pubmed/12579544

Here is a 2004 reference showing that guided self-help is effective in treating bulimia:
http://www.ncbi.nlm.nih.gov/pubmed/15101068

In conclusion, I do strongly recommend working through self-help books. I find that it can be important to look at several different ones, as there can be style or content differences causing you to prefer one over the other.

The main word of caution I have about self-help is that some authors may have a very biased point of view (perhaps influenced by dogmatic or eccentric beliefs regarding politics, religion, health care, etc.), and may therefore lead a vulnerable individual towards an unhelpful set of beliefs or actions.

So my main recommendation is for standard cognitive-therapy style self-help, as a place to get started. There need not be any bias in cognitive therapy, since it is merely a neutral frame for your own therapeutic work.

Blueberries are good for your brain

2010-01-29T13:55:00.000-08:00

Here's a reference to a 2010 article by Krikorian et al. published in The Journal of Agriculture and Food Chemistry:
http://www.ncbi.nlm.nih.gov/pubmed/20047325

The article describes a randomized, placebo-controlled study in which 9 elderly adults were given about 500 ml/day of blueberry juice, with another 7 given a placebo fruit juice without blueberries. The study lasted 12 weeks, at which time cognitive and mood tests were administered.

The blueberry group clearly showed better memory performance than the placebo group, and the results had a robust level of statistical significance. The blueberry group also showed some improvement in depression symptoms.

Here's a reference to another review article on this:
http://www.ncbi.nlm.nih.gov/pubmed/18211020

The authors allude to other studies showing improved cognitive performance in animals given blueberry supplementation.

In the meantime, it seems quite sound advice to include more blueberries in your diet. An excellent snack food, a much healthier alternative than junk foods such as chips or candies, etc.

Rating Scales: limitations & ideas for change

2010-01-21T16:13:00.001-08:00

A visitor's comment from one of my previous posts reminded me of an issue I'd thought about before.

In mental health research, symptom scales are often used to measure therapeutic improvement. In depression, the most common scales are the Hamilton Depression Rating Scale (HDRS), the Montgomery-Ashberg Depression Rating Scale (MADRS), or sometimes the Beck Depression Inventory (BDI). The first two examples involve an interviewer assigning a score to a variety of different symptoms or signs. The last example is a scale which is filled out by a patient.

Here are examples of questions from the HDRS, with associated ranges of scoring:
depressed mood (0-4); decreased work & activities (0-4); social withdrawal (0-4); sexual symptoms (0-2); GI symptoms (0-2); weight loss (0-2); weight gain (0-2); appetite increase (0-3); increased eating (0-3); carbohydrate craving (0-3); insomnia (0-6); hypersomnia (0-4); general somatic symptoms (0-2); fatigue (0-4); guilt (0-4); suicidal thoughts/behaviours (0-4); psychological manifestations of anxiety (0-4); somatic manifestations of anxiety (0-4); hypochondriasis (0-4); insight (0-2); motor slowing (0-4); agitation (0-4); diurnal variation (0-2); reverse diurnal variation (0-3); depersonalization (0-4); paranoia (0-3); OCD symptoms (0-2)

One can see from this list that depressive syndromes which have many physical manifestations will obviously score much higher. The highest possible score on the 29-item HDRS is 89. It is likely that physical manifestations of acute depression resolve more quickly, particularly in response to medications. Therefore, the finding that more severe depressions have better response to medication could be simply an artifact of the fact that physical symptoms respond better and more quickly to physical treatments.

A person who is eating and sleeping poorly, is tired, feels and looks physically ill, who is not working, who is not seeing friends as much, and whose symptoms fluctuate in the day, would already get an HDRS score of up to 30 -- without actually feeling depressed or anxious at all! A person feeling very depressed, struggling through life with little pleasure, meaning, satisfaction, or joy -- but sleeping ok, eating ok, and forcing self through daily routines such as work, social relationships, etc. -- might only get a score of 4-6 on this scale.

I acknowledge that the many questions on the HDRS cover a variety of important symptom areas, and improvement in any one of these domains can be very significant.

But -- a big problem of the scale, for me, is that the relative significance of the different symptoms is arbitrarily fixed by the structure of the questionnaire. So, for example, are the 4 points for fatigue of equivalent importance to the 4 points for guilt, or social withdrawal, or depressed mood? Would different individuals rate the relative importance of these symptoms differently? Maybe some people might prefer to sleep better, rather than socialize with greater ease. Also, perhaps some of the symptom questions deserve to be "non-linear," or context-dependent. So, for example, perhaps mild or intermittent depressed mood might deserve a score of only "1". Moderately depressed mood might warrant a score of "5". Severe depressive mood might warrant a score of "20". Or, relentless moderate symptoms over a period of years might warrant a score of "20", while only short-term or episodic moderate symptoms might warrant a score of "5".

It would be interesting to change the weighting of these symptom scores, on an individualized basis.

Also, it would be interesting to see the results of depression treatment studies portrayed with all the separate symptom categories broken down (i.e. to see how the treatment changed each item on the HDRS). Many researchers or statisticians would complain that to portray, or make conclusions, about so many results at once, would reduce the statistical significance. Statistically, a so-called "Bonferroni correction" is necessary if multiple hypotheses are being made simultaneously: if n hypotheses are made, the statistical significance is reduced by a factor of 1/n. Based on this statistical idea, most researchers prefer to analyze just a single quantity, such as the HDRS score, instead of looking at each component of the score separately.

But, this analysis dilutes the data from any study, in the same way that the analysis of artworks in a museum would be diluted if each piece were summarized only by its mass or area.

A more complete analysis would portray every category at once. A graphical presentation would be reasonable, perhaps taking the form of a 3-d surface (once again). The x-axis could represent the different symptom areas (or scores on each item on the HDRS); the y-axis could represent time; and the z-axis could represent the severity. With this analysis, we could say that we are not actually making n hypotheses--we are making a single hypothesis, that the multifactorial pattern of symptom results, manifest as a 3-d surface, is changing over time. Each individual patient's symptom changes, in every symptom category, could be represented on the graph. In this way, no data, or analytic possibility, would be lost or diluted. The reader would be able to inspect every part of the data from the study, and perhaps notice interesting relationships which the original researchers had not considered.

Some patterns of change with different treatment could present in the following ways, as shown in such as 3-d surface:
1) some symptoms improve dramatically with time, while others are much slower to change, or don't change at all. In depression treatment studies, sleep or appetite might change very quickly with a potent antihistaminic drug...this would immediately lead to pronounced improvement on the overall HDRS score, but might not be associated with any significant improvement in mood, energy, concentration, etc.
2) some symptoms might improve immediately, but deteriorate right back to baseline or worse after a few weeks or months. Benzodiazepine treatment would produce such as pattern, in terms of sleep or anxiety improvement. A medication which is sedating but addictive might cause rapid HDRS improvement, but only a careful look at individual category changes over a long period of time would allow us to see the addiction/tolerance pattern. Some people drink alcohol to treat their anxiety symptoms -- such a behaviour might rapidly improve their HDRS scores! But of course, the scores would return to worse than baseline within a few weeks or months. And the person would probably have new symptoms and problems on top of their original ones. So, we must be cautious about getting too excited about claims of rapid HDRS change!
3) some treatments might cause a global change in most or all symptoms...this would be the goal of most treatment strategies. Such a pattern would imply that the multi-symptom syndrome (in this case, the "major depressive disorder" construct) is in fact valid, all components of which improving together with a single treatment.
4) some combined treatments might work well together...for example, a treatment which helps substantially with energy or concentration (such as a stimulant), together with a treatment which helps with mood, socialization, optimism, or anxiety (such as psychotherapy, or an antidepressant). These treatments on their own might appear to be equivalent if only the total HDRS score is considered (since each would reduce symptom points overall); the synergistic effect would only be apparent by looking at each symptom domain separately.

Finally, I think it is important to look at very broad, simple indicators of quality of life, or of general improvement. The "CGI" scale is one example, although it is awkward and imprecise in design, and most likely prone to bias.

Quality of life scales are important as well, in my opinion, since they look at overall satisfaction with life, rather than merely a collection of symptoms.

In practice, only a discussion with the person receiving the treatment can really assess whether it is worthwhile to continue the treatment or not. In such a discussion, the subjective pros and cons of the treatment can be weighed. Even if the treatment has had a minimal impact on a rating score, it might be subjectively beneficial to the person receiving it. And even if the treatment has produced large rating score changes, it might not be the person's preference to continue. I suppose the role of a prescriber is mainly to facilitate such a dialog, and contradict the patient's wishes only if the treatment is objectively causing harm.

Health benefits of dietary nut intake

2010-01-21T09:00:00.000-08:00

Dietary nut intake is strongly associated with a variety of health benefits, particularly a lower risk of developing cardiovascular disease. Here is a link to a recent review of the subject:
http://www.ncbi.nlm.nih.gov/pubmed/19321572

This 2009 article describes a carefully controlled, inpatient, 4-day randomized study in which subjects were given a breakfast containing walnuts; or a "placebo" breakfast containing the same number of calories, and the same amount of carbs & fat, but no walnuts. The results showed that a breakfast containing walnuts leads to a significantly greater feeling of satiation (contentment and satisfaction with respect to food), at lunchtime:
http://www.ncbi.nlm.nih.gov/pubmed/19910942

Therefore, eating walnuts, as part of a balanced diet, is likely to maintain a feeling of satiation, and therefore reduce some of the physiological drives which can contribute to unhealthy eating behaviours.

This is a reference to a large prospective study of over 50 000 women followed over 8 years. The results included a multivariate analysis controlling for many other factors, such as physical activity, smoking, other dietary habits, etc. There was a slight reduction in weight gain or obesity in those who included more nuts in their diet, and in fact the more frequent the nut intake, the lower the risk of obesity:
http://www.ncbi.nlm.nih.gov/pubmed/19403639

With respect to mental health, I think that a balanced, healthy diet is important. Lifestyle habits, including nutritional choices, which reduce risk of cardiovascular disease, are likely also to reduce risk of degenerative brain disease. Walnuts are a source of omega-3 fatty acids, for which there is modest evidence of beneficial effects on mood.

Treatment of eating disorders requires deliberate attention to healthy, regular nutritional habits. Many individuals with eating disorders exclude certain types of food from their diets, based on an unfounded belief that the exclusion would lead to improved control of appetite or caloric intake.

Nuts in particular clearly deserve to be part of a healthy diet, unless there are issues such as food allergy.

Antidepressants only effective in severest depression?

2010-01-13T15:00:00.000-08:00

A recent article in JAMA by Fournier et al. is a meta-analysis of antidepressant treatment effects assessed in relation to depression severity. Here's the reference:
http://www.ncbi.nlm.nih.gov/pubmed/20051569

The results show that antidepressants work significantly well, compared to placebo, only for very severe depression (corresponding to Hamilton Depression Rating Scale scores of at least 25).

The analysis is quite well-done, and the results are also presented in a graphical form clearly showing a linear increase in antidepressant effect as baseline depression scores increase.

The authors observe that antidepressants are most commonly prescribed to people who have milder depressions--a population in which they show that medications arguably do not work.

Here are a few of my criticisms of this study:

1) the duration of each trial included in the meta-analysis was between 6 and 11 weeks. In my opinion, depressive disorders are long-term, highly recurrent problems, which have a natural period over at least 6-11 months, not 6-11 weeks. Treatments to address mood disorders of any severity require much longer durations. The short duration could cause a significant under-estimation of treatment effects.

2) the study, like many, looks at "depression alone." In most real-life situations, outside of a research study, individuals have several different problems, such as mild depression + social anxiety, or mild depression + panic attacks, etc. The presence of other symptoms, particularly anxiety symptoms, most likely would increase the likelihood of antidepressants helping.

3) Milder depressions, just like more severe depressions, may actually improve more consistently with a "second step" such as combination with psychotherapy, or combining two different antidepressants. The mildness of a medical syndrome does not necessarily mean that the effective treatments need only to be "mild."

4) Milder depressive syndromes may be more prone to misdiagnosis.

5) current "resolution" to measure treatment effects in depression is quite poor. "Depression" is a very broad category. An analogy could be considering "abdominal pain" to be a diagnostic category. If "abdominal pain" is the only category, and is simply rated on a severity scale (rather than subcategorized to obtain a precise diagnosis), and the treatment offered for "abdominal pain" is appendectomy, then we would probably see no difference in treatment effectiveness between appendectomy and placebo. This is because appendectomy is only effective to treat appendicitis (a subset of the abdominal pain population), and is either ineffective or harmful in treating abdominal pain patients without appendicitis (except, perhaps, for those patients who have a placebo improvement of psychosomatic or factitious abdominal pain, an improvement which they attribute to having surgery).

We currently do not have the science to subcategorize depression in a more clinically meaningful way (there are subcategorization schemes, but they don't have much relevance in terms of treatment).

But we do have a research method which could improve "resolution":
-instead of comparing two populations of depressed individuals, one group receiving antidepressant (or some other treatment), and the other receiving placebo (or some other alternative), the study design could instead be to offer every individual courses of placebo, alternating with antidepressant (or "treatment one" alternating with "treatment two"). Each course of treatment would have to last an adequate length of time. The analysis would aim to show whether there is a subset of individuals who respond to the antidepressant, or a subset of individuals who do better with placebo. The averaged results over the whole group might show that antidepressant effects do not differ from placebo (just like appendectomy might not differ from placebo in treating "abdominal pain"), but the individualized result could show that some individuals improve substantially with the antidepressant (just like appendectomy would save the lives of the small group of "abdominal pain" patients who have appendicitis).

---

In the meantime, though, I think it is reasonable to recognize that antidepressants are less consistently helpful when symptoms are less severe.

A Gene-Environment-Phenotype Surface

2010-01-06T10:50:00.000-08:00

I've been thinking of a way to describe the interaction between genes, environment, and phenotype qualitatively as a mathematical surface.

In this model, the x-axis would represent the range of genetic variation relevant to a given trait. If it was a single gene, the x-axis could represent all existing gene variants in the population. Or, the idea could be extended such that the x-axis could represent all possible variants of the gene (including the absence of the gene, represented as "negative infinity" on the x-axis). The middle of the x-axis (x=0) would represent the average expression of the relevant gene in the population.

The y-axis would represent the range of environmental variation relevant to a given trait. y=0 would represent the average environmental history in the population. y="negative infinity" would represent the most extreme possible environmental adversity. y="positive infinity" would represent the most extreme possible environmental enrichment.

The z-axis would represent the phenotype. For example, it could represent height, IQ, extroversion, conscientiousness, etc.

In my opinion, current expressions of "heritability" represent something like the partial derivative dz/dx at x=0 and y=0; or perhaps, since the calculation is based on a population sample, heritability would be the average of derivatives dz/dx over various sampled (x,y) points near x=0 and y=0.

Conventional heritability calculations give a severely limited portrait of the role of genes on phenotype, since it condenses the information from what is really a 3-dimensional surface into a single number (the heritability). This is like looking at a sculpture, then being told that the sculpture can be represented by a single number such as "0.6", based on the average tilt on the top centre of the artwork.

A more comprehensive idea of heritability would be to consider that it is the gradient, a component of which is dz/dx. This gradient would not be a fixed quantity, but could be considered a function of x and y.

It is particularly interesting to me to consider other properties of this surface, such as what is the derivative dz/dy at different values of y and x? This would determine the ease with which environmental change could change a phenotype regardless of genotype.

A variety of different shapes for this surface could occur:

1) z could plateau (asymptotically) as y approaches infinity. This implies that the phenotype could not be changed beyond a certain point, regardless of the degree of environmental enrichment.
2) z could appear to plateau as y increases, but this is only because we do not yet have existing environments y>p, where p is the best current enriched environment. It may be that z could increase substantially at some point y>j, where j>p. I believe this is the case for most medical and psychiatric problems. It implies that we must develop better environments. Furthermore, it may be that for some genotypes (values of x), z plateaus as y increases, but for other genotypes z changes more dynamically. This implies that some people may inherit greater or lesser sensitivity to environmental change.
3) dz/dx could be very high near the origin (x,y)=(0,0), leading to a high conventional estimate of heritability; but at different values of (x,y), dz/dx could be much smaller. Therefore, it may be that for some individual genomes or environmental histories, genetic effects may be much less relevant, despite what appears to be "high heritability" in a trait.
4) dz/dx could be very low near the origin, but much higher at other values of (x,y). Therefore, despite conventional calculations of heritability being low, there could be substantial genetic effects on phenotype for individuals with genotypes or environmental histories which are farther from the population mean.

The idea of x itself being fixed in an individual may also not be entirely accurate, since we now know of epigenetic effects. Also, evolving technology may allow us to change x therapeutically.

In order to describe such a "surface", many more data points would need to be analyzed, and some of these might be impossible to obtain in the current population.

But I think this idea might qualitatively improve our understanding of gene-environment interaction, in ways that could have practical applications (current heritability estimates are typically 0.5 for almost anything you can think of--this fact seems intuitively obvious, but is not very helpful to inspire therapy or change, can sometimes increase a person's sense of resignation about the possibility of therapeutic change, and can distort understanding about the relative impacts of genes and non-genetic environment).

Non-human Primate Models of Psychiatric Treatment Effects

2009-12-08T12:07:00.001-08:00

Before starting the main body of my post, here's a little introduction:

I've been doing quite a bit of reading lately about the history of psychiatry (in particular, an excellent book by Lisa Appignanesi; I'll write a post about it when I've finished, which could be in a while, since the book is 5 cm thick!). Also I've been reading about cultural psychology (another very interesting field), after finding a free set of university lecture notes published online. I'd like to write another post about this subject as well, when I get around to it.

What does this have to do with "non-human primate models of psychiatric treatment effects?" Well, I'm becoming more strongly aware of the powerful effects of culture upon the manifestations of psychological (and, possibly, physical) health and distress. The book I'm reading deals with cultural change through history; these changes have influenced the presentation, management, and course of many psychiatric phenomena. Even terms like "psychiatric phenomena" or "symptoms," etc. are culturally influenced jargon. The cultural psychology subject also deals, of course, with cultural differences, but in this case mainly with the way different groups of people in the present era around the world experience or perceive emotions, psychological distress, social interactions, or cognitive processes. I suspect that cultural differences may exist between families as well, within the same geographical area.

These factors complicate the study of psychiatric therapies, perhaps in many ways that could be subtle but powerful.

I've been interested in finding more evidence about the effect of physical and psychological treatments for psychiatric symptoms in non-human primates. In this case, cultural or personal history biases could be much more carefully controlled.

There are a lot of studies done in rodents, of behavioural therapies and of medication, including a very questionable rodent "model" of antidepressant effectiveness. I think that possible conclusions are much more limited, about human therapies based on research done in mice, etc.

Monkeys or apes are much closer to humans, in terms of genetic similarity and brain structure. They may exhibit behavioural problems that are much more closely analogous to psychiatric symptoms in humans. So, I have been looking for good research about medication and "psychotherapy" effects in primates. Here's a start:

http://www.ncbi.nlm.nih.gov/pubmed/19383215

This 2009 article describes self-injurious behaviour in rhesus macaques. These animals may bite themselves severely; this is thought to be due to an underlying vulnerability combined with social deprivation in infancy or being isolated in captivity. About one-third of macaques experiencing solitary captivity exhibit self-directed stereotypic behaviour. The behaviour is exacerbated by separation from the social group, by disruption of daily routines, or by exposure to a fear-provoking stimulus (for animals, this could be an unfamiliar person trying to interact with them closely). It is interesting to consider that analogous behaviours in humans are probably related to similar vulnerabilities, deprivations, or triggers.

The experiment described in the article is about treating these self-injuring monkeys. Each group started off with 4 weeks of baseline observation, followed by 4 weeks of placebo, before randomization to fluoxetine, venlafaxine, or placebo for the final 4 weeks.

The individuals in the fluoxetine groups, at higher doses in particular, had substantial reductions in self-injurious behaviour (at least 50-75% less self-injury than the placebo group). The venlafaxine group did not improve as much.

There were no changes in "general behaviour" aside from a reduction in "aggressive displays." In particular, there were no signs of sedation or reduced engagement, etc.

I don't mean to make too much of results of this type, but I do think that this is strong evidence that the effect of an SSRI is not simply of an elaborate active placebo, influenced by cultural expectation. Also, just because a symptom is reduced doesn't necessarily mean a problem is solved...however, reducing a problematic behaviour such as self-injury may be a necessary prerequisite to resolving other types of psychological problems.

This type of study would be strengthened if it was extended for a year or more, and if it was to include data about other "quality of life" indicators, such as social integration, longevity, physical health, etc.

Here's another study, showing that tryptophan administration over a 4-week period substantially decreased self-injurious behaviour (again, by 50-75%) in small monkeys. There was also a decrease in previously high levels of cortisol. The dose of tryptophan was over 100 mg/kg per day, which would be a bit inconvenient to administer to humans:
http://www.ncbi.nlm.nih.gov/pubmed/19383216

Here's another study of self-injury in macaques. In this case, housing the animals outdoors led to significant reductions in self-injury. I think the message here could be that a healthy environment which optimizes freedom of movement, space, and natural sensory cues (e.g. of light, sound, and temperature), leads to diminished stress and and diminished symptoms of psychological distress. We could confidently generalize this statement to humans, I think.
http://www.ncbi.nlm.nih.gov/pubmed/16995645

Here is a relevant review on the subject of self-injury in human vs. non-human primates:
http://www.ncbi.nlm.nih.gov/pubmed/16713051

Here's an amusing (and, unfortunately, not very strong) study showing that hearing music leads to increased affiliative behaviour and decreased aggressive behaviour in chimpanzees. There were different degrees of responsiveness to different types of music:
http://www.ncbi.nlm.nih.gov/pubmed/17203919

I'll try to add to this post later. In the "psychotherapy" realm, some of the first important animal studies in primates were done by Harlow. I'm interested to find some more recent stuff in the research literature. I guess there won't be much on cognitive therapy in monkeys, since there is a bit of a problem encouraging non-human primates to keep written diaries with thought records...similarly, psychoanalytic studies are probably in short supply (!) Yet, in all seriousness, I suspect that the key elements for successful therapy in non-human primates involve positive, gentle, consistent relationships; and gentle, non-punitive behavioural education & modeling.

Authoritative, Authoritarian, and Permissive Self-Parenting

2009-11-22T09:05:00.000-08:00

Here's a nice summary of different parenting styles:
http://en.wikipedia.org/wiki/Parenting_styles

The authoritarian style is strict and dictatorial, with no dialog between parent & child.

The permissive or indulgent style is lenient, with little discipline or rules.

The authoritative style is balanced: there are clear rules, clear boundaries, which are consistently enforced, but lots of empathy, understanding, dialog, and flexibility. Strong consideration is given to the child's point of view.

I think these different styles could be applied to one's own individual mind -- I encourage aiming for a healthy, balanced, authoritative style.

Authoritarian styles will be oppressive, and foster resentment, unhappiness, anger, and rebellion within oneself (sometimes an "underground" rebellion manifesting itself as depressive self- harm).

Permissive styles could feel liberating, but could lead to an experience of drifting, with a lack of direction, without a feeling of growing or developing one's potential.

An authoritative style would lead to a healthy balance between freedom and self-discipline, allowing for growth, challenge, and happiness. It could also tame the wilder forces within your mind, not by suppressing them, but by hearing them and guiding them in a well-boundaried, safe context.

Becoming a "Self Whisperer"

2009-11-20T16:47:00.000-08:00

Well, you may accuse me of having sentimental tastes in film, but I really did enjoy the 1998 movie with Robert Redford, called The Horse Whisperer. It's about a reclusive Montana rancher who has an almost mystical ability to gently connect with and rehabilitate horses (and humans?) who are wild, traumatized, or out-of-control.

Since 2002, a dog trainer named Cesar Millan has called himself "the dog whisperer," and has a TV show, website, and has sold millions of books. His approach is basically one of gentle, calm authority: maintaining clear and consistent boundaries without losing one's cool or becoming excessively punitive. Mind you, I see that there is a little bit of debate about some of his techniques. And it's a bit dicey to apply animal training ideas to humans.

Recently, however, people have been trying to generalize these ideas a little bit, to the subject of parenting. Hence the idea of becoming a "child whisperer." Many parents have unhelpful interactions with their children: perhaps there are behavioural or discipline problems, but often times the parents are losing their cool, the parents are resorting to excessive and ineffective punishments, or the parents are giving a lot of praise but without any discipline. Sometimes the timing of praise or discipline is out of synch with the child's behaviour. Some methods of discipline may be harmful to both child and parent. Sometimes misbehaving children seem to be ruling the house, leaving the parents frustrated and exhausted. An exhausted parent in this situation may end up just spending less and less time parenting, in order to find distractions from the problems, or in order to escape. While respite is necessary, this tactic would of course make the parent-child dynamics even worse.

Here's an article from the New York Times on this:
http://www.nytimes.com/2009/11/22/fashion/22dog.html

I would like to generalize this idea one step further, to consider ways to become a "self whisperer."

This may involve nurturing a sense of calm, gentle understanding and authority over the various forces within your own mind:

-in this sense exercises to relax or meditate need not be considered exercises in tolerating an unhealthy state, but rather exercises to produce a stance of calm, loving, gentle authority, which is ideal in "self-whispering."

-part of the process may involve setting very clear boundaries within your own mind, without becoming excessively punitive, bossy, critical, or authoritarian towards aspects of yourself or others. Various therapy styles can help in this sense, including cognitive-behavioural ideas. Methods of non-harmful self-discipline may need to be learned and practiced.

-it can be important to have "respite", but it will be important "to do activities together" with the more challenging aspects of your mind, to be an effective "self whisperer." There needs to be time for reflective, empathic dialog with self, provided there is a benevolent structure, healthy boundaries, and clear safety rules.

--I'll have to edit this posting a bit, I think it's in a formative stage right now, but I thought I'd put it up here as the start of an idea I found enchanting in the moment--

Physical Warmth promotes Interpersonal Warmth

2009-11-19T14:21:00.000-08:00

In an amusing study by LE Williams and JA Bargh, published in Science in 2008, subjects exposed to warm objects behaved in a manner which was more interpersonally warm. Here is the reference:
http://www.ncbi.nlm.nih.gov/pubmed/18948544

In the first experiment described by the authors, subjects in the elevator on the way to the study lab were asked to hold an experimenter's drink cup for a moment, while the experimenter wrote some identifying information down on a clipboard. The experimenter in the elevator did not have knowledge of the study's hypotheses. In the study lab afterward, the subjects were given a brief written description of a person (the same description given to all subjects), and were asked to rate that person in terms of a variety of personality dimensions. The subjects who briefly had held a cup of hot coffee gave personality ratings that were significantly "warmer," compared to the subjects who had held a cup of iced coffee. The ratings for warmth were 4.71 out of 7 for the "hot coffee" group, compared to 4.25 out of 7 for the "iced coffee" group; these differed with a p value of 0.05. "Warmth" in this sense refers to traits such as friendliness, helpfulness, and trustworthiness.

The second experiment was more blinded, in that the experimenters did not know whether the subjects were handling a warm or cold object. This time, subjects were offered a choice of two types of gifts after the experiment: the first type would be for personal use, the second would be a gift for a friend. Those who had handled a warm object were substantially more likely to choose a gift for a friend, rather than for themselves.
Those who had handled a cold object chose a "selfish" gift 75% of the time.
Those who had handled a warm object chose the "selfish" gift 46% of the time.

The authors discuss attachment theory, and suggest that one explanation for these findings, on a neurobiological level, is that the insular cortex in the brain is responsible for processing information about both physical and psychological warmth, therefore the two types of warmth perception may influence each other.

I find this type of cross-sectional social-psychological research fun and a bit lighthearted, but often containing kernels of wisdom.

It would be interesting to do similar studies of this sort, but with different groups of subjects who are stratified according to interpersonal style, depressive symptoms, etc. Perhaps there are subjects who are most sensitive to these environmental effects.

I'm amused and delighted, in any case, that figurative or "metaphorical" warmth seems to match up with literal or physical warmth. A nice meeting of the metaphorical with the literal. Perhaps this is typical of what the brain does.

In any case, this little piece of evidence further supports the recommendation to do sensually pleasing, "warmth-oriented" activities, as part of a regimen for maintaining psychosocial health. There may be something in particular about heat which could be therapeutic. Hot baths are anecdotally helpful for relaxation, pain relief, and to promote deeper sleep. I've encountered a few examples in which people found saunas quite helpful for seasonal depressive symptoms. Maybe a very warm, cozy sweater can be helpful for your mental health, and even have positive effects on others!

Here are references to a few studies showing improvement in insomnia following hot baths:
http://www.ncbi.nlm.nih.gov/pubmed/10566907 {a 1999 study from the journal Sleep, showing improvements in sleep continuity and more slow-wave sleep earlier in the night, in older females with insomnia who had 40-40.5 °C baths 1.5-2 hours before bedtime}
http://www.ncbi.nlm.nih.gov/pubmed/15879585 {a 2005 study in the American Journal of Geriatric Psychiatry showing improved sleep in elderly people with vascular dementia, following 30 minute baths in 40°C water, 2 hours before bedtime}

A precipitant of some seasonal depression, at least in Canada, may be not only the darkness but the cold. The cold may lead not only to a disinclination to go outside, but also to a less generous or a "colder" interpersonal stance, which would further perpetuate a depressive cycle. This is another reason to heed that advice mothers often give young children, to dress warmly in the winter.

Here is a link to the abstract of a study from Japan, published in Psychosomatic Medicine in 2005: http://www.ncbi.nlm.nih.gov/pubmed/16046381

In this study, mildly depressed subjects were randomized to receive one of two treatments, 5 days per week, for 4 weeks, in addition to daily physical and occupational therapy:
1) "thermal therapy" in a 60 °C sauna for 15 minutes, followed by 30 minutes wrapped in a blanket, in a 28 °C room.
2) "non-thermal therapy" of 45 minutes in a 24°C room

The thermal therapy group had a 33% reduction in psychological symptoms, compared to a 14% reduction in the non-thermal therapy group.
The thermal group had a 42% reduction in somatic complaints, compared to an 8% reduction in the non-thermal group.

The research literature on this subject is quite limited, but there is some evidence that warmth--physical and psychological--is therapeutic!

Chocolate & Stress

2009-11-11T21:26:00.001-08:00

This is a sequel to one of my previous posts:
http://garthkroeker.blogspot.com/2008/10/chocolate.html

A recent study looked at various hormonal and metabolic changes associated with consuming chocolate. In this case, 30 people were given 40 g of dark chocolate daily for 2 weeks. The authors conclude that the chocolate consumption was responsible for reducing metabolic changes associated with stress, including cortisol and catecholamine excretion.

Weaknesses of the study include its brief, non-randomized, non-blinded nature (mind you, many of us would not easily be fooled by a placebo chocolate substitute!). And I see that the study is associated with the "Nestle Research Centre" in Switzerland. While I am pleased to know that a large chocolate company has a "research centre," I do have to wonder if there could be a higher risk of bias at play.

Here's a link to the abstract:
http://www.ncbi.nlm.nih.gov/pubmed/19810704

In the meantime, there is a variety of evidence out there that chocolate consumption in moderation is good for your health, in a variety of ways.

However, one concerning issue I just learned about has to do with lead contamination in cocoa and chocolate products. Lead is a heavy metal poison which should not have any presence in the diet. It can have widespread toxicity, particularly affecting the nervous system, through either acute or chronic exposure. The issue of lead in chocolate is discussed in mainstream research, such as by Rankin & Flegal (references:http://www.ncbi.nlm.nih.gov/pubmed/16757407, http://www.ncbi.nlm.nih.gov/pubmed/16203244). Based on some of this research, it may be true that raw, unprocessed cocoa nibs have no significant lead contamination, rather the lead in some cocoa and chocolate products may be the result of industrial processing.

Hopefully, manufacturers can address this issue, so that we can be reassured about safety, and so that we can get on with the enjoyment of one of life's great pleasures, knowing that it, in moderation, may also be good for psychological and medical health.

Why Cats Paint

2009-11-10T22:21:00.000-08:00

Why Cats Paint: A Theory of Feline Aesthetics by Heather Busch & Burton Silver.

I find this book a masterpiece of humour, a wonderful parody of art criticism, and also a simple entertainment for those of us who enjoy pets.

Have a look at the customer review comments from Amazon:
http://www.amazon.com/exec/obidos/ASIN/0898156122/qid=1005224759

More evidence about the impact of nutrition on mood

2009-11-05T16:14:00.000-08:00

An important paper was just published by Akbaraly et al. in The British Journal of Psychiatry, in which 3486 people were followed prospectively for 5 years, with an analysis of nutritional habits and depression symptoms. Here's a link to the abstract:
http://www.ncbi.nlm.nih.gov/pubmed/19880930

The data showed that individuals consuming a diet rich in "processed foods" (such as sweetened desserts, fried food, processed meat, refined grains, and high-fat dairy products) had a much higher rate of depression compared to those consuming a diet heavily loaded with vegetables, fruits, and fish.

The analysis controlled for confounding factors such as gender, age, caloric intake, marital status, employment grade, education, smoking, physical activity, hypertension, diabetes, and cardiovascular disease. A component of the analysis also strongly suggests that the association is not due to reverse causation, of depression leading to worse nutrition. Rather, the analysis strongly suggests that poor diet is a component of causation: that is, poor diet directly increases the risk of becoming depressed, or of having worse depressive symptoms.

Those in the third of people with diets highest in processed foods had a 58% higher chance of having clinical depression compared to the third of people with the healthiest diets.

So, once again, more evidence-based advice to eat healthily in order to protect your mental health:
-more vegetables, fruits, and fish
-less sweets, fried foods, white flour, whole milk, ice cream, etc.

Memory Games

2009-11-05T11:10:00.001-08:00

Here are a few links to some free memory games. They may be directed towards children, but I think people of any age could find them useful or fun exercises to improve attention & memory (or even better: you can devise your own memory games, to play with a friend, away from a computer screen):

http://faculty.washington.edu/chudler/chmemory.html
http://www.kidsmemory.com/memory_face_off/face_up_memory_game.php
http://www.kidsmemory.com/light_it_up/light_it_up_memory_game.php
http://www.kidsmemory.com/number_scrambler/index.php
http://users.netrover.com/~kingskids/memory.htm

Rhythm Practice

2009-11-04T15:25:00.000-08:00

There's a lot out there about various exercises or games you can do to keep your brain sharp.

I would like to compile a list of things for sharpening your mind that I think are interesting, which you can do at little or no financial cost.

I think that music practice can take many forms, many of which are not only intellectually stimulating, but also possibly quite meditative: a way to let go of worries or agitation.

Here are a few sites where you can do some rhythm practice (i.e. reading rhythms or imitating them). The difficulty is quite variable, from beginner to advanced:

http/www.emusictheory.com/practice/rhythmPerf.html
http://www.tedvieira.com/onlinelessons/sightreading101/values/reading.html
http://www.rhythmpatterns.com/

Swine Flu Anxiety

2009-11-02T13:00:00.001-08:00

While in the midst of an epidemic, a great deal of anxiety arises in the population.

Anxiety can lead to an exaggerated or inaccurate perception of risk, particularly when the mass anxiety is spread in the media, such as via front-page accounts of unexpected deaths.

In approaching any type of anxiety, I think it is important to know exactly what the risks are.

So, for example, it would be dishonest to tell an airplane-phobic person that air travel is perfectly safe. It isn't: there is about a 1 in 1 million chance of the plane crashing. (In a future post, I'd like to present my analysis of the statistics, and also show that the average spontaneous death rate in the population, for a person beyond young adulthood, exceeds the death rate from flying in an airplane--therefore I could claim--flippantly--that flying is statistically a "life-prolonging activity" for most travelers).

The current flu epidemic is clearly a serious matter. There definitely is a risk of death for those infected.

Estimates I've seen of the mortality rate vary, but the prevailing opinion seems to be that it is less than 0.1% (1 in 1000) for those infected.

This is not particularly different from the mortality rate of ordinary seasonal flu.

HOWEVER, the significant difference in this epidemic is the mortality rate by age. It is clearly true that swine flu has a higher mortality rate for healthy young adults--probably at least triple-- compared to seasonal flu.

Therefore, we are seeing more young, healthy adults die of flu this year. The total numbers are very low, but are much higher than in other years. The reason the overall mortality rate is the same is that fewer elderly individuals are dying of swine flu, most likely because of heightened immunity in that population due to exposure to a similar virus decades ago.

The CDC site shows that in a cohort of 268 people who died from swine flu early in the epidemic, 39% were in the 25-49 age group, and 25% were in the 50-64 age group. This is very different from seasonal influenza, in which about 90% of the deaths are in the over 65 age group. Here's a link to a pertinent page from their site:
http://www.cdc.gov/H1N1FLU/surveillanceqa.htm

Here's another important page from the CDC:
http://www.cdc.gov/h1n1flu/estimates_2009_h1n1.htm

Based on the table shown on this page, here are estimated risks of death for individuals infected with H1N1, stratified by age:
0-17 age group: between 1 in 10 000 and 1 in 20 000.
18-64 age group: between 1 in 2400 and 1 in 6000.
65+ age group: between 1 in 2300 and 1 in 6800.

I found a table of age-standardized "excess deaths" due to pneumonia and influenza in Italy between 1969-2001. (http://www.cdc.gov/eid/content/13/5/694-T2.htm) Based on this table, and assuming that only 10% of the population is infected during typical seasonal flu years, here is a very rough estimate of the risks of death by age for seasonal flu:
0-44 age group: 1 in 100 000
45-64 age group: 1 in 20 000
65+ age group: 1 in 750

The above data show that H1N1 influenza has a substantially higher death rate for those under 65 compared to seasonal flu, but as you can see the chances of dying if you catch the flu are still quite low, regardless of your age.

The risk of flu vaccines appears to be extremely low.
There is a substantial risk of contracting flu without the vaccine.
There is a low but non-zero risk of severe illness or death if you contract the flu.
The risk of a severe adverse reaction to the vaccine is much lower than the risk of a severe adverse effect from the flu itself.
The vaccine is likely to reduce the risk of contracting the flu by at least 90%.
Therefore, the benefit:risk ratio regarding the flu vaccine is very favourable. Here are references:
http://www.cdc.gov/h1n1flu/vaccination/safety_planning.htm
http://www.who.int/csr/disease/swineflu/frequently_asked_questions/vaccine_preparedness/safety_approval/en/index.html

So, my recommendations regarding swine flu anxiety are to be informed about the most accurate facts available:

1) the risk of death or severe illness remains low, for anyone infected

2) but the risk of a healthy young adult becoming severely ill or dying is relatively higher compared to seasonal flu

3) public health measures, such as very careful hygiene and mass vaccinations, are likely to save many lives (this is true of seasonal flu as well). Statistically, you as an individual are unlikely to contract severe flu illness. Hygiene and vaccine recommendations are more likely to be part of reducing the spread of flu in the population: therefore such recommendations, if you follow them, are statistically more likely to spare severe disease in someone else, rather than yourself. That is, if you receive a vaccination, that vaccination is more likely to save someone else's life rather than your own, since the average active case of flu is likely to spread to about 2 other people, even if the case is mild.

4) Therefore, I encourage following hygiene protocols and receiving the vaccine when it becomes available. It may spare you severe illness, and it has an even higher likelihood of being an altruistic act, which spares other people severe illness. Prompt use of anti-influenza medications such as Tamiflu are likely to further reduce the risk of severe complications, and most likely will further reduce the risk of contagion.

Altruistic acts, such as getting vaccinated or washing your hands, are psychologically healthy (this is my justification for posting something about influenza in a psychiatry blog!).

*It may be important to keep in mind, for the sake of perspective, that automobile accidents, for example, claim about 600 000 lives per year among young, healthy adults. In Canada alone, there are about 1000 deaths of young, healthy adults per year due to car accidents. (reference:http://www.statcan.gc.ca/pub/82-003-x/2008003/article/10648-eng.pdf) Another altruistic act of very practical importance is to slow down on the road!

Addendum:
A good article in the November 10, 2009 edition of CMAJ (p. 667-668) presents evidence that handwashing is not actually likely to be very effective in reducing the spread of influenza. Microbiologist Dr. Donald Low argues that hand hygiene has not been proven to reduce influenza spread, and that the influenza virus is primarily spread by fine droplets from coughing, which then have to be inhaled deeply. He points out that receptors for the influenza virus are located farther back in the respiratory tract, hence cannot be easily infected by touching mouth or eyes with hands, etc.
Here is an excellent article on the subject:
http://www.scienceadvice.ca/documents/%282007-12-19%29_Influenza_PPRE_Final_Report.pdf

His evidence-based position is that the N95 mask is the best mechanical way to prevent infection if you are near an infected person. Other than that, the best practice to prevent contagion would be to contain any coughing or sneezing, to stay away from other people if you are coughing, and to avoid close proximity with those who are infected, if possible.

Meanwhile, it is undoubtedly true that good handwashing practices do reduce the spread of the common cold and other infectious diseases. So all the handwashing and hand-sanitizing stations you see all over the place remain a good idea -- it's just that handwashing might not actually protect you very much from contracting influenza, compared to other measures.

Spread of psychological phenomena in social networks

2009-10-29T16:43:00.000-07:00

Here is a link to the abstract of an interesting article by Fowler & Christakis, published in the British Medical Journal in December 2008:
http://www.ncbi.nlm.nih.gov/pubmed/19056788

I think it is a delightful statistical analysis of social networks, based on a cohort of about 5000 people from the Framingham Heart Study, followed over 20 years. This article should really be read in its entirety, in order to appreciate the sophistication of the techniques.

They showed that happiness "spreads" in a manner analogous to contagion. Having happy same-sex friends or neighbours who live nearby, increases one's likelihood of being, or becoming, happy. Interestingly, spouses and coworkers did not have a pronounced effect.

Also, the findings show that having "unhappy" friends does not cause a similar increase in likelihood of being or becoming "unhappy" -- it is happiness, not unhappiness, in the social network, which appears to "spread."

So the message here is not that people should avoid unhappy friends: in fact the message can be that befriending an unhappy person can be helpful not only to that unhappy individual, but to that unhappy person's social network.

There has been some criticism of the authors' techniques, but overall I find the analysis to be very thorough, imaginative, and fascinating.

Here are some practical applications suggested by these findings:

1) sharing positive emotions can have a substantial positive, lasting emotional impact on people near you, including friends and neighbours.
2) nurturing friendships with happier people who live close to you may help to improve subjective happiness
3) this does not mean that friendships with unhappy people have a negative emotional impact, unless all of your friendships are with unhappy people.
4) in the treatment of depression, consideration of the health of social networks can be very important. Here, the "quantity" of the extended social network is not relevant (so the number of "facebook friends" doesn't matter). Rather, the relevant effects are due to the characteristics of the close social network, of 2-6 people or so, particularly those who have close geographic proximity. As I look at the data, I see that having two "happy friends" has a significantly larger positive effect than having only one, but there was not much further effect from having more than two.
5) I have to wonder whether the value of group therapy for depression is diminished if all members of the group are severely depressed. I could see group therapy being much more effective if some of the members were in a recovered, or recovering, state. This reminds me of some of the research about social learning theory (see my previous post: http://garthkroeker.blogspot.com/2008/12/social-learning-therapy.html)
6) on a public health level, the expense involved in treating individual cases of depression should be considered not only on the basis of considering that individual's improved health, function, and well-being, but also on the basis of considering that individual's positive health impact on his or her social network.
7) There is individual variability in social extroversion, or social need. Some individuals prefer a very active social life, others prefer relative social isolation. Others desire social activity, but are isolated or socially anxious. Those who live in relative social isolation might still have a positive reciprocal experience of this social network effect, provided that relationships with people living nearby (such as next-door neighbours or family) are positive.

I should conclude that, despite the strength of the authors' analysis, involving a very large epidemiological cohort, my inferences and proposed applications mentioned above could only really be proven definitively through randomized prospective studies. Yet, such studies would be virtually impossible to do! I think some of the social psychology literature attempts to address this, but I think manages to do so only in a more limited and cross-sectional manner.

Positive Psychology (continued)

2009-10-27T12:24:00.000-07:00

This is a response to a reader's comment on my post about positive psychology:
http://garthkroeker.blogspot.com/2009/10/positive-psychotherapy-ppt-for.html

Here's a brief response to some of your points:

1) I don't think there's anything wrong with focusing on pathology or weaknesses. In fact, I consider this type of focus to be essential. Imagine an engineering project in which structural weaknesses or failures were ignored, with a great big smile or a belief that "everything will be fine." Many a disaster has resulted from this kind of approach. I think of the space shuttle disaster, for example.

The insight from positive psychology though, in my opinion, has to do with re-evaluating the balance between a focus on "positivity" vs. pathology.

In depressive states, the cognitive stance is often overwhelmingly critical, about self, world, and future. Even if these views are accurate, they tend to prevent any solution of the problem they describe. It is like an engineering project where the supervisor is so focused on mistakes and criticism that no one can move on, all the workers are tired and demoralized, and perhaps the immediate, relentless focus on errors prevents a different perspective, and a healthy collaboration, which might actually definitively solve the problem.

2) I believe that pronouncements of the "right or wrong" of an emotional or intellectual position are finally up to the individual. It is not for me, or our culture, to judge. There will be all sorts of points of view about the morality or acceptability of any emotional or social stance: some of these points of view will be very critical or judgmental to a given person, some won't. I suppose there are elements of the culture that would harshly judge or criticize someone who appears too "happy": perhaps such a person would be deemed shallow, delusional, uncritical, vain, etc. I prefer to view ideas such as those in "positive psychology" as possible instruments of change, to be tried if a person wishes to try them. CBT, medications, psychoanalysis, surgery, having "negative friends" or "ditching them", etc. are all choices, change behaviours, or ways of managing life, which I think individuals should be free to consider if available, and if legal, but also free to reject if they feel it is not right for them.

In terms of the "gimmicky" nature of positive psychology, I agree. But I think most of the ideas are very simple, and are reflected in other very basic, widely accepted research in biology & behaviour. In widely disparate fields, such as the study of child-rearing, education, coaching, or animal training, it is clear that recognition and criticism of "faults" or "pathologies" is necessary in order for problems to be resolved. Yet the mechanism by which change most optimally occurs is by instilling an atmosphere of warmth, reward, comfort, and joy, with a minority of feedback having to do with criticism. The natural instinct with problematic situations, however, is often to punish. Punishing a child for misbehaviour may at times be necessary, but most times child punishments are excessive and ineffectual, often are more about the emotional state of the punisher rather than the behavioural state of the child, and ironically may reinforce the problems the child is being punished for. Punishing a biting dog through physical injury will teach the dog to be even more aggressive. I find this type of cycle prominent in depressive states: there may be a lot of internal self-criticism (some of which may be accurate), but it leads to harsh self-punishment which ends up perpetuating the depressive state. I find the best insights of "positive psychology" have to do with stepping out of this type of punitive cycle, not by ignoring the negative, but by deliberately trying to nurture and reward the positive as well.

3) The research about so-called "depressive realism" has always seemed quite suspect to me. In a person with PTSD (a disorder which I consider highly analogous to depression and other mental illnesses), very often there is a high degree of sensitivity to various stimuli, that may, for example, cause that person to be able to have better vigilance regarding the potential dangers associated with the sound of footsteps in the distance, or of the smell of smoke, etc. Often times, though, this heightened vigilance comes at great expense to that person's ability to function in life: a pleasant walk, a work environment, or a hug, may instead become a terrifying journey or a place of constant fear of attack.

Similarly, in depressive states, there may be beliefs that are, on one level, accurate, but on another level are causing a profound impairment in life function (e.g. regarding socializing, learning, work, simple life pleasures, spirituality, etc.).

With regard to science, I do not find any need to say that "positive psychology" etc. is about a biased interpretation of data. Instead, my analogy would be along the lines of how one would solve a complex mathematical equation:
-a small minority of mathematical problems have a straightforward answer. If one was to look only at precedents in data, one might conclude that there is no definable answer for many problems. A cynical and depressive approach would be to abandon the problem.
-but most complex problems today require what is called a "numerical analysis" approach. This necessitates basically guessing at the solution, then applying an algorithm that will "sculpt" the guess closer to the true answer. Sometimes the algorithm doesn't work, and the attempted solutions "diverge." But the convergence to a solution through numerical analytical methods is the most powerful phenomenon in modern science. It has permitted most every single major advance in science and engineering in the past hundred years. It is basically analogous to positive behavioural shaping in psychology. It is not about biased interpretation of data, it is about using a set of "positive" tools to solve a problem (in the mathematical case, to get numerical solutions; in the psychological case, to relieve symptoms, to increase freedom of choice, and to expand the realm of possible life functions available).

4) Some of the experiments are weak, no doubt about that. I don't consider experiments evaluating superficial cross-sectional affect to be relevant to therapy research. Experiments which evaluate the change in symptoms and subjective quality of life measures over long periods of time, are most relevant to me. I consider "positive psychology" to be just one more set of ideas that may help to improve quality of life, and overall life function, as subjectively defined by a patient.

In my discussion of this subject, I am not meaning to suggest that so-called "positive psychology" is my favoured therapeutic system. Some of the ideas may be quite off-putting to individuals who may need to deal with a lot of negative symptoms directly before doing "positivity exercises." But I do think that some of the ideas from positive psychology are important and relevant, and deserve to be adopted as part of an eclectic therapy model.

Marijuana

2009-10-23T15:16:00.000-07:00

I am updating this old post today, based on a couple of new studies published in 2009.

Marijuana use is quite common in the university population I see in my clinic.

It is my opinion that marijuana use is less dangerous than alcohol use, for the vast majority of people.

But, it is an acute intoxicant, which could make activities such as driving much more dangerous. Also, smoking marijuana undoubtedly causes harm to the lungs, though probably not quite to the same degree as smoking tobacco cigarettes (see references below).

There is strong evidence that marijuana use increases the risk of developing a psychotic disorder, probably by about 40%.

People who have a psychotic illness, or who have a family history of psychotic illnesses, are at higher risk for having new or continuing psychotic symptoms if they use marijuana.

Also, based on some of the evidence cited below, I would say that children and adolescents are probably much more vulnerable to negative, long-term emotional and cognitive effects from marijuana use. So I strongly recommend that adolescents and young adults abstain.

I commonly see individuals who use marijuana frequently, who have longstanding problems with motivation. Whether or not this association is caused directly by marijuana use, I do think that a redirection of motivational energy away from recreational drug use is likely to help increase energy for other creative life pursuits.

There is strong evidence that marijuana use is associated with more severe psychiatric symptoms, of almost every type; but much of this association could be due to the fact that persons with more severe symptoms are more likely to use marijuana, not the other way around. In any case, those who choose to use marijuana more regularly as a cultural pursuit may be surrounding themselves with others who have more severe symptoms.

There is some evidence that marijuana or other cannabinoids could be helpful to treat a variety of medical ailments. This evidence needs to be taken seriously.

Here is a brief survey of the very large literature on this subject:

This 2007 review from Lancet shows convincing evidence that marijuana use increases the risk of developing a psychotic disorder, and that the risk is dose-dependent (i.e. the more marijuana one uses, the higher the risk is of developing a psychotic disorder):
http://www.ncbi.nlm.nih.gov/pubmed/17662880

It concluded that the evidence is less clear linking marijuana to other problems, such as depression and anxiety: many of the studies looking at this did not sufficiently address non-causal reasons for the association between marijuana and other problems. For example, people who are more depressed or anxious may have a higher likelihood of using marijuana to treat their symptoms. Or, people whose cultural style may lead them away from conventional treatments for depression, may be more likely to use marijuana regularly.

In this 2008 review from the British Journal of Psychiatry, the authors conclude that marijuana use is associated with worse outcome in psychotic disorders--but they say that the existing studies show only an association, not causality. Once again, confounding variables may cause this association to exist:
http://www.ncbi.nlm.nih.gov/pubmed/18978312

Many other studies looked at populations who used different amounts of marijuana over time, and compared them in terms of various symptoms and intellectual functions, etc. Unfortunately, I find this type of retrospective analysis to be weak, and highly prone to confounding variables. In order to understand marijuana's long-term effects for sure, we would need to do a long-term, prospective, randomized, controlled study. Such a study would not be ethical, so it probably will never be done.

Here are some studies looking at risk to the lungs associated with marijuana smoking:

These studies show an increased risk of lung cancer in marijuana smokers:
http://www.ncbi.nlm.nih.gov/pubmed/19057263

http://www.ncbi.nlm.nih.gov/pubmed/18238947

These studies show a likely causal association between long-term marijuana smoking and obstructive lung disease:
http://www.ncbi.nlm.nih.gov/pubmed/18238947

http://www.ncbi.nlm.nih.gov/pubmed/17666437

A significant cannabis withdrawal syndrome is described in the literature, particularly for heavy, long-term users. The syndrome involves about 2 weeks of irritability, restlessness, and insomnia, which could be quite destabilizing for someone struggling with mood symptoms, therefore leading to continued marijuana/cannabis use. Here is a 2006 review of the subject:
http://www.ncbi.nlm.nih.gov/pubmed/16612207

Animal studies could add a little bit more information into the picture, since these have been done in a prospective, controlled fashion. Here is what I've found from the animal research literature:

This study showed that chronic marijuana exposure impairs spatial memory & learning in rats:
http://www.ncbi.nlm.nih.gov/pubmed/19179850

This study showed that chronic marijuana exposure impairs social and cognitive functions in rats, but especially when the period of exposure is during the pubertal ("adolescent") phase of development:
http://www.ncbi.nlm.nih.gov/pubmed/18782382

Another study showing that marijuana exposure may be particularly harmful to the "adolescent" brain:
http://www.ncbi.nlm.nih.gov/pubmed/15582916

This study from UBC suggests that high-dose cannabinoids increase emotionality and "sensitize the stress axis":
http://www.ncbi.nlm.nih.gov/pubmed/16442741

This study shows that a synthetic cannabinoid promotes neurogenesis in the hippocampus, and may have antidepressant and anxiolytic effects:
http://www.ncbi.nlm.nih.gov/pubmed/16224541

There are various references supporting the use of cannabinoids in treating pain disorders (especially neuropathic pain), spasticity, glaucoma, and nausea; some of these references are from major journals. However, I think this area is still one which requires ongoing
research to more clearly estimate benefits vs. risks, especially over long-term use.
Here is a reference to a good 2008 review of the pharmacology and potential therapeutic applications of cannabinoids such as marijuana:
http://www.ncbi.nlm.nih.gov/pubmed/18482430

This 2005 study from the prestigious journal Nature suggests that cannabinoids could reduce the progression of atherosclerosis (the main cause of heart disease):
http://www.ncbi.nlm.nih.gov/pubmed/15815632

In conclusion, I think that marijuana use is dangerous, and harmful to your health in a variety of ways, due to acute intoxication, increased risk of psychosis, possible cognitive side-effects, and lung damage. It may be particularly harmful to adolescents. As a cultural pursuit, it may distract people from other life activities, or meaningful life roles, just as any habit or addictive behaviour can. But it may have beneficial effects for a variety of medical problems. Perhaps some people even have psychological benefits from marijuana use -- I think the evidence is not clear on this point. More research is needed to gain a better understanding of the potential risks or benefits of cannabinoids, especially over longer-term use.

Addendum: a few recent prospective studies have demonstrated increased dysphoria, anxiety, tiredness, ideas of reference, and schizotypal symptoms as a result of marijuana intoxication. In particular, individuals with pre-existing schizotypal personality traits had a more substantial increase in schizotypal symptoms following THC exposure. This adds to an evidence base suggesting that marijuana use carries a significant risk of exacerbating a variety of psychiatric symptoms, particularly psychosis-spectrum symptoms, and particularly in those with risk factors for psychotic illness.
Here are the references, which are both from Psychological Medicine in 2009:
http://www.ncbi.nlm.nih.gov/pubmed/19017430
http://www.ncbi.nlm.nih.gov/pubmed/19335936