Wednesday, December 17, 2008

Social Learning Therapy

Here's another style of therapy probably under-utilized:

This is based on Bandura's work on social learning theory and self-efficacy.

The best examples along this line involve the treatment of phobias. Many approaches to phobias involve graded exposure (i.e. practicing the feared activities), cognitive therapy (examining and challenging thoughts which are associated with the fears), relaxation training, and medication (sedatives and antidepressants).

A neglected but extremely important component of therapy for phobias includes a social learning, or social modeling approach.

For example, a person afraid to swim would simply watch others swim, as a component of treating the fear. But, of course, this could just lead to the frightened person feeling left out, and heighten the sense of alienation or futility. A more effective social modeling experience would be for the person with the phobia to watch OTHER people with the same phobias learning successfully to swim. This could start off with watching videos, and move on to working directly with other people. It may not be convincing evidence that swimming phobia can be overcome just by watching a bunch of swimmers; but it may well be much more convincing evidence to watch other FEARFUL swimmers successfully learn.

If we see someone we feel is similar to ourselves do a difficult task successfully, we are more likely to be able to try or do that task.

I think this is one of the advantages of group therapy, provided there are abundant examples of individuals in the group who are beginning to cope well with their problem. Social modeling of this sort is a particular strength of 12-step groups, where individuals can see others struggling, sometimes slipping back, but finally succeeding, in a way that they can relate to and see themselves in.

Here are a few links to some sites dealing with Bandura's theories:
(this link summarizes some of Bandura's opinions about the influence of media violence, etc. on children's behaviour -- an important subject which could be generalized in many ways)
(a nice biographical sketch of Bandura and his ideas)

An introductory experience to something like a social learning therapy approach could involve looking at videos or documentaries showing individuals struggling with and resolving longstanding mental illnesses. This could be a source of inspiration, motivation, and hope. I would like to find some examples of documentaries of this type; if any readers are aware of good examples, please let me know.

I've just found one site that has a few videos (actually the site seems pretty mediocre to me, but I can't find a lot of other better stuff right now); I think the most pertinent videos to look at from here are in the "programmes" section and would be the case studies on page 3 about phobias (you have to log in to this site as a guest to get into the videos):

Relaxation Training

Here's another example of a therapy style that is probably under-emphasized.

Relaxation techniques are simple, straightforward, and intuitive. There is evidence that they work; here is a reference to a Cochrane review on relaxation techniques for treating depression:

As with most any other strategy to deal with psychological symptoms, I do believe that a lot of practice is required.

Many people abandon relaxation techniques because they do not work when they try them. I encourage persistence--it could take months of daily practice for these skills to become more effective, effortless, and automatic.

There are different styles of relaxation training out there, and I encourage people to do a bit of research, and try a few different types. There are self-help books on the subject, as well as audio CDs and videos. Joining a group or taking a course can be a good way to learn and practice as well.

The beauty of relaxation therapy is that there is no risk of harm, it is side-effect free. However, some people with panic or psychotic symptoms can feel uncomfortable with certain types of relaxation experiences. If this happens, I think it is a technical problem to work around, rather than necessarily a reason to abandon the technique altogether.

Neuroimaging Research

I think modern technology is wonderful.

We now have machines which can image the living brain and measure activity in different parts of the brain as events are happening.

Whenever there are interesting new measuring devices, there will be many research scientists who will compete for time on the machines, to conduct experiments.

In psychiatry, brain imaging has been an active area of research. Most every week there is something in newspaper headlines about brain imaging findings pertaining to human emotion, perception, personality, or behaviour.

I think such studies will eventually help guide us to understand and help a greater variety of problems, perhaps in a more proactive and specific way.

But, in my opinion, we are not nearly there yet. Functional imaging has few practical applications. And, in the excitement about seeing something light up on a computer screen, people are suspending common sense at times.

For example, the other day I was reading an article in the paper, which was citing an imaging study apparently showing that people had less empathy for those struggling with addiction, compared to those with other problems.

I would not doubt that many people truly do have less empathy for addicted indididuals. But in the article, the "proof" that people had less empathy was that some area of their brains, when scanned, showed less activity, when contemplating scenes depicting individuals with addiction problems. This imaging finding was used as a rhetorical device in the article.

This reminds me of trying to determine if people outside believe it is daytime or night-time, by making them wear hats that have solar panels on top, and measuring the intensity of light picked up by the solar panels during the day.
--i.e. such measurements are indirect, imperfectly correlated, and absurdly unnecessary--
People may certainly believe it is daytime when the solar panel is picking up the strongest signal. But does that mean that this evidence from the solar panel data is somehow more intellectually superior to simply asking the person what they think? The most direct measure is to ask the person outside "do you think it is day or night"? The solar hat is just silly. However, it might at times pick up a situation in which someone is lying or unaware. Even then, such a finding would merely warrant further investigation, and would hardly constitute proof of anything.

It is an obvious truth that changes in thought, emotion, and behaviour, will correlate with, or be the result of, changes in brain activity. Yet it is NOT an obvious truth that a change in regional brain activity--particularly with the relatively crude spacial and temporal resolution permitted by today's technology-- proves that there is a particular change in thought, emotion, or behaviour, or that such measures of brain activity have higher levels of validity than simply having a conversation with someone.

I worry that findings from machine-generated data may so dazzle the audience that it causes unwarranted persuasion to occur, despite the findings being vague or associative. People tend to be impressed by colourful pictures made by expensive machines. We can't let this kind of phenomenon cause us to suspend critical judgment.

A related example of this leaps to mind, in pharmaceutical marketing. There has been a lot of competition out there, in past decades, for companies selling antidepressants and antipsychotics. Typically, in a sales spiel, for a given drug, there would be information given such as:

"most receptor-specific"
or "dual mechanism of action"
or "highest potency"

These facts would certainly be true, and they would have the evidence to prove it. But -- the evidence does not actually exist that these facts are clinically relevant. Whether a drug is "receptor-specific" or not may not really matter at all in terms of how well the drug works. In fact, some drugs such as clozapine, are not "receptor specific" at all, yet work better than the others in its class. "Dual mechanism of action" actually refers to a drug affecting two different receptors (hence, actually it would be less "receptor-specific" yet the phrase is still used as a selling point). Venlafaxine is often marketed this way. Whether or not venlafaxine is a superior antidepressant because of its "duality" is hardly proven, yet the marketing catch-phrase can be compelling to many. And "highest potency" is almost always clinically irrelevant. A drug with smaller "potency" can simply be dosed differently, so that it produces the same effect as a "high potency" drug.

I wholeheartedly support ongoing imaging research, yet I think we need to be careful about inferring too much from the findings at this point.

Thursday, December 11, 2008

Finding Help

It can be hard to find help that suits you well.

Individuals seeking help sometimes ask me directly if I will see them. At this point, I am not able to see very many new patients; those new patients I do see have often been waiting a very long time, and because I work as part of the staff in a university clinic, I need to restrict new assessments or psychiatric follow-up to the university student population.

Here is some general advice about finding psychiatric care in the Vancouver area (maybe some of these suggestions could apply to other parts of the world too):

1) Find a primary care physician you are comfortable with. Many gp's (general practice physicians) are at least as capable as a great many psychiatrists, in terms of providing good, thorough, compassionate psychiatric care. A good gp should be a good listener, have a good knowledge of psychiatric conditions, be comfortable dealing with psychiatric problems, and be comfortable with some psychotherapy principles as well as with medications.

It can be hard to find a gp you are comfortable with. But it is probably a much easier task in most cases than finding a psychiatrist or other therapist.

2) Be familiar with other mental health resources in the community. In Vancouver this would include the community mental health teams and specialty clinics such as the Mood Disorders Clinic. Some of these resources may not offer follow-up but could at least offer some advice to help you and your gp move on with some new therapeutic ideas.

3) Be well-informed yourself, so that you can communicate your problems clearly to any new physician or therapist. If there is a past medical record, it can be helpful to have copies of this information yourself, which can speed up the process of a new person understanding your history.

4) Be open to alternative resources: other types of therapy or counseling outside of the medical or psychiatric system can sometimes be very helpful.

5) Be open to therapeutic ideas that might not necessarily be your first choice. For example, you might be referred to some kind of group therapy program, instead of to a 1-on-1 therapist (sometimes groups are more readily and immediately available). This kind of experience can sometimes be very helpful, and also help you become more connected with other resources. Many people are so insistent on wanting 1-on-1 therapy that they will not consider a group.

6) Be reminded that the hospital emergency rooms are always open, and help is available at any time. In most hospitals a psychiatrist would be available to see you for an urgent or life-threatening problem. Also, most hospitals would have other resources, such as social work, which could be useful to help with other circumstantial difficulties accompanying your symptoms. The emergency room experience can be chaotic and frustrating, though.

More links to some different Vancouver-area resources:

Friday, December 5, 2008

Antipsychotic Medications

Antipsychotic medications are frequently prescribed by psychiatrists. They help directly to reduce symptoms such as hallucinations, extremely disorganized thinking, suspiciousness, agitation, or delusions.

The first conventional antipsychotic medication was chlorpromazine, which began to be studied in the treatment of schizophrenia in the early 1950's. Many other antipsychotics were developed afterwards.

There is not much evidence that any one of the conventional, or "typical" antipsychotics works better than another. But there are differences in side-effects: some of these drugs--such as chlorpromazine-- are more sedating; others are less sedating but more prone to cause muscle stiffness--such as haloperidol.

All of the older antipsychotics cause an increased risk of developing a movement disorder called tardive dyskinesia, in which there is abnormal, involuntary muscle activity, often involving the mouth or tongue. Sometimes tardive dyskinesia can be irreversible. The risk is approximately 20-30% for individuals taking older antipsychotics long-term; the risk is probably higher in women, in the elderly, and in those with mood disorders.

I have not prescribed an old "typical" antipsychotic in years. But some people may have taken them for years, and may prefer to continue with them, especially if they are benefiting from the medication without having side-effect problems. They are still used quite frequently in hospitals, since they come in an injectable form which can more rapidly help to calm some extremely agitated patients who are unable to take oral medication.

In recent years, a new class of antipsychotics has appeared on the market; these are usually called "atypical antipsychotics". These include risperidone, quetiapine, olanzapine, ziprasidone, and clozapine (there are a few other newer ones, less commonly used in Canada).

Initial enthusiasm for these new antipsychotics led to various claims about their superiority over the older drugs for treating symptoms of schizophrenia. There is a lot of marketing money being spent on the atypicals. But there is more evidence right now that they actually don't work very much better than the old drugs, if at all. However, the evidence is quite clear that the atypicals have a smaller likelihood of causing movement disorders, especially tardive dyskinesia. For this reason, I consider them to be the drugs of choice to use when prescribing antipsychotics.

Because they are safer than the older drugs, the atypicals have been used quite liberally to treat other psychiatric symptoms aside from those of schizophrenia. They are probably useful mood-stabilizers to treat or prevent manic episodes in bipolar disorder, and there is also evidence that they can be useful adjuncts to treat symptoms of depression. Many of my patients, who may have mixed symptoms of anxiety, depression, primary insomnia, and emotional lability under stress, benefit from small doses of atypical antipsychotics, at least for short periods of time.

There is not much evidence showing that any one atypical antipsychotic is superior to another, with a few exceptions:
1) olanzapine may be slightly superior to other antipsychotics except for clozapine. However it has worse side-effects, including weight gain, which can sometimes be severe.
2) clozapine is without a doubt the most effective antipsychotic. For the majority, it works about as well as any of the others. But for a significant minority (maybe 30% of people) it is markedly superior, and leads to a vast, sometimes miraculous, improvement in symptoms and quality of life. However, clozapine has serious side-effect problems, including a small life-threatening risk that white blood cell levels can drop dangerously (agranulocytosis). Also there is a small but significant risk of seizures. So, at this point, the standard practice is to reserve clozapine for those who have attempted several other antipsychotic medications without adequate benefit.

Antipsychotic medications are imperfect. For the majority of people, they are helpful in reducing psychotic symptoms, and are tolerated reasonably well. For some, they almost instantly and completely relieve symptoms. For many others, they do not reduce symptoms very well, and may merely cause a type of unwelcome sedation. The sedation can feel like sleepiness, but often the most bothersome type of sedation from antipsychotics is a feeling of indifference, or emotional restrictedness. A common phenomenon among people struggling with schizophrenia or bipolar disorder is of stopping medications against medical advice -- often people stop the medications because they don't like the side-effects, and they don't feel feel that the medication is helping with respect to quality of life.

In any case, it is certainly true that it can take time for antipsychotics to work best. There is some evidence that a full therapeutic effect may accumulate over a period of at least 6 months. So I encourage people who are giving these drugs a try to be patient with them, to give them a chance. Also, there are a variety of options to choose from, and sometimes one drug can suit a person better than another. Dosing is another matter; sometimes larger doses deserve a thorough try; other times it can be worth trying a much smaller dose, which may work as well, with fewer side-effects, provided it can be stuck to consistently for a long trial (e.g. at least 6 months).

--a study summarizing the expected effects of a standard antipsychotic (in this case, chlorpromazine) in schizophrenia; in general, the evidence supports that relapse rates are reduced by at least 50%, with a modest improvement in quality of life and symptom control--
--an important study showing no advantage to quality of life among those using atypical antipsychotics, compared to those using older, typical antipsychotics, in fact the data from this study show a slight advantage for the older drugs--
--a summary of an important study showing a slight advantage of olanzapine over several other atypicals, and with the older typical antipsychotic perphanazine working as well as these other atypicals--
--a study showing no significant difference in effectiveness between risperidone and olanzapine--

--another large recent meta-analysis showing a slight advantage for olanzapine and clozapine--

--another major European study showing a slight advantage for olanzapine and clozapine over other antipsychotics--
--a study showing that extremely high doses of olanzapine (over 30 mg/day) may work as well as clozapine for treatment-resistant patients with schizophrenia; but the olanzapine caused more weight gain--
--a very recent study showing that clozapine is markedly superior to high-dose olanzapine for treatment-resistant adolescents--
--a study showing a reduced rate of tardive dyskinesia in patients taking atypical antipsychotics, compared to those taking typical antipsychotics. Of note, this study showed a risk of tardive dyskinesia in patients not taking any antipsychotic at all, and this rate was actually slightly higher than the rate in patients taking atypicals. This is consistent with some evidence that atypicals such as olanzapine and clozapine may actually be used to treat tardive dyskinesia--

--a nice long-term study showing that antipsychotic+mood stabilizer (in this case, fairly low-dose quetiapine plus either lithium or valproate) was much superior to antipsychotic alone or mood stabilizer alone in preventing relapses in bipolar disorder--
--a study showing that an atypical antipsychotic (in this case, risperidone) can reduce suicidal ideation and other symptoms when added to an antidepressant in treating depression--

It should be noted that the results of these studies, as with those from most studies, give us ideas about how groups of people with specific diagnoses respond to certain treatments. The studies rarely tell us how a particular individual would respond to a given therapy; I find that in clinical practice, sometimes one particular medication or therapy suits an individual much better than another, regardless of what the studies show. In this case I think the studies show that a whole variety of different medications--including the older ones--have a decent chance of working, and so I think this could instill some hope that it can be worthwhile for an individual to keep searching for the one that works best.