Thursday, April 30, 2009

Dietary Fat and Mood

Dietary fat is necessary for mental and physical health. Excessively lean diets may be mentally and physically unhealthy. A balanced diet, with abundant fruits and vegetables, at least 30% of calories coming from fat, and with carbohydrates coming from foods with a lower glycemic index (e.g. reducing amounts of simple sugars), is probably a sound recommendation for good physical and mental health.

The type of fat is important, though: trans-fats are particularly harmful (these are from hydrogenated oils including hydrogenated margarines). It is probably true that omega-6 fatty acids (present in vegetable or soybean oils), while necessary in moderation, are over-abundant in western diets. Saturated fats (such as from red meat and dairy) have been associated with worse health outcomes.

Yet, as I review the literature, I see that this assumption about saturated fat may not be as clear as what most people assume. I intend to review this literature more thoroughly, and add to this post later. It may be that saturated fats from plant foods such as coconut are more benign. And it may be that health problems associated with eating a lot of red meat are due to factors aside from the saturated fat content.

*As I look into the coconut oil issue, I see there is a tremendous amount of hype and salesmanship going on--it seems to be touted as some kind of miracle food, also with a variety of scientific claims (e.g. about medium-chain triglyceride content) intended to strengthen the persuasion. When I look into what the research literature has to say, there really isn't a lot out there. What is out there at this point is not very consistent. It is true that there are groups of people, such as in Polynesia, who consume a lot of coconut oils, apparently without developing high rates of heart disease. In any case, I think it is fair to say that coconut or coconut oil in small quantities could be reasonably included in a healthy diet.

Clearly healthy sources of fat include fish, olive oil, nuts, avocados, and canola oil.

There are several types of cholesterol in the blood, the main subtypes being LDL and HDL. High LDL is a risk factor for cardiovascular disease (e.g. heart attacks and strokes). HDL is considered "the good cholesterol", and it is quite clear that higher HDL levels reduce the risk of developing cardiovascular disease. It is possible to increase HDL by exercising regularly, maintaining a healthy weight, stopping smoking, increasing dietary intake of monounsaturated fat (e.g. olive oil & canola oils), and increasing soluble fiber in the diet (e.g. oats, fruits, vegetables, legumes). 1-2 drinks per day (but no more) of alcohol may favourably impact HDL levels and overall health. It is important to note that the actual cholesterol present in certain foods, such as eggs, has an inconsistent relationship with serum cholesterol levels (perhaps a stronger relationship in some people than others), and an even less consistent effect on health variables--so cholesterol content of foods need not be a particularly important variable to assess.

In this 1998 study from the British Journal of Nutrition, subjects initially consumed a diet with 41% of calories coming from fat, then half of these subjects switched to a low-fat diet with only 25% of calories from fat. The group with the lower-fat diet developed higher levels of anger, hostility, and anxiety compared to the group continuing the higher-fat diet:

In this 2008 meta-analysis from Annals of Behavioural Medicine, an inverse association is found between serum cholesterol levels and depression. It is an interesting and surprising finding, given that we recognize lower cholesterol levels as beneficial for your heart:

In this 2008 study, a group with chronic depression was compared with a group with normal mood, and it was found that depression was associated with lower HDL levels (i.e. lower "good cholesterol"), even after controlling for several confounding factors. This type of study is unfortunately a bit weak. Here's a link to the abstract:

Here's a reference to a 2003 article from Encephale reviewing some of the evidence about low cholesterol being associated with depression and suicide. The authors also suggest that inadequate omega-3 fatty acids compared to omega-6 fatty acids in the diet may be a contributing factor to higher rates of depression.

This is a small but convincing 2008 study which showed significantly lower cholesterol levels in suicidal patients with schizoaffective disorder, compared to non-suicidal patients with schizoaffective disorder, and compared to healthy controls. HDL (the "good cholesterol") was higher in the non-suicidal patients and in the control group. The groups did not differ significantly with respect to BMI, so the association between cholesterol and symptoms would not have been due to weight.

Here's another 2007 study showing low cholesterol levels in an elderly group with cognitive impairment, and in an elderly group with depression, compared to a healthy elderly group.

Here's a 2007 study showing strong association between higher HDL cholesterol and better physical functioning among the oldest elderly (over 80 years old):

Here's a 2004 review describing the many findings about higher HDL being associated with better physical and mental functioning in the elderly, and in particular that people who live over 100 years have higher HDL levels:

In this strong, prospective 2009 study following 1,468 nurses with type II diabetes, higher dietary saturated and trans fat intake, and a lower ratio of polyunsaturated fat to saturated fat in the diet, was associated with worse cognitive decline (those in the highest third of saturated+trans fat intake effectively aged an extra 7 years with respect to cognitive decline, compared to those in the lowest third):

Here's a similar 2004 article from Neurology showing worse cognitive decline associated with higher saturated fat intake, lower monounsaturated fat intake, and a lower ratio of polyunsaturated to saturated fat intake:

In this strong, prospective, randomized 2007 study from JAMA, a diet with a low glycemic load (e.g. reducing simple sugars and increasing complex, slowly-digested carbs) and 35% of energy coming from fat, was compared with a low-fat diet (20% of energy from fat), with follow-up over 18 months. The higher-fat, low-glycemic load diet led to better improvement (increase) of HDL levels, and considerably better weight control:

Wednesday, April 22, 2009

Studying & Practicing Techniques

The field of optimizing study or practice time is quite interesting. There are elements of wisdom from diverse points of view, such as from athletic trainers & coaches, elementary and high school teachers, musicians, and educational psychologists.

Here are a few ideas:

1) make a commitment to spend regular, frequent periods of time in study or practice

2) make your study or practice time interesting or fun

3) if your attention is failing, try to compete with yourself gently (e.g. put a mark on your page if you catch your attention wandering off); but also allow yourself brief breaks. In order to control this process (and to prevent your brief break from becoming a 6-hour break), you could use a timer. During breaks, you could rest quietly or go for a walk, perhaps reviewing in your mind some of what you have just learned. During periods of decreased attention, you may need to allow for more frequent breaks.

4) frequent review helps with memory consolidation. If you have just learned something, go back right away to remind yourself of it--maybe ask yourself, and answer to yourself, a few questions about it, rather than immediately plowing ahead with the next chapter.

5) Sleeping after learning improves consolidation of memory. Slow-wave sleep, which tends to occur in the first few hours after you fall asleep, is particularly important for memory consolidation. In one clever 2007 study published in the presitigious journal Science, subjects were exposed to an odor when learning a task. If they were exposed to that same odor during subsequent slow-wave sleep, their retention of the learning task was significantly improved. Here's the reference:
This suggests a simple aromatherapy technique to enhance your studying: infuse your study environment with a distinct, pleasant fragrance (for example, try an aromatherapy oil) -- then infuse your pillow with the same fragrance afterwards. During an exam or test, try infusing the same fragrance on your skin or clothes (just don't overdo it, or you might irritate the people writing their exams next to you!)

Furthermore, there is evidence that brief naps (60-90 minutes) in the middle of the day can help with memory consolidation, motor learning, and can also prevent the deterioration of mental and physical performance which tends to happen in a long day. Here is one reference about this:

6) choose a study or practice environment which is psychologically pleasing. This could include multi-sensory environmental manipulation, including access to healthy foods, smells, comfortable seating, quietness, soothing background noise, etc.

7) if part of the learning task requires repetition, make special effort to infuse the repetition with something imaginative.

8) if part of the practice is for exam preparation, etc. then you could try to mimic the exam environment repeatedly--e.g. by doing mock exams at the same time of day as the scheduled exam, or by doing these practices in the same physical location as the actual exam, if possible.

9) if the practice is for a performance, it can help to record yourself periodically; when you hear or look at your recording you may need to be critical but you should also consciously affirm the aspects of your performance that went well. Self-criticisms should never be in the form of a personal attack (e.g. "I'm stupid!") but should be gentle observations of areas to work on or change.

10) a tutor could be quite helpful, not merely to "teach you" but as a motivational figure to help you practice or study more efficiently or with greater enjoyment (along the lines of a personal trainer for fitness). A friend or study partner could have this type of role, provided the friend does not become a distraction from your work.

Tuesday, April 21, 2009

Good News

Here are a few "good news" websites:

There is so much bad news in the world today...

Yet, of course, the bad news is accurate: many people are doing many horrible things; whole nations are behaving badly; the whole planet is at risk for irreversible deterioration... It is important and healthy for us to be aware of the truth, even if the truth is difficult to hear.

This reminds me of the way depression can work, particularly chronic depression: the negative, cynical, painful, or pessimistic thoughts associated with depression may represent accurate truths about one's life or about the world.

It can feel frustrating, irritating, and shallow to simply ignore the negative thoughts or negative truths, and focus strictly on "happy thoughts." It can feel like mental manipulation to try to convert a negative observation into a positive one.

I believe that part of the solution is not necessarily to try to negate negative thinking. This would be like refusing to learn about the realities of global hunger, environmental pollution, or about a child being bullied in your neighbourhood, and just simply carrying on with a smile as though everything was fine. This is just denial--things have to be done about hunger, pollution, and bullies.

But I do believe that part of the solution is to be informed about positive news that is going on in the world...this requires very deliberate effort.

Human nature, and the human brain, tends to focus on things that are going wrong. This is a vital safety has kept us safe from predators and other environmental dangers over millions of years of evolution. This tendency shows up in news reporting--headlines are all about disasters, not about moments of sublime beauty or courage or hope. Disaster reporting sells more papers, it grabs our attention more strongly--that's the way our brains are made.

In order to have a healthy and balanced lifestyle we must actively inform ourselves of things that are going right, alongside whatever information comes to us about things that are going wrong. We must do this on a global scale, a local community scale, and on a personal scale (within our own thoughts or minds).

Many anxious negative thoughts represent strong over-estimations of risk (e.g. a fearful airline passenger may feel that the likelihood of crashing is 90%, when in fact the likelihood is 0.0001%); in cases like this an objective "cognitive therapy style" analysis and challenging of thoughts can be therapeutic and reassuring.

Cognitive therapy need not discount negative thoughts. An acknowledgment of a very negative reality may be an honest and frank therapeutic step.

But I think cognitive therapy for depression must allow space for seeking out things that are positive.

I invite you to check out some of the websites above, and seek out more (or better) sources of good news (let me know if you find some). I also invite you to pay attention to examples of "good news" in your community, in your daily life, and in your thinking.

Wednesday, April 15, 2009

Preparing for a psychiatry interview

There are many reasons to see a psychiatrist. There are different types of psychiatric interviews, depending on the situation and on the individuals involved.

A psychiatric interview is a chance to describe your history, examine your problems, review your symptoms in detail, and hopefully to make a plan for things to change.

You may feel reserved about sharing your personal history in detail until you have built up a greater trust in the therapeutic relationship. I think it is important to feel comfortable with your psychiatrist, and to know that you don't have to talk about certain things, or to answer certain questions, unless it is your wish to do so.

There are some elements of a psychiatric history which you can organize or prepare in advance, if you wish, and if these things are relevant to you:

1) charts or chronologies of specific symptoms
-if you have had a history of mood symptoms, it can be informative to prepare a chart showing how your symptoms have changed over time.
-your chart might start literally at your birth, continuing up to the present, with a graph showing how your mood has changed (e.g. showing when your mood has felt good, felt anxious, felt depressed, felt manic, etc.)
-a closer examination of the past few months, or past few years, could allow you to show mood changes in more detail
-underneath the graph of your symptom, you might include significant life events (e.g. losses, changes or problems in school, work, relationships, family, finances, etc.). This allows an examination of the relationship between life events and symptoms
-in another row underneath the graph of your symptoms, you might include any treatments you have attempted (e.g. starting, changing, or stopping any counseling, medications, or self-help)
-these charts could illustrate the long-term pattern of your mood, and illustrate what things might have helped or hindered your problems over the years
-if you have had medication treatments, it can be especially useful to see how your symptoms have changed in association with starting or stopping the medication

Here is an on-line example of a so-called "restrospective life chart": I find this particular chart cumbersome and cluttered--I invite you to make your own simple, personalized version of such a chart, with areas on the chart pertinent to your own specific symptoms or treatments.

There are various monthly mood symptom charts you can find on-line. I have included my own version of a monthly mood chart, which you could adapt according to your own symptoms. You can right-click on the chart above, select "copy image", then open your word processor and paste the image onto a new empty word processing file. To use my chart, you could circle the number most representative of how your symptom is on a given day; or make an oval over several numbers at once to show symptoms that have fluctuated during the same day; or you could gradually trace a line showing symptom changes, without circling the numbers, etc. I made my chart in a few minutes using Excel--you could make your own, with different categories relevant to your situation.

2) sometimes writing a narrative essay about your life can be a useful exercise to prepare for a psychiatric interview; however, you may wish to speak out this narrative during therapy sessions, rather than write it down in advance. You may find that you can do both: in the course of therapy, you may find elements of your written narrative to expand upon or emphasize more strongly, other new elements to write about for the first time, and other elements you may wish to retire from the foreground.

Tuesday, April 14, 2009

Interesting mental health journals

Here are a few journals I recommend following. At my university office I enjoy the luxury of full electronic access to these journals, but almost everyone should at least be able to find on-line abstracts (brief summaries) of articles from each journal. Browsing through some of these will give you a general idea of what's going on in research. There might be a few of these journals you will want to follow in more detail; for this I recommend a monthly trip to a local university library.

I may add to or modify this list over time.

General Psychiatry Journals:
The American Journal of Psychiatry:
Archives of General Psychiatry:
British Journal of Psychiatry:
Canadian Journal of Psychiatry:

II. Psychotherapy Journals:
Psychotherapy Theory, Research, Practice, Training:
American Journal of Psychotherapy:
Clinical Psychology and Psychotherapy:
British Journal of Psychotherapy:
Behavioural and Cognitive Psychotherapy:
Sexual and Relationship Therapy:

IV. Psychology Journals:
Journal of Personality and Social Psychology:
Journal of Educational Psychology:
Journal of Consulting and Clinical Psychology:

V. Journals pertaining to specific areas within mental health:
Eating Disorders: the Journal of Treatment and Prevention:
International Journal of Eating Disorders:
Schizophrenia Research:
Depression and Anxiety:
Journal of Personality Disorders:
Archives of Sexual Behavior:
The Journal of Sexual Medicine:

VI. Journals pertaining to general health and medicine:
American Journal of Clinical Nutrition:
American Journal of Epidemiology:
Journal of the American Medical Association:
Archives of Internal Medicine:
New England Journal of Medicine:
Science: (particularly the medicine & neuroscience sections)
Nature: (particularly the medical research & neuroscience sections)

Wednesday, April 1, 2009

Predictably Irrational - a book review with ideas about psychiatric applications

Dan Ariely has written an interesting book, based on his research, called Predictably Irrational (HarperCollins, 2008).

Ariely is an economist but his research is about human behaviour.

There are a lot of studies done over the past few decades in the field of social psychology, which illustrate very similar behavioural phenomena. Ariely's work reminds me specifically of the work of Robert Cialdini, a social psychologist who studied persuasion.

I think this work is important to look at, because it shows that there are powerful factors which influence our decision-making or judgment, which we may not be aware of. The factors are not mysterious phenomena residing in unconscious childhood memories, etc., but are fairly simple--here are some of Ariely's examples:

1) If a person has to choose between two things which are approximately equal (let's call them "item A" and "item B"), there is about a 50% chance of either one being chosen. Suppose a third thing is added, which is similar but modestly inferior to item A; let's call that thing "item A-". This third item could be called a "decoy". If a person has to choose one item out of this group of three, then item A is chosen much more often than item B (in Ariely's experiments, the "item A" gets chosen about 75% of the time).
These experiments show that our decisions are often strongly influenced by irrelevant comparisons.

2) If a cost of something is suggested, it causes us to form an "anchor" in our minds, such that we are more willing to pay that cost or thereabouts, regardless of the true value. This phenomenon is exploited in advertising. But I suspect that as a general principle, we may be influenced to choose something, or to invest a certain amount of energy or commitment into something, based on suggestions, precedents, or personal "anchors", instead of based on the "true value" of the thing.

3) People are much more likely to choose something that is "free" even if it is a worse deal than something else. Free offers substantially bias judgment. Ariel's studies show this nicely, in a quantitative way.

4) Monetary norms and social norms are conflicting motivators. Social norms are healthier and more powerful motivators. Motivations based on money are tenuous, shallow, and easily changeable. Motivations based on social goals are deeper and more stable. The corporate trend to optimize productivity by continuously monitoring worker output is a type of "monetary" strategy. On a social level, it is often offensive and demoralizing. If workers have a sense of social belonging in their workplace, and also a sense that their employer will care for them in a time of need, then the health of the entire system will be much stronger.

Social language can be a persuasive tactic in advertising though, typically through ads (such as with a bank, cable, or insurance company) which make it sound like your relationship with the seller will be something like with a friend or family member. Such advertising could seem persuasive to some, but I think most sellers would not behave like a friend or family member if you got sick and couldn't make your payment on time!

Ariely wisely encourages the development of healthier social goals in education -- to encourage
education as a means to participate in the improvement of society, rather than as a means to get higher scores on a standardized test, or to attain a higher-paying job.

5) Emotional arousal substantially increases the likelihood of making a risky decision. For example, his experiments showed that a random group of college students were about twice as likely to consider engaging in dangerous or illegal sexual activities if they were sexually aroused when asked about it. This phenomenon highlights the need for two types of protection: first, people need to be protected from the potential consequences of making rash decisions in the heat of passion (e.g. being equipped with condoms would protect against the risks of impulsively-chosen sexual activity).

Second--and this is a point that Ariely does not make--people cannot just learn about how to make decisions while in a cool, "rational" state. Perhaps it is important to teach people--through practice-- how to make decisions while in the heat of passion.

I think this is an important idea in a psychotherapeutic process: calm, gentle analysis of thoughts and emotions is valuable (whether this happens in a therapy session or in a CBT journal, etc.) but it may also be necessary to practice rational and healthy decision-making while in an emotionally heated state. This, too, can sometimes happen in therapy sessions, or in CBT journals, etc.

6) Procrastination. Ariely's studies with groups of students showed that a rigid, external imposition of regular deadlines led to the best grades. Requiring students to commit to their own set of deadlines, in advance, led to grades in a middle range. Having no deadlines at all, except for the requirement that all work had to be in by the end of the term, led to the worst grades. Those in the middle group who committed to regularly-spaced deadlines did as well as the first group. This experiment shows that people have a tendency to procrastinate (no surprise here!), and that a commitment to regularly-spaced deadlines is the best way to improve the quality of the work (whether this commitment is chosen by you, or imposed upon you).

I do suspect that there are individual exceptions to this -- I'd be curious to see a study to show this -- in which some people have a better experience with a bit less structure.

He gives a few good applications of this phenomenon: committing in advance to some kind of care plan (whether it be for your health, your car, your teeth, your finances, etc.) will make it less likely that you will procrastinate or forget to do these tasks (e.g. medical check-ups, oil changes, dental cleanings, etc.). With such a system, everyone benefits (e.g. you stay healthier, your car stays in good shape, the auto mechanics get regular work, etc.). The main problem with this is if you are being sold something that you don't really need. The solution is to be be well-informed in advance about the type of care that works best for your needs.

A psychotherapy frame is usually a regularly-spaced commitment of one's time--I certainly do find that people I see are more likely to engage in a beneficial therapeutic process if this kind of structure is in place.

7) Ownership. People have a tendency to value things more when they "own" them already (Ariely gives entertaining examples of studies showing this phenomenon in a monetary sense). This can lead to biased decision-making if the "owned" item is not valuable, necessary, or healthy. This is a similar phenomenon to loss-aversion. We don't like losing something, even if that something is not really good for us. Other social psychology research has shown that this principle applies to ideas as well: if we have espoused an idea, or a viewpoint, or an attitude, about something, we are much more likely to "own" this idea, and to stick to it. We are less likely to change our view, even if the view is unhealthy for us. I find such thinking patterns often involved in chronic depression.

This is definitely a phenomenon that occurs in a psychotherapy environment: therapy is an invitation to change. Even if the change leads to a better quality of life, people are resistant to change, and are more likely to hold on to systems of thought, perception, or behaviour, which perpetuate unhappiness.

8) People are more likely to choose things that seem to be disappearing. Ariely again demonstrates this phemonenon, using economic measures, in a clever experiment. We see this in sales tactics all the time, such as when we are warned that some item is selling out quickly, so we had better act soon! In life, we may tend to spend a harmful amount of time, energy, money, and commitment, keeping multiple options open: as a result, we may never get very far into any pathway we choose.

9) Stereotypes and expectations substantially affect behaviour and choice. In an amusing experiment involving a blinded beer-tasting test, Ariely showed that college subjects presented with two unlabeled containers actually preferred a beer that had been tainted by 10 drops of balsamic vinegar, over the untainted version. But if the students knew in advance that vinegar had been added, then nobody preferred the "vinegar beer". If we believe--or are persuaded to believe--that something is good or desirable, or that something is bad or undesirable (that "something" could be anything from toothpaste, to a new acquaintance, to a job, to our own self or our own skills), then we are significantly more likely to find our beliefs substantiated.

We need to have ways to "stand outside ourselves" at times, to reduce the biases caused by our own beliefs. I think that this, too, is one of the roles of psychotherapy.

10) Things that cost more tend to have a stronger effect. A more expensive placebo tends to be more effective than a less expensive placebo. This is an important, powerful bias to be aware of. This, too, can be a tool exploited by advertisers, in which the high price of their product is displayed prominently as a signifier of higher quality.

I have one major complaint about this book:

Ariely makes a few statements about medical treatments, including "when researchers tested the effect of the six leading antidepressants, they noted that 75% of the effect was duplicated in placebo controls." (p. 178) This claim is based on one single study, from a minor journal, published over 10 years ago, without considering other data from hundreds or thousands of other publications in the research literature. Furthermore, even if this 75% figure was accurate, the remaining 25% of the effect may be very significant for many suffering people. The psychological impact of Ariely's statement may be to cause skepticism and a dismissive attitude towards certain medical treatments, including antidepressant therapy. Ironically, Ariely would then be persuading people against something, based on a tiny, inadequate, and negatively-framed presentation of the evidence.

11) Randomly-chosen college students in Ariely's experiements had a strong tendency to cheat; but if these subjects were reminded of some kind of honour code immediately prior, they had a much smaller tendency to cheat. Based on his findings, he encourages a more prominent role for "honour codes" to reduce dishonesty. He observes that cheating is no trifling matter: fraud accounts for much more stolen money and property than all other forms of crime put together. Also, cheating is much more likely and pronounced if it is perceived to be indirect: people will cheat more if some kind of token is involved, even if the token is worth the same amount as actual money. Our society is evolving to use indirect currencies much more (various forms of credit, for example), which probably will increase systemic dishonesty.

The idea of an "honour code" may seem a bit odd or trite, maybe hard to take seriously. But I think its application could be imaginative and important, and could, at least in a small way, address something that is missing in many workplaces, homes, or individual lives. I suggest this not necessarily as a way to reduce dishonesty, but as a motivational tactic, that can remind us of ways to live healthily. Many workplaces or lives can be so caught up with being busy, competing, getting through the day, that a grounding sense of purpose is rarely contemplated.

An "honour code" in a psychotherapy frame could involve a formal set of statements for oneself, a "mission statement", which could guide choices, motivations, priorities, and attitudes over time.

So it could be an interesting exercise to write down, and answer for yourself:
"What are your morals/values/guiding principles?"
"What is it to be a good person?"
"How can I live honourably in a world which can be harsh and difficult at times, and in a life which can be harsh and difficult at times?"