Friday, March 19, 2010

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

Blanco et al. published this study in the March 2010 issue of Archives of General Psychiatry.  Here's a link to the abstract: 

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

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

Here's the link:

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 ( 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?

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:

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:

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. 

Friday, March 12, 2010

Intellectual Lineage & the Sources of Therapeutic Ideas

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 or or ):  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.

Wednesday, March 10, 2010

Man's Search for Meaning

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...

Monday, March 8, 2010

Losing at the Olympics

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.

Wednesday, March 3, 2010

Book Review: Mad, Bad and Sad

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.