Thursday, August 18, 2011


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.

Wednesday, August 10, 2011

Chronic Pain & Rumination

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: ; )

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: 

This study shows improvements in various types of chronic pain conditions, with greater improvements in symptoms when subjects practiced more at home:

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: 

This study shows a slight advantage for a mindfulness meditation program to treat back pain:

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:

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: 

Here's another study once again showing that mindfulness is specifically helpful to reduce rumination:

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:
chronic TMJ (jaw) pain:
severe back pain:
back pain (here, active behavioural/physical therapy was necessary for optimal improvement in performance, as expected):
chronic headaches:

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:   

Here`s a negative study on moclobemide for physical pain:

This study shows equivalent benefits from amitriptyline and duloxetine, with over 50% of patients having good pain relief in diabetic neuropathy:

This study shows benefits from duloxetine in fibromyalgia; again with over 50% of patients feeling much better, compared to about 30% with placebo:

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:

This study shows relief attributable to duloxetine in depressed patients with idiopathic pain symptoms:

Here, venlafaxine is shown to be an effective agent to prevent migraine headaches:

Venlafaxine shown to be effective in treating functional chest pain: 

A 2007 Cochrane review concluding that venlafaxine and tricyclics are effective for chronic pain: 

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:

A review of gabapentin treatment for neuropathic pain, affirming its usefulness, particularly at higher doses of 1800-3600 mg per day: 

This is a negative review article, showing that lamotrigine is unfortunately not likely to be useful in treating chronic pain:

An interesting study showing that pregabalin can reduce postoperative morphine requirement acutely:

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:

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:

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:

Tramadol can be identified subjectively as having opiate-like effects, but mainly at higher doses:

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):

An animal study suggesting that tramadol and anticonvulsants (in this case, specifically topiramate) can work synergestically (cooperatively) in relieving neuropathic pain:

Treatment of refractory major depression with tramadol monotherapy:

Rapid remission of ocd with tramadol:

Restless legs treatment with tramadol:

Treating catalepsy with tramadol:

Tramadol dependence :  in general these articles show that tramadol dependence occurs, but is significantly less likely than with stronger opiates:

There is a risk of serotonin syndrome with tramadol, particularly if combined with other serotonergic drugs, such as SSRI antidepressants:

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:

Here`s a similar recent study showing improved relief in chronic depression with a CBT style modified to target rumination: 

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.

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:

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:

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."