Optimal Learning & Training Schedules

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

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

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

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?

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

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

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

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

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

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

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

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.

Rating Scales: limitations & ideas for change

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

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?

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

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

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

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"

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

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

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

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

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

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

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

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

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.