Cymbalta

Cymbalta (duloxetine) is one of the newer antidepressants on the market. It is being quite aggressively marketed. I notice various lecturers speaking enthusiastically about its merits.

I am immediately wary of this phenomenon:
-new drug enters the market
-lots of advertising
-lots of money to pay for psychiatrists (some of whom, to my embarrassment, are mood disorders specialists) to give educational lectures about the new drug

...

-down the road, it is often found that the new drug is not quite as spectacular or good as everyone was thinking...
-most often, the new drug is effective and useful, but not qualitatively better than any other related drug
-the new drug becomes simply another option to try, that might work, or might not, for someone struggling with depression
-the new drug otherwise does not become a "first choice" for someone wanting to start a medication, because the many other drugs in its category (e.g. antidepressants) work just as well, on average


--my reading of the evidence is that duloxetine IS an effective antidepressant. It is an appropriate option for treatment-resistant patients who have tried many other medications. But it is no more effective than its competitors on average. I also do not see any compelling advantages with respect to side-effect profile. And it is more expensive! (of course it has more marketing dollars behind it right now, but should this be a reason to consider it first?)
--it is also being marketed for treating pain syndromes -- yet there are few studies comparing duloxetine with other existing antidepressants, for treating these pain syndromes -- so its apparent advantage may simply be due to the fact that no one has done adequate comparative studies including other treatments.

When looking at references regarding a new treatment, the interested reader should take a look at who the authors are, who sponsored the research (was it the drug company?), how often the authors have been involved by industry-funded research, and how frequently the authors have received money for giving lectures supporting the use of the new treatment. Also, look carefully at what the paper is saying as a conclusion vs. what the data from the paper shows: do the authors try to aggrandize the new drug using words (e.g. "this verifies that... is effective and safe, ... ") while the data from the very same study actually show that the new drug is not actually any better than the old drug?
Also, if the study is comparing one drug with another, are the results biased? For example, did the study protocol only allow a limited, less-than-optimal dose of the comparison drug?


Here are some references:
http://www.ncbi.nlm.nih.gov/pubmed/16867188
http://www.ncbi.nlm.nih.gov/pubmed/16189284
http://www.ncbi.nlm.nih.gov/pubmed/17445831
http://www.ncbi.nlm.nih.gov/pubmed/18850765
http://www.ncbi.nlm.nih.gov/pubmed/17563128
http://www.ncbi.nlm.nih.gov/pubmed/18545055
http://www.ncbi.nlm.nih.gov/pubmed/17559729
http://www.ncbi.nlm.nih.gov/pubmed/17472599

Vitamins & other nutritional supplements

There are many people who believe that nutritional supplements can help with a variety of health problems. There is a field called "orthomolecular psychiatry", in which the practioners believe that vitamin supplements and other nutritional adjuncts can treat mental illnesses. I consider many of these beliefs to be spurious, and to be lacking a significant evidence base. I think many of those who benefit from these treatments are experiencing a combination of a placebo effect, and are perhaps benefiting from the psychotherapeutic care involved as well. Perhaps some of these individuals are also benefiting from not having the side-effects of other conventional therapies that were not working for them.

Here is a look at the evidence regarding vitamin supplementation; I restrict any references to journals that I consider to have a high professional standard:

1) Folic acid. There are a few studies which suggest that folic acid supplements may help augment the effectiveness of antidepressants. Here are a few references:
http://www.ncbi.nlm.nih.gov/pubmed/10967371
(in this study, adding 0.5 mg of folic acid daily to the antidepressant fluoxetine, improved depression severity, in women only)

http://www.ncbi.nlm.nih.gov/pubmed/15323594
and
http://www.ncbi.nlm.nih.gov/pubmed/15323595

(In these studies, low folic acid levels were strongly associated with resistance to fluoxetine treatment and more frequent depressive relapse. However, I am curious to know if this is merely an association--that is, whether the low-folic acid level group had other factors such as generalized poor nutrition or self-care, etc. that caused them to be more treatment-resistant.)


2) Thiamine (vitamin B1)
Thiamine can treat and prevent an extremely severe neurological syndrome called Wernicke-Korsakov encephalopathy; this syndrome occurs in nutritionally-deficient alcoholics, and causes devastating, permanent, sometimes total inability to form short-term memories. But there is not a lot of evidence about using thiamine to help other psychiatric disorders. Mind you, it hasn't been studied much. There are a few studies in the elderly, which suggest that thiamine supplementation helps with energy and well-being:
http://www.ncbi.nlm.nih.gov/pubmed/1986037

3) Other B vitamins:

Here's a study showing a relationship between folic acid levels--but not any other B vitamins or omega-3 fatty acid levels--and depressive symptoms in a group of Japanese adults.
http://www.ncbi.nlm.nih.gov/pubmed/18061404

Vitamin b-6: High doses may cause damage to sensory nerves, and I would not recommend taking more than 10 mg daily. Most daily multivitamins have about 3 mg. The toxicity is quite clear for doses over 100 mg/d.

http://www.ncbi.nlm.nih.gov/pubmed/16320662

http://www.ncbi.nlm.nih.gov/pubmed/14584010

Here is a reference to a new study including over 5000 women, over 7 years of follow-up, from Archives of Internal Medicine. It showed significantly reduced rates of macular degeneration in a large cohort of people taking high-dose b-vitamins (2.5 mg/d of folic acid; 50 mg/d of b-6; 1000 mcg/d of b12):
http://archinte.ama-assn.org/cgi/content/full/169/4/335

4) Vitamin D
There is accumulating evidence that higher doses of vitamin D are beneficial for a variety of health variables. Also, it is becoming apparent that many people are vitamin-D deficient, especially those who live in northern climates. Most supplements contain 400 IU, but probably a dose of at least 1000 IU daily could be recommended. Doses less than 10 000 IU have not been associated with toxicity, according to my review of the evidence, but we could conservatively say that doses up to 4000 IU daily are very likely to be safe, unless there is some medical disorder present (e.g. sarcoidosis) that causes a disturbance in calcium metabolism. Here is a very interesting and promising recent study suggesting beneficial mood effects from higher-dose vitamin D supplementation; the study is from a major, highly respected internal medicine journal:
http://www.ncbi.nlm.nih.gov/pubmed/18793245


It should be emphasized that more is not always better! Many vitamins cause toxicity if they are taken in excess. Also, some of the studies are showing that groups who took certain vitamin supplements (such as vitamin E and beta-carotene) actually fared more poorly, rather than better.
http://www.ncbi.nlm.nih.gov/pubmed/12876090

http://www.ncbi.nlm.nih.gov/pubmed/16645413

5) Omega-3 fatty acids
There is some evidence that omega-3 supplementation (containing the fatty acids EPA & DHA) can help reduce depressive symptoms, particularly in those with bipolar disorder. Omega-3 fatty acids can be found most abundantly in fish such as salmon. Plant sources include canola oil, flax, and walnuts (however, the plant sources only have one of the 3 types of omega-3 fatty acids). Here's a link to recent Cochrane Review abstract:
http://www.ncbi.nlm.nih.gov/pubmed/18425912
Here are some links to other reviews:
http://www.ncbi.nlm.nih.gov/pubmed/17685742med_RVDocSum

http://www.ncbi.nlm.nih.gov/pubmed/18370571
However the evidence appears to be fairly weak at this point, there may be some publication bias (i.e. studies showing no effect may not have been published) so more research really needs to be done. In the meantime, though, omega-3 supplementation (usually in the form of fish oil capsules) appears to be harmless, and potentially beneficial. The dose corresponding to what many of the studies used is about 3-6 grams of salmon oil daily (usually 3-6 capsules, each of which containing 1 gram).

Omega-3 supplementation may be beneficial in other ways--it may help protect against macular degeneration (vision deterioration during old age). Also there is some data showing that higher omega-3 intakes, or fish consumption, may slow the rate of cognitive decline in old age. Here's the best such study I could find showing this:

http://www.ncbi.nlm.nih.gov/pubmed/16216930

I suspect that some of the benefits from increasing omega-3 intake could be augmented by consuming a diet in which other unhealthy lipids are minimized--this would involve reducing omega-6 intake, eliminating trans fatty acids, and moderating the intake of saturated fats. I invite the interested reader to research this subject further.

Insomnia

Sleep problems can be frustrating and exhausting. Sometimes a person can have trouble sleeping for no apparent reason, and with no other associated symptoms.

More commonly insomnia is a symptom associated with another medical or psychiatric problem. Here are some of the causes of insomnia:

A) Physical Medical Problems
Here's a partial list:

• any painful condition

• infectious diseases (anything from a common cold to any more severe disease)

• endocrine disorders (e.g. hyperthyroidism)

• respiratory diseases

• bladder or kidney problems (e.g. causing a need to use the bathroom in the night)

• heart disease (e.g. in heart failure it may be very uncomfortable to lie flat)

B) Psychiatric Problems

• depression

• anxiety

• psychotic disorders

• mania

• situational stress

• substance use disorders

• specific sleep-related disorders such as sleep apnea or narcolepsy

• post-traumatic stress disorder (e.g. in which the past trauma occurred at night)

C) Environmental Problems

• uncomfortable bed, bedding, or pillow

• noisy bedroom at night

• too much light in the bedroom (e.g. street lights shining through a window)

• too hot, too cold, poor air quality, etc.

• sleeping next to someone who snores loudly or moves around a lot during sleep

In the management of insomnia, it is important to consider all of the above categories. A medical check-up to rule out or start treatment for physical diseases will be important. All possible improvements to the bedroom environment should be made. Evaluation and treatment of other psychiatric symptoms or conditions is important. If there is any question of breathing problems during sleep, or of a specific sleep disorder such as narcolepsy, then other tests may need to be done, such as an overnight sleep study.

For some people with allergies, I have found at times that a simple measure--such as starting a nasal spray at night which allows for easier breathing, or starting an antihistamine--can be a remarkably effective relief for insomnia and resulting mood/energy problems.

Beyond this, there are specific ways to manage sleep problems:

1) Careful documentation of exactly what is happening with sleep:
A sleep log can be very useful. In the sleep log, you can keep the following records for each day:
a) what time you went to bed
b) what times you were actually asleep
c) what time you got out of bed
d) what times you spent in bed or asleep during the daytime
e) your assessment of how good the quality of your sleep was
You can keep your log in the form of a chart, with sleep times indicated by a solid bar going across the chart, and times spent awake represented by interruptions in that solid bar. Here are some examples of a sleep log:
https://www.healthatoz.com/ppdocs/us/cns/content/atoz/tl/misc/sleeplog.pdf
http://www.snoozeorlose.com/index.php?id=40

2) Behavioural treatments:

• maintaining a constant wake time: it may be impossible to control when you fall asleep, but it is possible (even if difficult) to control when you wake up and get out of bed. If you are out of bed at the same time every morning, you will be more sleep-deprived after a night of insomnia, and will therefore have an easier time sleeping the next night. If you allow yourself to sleep in after a night of insomnia, you will not be as sleepy, and will have a harder time sleeping the next night.
  
• If you have a hard time waking and getting out of bed at the same time every morning, external stimuli can help, such as a timer circuit which turns on a bright light next to your bed in the morning, or even an automated coffee machine which starts at the same early time.
  
• leaving the bedroom if you are having a hard time sleeping. Otherwise there is a conditioning effect in which your brain associates your bed with being awake. Go back to your bed when you feel more sleepy.
  
• avoiding wakeful activities in the bed, such as watching TV or reading. Do these things in another place.
  
• avoid or minimize napping. If you must nap, keep it earlier in the afternoon if possible, and as brief as possible.
• sleep restriction: for example, if you are in bed for 9 hours per night, but are only asleep for 5 of those 9 hours, then you can try going to bed exactly 5 hours before your planned wake time. This strategy is intended to cause you to become more sleepy before you go to bed, to have deeper sleep while you are in bed, and to spend less time lying awake in bed. If this strategy works, a next step can be to gradually start going to bed earlier in order to extend the total number of sleep hours. It is harder to adjust to an earlier bedtime, so this process has to be very slow, perhaps trying a bedtime 15 minutes earlier than your previous bedtime, then sticking with it for a week or so, before adjusting again.
  
• morning exercise -- here's a link to a study showing this: (http://www.ncbi.nlm.nih.gov/pubmed/14655916)
  

3) Cognitive Treatments

• There are many thoughts which occur in the midst of insomnia; some of these thoughts can perpetuate the insomnia, or be part of a vicious cycle. For example, as you lie awake you might think:
• - "oh, no, not again! I'm still awake! I'll never be able to function tomorrow!"
• -"It's 3:21. I've been awake for 57 minutes. I have only 3 hours and 39 minutes before I have to get up."
• -"I can't slow down my thoughts! I'll never fall asleep!"
• -"No matter what I do, I still can't sleep."
• In working on insomnia cognitively, it is important to "talk back" to all of these thoughts in a way which is brief, without becoming an inner intellectual debate (this would be another example of a cognitive process which would keep you awake). Much of the "talking back" might involve reassuring yourself, accepting the thoughts and then letting them go, letting go of the need to control your thoughts, and accepting that sleep will happen on its own without your intellectual input, or regardless of whether your thoughts are active or not.
  

There is some solid evidence that cognitive-behavioural techniques are effective in treating insomnia. Here are some references:
http://jama.ama-assn.org/cgi/reprint/295/24/2851
http://jama.ama-assn.org/cgi/reprint/285/14/1856
http://archinte.ama-assn.org/cgi/reprint/164/17/1888

4) Other physical treatments

• Light therapy: use of a 10 000 lux light box for 45 minutes in the morning can help with night-time insomnia. Here's a reference:http://www.ncbi.nlm.nih.gov/pubmed/15172210
• There is some evidence that using a light box in the EVENING can help "early morning awakening insomnia". In depressed states, waking too early in the morning is a frequent sleep disturbance. It could be an interesting and low-risk therapy for this to use evening bright light. Here's a reference: http://www.ncbi.nlm.nih.gov/pubmed/16171276
  
• There is a lot of evidence that sedative medications are effective short-term treatments for insomnia. Mind you, some of the evidence is not as robust as one might think it should be. Unfortunately, most of these sedatives tend to be habit-forming or addictive. And tolerance tends to develop to the sleep-promoting effects.
  
• Sedating antidepressants (e.g. trazodone, amitriptyline, doxepin, mirtazapine) could be useful in selected cases. Sedating antipsychotic medications in low dosages can also help sometimes (e.g. quetiapine). There is some current interest in very low-dose doxepin for treating insomnia, because it appears to have a very selective antihistamine effect at these doses; here's a link to an abstract about this-http://www.ingentaconnect.com/content/apl/eid/2007/00000016/00000008/art00014
  
• Melatonin: There is some modest evidence that melatonin can help with insomnia, with few side-effect problems. Here's a link to a study, in which they were looking at the effectiveness of 2 mg of prolonged-release melatonin: http://www.ncbi.nlm.nih.gov/pubmed/18036082
  

Journaling

I think it is beneficial to journal.

A journal can become a sort of relational experience, in which the journal becomes your confidant; in this way the journal experience becomes something similar to a psychotherapy experience (e.g. the journal may become a non-judgmental, accepting, well-framed safe place for exploring ideas, feelings, joys, and problems).

As with all other relational experiences, some tactics can work better than others:

A psychotherapy experience is likely to be quite limited if the only things spoken are descriptions or repetitions of problems, with no response from the therapist.

Likewise, I believe that a journaling experience will be very limited if it involves only the documentation of problems or sorrows.

I think the experience of journaling can be much more powerful and therapeutic if "the journal" can offer empathy, support, or advice. Here, the "point of view" of "the journal" would need to be composed by you, the author.

A cognitive-behavioural model of journaling can include this idea more clearly: here, every problem or issue related in the journal would be written in one column, with the adjacent column devoted to "talking back" to the problem or issue, either through reassurance, empathy, advice, analysis, problem-solving approaches, etc. It may seem not to be very genuine to "force" such a "talking back" when you may not feel in any mood to write down a supportive comment about your journal entry. But as an exercise, frequently repeated, it can start to train your mind always to "talk back" to various symptoms, recurring negative thought patterns, or "negative self-talk".

So I encourage such a style of journaling, in which every sorrow or symptom is always "talked back to" in the next column.

Another role of journaling can be as a creative outlet, which I think is independently therapeutic. Here, the journal could include descriptions of your day, but also other creative forms such as poetry, drawings, photographs, video, audio recordings, other media, etc.

It can be satisfying to have an experience of your journal as a place to do work and have a sense of accomplishment. The beginning of the accomplishment can be simply to maintain the frame of keeping your journal regularly. Further accomplishment comes from your journal becoming a place in which problems are addressed, examined, worked through, and solved. Or a place where the joys of your life can be celebrated.

Politics & Economy in the Mind

Different political styles, views, and beliefs could be considered different strategies or algorithms to solve problems.
So-called "right-wing" beliefs may include the following features:
1) strict rules
2) a clearly polarized distinction between "right" and "wrong"
3) perhaps an emphasis on facilitating the progress of the most "elite" members of the group (whether this be in an economic sense, or in terms of other types of accomplishment). The thinking could be that if the "elite" are flourishing, then the entire society will ultimately flourish, either through a "trickle-down" effect, or through a type of "natural selection" process.

Disadvantages of the right-wing strategy include the following:
a) the "elite" groups may be "elite" for unfair reasons (e.g. luck; born into a rich family, despite a lack of earned merit). Or the "elitism" may be founded upon a skill which benefits merely the individual but which may have a detrimental effect on the community as a whole (e.g. an unscrupulous businessperson who may maximize profits through narcissistic and bullying disregard towards others, towards the environment, towards the law, etc.)
b) the "trickle-down" effect may not actually work in all cases. The rich may simply get richer, and the poor get poorer.
c) The strict rules may cause a rigidity to the culture which leaves various groups feeling excluded, marginalized, or persecuted.
d) The so-called "natural selection" may either occur at the cost of great suffering for many individuals, and therefore be morally intolerable--or the "natural selection" may not occur at all, paradoxically (here, the literal example would be that birth rates in highly advantaged groups are usually lower than birth rates in disadvantaged groups).

So-called "left-wing" beliefs may include the following features:
1) more flexible rules
2) an emphasis on investing society's energy in all members of the group, so as to directly support those who are struggling most. The thinking here is that if everyone is supported equally, then the entire society will flourish.

Disadvantages of the "left-wing" strategy include the following:
a) the strategy may be inefficient, and in some cases may discourage excellence. For example--by analogy but perhaps also literally--if there is a group of athletes wanting to train for the Olympics, but there are only a few trainers or facilities, the "left-wing" model might give every athlete equal training time. The star athletes would get only a mediocre ability to train, and therefore would never excel as they could have. Or, entire areas of human excellence might never be developed: space travel to the moon, heart or brain surgery, organ transplantation, etc. might never happen because they are expensive, might not be seen as efficient ways to invest energy, time, and money, and they would require the formation of a type of "elite" group (e.g. astronauts, heart surgeons, etc.). This inefficiency may certainly happen in some forms of "left-wing" economic management.

Most groups, be they nations, cities, clubs, or families, have some mixture of strategies, between the extreme "right wing" and "left wing". Perhaps part of the choice of style is determined by the cultural history of the group, though part of it could be determined by the active choice of the group.

Mind you, it seems to me that many people's positions on these matters are highly influenced by factors such as what their parents or peers think, or even by inherited predisposition--see the following twin study :

Alford, John R., Carolyn L. Funk, and John R. Hibbing "Are Political Orientations Genetically Transmitted?." American Political Science Review, 99 (2005, May): 153-167.

The study shows a significant contribution of inherited factors which influence a person's ideological stance. There are some subtleties to the findings which make the article worth a look.

An advantage to a "democratic" system is that the style could be more changeable, and that individuals don't have to be stuck permanently in a style that they don't like. A disadvantage of democratic systems is that most groups and most individuals vacillate a lot, and are often almost equally divided between "left" and "right" (e.g. look at the U.S. electorate). This can result in leadership which is itself ambivalent and unstable.

The above comments are a prelude to a metaphor I've been considering, about how the mind, or how strategizing about life, works.

A "right-wing" approach in the mind or in one's life might be to develop one's strengths, and to pay little attention to one's weaknesses, with the belief that optimizing one's strengths will optimize success in life. So if you are a talented musician but have weaker math skills and social skills, the strategy would be to practice music 12 hours per day, to skip out on math, and not to bother socializing.

A "left-wing" approach might be to divide one's day up into 30 minute blocks, and devote equal attention to music, math, socializing, knitting, soccer, cooking, etc.

Both the above approaches, in their extremes, would probably not work out very well, or whatever successes would result would come at a high cost. In the first case, we might have a brilliant but isolated, depressed, and autistic musician. In the second case, we might have a pretty well-rounded person, who however would never be able to make a career out of music, and who might carry a lifelong frustration about never having had the chance to fully develop gifts or potential.

I think most of us would agree that a moderate position between those two extremes would be most beneficial in the above example. The theoretical musician described above probably ought to practice a lot -- much more than most others -- but probably ought to spend some time struggling through some math, and trying to get involved in social activities. In the long term, such a mixed model would probably lead to even more excellence, since a well-rounded person with good morale and multiple strengths is likely to have more energy to share with society, and is less likely to be sidelined by depression. Furthermore, there can be unexpected synergistic benefits from having a broad range of experiences.

So, in my opinion, from a psychological point of view, I believe that a "moderate" position in the "political spectrum" of the mind is healthiest and most beneficial, perhaps a position which is able to flexibly assimilate ideas from both sides of an ideological spectrum.

Another phenomenon that occurs in political debate is intense polarization: opposing groups merely fight and argue with each other. The fighting and arguing rarely seem to resolve anything, but may in fact further entrench the polarization of the opposing points of view. I think it is healthy -- in the politics of the world, and the politics of the mind -- to always be on the watch for polarization, and to take active steps to diminish it. Groups of individuals tend to separate, polarize, and compete -- sports fans or athletes are one example. In can be fun to playfully feel polarized into "us" and "them" at a sports event. But it isn't fun when the polarizing occurs automatically, and interferes with problem solving, whether it be in political debate, in an argument with a loved one, or within one's own mind.

In the internal "politics" of the mind, I think it is healthy to have a clear sense of identity, to develop your positions, ideas, beliefs, values, etc. But I think it is important to watch for polarization. This may require an openness to sometimes respectfully consider ideas that seem opposed to your position.

Likewise, in world politics, I think it is important for opposing parties to work at affirming or considering the validity of their opponents' positions, to find common ground, to even find some wisdom or inspiration -- once in a while -- in the opponents' ideas.