Sugar

Many people believe that sugar (sucrose) intake causes behavioural problems. The two most common specific beliefs are that eating sugar causes worsened hyperactivity; or that eating sugar causes a rush of energy, followed by a plunge into fatigue as the sugar level "crashes".

In fact there have been a lot of very good studies looking at this, and the evidence is quite clear that sugar does not cause hyperactivity. There is an association between high sugar intake and antisocial behaviour, but the relationship is probably not causal. It is much more plausible that those with more antisocial behaviour in the first place happen to choose to consume more sugar.

In some of the prospective, randomized studies, in fact, individuals consuming sugar (instead of a placebo) did better, particularly in terms of learning tasks.

The evidence is also very clear that so-called "reactive hypoglycemia" is very rare, even in people who insist that they have it. However, there may be some individuals who become more irritable as their blood glucose level drops, even if the drop is not down to clinically hypoglycemic levels.

There is evidence that some individuals may respond adversely, in terms of their behaviour, to certain foods, but actually sugar is not a common such food, according to well-controlled studies.

I do affirm that moderating sugar intake, and also eating meals with a lower glycemic index, is part of overall good long-term health.

But most of the claims about sugar influencing behaviour adversely are part of a myth, not supported by clear evidence.

For an excellent review of the evidence on this matter, see this article by David Benton (May 2008):
http://www.informaworld.com/smpp/content~db=all?content=10.1080/10408390701407316

Chocolate is Good for You

There is evidence that dark chocolate is healthy for you in a variety of ways:

1) May reduce high blood pressure and improve other cardiac risk factors:
http://www.ncbi.nlm.nih.gov/pubmed/18716168

http://www.ncbi.nlm.nih.gov/pubmed/18827977

Here's a reference to an article in JAMA, one of the world's leading medical journals:
http://www.ncbi.nlm.nih.gov/pubmed/17609490

2) Here's a whimsical reference to a study suggesting that pregnant women who eat chocolate end up having babies with more positive temperaments, also these women may be more resilient to stress during the pregnancy:
http://www.ncbi.nlm.nih.gov/pubmed/14757265

However, it should be acknowledged that many people have trouble moderating their chocolate intake. For some people with atypical depression or eating disorders, excessive chocolate consumption can be part of their unhealthy eating behaviours. Yet, it pleases me to know that chocolate (dark chocolate, or cocoa, in particular) is good for you (in moderation of course)

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