Neuroplasticity

This is an important book which I highly recommend:
The Brain that Changes Itself, by Norman Doidge (Penguin, 2007).

Doidge is a psychoanalyst who has done a fine job compiling evidence from recent neuroscience research, and from some older but neglected neuroscience research, that the brain has a tremendous capacity--a capacity which is arguably its most basic, core, innate quality-- for change and adaptation.

The idea of the brain as permanently "hard-wired" is refuted, with solid evidence.

Many of these ideas I have always felt to be obvious truths. For example, it seems an obvious necessity that the brain would have to build new connections in order to form any new thought, experience any new feeling, store any new memory, learn any new skill. But the degree to which whole areas of the brain can "re-wire" themselves is extremely interesting, and the evidence Doidge presents is very convincing.

Also, it has always been an obvious truth to me that any kind of sensitive neuroimaging device would of course demonstrate changes following a successful course of therapy (or of any other sort of learning or substantive life change).

The therapeutic applications based on this book are numerous, here are a few I can think of:

1) structured, intensive practice could lead to far greater effects than what has previously been assumed. The brain itself, as well as people in society, informed by culturally-based attitudes, tend to "work around" problems if the situation allows, whereas it can be the case that the problems themselves can be solved directly under the right conditions. For example, if an English-speaking person moves to a small town in a foreign country, that person will quickly learn that new foreign language, if it is necessary in order to survive. But if there are numerous English speakers in that small town, that person may not learn much of the new language at all.
We may need a type of immersive, constrained experience in order to compel our brain to develop a new faculty.

2) structured, intensive activities that have become part of a cultural norm (e.g. internet use, TV watching, etc.) could substantially alter the brain's connectivity and functionality, to optimally adapt to these new media. This could serve us well, culturally--but it may come at a cost of reduced functionality in media away from the TV or internet, particularly with respect to sustained attention, other intellectual and emotional faculties, and various types of social interaction.

3) Addictive processes are fed by the brain's capacity to adapt, to "re-wire" itself to expect a frequently reinforced behavioural pathway. "Un-learning" addictive behaviour once again may require a massive amount of work, akin to learning a new language.

--I have yet to review all of the references cited in this book. I think the primary source data will be important to go through in detail. There are some areas and claims that I think may possibly be overstated, in my opinion. But first I would like to review the evidence directly. I actually find the term "neuroplasticity" somewhat annoying, especially when therapeutic ideas are labeled "neuroplasticity-based treatments", etc. --I would say in response that ALL therapy, of ANY sort, is of course "neuroplasticity-based", so such lingo is unnecessary, and rings of salesmanship to me (indeed, there are several corporate ventures mentioned in the book). What matters most is the new types of therapeutic ideas that have been conceived by some of the researchers cited in the book, and how well they can work for very entrenched problems.


In the meantime, I do recommend Doidge's book highly.

Physicians in need of help

There is a high incidence of psychiatric problems in the medical community. Physicians may have a difficult time finding help. There are a variety of reasons for this, the most common of which is that the sources of help may all involve people the physician knows personally.

In BC we have something called the "physician health program", which is a resource especially for physicians in need of help. Here is the website:
http://www.physicianhealth.com/

Hopefully other communities have similar programs.

If a hospital admission is needed, it may be desired to arrange this in a different place, if privacy or confidentiality issues are major concerns.

Exercise benefits Quality of Life

You can click on the chart to expand it; the chart above is from a randomized, controlled, 2009 study by CK Martin et al., published in the major journal Archives of Internal Medicine, in which 6 months of regular aerobic exercise is shown to improve numerous domains of quality of life, including mental health, vitality, and social functioning, in a group of 430 sedentary postmenopausal women.

To interpret the chart, look at each symptom domain. There is a control group (which did not exercise), then groups which exercised approximately 1, 2, and 4 hours per week, with the groups which exercised more represented towards the right-hand side of the chart.

The improvement in quality of life did not depend on any weight loss occurring with the exercise. And it appeared that as little as an hour a week of exercise was beneficial, though 2-4 hours per week were slightly more beneficial than just one. Here's a link to the abstract:

http://www.ncbi.nlm.nih.gov/pubmed/19204218

As a cautionary note, I find "exercise addiction" to be another potentially serious problem, which could substantially REDUCE quality of life. The above data support a very modest amount of exercise, in the order of 4 hours PER WEEK , for improving quality of life.

I strongly encourage people to exercise. I believe it is basic self-care, a requirement for health.

It is intuitively obvious that exercise would be beneficial for psychological health, and be a good potential therapy for depression or anxiety.

Yet, there is an important recent study of over 5000 Dutch twins, which shows that exercise did not have a direct influence on anxiety or depression. This is a surprising result, but it needs to be taken seriously. Twin studies are very powerful in research, since they look at individuals who are genetically identical -- any differences in symptoms would have to be caused by environmental factors, as opposed to genes. Twins who exercised more than their co-twins were not in fact any less anxious or depressed. (Actually, as I look at the results directly, I see there was a small association, but it was judged to be "non-significant")

The study did confirm that people who exercise are, on average, less anxious and depressed than those who do not exercise. But the conclusion was that this is not because exercise improves emotional symptoms -- it is because there is a genetic factor which predisposes some people both to exercise more, and to have fewer psychological symptoms.

Here is a link to the study:
http://www.ncbi.nlm.nih.gov/pubmed/18678794

On the other hand, there are a few studies which show a therapeutic effect of exercise on psychological symptoms:

http://www.ncbi.nlm.nih.gov/pubmed/17846259

http://www.ncbi.nlm.nih.gov/pubmed/11020092

The above studies show a beneficial effect of exercise, of at least 3 times per week, 30 minutes per session.

Why are there seeming contradictions with these studies?

It may be because the twin study was looking at individuals' intrinsic exercise behaviours, as determined by their life circumstances & inherited factors. Variations in exercise between twins may have been due mainly to opportunity or chance.

The other studies were looking at exercise as a formally prescribed treatment. This would involve a directed change of behaviour, outside of what the individuals would normally do on their own.

It could be that prescribed changes of behaviour, if adhered to for health reasons, could have a stronger therapeutic effect than the behaviours engaged in for other reasons.

Active Placebo Studies show smaller benefits from Antidepressants

In most of the better clinical studies, a "placebo group" acts as a control. The placebo would consist of something totally inert, such as a capsule with nothing inside, or possibly with a small quantity of a sugar such as lactose.

The idea of an "active placebo" is interesting: in this case, the placebo is an agent shown not to have any beneficial or detrimental effect on the disease in question, but which clearly has side-effects.

An example would be using a tablet of Gravol (dimenhydrinate) as the "placebo". It is not an antidepressant, but it has side-effects (sedation, dry mouth, etc.). In this way, it is a more convincing placebo, since a person taking an agent which produces side effects is more likely to believe that they are taking the "active" agent. If a person is taking a placebo they strongly believe to be a placebo (since it produces no side effects) they are less likely to have any "placebo effect" response, and the whole point of the placebo control will be relatively "unblinded."

There is a body of research literature looking at using "active placebo" vs. antidepressants to treat depression.

http://www.ncbi.nlm.nih.gov/pubmed/9614471

{a 1998 meta-analysis from the British Journal of Psychiatry showing that the effect sizes of antidepressant therapy are only about half as large when compared against an active placebo, rather than an inert placebo}

http://www.ncbi.nlm.nih.gov/pubmed/14974002
{a 2004 Cochrane review with similar findings}

These results support the evidence that antidepressants work -- but they suggest that probably most of the studies overestimate how well they work, because they are measured against inert placebos in most cases.

I think that more clinical studies need to include active placebos.

I post this not to be cynical, or to discourage the use of antidepressants--as you can see from the rest of this blog, I strongly support medication trials to treat psychiatric problems--but I believe that we have to always search for the most accurate, least biased sources of information. We need to be wary of exaggerated claims about the effectiveness of anything, especially since I see in my practice that many of the treatments don't seem to work quite as well as the ads claim they should.

Trazodone

Trazodone is another antidepressant introduced in the early 80's. Once again, its use was fashionable for a time, gradually faded, and at this point it is mainly used adjunctively to treat insomnia.

It is notable among antidepressant choices in not causing sexual side effects (other than the rare incidence of priapism, which is a medically dangerous, painful, abnormally sustained penile erection, which occurs in probably less than 1 in 1000).

The trouble with trazodone is that for many people, it causes too much daytime sedation. However, it can be worth a try, to treat insomnia associated with depression or antidepressant therapy, or possibly as an augmentation to treat depression or OCD.

In my experience, about 50% of people find trazodone a helpful adjuct, but the other 50% find it causes too much tiredness or dizziness the next day to be worth continuing.

Here is a literature review:


http://www.ncbi.nlm.nih.gov/pubmed/19112384
{in this 2008 study from a minor journal, trazodone was shown to increase the amount of slow-wave sleep in treating chronic insomnia}

http://www.ncbi.nlm.nih.gov/pubmed/12930437
{a 2003 urology article showing evidence that trazodone may help treat erectile dysfunction, especially at higher doses}

http://www.ncbi.nlm.nih.gov/pubmed/18978492
{a small 2008 study showing that 50-100 mg of trazodone may reduce SSRI-induced sexual dysfunction}

http://www.ncbi.nlm.nih.gov/pubmed/16968574
{a small 2006 study showing equivalence between trazodone and sertraline in treating depression over 6 weeks}

http://www.ncbi.nlm.nih.gov/pubmed/10507215
{a small 1999 study from a podiatry journal, showing that trazodone can help with painful diabetic neuropathy symptoms}

http://www.ncbi.nlm.nih.gov/pubmed/8010365
{a 1994 American Journal of Psychiatry article showing that trazodone can help with antidepressant-induced insomnia, particularly helping with overall subjective sleep quality, reducing waking in the middle of the night, and reducing early morning waking}

http://www.ncbi.nlm.nih.gov/pubmed/8988452
{this awkardly-designed 1996 study suggests that combination treatment including 100 mg of trazodone may help in treatment-resistant depression}

http://www.ncbi.nlm.nih.gov/pubmed/11518472
{this quite weak 2001 study nevertheless suggests that trazodone helps to reduce nightmares in PTSD patients}

http://www.ncbi.nlm.nih.gov/pubmed/6337131
{an early, 1983 study, of trazodone vs. imipramine for treating moderately to severely depressed outpatients. Despite the weaknesses of the study design, it did have some follow-up over 3 years, showing that trazodone works well for some people, and worked as well as imipramine overall}

http://www.ncbi.nlm.nih.gov/pubmed/18311107
{an example of a small study suggesting that adjunctive trazodone could help improve OCD symptoms. Some studies have shown no anti-OCD effect with trazodone alone, but others have shown trazodone alone to be beneficial in refractory OCD. In any case, I think the evidence base suggests that trazodone could at least be worth a try, either together with an SSRI, or even on its own.}