Good News

Here are a few "good news" websites:

http://www.happynews.com/index.aspx
http://www.goodnewsnetwork.org/
http://www.only-positive-news.com/archives
http://globaldialoguecenter.blogs.com/jbgoodnews/

There is so much bad news in the world today...

Yet, of course, the bad news is accurate: many people are doing many horrible things; whole nations are behaving badly; the whole planet is at risk for irreversible deterioration... It is important and healthy for us to be aware of the truth, even if the truth is difficult to hear.

This reminds me of the way depression can work, particularly chronic depression: the negative, cynical, painful, or pessimistic thoughts associated with depression may represent accurate truths about one's life or about the world.

It can feel frustrating, irritating, and shallow to simply ignore the negative thoughts or negative truths, and focus strictly on "happy thoughts." It can feel like mental manipulation to try to convert a negative observation into a positive one.

I believe that part of the solution is not necessarily to try to negate negative thinking. This would be like refusing to learn about the realities of global hunger, environmental pollution, or about a child being bullied in your neighbourhood, and just simply carrying on with a smile as though everything was fine. This is just denial--things have to be done about hunger, pollution, and bullies.

But I do believe that part of the solution is to be informed about positive news that is going on in the world...this requires very deliberate effort.

Human nature, and the human brain, tends to focus on things that are going wrong. This is a vital safety mechanism...it has kept us safe from predators and other environmental dangers over millions of years of evolution. This tendency shows up in news reporting--headlines are all about disasters, not about moments of sublime beauty or courage or hope. Disaster reporting sells more papers, it grabs our attention more strongly--that's the way our brains are made.

In order to have a healthy and balanced lifestyle we must actively inform ourselves of things that are going right, alongside whatever information comes to us about things that are going wrong. We must do this on a global scale, a local community scale, and on a personal scale (within our own thoughts or minds).

Many anxious negative thoughts represent strong over-estimations of risk (e.g. a fearful airline passenger may feel that the likelihood of crashing is 90%, when in fact the likelihood is 0.0001%); in cases like this an objective "cognitive therapy style" analysis and challenging of thoughts can be therapeutic and reassuring.

Cognitive therapy need not discount negative thoughts. An acknowledgment of a very negative reality may be an honest and frank therapeutic step.

But I think cognitive therapy for depression must allow space for seeking out things that are positive.

I invite you to check out some of the websites above, and seek out more (or better) sources of good news (let me know if you find some). I also invite you to pay attention to examples of "good news" in your community, in your daily life, and in your thinking.

Preparing for a psychiatry interview

There are many reasons to see a psychiatrist. There are different types of psychiatric interviews, depending on the situation and on the individuals involved.

A psychiatric interview is a chance to describe your history, examine your problems, review your symptoms in detail, and hopefully to make a plan for things to change.

You may feel reserved about sharing your personal history in detail until you have built up a greater trust in the therapeutic relationship. I think it is important to feel comfortable with your psychiatrist, and to know that you don't have to talk about certain things, or to answer certain questions, unless it is your wish to do so.

There are some elements of a psychiatric history which you can organize or prepare in advance, if you wish, and if these things are relevant to you:


1) charts or chronologies of specific symptoms
-if you have had a history of mood symptoms, it can be informative to prepare a chart showing how your symptoms have changed over time.
-your chart might start literally at your birth, continuing up to the present, with a graph showing how your mood has changed (e.g. showing when your mood has felt good, felt anxious, felt depressed, felt manic, etc.)
-a closer examination of the past few months, or past few years, could allow you to show mood changes in more detail
-underneath the graph of your symptom, you might include significant life events (e.g. losses, changes or problems in school, work, relationships, family, finances, etc.). This allows an examination of the relationship between life events and symptoms
-in another row underneath the graph of your symptoms, you might include any treatments you have attempted (e.g. starting, changing, or stopping any counseling, medications, or self-help)
-these charts could illustrate the long-term pattern of your mood, and illustrate what things might have helped or hindered your problems over the years
-if you have had medication treatments, it can be especially useful to see how your symptoms have changed in association with starting or stopping the medication

Here is an on-line example of a so-called "restrospective life chart":http://www.bipolarnews.org/pdfs/Patient%20Retrospective%20Form%20.pdf I find this particular chart cumbersome and cluttered--I invite you to make your own simple, personalized version of such a chart, with areas on the chart pertinent to your own specific symptoms or treatments.

There are various monthly mood symptom charts you can find on-line. I have included my own version of a monthly mood chart, which you could adapt according to your own symptoms. You can right-click on the chart above, select "copy image", then open your word processor and paste the image onto a new empty word processing file. To use my chart, you could circle the number most representative of how your symptom is on a given day; or make an oval over several numbers at once to show symptoms that have fluctuated during the same day; or you could gradually trace a line showing symptom changes, without circling the numbers, etc. I made my chart in a few minutes using Excel--you could make your own, with different categories relevant to your situation.

2) sometimes writing a narrative essay about your life can be a useful exercise to prepare for a psychiatric interview; however, you may wish to speak out this narrative during therapy sessions, rather than write it down in advance. You may find that you can do both: in the course of therapy, you may find elements of your written narrative to expand upon or emphasize more strongly, other new elements to write about for the first time, and other elements you may wish to retire from the foreground.

Interesting mental health journals

Here are a few journals I recommend following. At my university office I enjoy the luxury of full electronic access to these journals, but almost everyone should at least be able to find on-line abstracts (brief summaries) of articles from each journal. Browsing through some of these will give you a general idea of what's going on in research. There might be a few of these journals you will want to follow in more detail; for this I recommend a monthly trip to a local university library.

I may add to or modify this list over time.

I. General Psychiatry Journals:
The American Journal of Psychiatry: http://ajp.psychiatryonline.org/
Archives of General Psychiatry: http://archpsyc.ama-assn.org/
British Journal of Psychiatry: http://bjp.rcpsych.org/
Canadian Journal of Psychiatry: http://publications.cpa-apc.org/browse/sections/0


II. Psychotherapy Journals:
Psychotherapy Theory, Research, Practice, Training: http://www.apa.org/journals/pst/
American Journal of Psychotherapy: http://web.ebscohost.com/ehost/detail?vid=1&hid=104&sid=e3578a6f-d67f-4195-bde8-70686c4c1f0c%40sessionmgr103&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=a9h&jid=ATC
Clinical Psychology and Psychotherapy: http://web.ebscohost.com/ehost/detail?vid=1&hid=104&sid=81922580-de66-4070-9f45-506927e0361c%40sessionmgr108&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=a9h&jid=BUX
British Journal of Psychotherapy: http://www3.interscience.wiley.com/journal/117987371/home
Behavioural and Cognitive Psychotherapy: http://journals.cambridge.org/action/displayJournal?jid=BCP
Sexual and Relationship Therapy: http://www.informaworld.com/smpp/title~content=t713446685~db=all

IV. Psychology Journals:
Journal of Personality and Social Psychology: http://www.apa.org/journals/psp/
Journal of Educational Psychology: http://www.apa.org/journals/edu/
Journal of Consulting and Clinical Psychology: http://www.apa.org/journals/ccp/homepage.html

V. Journals pertaining to specific areas within mental health:
Addiction: http://www3.interscience.wiley.com/journal/117967480/toc?CRETRY=1&SRETRY=0
Eating Disorders: the Journal of Treatment and Prevention: http://www.informaworld.com/smpp/title~content=t713666342~db=all
International Journal of Eating Disorders: http://www3.interscience.wiley.com/journal/34698/home
Schizophrenia Research: http://www.sciencedirect.com/science/journal/09209964
Depression and Anxiety: http://www3.interscience.wiley.com/journal/38924/home
Journal of Personality Disorders: http://www.atypon-link.com/GPI/loi/pedi?cookieSet=1
Sleep: http://www.journalsleep.org/
Archives of Sexual Behavior: http://www.springerlink.com/content/101587/
The Journal of Sexual Medicine: http://www3.interscience.wiley.com/journal/118495964/home

VI. Journals pertaining to general health and medicine:
American Journal of Clinical Nutrition: http://www.ajcn.org/
American Journal of Epidemiology: http://aje.oxfordjournals.org/
Journal of the American Medical Association: http://jama.ama-assn.org/
Archives of Internal Medicine: http://archinte.ama-assn.org/
New England Journal of Medicine: http://content.nejm.org/
Science: http://www.sciencemag.org/ (particularly the medicine & neuroscience sections)
Nature: http://www.nature.com/nature/index.html (particularly the medical research & neuroscience sections)

Predictably Irrational - a book review with ideas about psychiatric applications

Dan Ariely has written an interesting book, based on his research, called Predictably Irrational (HarperCollins, 2008).

Ariely is an economist but his research is about human behaviour.

There are a lot of studies done over the past few decades in the field of social psychology, which illustrate very similar behavioural phenomena. Ariely's work reminds me specifically of the work of Robert Cialdini, a social psychologist who studied persuasion.

I think this work is important to look at, because it shows that there are powerful factors which influence our decision-making or judgment, which we may not be aware of. The factors are not mysterious phenomena residing in unconscious childhood memories, etc., but are fairly simple--here are some of Ariely's examples:

1) If a person has to choose between two things which are approximately equal (let's call them "item A" and "item B"), there is about a 50% chance of either one being chosen. Suppose a third thing is added, which is similar but modestly inferior to item A; let's call that thing "item A-". This third item could be called a "decoy". If a person has to choose one item out of this group of three, then item A is chosen much more often than item B (in Ariely's experiments, the "item A" gets chosen about 75% of the time).
These experiments show that our decisions are often strongly influenced by irrelevant comparisons.

2) If a cost of something is suggested, it causes us to form an "anchor" in our minds, such that we are more willing to pay that cost or thereabouts, regardless of the true value. This phenomenon is exploited in advertising. But I suspect that as a general principle, we may be influenced to choose something, or to invest a certain amount of energy or commitment into something, based on suggestions, precedents, or personal "anchors", instead of based on the "true value" of the thing.

3) People are much more likely to choose something that is "free" even if it is a worse deal than something else. Free offers substantially bias judgment. Ariel's studies show this nicely, in a quantitative way.

4) Monetary norms and social norms are conflicting motivators. Social norms are healthier and more powerful motivators. Motivations based on money are tenuous, shallow, and easily changeable. Motivations based on social goals are deeper and more stable. The corporate trend to optimize productivity by continuously monitoring worker output is a type of "monetary" strategy. On a social level, it is often offensive and demoralizing. If workers have a sense of social belonging in their workplace, and also a sense that their employer will care for them in a time of need, then the health of the entire system will be much stronger.

Social language can be a persuasive tactic in advertising though, typically through ads (such as with a bank, cable, or insurance company) which make it sound like your relationship with the seller will be something like with a friend or family member. Such advertising could seem persuasive to some, but I think most sellers would not behave like a friend or family member if you got sick and couldn't make your payment on time!

Ariely wisely encourages the development of healthier social goals in education -- to encourage
education as a means to participate in the improvement of society, rather than as a means to get higher scores on a standardized test, or to attain a higher-paying job.

5) Emotional arousal substantially increases the likelihood of making a risky decision. For example, his experiments showed that a random group of college students were about twice as likely to consider engaging in dangerous or illegal sexual activities if they were sexually aroused when asked about it. This phenomenon highlights the need for two types of protection: first, people need to be protected from the potential consequences of making rash decisions in the heat of passion (e.g. being equipped with condoms would protect against the risks of impulsively-chosen sexual activity).

Second--and this is a point that Ariely does not make--people cannot just learn about how to make decisions while in a cool, "rational" state. Perhaps it is important to teach people--through practice-- how to make decisions while in the heat of passion.

I think this is an important idea in a psychotherapeutic process: calm, gentle analysis of thoughts and emotions is valuable (whether this happens in a therapy session or in a CBT journal, etc.) but it may also be necessary to practice rational and healthy decision-making while in an emotionally heated state. This, too, can sometimes happen in therapy sessions, or in CBT journals, etc.

6) Procrastination. Ariely's studies with groups of students showed that a rigid, external imposition of regular deadlines led to the best grades. Requiring students to commit to their own set of deadlines, in advance, led to grades in a middle range. Having no deadlines at all, except for the requirement that all work had to be in by the end of the term, led to the worst grades. Those in the middle group who committed to regularly-spaced deadlines did as well as the first group. This experiment shows that people have a tendency to procrastinate (no surprise here!), and that a commitment to regularly-spaced deadlines is the best way to improve the quality of the work (whether this commitment is chosen by you, or imposed upon you).


I do suspect that there are individual exceptions to this -- I'd be curious to see a study to show this -- in which some people have a better experience with a bit less structure.

He gives a few good applications of this phenomenon: committing in advance to some kind of care plan (whether it be for your health, your car, your teeth, your finances, etc.) will make it less likely that you will procrastinate or forget to do these tasks (e.g. medical check-ups, oil changes, dental cleanings, etc.). With such a system, everyone benefits (e.g. you stay healthier, your car stays in good shape, the auto mechanics get regular work, etc.). The main problem with this is if you are being sold something that you don't really need. The solution is to be be well-informed in advance about the type of care that works best for your needs.

A psychotherapy frame is usually a regularly-spaced commitment of one's time--I certainly do find that people I see are more likely to engage in a beneficial therapeutic process if this kind of structure is in place.

7) Ownership. People have a tendency to value things more when they "own" them already (Ariely gives entertaining examples of studies showing this phenomenon in a monetary sense). This can lead to biased decision-making if the "owned" item is not valuable, necessary, or healthy. This is a similar phenomenon to loss-aversion. We don't like losing something, even if that something is not really good for us. Other social psychology research has shown that this principle applies to ideas as well: if we have espoused an idea, or a viewpoint, or an attitude, about something, we are much more likely to "own" this idea, and to stick to it. We are less likely to change our view, even if the view is unhealthy for us. I find such thinking patterns often involved in chronic depression.

This is definitely a phenomenon that occurs in a psychotherapy environment: therapy is an invitation to change. Even if the change leads to a better quality of life, people are resistant to change, and are more likely to hold on to systems of thought, perception, or behaviour, which perpetuate unhappiness.

8) People are more likely to choose things that seem to be disappearing. Ariely again demonstrates this phemonenon, using economic measures, in a clever experiment. We see this in sales tactics all the time, such as when we are warned that some item is selling out quickly, so we had better act soon! In life, we may tend to spend a harmful amount of time, energy, money, and commitment, keeping multiple options open: as a result, we may never get very far into any pathway we choose.

9) Stereotypes and expectations substantially affect behaviour and choice. In an amusing experiment involving a blinded beer-tasting test, Ariely showed that college subjects presented with two unlabeled containers actually preferred a beer that had been tainted by 10 drops of balsamic vinegar, over the untainted version. But if the students knew in advance that vinegar had been added, then nobody preferred the "vinegar beer". If we believe--or are persuaded to believe--that something is good or desirable, or that something is bad or undesirable (that "something" could be anything from toothpaste, to a new acquaintance, to a job, to our own self or our own skills), then we are significantly more likely to find our beliefs substantiated.

We need to have ways to "stand outside ourselves" at times, to reduce the biases caused by our own beliefs. I think that this, too, is one of the roles of psychotherapy.

10) Things that cost more tend to have a stronger effect. A more expensive placebo tends to be more effective than a less expensive placebo. This is an important, powerful bias to be aware of. This, too, can be a tool exploited by advertisers, in which the high price of their product is displayed prominently as a signifier of higher quality.

I have one major complaint about this book:

Ariely makes a few statements about medical treatments, including "when researchers tested the effect of the six leading antidepressants, they noted that 75% of the effect was duplicated in placebo controls." (p. 178) This claim is based on one single study, from a minor journal, published over 10 years ago, without considering other data from hundreds or thousands of other publications in the research literature. Furthermore, even if this 75% figure was accurate, the remaining 25% of the effect may be very significant for many suffering people. The psychological impact of Ariely's statement may be to cause skepticism and a dismissive attitude towards certain medical treatments, including antidepressant therapy. Ironically, Ariely would then be persuading people against something, based on a tiny, inadequate, and negatively-framed presentation of the evidence.

11) Randomly-chosen college students in Ariely's experiements had a strong tendency to cheat; but if these subjects were reminded of some kind of honour code immediately prior, they had a much smaller tendency to cheat. Based on his findings, he encourages a more prominent role for "honour codes" to reduce dishonesty. He observes that cheating is no trifling matter: fraud accounts for much more stolen money and property than all other forms of crime put together. Also, cheating is much more likely and pronounced if it is perceived to be indirect: people will cheat more if some kind of token is involved, even if the token is worth the same amount as actual money. Our society is evolving to use indirect currencies much more (various forms of credit, for example), which probably will increase systemic dishonesty.

The idea of an "honour code" may seem a bit odd or trite, maybe hard to take seriously. But I think its application could be imaginative and important, and could, at least in a small way, address something that is missing in many workplaces, homes, or individual lives. I suggest this not necessarily as a way to reduce dishonesty, but as a motivational tactic, that can remind us of ways to live healthily. Many workplaces or lives can be so caught up with being busy, competing, getting through the day, that a grounding sense of purpose is rarely contemplated.

An "honour code" in a psychotherapy frame could involve a formal set of statements for oneself, a "mission statement", which could guide choices, motivations, priorities, and attitudes over time.

So it could be an interesting exercise to write down, and answer for yourself:
"What are your morals/values/guiding principles?"
"What is it to be a good person?"
"How can I live honourably in a world which can be harsh and difficult at times, and in a life which can be harsh and difficult at times?"
etc.

Long-term antidepressant therapy to prevent relapse

Maintenance antidepressant therapy is likely to reduce the probability of depressive relapse. This would involve continuing to take an antidepressant, long-term, even when feeling better. I would restrict such a recommendation to those who have had recurrent or severe depressions. Such maintenance therapy is best indicated for those who have actually had an acute benefit from a specific antidepressant.

I emphasize the importance of psychotherapy and healthy lifestyle change, which also reduce relapse rates (in the case of CBT, for example, the reduction in relapse rate persists long after the course of CBT is over).

This is a 2008 link to findings from the so-called PREVENT study, which showed that 67% of patients on venlafaxine remained well over 2.5 years of follow-up, compared to 41% of patients on placebo:

http://www.ncbi.nlm.nih.gov/pubmed/18854724

A weakness of this study is that they did not allow for an extremely gradual taper of venlafaxine in the group randomized to receive placebo maintenance; therefore the worse outcome in the placebo maintenance group could have partly been due to withdrawal symptoms. However, there is a brief discussion of this possibility in some letters from the Journal of Clinical Psychiatry (2008 May; 69(5): 865-866) , and the authors of the PREVENT study make some good points about why withdrawal symptoms are not likely to account for the worse outcome in the placebo group.

There are a variety of older studies showing reduced relapse rates in patients taking long-term antidepressant maintenance. Here is an example, using imipramine:
http://www.ncbi.nlm.nih.gov/pubmed/8478502

Withdrawal effects are unlikely to account for the worse outcome in the control group, because the control group actually still received the active antidepressant, but just at a lower dose. The point of this study is that a full dose of the antidepressant is probably required in a long-term maintenance phase.

Here is another study from 1992 in Archives of General Psychiatry, showing significant preventative effects from taking full-dose imipramine over 5 years of follow-up, with or without adjunctive psychotherapy:
http://www.ncbi.nlm.nih.gov/pubmed/1417428

Here is a link to a 1990 study in Archives of General Psychiatry showing that full-dose imipramine had substantial preventative effects, moreso than interpersonal therapy, over 3 years of follow-up:
http://www.ncbi.nlm.nih.gov/pubmed/2244793

For this study, I need to go back and look carefully over the full text, which I can't find at this moment.

This study is another compelling piece of evidence, from JAMA in 1999, supporting antidepressant maintenance, and it had an excellent design:
http://www.ncbi.nlm.nih.gov/pubmed/9892449

It showed that elderly patients who had recovered from a bout of recurrent depression, who then received placebo, had a relapse rate of 90% over 3 years. Treatment with interpersonal psychotherapy alone reduced the relapse rate to 64% over 3 years. Treatment with the antidepressant nortriptyline alone reduced this relapse rate to 43% over 3 years. Nortriptyline plus interpersonal therapy combined, led to a relapse rate of only 20% over 3 years. Withdrawal effects from notriptyline are unlikely to have substantially favoured the nortriptyline group, since the follow-up was over a 3 year period, which is way beyond any period of withdrawal effects.

Here is another 2007 review paper, from The Canadian Journal of Psychiatry, summarizing strong research support that long-term antidepressant therapy reduces relapse rate in major depression by about 50%:
http://www.ncbi.nlm.nih.gov/pubmed/17953158