Omega-3 supplements: update

 A number of negative studies have come out in the past year or two, regarding various types of supplements.  

I think it is good to be wary of claims about supplements, just as we should be wary of biases related to pharmaceutical marketing or to therapists touting particular styles of psychotherapy.  

Here is a review of some recent research regarding omega-3 supplementation: 

A simple 12-week study by Fristad et al (2015), published in the Journal of Child and Adolescent Psychopharmacology, showed that omega-3 supplements, given over 12 weeks,  had a modest antidepressant effect in children with bipolar-spectrum symptoms.  The effect size was greater than placebo, but less than that of "psychoeducational psychotherapy." 

http://www.ncbi.nlm.nih.gov/pubmed/26682997

In a very recent meta-analysis by Cooper et al (2016), it is concluded that omega-3 supplements given to children with ADHD do not cause large symptom improvements.  But there is enough evidence, including from high-quality studies, to believe that omega-3 supplementation could lead to small improvements in emotional lability and oppositional behaviour. 
http://www.ncbi.nlm.nih.gov/pubmed/?term=10.1016%2Fj.jad.2015.09.053

Bos et al (2015) compared omega-3 supplements (650 mg/day EPA+DHA) with placebo, in a 16-week study of 79 boys with ADHD.  They found improved parent-rated attention scores in the omega-3 group.   The effects they report appear to be clinically significant.   http://www.ncbi.nlm.nih.gov/pubmed/25790022

Widenhorn-Muller et al (2014) showed an improvement in working memory in children with ADHD given 720 mg/day of omega-3 supplements for 16 weeks. 

http://www.ncbi.nlm.nih.gov/pubmed/?term=10.1016%2Fj.plefa.2014.04.004

In a JAMA article by Chew et al (2015), the authors show that omega-3 supplements, given daily over 5 years, do not slow down the rate of cognitive decline in elderly people.
 http://www.ncbi.nlm.nih.gov/pubmed/26305649

For a recent review, Mischoulon and Freeman's 2013 chapter in Psychiatric Clinics of North America is a good contribution.

Animal Studies
Gonzales et al (2015) showed that omega-3 supplements, given to rats, led to "increased adaptive coping with stressful events."

http://www.ncbi.nlm.nih.gov/pubmed/?term=10.1016%2Fj.bbr.2014.11.010

In this interesting article by Bondi et al, they suggest from their findings that omega-3 deficiency, continued over several generations, can cause "impairment in cognitive and motivated behaviour" in adolescent rats.  This may speak to the importance of the dietary quality through the entire lifespan, as a factor in psychological resilience.  The typical western diet is often described as progressively omega-3 deficient. 

http://www.ncbi.nlm.nih.gov/pubmed/?term=10.1016%2Fj.biopsych.2013.06.007

Conclusion

I continue to recommend omega-3 supplementation.  It is a reasonable supplement for those with symptoms of depression, ADHD, or bipolar disorder.   The dose to aim for is between 1 and 2 grams per day of EPA+DHA combined, usually with the EPA:DHA ratio at least 3:2.

I base this recommendation on the fact that there is reasonable evidence of a slight improvement, not only in measures of psychological health, but also in various other aspects of physical health (such as inflammatory diseases). 

I think the magnitude of any improvement due to omega-3 supplements is likely to be very slight.  But in combination with other factors, such as healthy lifestyle and responsible use of medication, it could be a component of balanced, holistic health care, particularly if continued regularly for long periods of time.  

One of the weaknesses of many of these studies is the lack of consideration for other lifestyle elements.   Considering diet alone, it is unlikely that omega-3 supplements would help very much if the rest of a person's diet is unhealthy.    A healthy, balanced, "Mediterranean" style diet, with lots of vegetables, healthy oils (such as olive), fish, and nuts, with minimal processed foods, minimal sugar, minimal simple carbs, is likely to be much more important in terms of nutritional care of mood, compared to any supplement alone.  However, omega-3 supplements could be a safe and possibly useful adjunct to an already healthy diet.

Parenting & Psychotherapy

There are many books out there about how to be a better parent.  The fact that this genre is popular is, in my opinion, a good sign of societal health:  perhaps part of parenting well is being interested in learning about ways to parent well!  It speaks to a cultural change as well, in which quality of parenting is considered important as a societal theme.

Demographics have changed over the centuries, in a way which bodes well for the earth's future:
 At this point, there is about 1.1% of population for each year of age, up to 1.6% per year for people in their 50's (the baby-boomers), then declining gradually for elderly.  In general, the population pyramid now looks more like a "solid bar" rather than a triangle, indicating that people of all ages are more equally represented in the population, rather than young children being most common.

This means that each family with children, on average, can invest more time, attention, and resources, with each individual child. 

What is the evidence about the merits of different styles of parenting?

Here we have the very surprising finding that differences in "shared family environment" have a much smaller impact on most phenomena, such as personality traits, intelligence, and mental illnesses, compared to differences "non-shared environment" (i.e. the environmental factors unique to the individual) and to differences in genetics.

 Yet, these findings refer to population averages. It is obvious that extremes of environmental experience will obviously influence outcomes much more.  An atmosphere of severe abuse and neglect is likely to have a damaging effect, while smaller differences in home environment within the "average" range in the society are much less likely to have significant effects.

People tend to focus excessively on the "smaller differences" side of things, with respect to parenting and home environment.  Provided that the home is secure, safe, relatively stable, with access to reasonable social and educational resources, it is probably true that variations within one or two standard deviations of the mean of parenting style are unlikely to make very much difference, in terms of subsequent illnesses, intellectual achievement, or overall well-being among children who grow up in such family environments.    The key thing is the avoidance of extreme negatives such as abuse or neglect.

Is there any other parenting variable that clearly matters?

I believe it is simply time, involvement, and availability.  Better parenting does not necessarily require parent education groups, expanded community resources and collaboration, better activity groups for the children, more efficient time-management strategies, etc.

Rather, better parenting simply involves being joyously, affectionately present for your children!

Presence and availability alone are not enough.  The availability has to be provided with a spirit of joy and delight.  Child-rearing cannot merely be a chore or a technical skill -- it must be nurtured as a joy of life.  Children who see that their parents actually enjoy parenting, enjoy laughing and playing and working together, are much better off than those whose parents spend equal amounts of time, but with a spirit of stress, negativity, or conflict.


I wish to make an analogy between parenting and psychotherapy.  I know it is an imperfect comparison, in many cases at least.  Some patients do not desire or need any such dynamic with a therapist, and it could be intrusive or presumptuous for the therapy relationship to have some kind of unwelcome "parental" quality.    For other patients, there is a more overt "parental" dynamic in therapy frames.  In any case, I think that there is a direct analogy between optimal "parenting strategy" and optimal "psychotherapeutic strategy."

Most of us, examining evidence of psychotherapy, emphasize technical differences in the therapy style or actions (e.g. using CBT vs. psychodynamic approaches).  Yet, evidence about relative advantages of one technique vs another is actually very minimal.

I do think there are technical elements which are important.   For example, I think principles of behavioural therapy must be called upon for management of any condition or problem -- it is like prescribing exercise to strengthen a muscle -- all the talking in the world cannot replace the need to actually practice something actively to become stronger or more skilled.   Similarly, a parent does need to literally teach a child to speak, to throw a ball, to ride a bike, to read, etc.  Time and togetherness alone are not usually enough to help a child acquire these skills.  

However, the biggest factor of all, in psychotherapy, is just like with parenting:   it is all about being available, and offering time and attention.  But just like with parenting, time and attention are not enough:  the time and attention must be provided with a spirit of joy, interest, and engagement, and with stable, healthy, safe boundaries. 

Nowadays, we have pressures upon medical and mental health care which seek to "optimize" care delivery.  Evidence is gathered about efficiency of care.  This tends to push medical and psychotherapeutic practice towards shorter visits, less frequent visits,  limited numbers of visits (for example, 6 month limits on courses of therapy), and indirect visits (e.g. through video links).    Most of the evidence supporting such methods is short-term. 

Imagine instructing a parent to become "more efficient,"  encouraging briefer interactions with children, less frequently, and for no more than 6 months at a time, particularly if it was found that the children's "symptom scores" had reached a particular threshold.

Optimal psychotherapeutic care requires time, patience, and availability.  In a setting of impoverished resources, there may be less time and availability to be shared.  But sometimes, such as in Canada, we do not actually have an impoverishment of resources.  It is "pseudo-impoverishment."  If it is difficult to access resources, the solution does not need to involve spartan rationing or obsessing about "efficiency."  It may mean that it is worth considering, for society as a whole, that it is good to invest more of our nation's vast wealth to offer personalized, patient, ongoing empathic care to those who desire or need it. 

Antidepressants in Pregnancy: Autism Risk?

On December 14, 2015, Boukhris, Sheehy, Mottron, and Berard published a paper in JAMA Pediatrics which described their  study of the association between autism-spectrum disorders and exposure in utero to antidepressants.

They looked at all women who had pregnancies in Quebec between 1998 and 2009.  These 186 165 women have been followed prospectively in the Quebec Pregnancy Cohort (QPC).  The authors looked only at those infants born at full term; all antidepressant exposure was recorded, and there was up to 11 years of follow-up. 

They found that 3.2% of all infants born to this cohort were exposed to antidepressants in utero.  Of those infants who had this exposure, 46 later received a diagnosis of an autistic-spectrum disorder (1 %).  More specifically, among those exposed in the second or third trimester, there were 31 autistic-spectrum diagnoses (1.2 %).   Among those infants with no in utero antidepressant exposure, 1008 later received an autistic spectrum disorder diagnosis (0.7 %).

When the diagnoses were restricted to those made by a neurologist or psychiatrist, the findings remained positive, but with reduced statistical confidence.


Other factors, such as maternal history of psychiatric disorders, mother living alone, maternal gestational diabetes or hypertension, were also positively correlated with the infant later having an autistic-spectrum disorder diagnosis.

A major weakness of the study was that it did not have a detailed analysis or discussion of autistic-spectrum symptoms (even subsyndromally) in the parents or other relatives of the infants.  They state "although our sample size is large, the size decreased substantially in stratified analysis on family history of ASD, which led to decreased statistical power."  And they observe that "those using [antidepressants] were...more likely to have had another child with ASD than those not using ADs", but did not expand on this finding.      The most likely contributing factor towards autism-spectrum phenomena would be the presence of these same phenomena in the family, which would be heritable.   It is possible that the presence of this hereditary factor could have been an underlying cause for the heightened risk which they observed.   This same risk factor could theoretically have contributed to the mothers using antidepressants more frequently during the pregnancy.

Another weakness of the study concerns the use of the "autism spectrum disorder" diagnostic label.  The use of this label is more frequent nowadays.  The degree to which it is appropriately considered a "disorder" could be subject to debate about criteria or severity.  For example, with the "autism spectrum quotient" questionnaire,  criteria such as "I don't like reading fiction,"  "I am fascinated by numbers," and "I would rather go to a library than a party" increase the score towards an autism diagnosis!  It seems much more important to restrict such a label to some kind of marked social, behavioural, or communicative problem, rather than intellectual or recreational preferences.   Enjoyment of libraries should not lead to a DSM label! 

Another related confounding factor could be that someone who has taken antidepressants might be more likely to have their children assessed by someone able to "diagnose."   It could be that if an autism questionnaire was administered to every child in the cohort, then 1.2% (rather than 0.7%) of the entire cohort could meet some "autism spectrum" threshold.  Perhaps the increased incidence in the group who had taken antidepressants is simply due to these mothers having a higher likelihood of asking for their children to be assessed.   In order to determine whether this is true, we would have to ensure that every child in the cohort received the same type of assessment, including the same questionnaires (such as the "autism spectrum quotient").   But in this study, this was certainly not the case. 

While the authors find that SSRIs in particular were associated with increased ASD incidence, with minimal associations from other antidepressant classes, it is notable that there were far too few cases of  non-SSRI antidepressant exposure to make any reliable statement at all about non-SSRI antidepressants.   Therefore, they should remove the implied message that only SSRIs are involved with the association. 

Nevertheless, it is an important study with a very large cohort.  We must be vigilant about the possibility of risks for giving any medications, particularly in pregnancy.

If, in future studies, this difference in autism incidence is found to be directly caused by antidepressant exposure, the evidence here shows that the risk increases from 0.7% to 1.2%.  Posed differently, the probability of not having an autism-spectrum diagnosis changes from 99.3% to 98.8%.


In some cases, the risk of severe depression in pregnancy could outweigh the risk of a treatment causing harm, but this would need to be carefully evaluated and discussed.   A question to ask in this situation would be whether the antidepressant is specifically required for treatment of the depression.  In some cases, it might indeed be very helpful, with a much higher likelihood of depressive symptoms, and various adverse outcomes for mother and child, without it.  But in other cases, despite high depressive severity, the antidepressant might not clearly be an imperative component of the therapy.  Perhaps in some cases other treatment modalities could be sufficient, at least during the pregnancy.  It depends on the specific case or situation.  

I am bothered by the author's concluding remarks in their abstract; the remarks assert causation, despite the findings really being associative:  they say "use of antidepressants...increases the risk of ASD in children."  It would be more appropriate for them to have said, as they were more careful to do elsewhere in the body of the paper, that "there is an association between antidepressant exposure in utero and subsequent ASD diagnosis."

In any case, it is not controversial to assert that all possible non-medication strategies should be optimized in the treatment of depression, particularly in pregnancy.  This includes promotion of healthy lifestyle factors, careful attention to social and community support, and psychotherapy.   

Changes in Psychiatric Culture -- Wait Lists, "Efficiency," and Superficial Care

Psychiatrists are more commonly offering the following services:

1) "Assessment":  This is a single 1-hour interview, yielding an obligatory report with diagnostic label, and treatment advice.  In some places, this single interview is all the psychiatric input that is offered.

The single assessment has rich prececents in other areas of medicine.  For example, a visit to a dermatologist could yield a very accurate and fruitful diagnosis of a specific type of chronic skin disease, leading to a clear set of instructions for safe and effective treatments.  In many cases, it would  not be necessary to see the dermatologist regularly after this assessment, unless the treatment regime was going very poorly.

But psychiatry and dermatology are quite different!   Despite our attempts to have a reductionistic and medicalized diagnostic scheme in psychiatry (e.g. the DSM-V), we see that two different people with the exact same diagnosis frequently do not follow the same pathway of symptom progression. Identical treatments do not work in identical ways with different people.

Furthermore, I believe it is an act of significant hubris to assume that one can effectively "diagnose" someone, with respect to issues touching on a person's entire history of self, character, emotion, and intellect, following a single one-hour visit.   The "first impression" from a first interview can be very important to understand a person's life and problems, but as we all know, first impressions can very, very often be inaccurate or incomplete.  For some people, it could take weeks, months, or even years, to share their story. 


Yet, this pattern of assessments may, on paper, appear to be very efficient.  One could "manage" wait lists much more quickly.  The problem is that a single assessment is actually not very useful, despite yielding an official-looking report which appears useful.   Offering single assessments only is similar to a teacher offering a single day of school to each of 4 000 students, rather than a whole year of daily teaching for a classroom of 20.   Another insidious consequence of the apparently "efficient" pattern of doing multiple "assessments" is that the therapist, or teacher, who may have a great joy and talent for deeply helping people in an ongoing collaborative relationship, may instead not really get to help anyone very much, leading to sinking morale and rising cynicism.  Burnout would probably follow, much more often.  But the paycheque would not go down -- it would actually be higher (in psychiatry, the fees for assessments are about 25% higher than for spending the same length of time offering a follow-up therapy appointment).  

Many of the patients I have seen have had an incredible, audible sigh of relief, when they have discovered that I am actually going to make time to see them regularly!   There is often some sense of surprise that I do not focus on diagnostic labels.   The experience of mental health care, for many, has been one of shuttling between various short-term groups, superficial courses of CBT in a sort of group lecture format, brief one-on-one followup which ends just as a deeper sense of trust is forming, and medication trials with primary care doctors.   

2) "Medication management visits":  In many cases, psychiatrists do not offer what could be called "psychotherapy."  Instead, patients are seen for a few minutes,  to discuss medication doses.   These visits could possibly be more frequent if the patient is not doing as well.  It is understandable to have such visits, for people who are wishing to take medication.  In clinics serving those who have major mental illnesses, who are taking complex medication combinations, this type of service is undeniably important.   Other types of psychotherapy or health care may be happening elsewhere.  But if this is the only style of visit which psychiatrists are offering, it creates a frame in which medication use is implied as a norm.  Why would you have a "medication management visit" if you didn't want or need medication?  From the psychiatrist's point of view, why discuss other matters, such as relationships, goals, dreams for the future, etc. unless it pertains to the medication management plan?  The frame leads to an atrophy of therapeutic skill.  I think it is a serious problem if psychiatric visits are framed with an expectation of medication management, particularly when we know what an incredibly, strongly loaded set of biases exist around medication use and marketing.  The medication management visit framework is surely designed to "optimize" the use of psychiatry, in a setting of long wait lists and shortages of care, but in setting things up this way we are inviting a possible massive deterioration in the quality of care.  I note again, that psychiatrists using the provincial fee schedule receive a large financial gain by seeing larger numbers of patients for briefer, more superficial, medication-oriented visits.  The decrement in the quality of care may tragically not be noticed in the short term, because wait lists would be shorter, appearing to be beneficial. 

Also, "improved" wait list management may cause an external observer to assume that the system has been "fixed," therefore delaying more substantive systemic changes.  

In a further sort of game-theoretical analysis of these evolving trends, I believe that there are even more adverse consequences:   because of the changing culture of the type of psychiatric practice which is considered a norm, the profession itself will attract those who are most comfortable offering this style of service.  Those wishing to do more psychotherapeutic work, or having more skepticism about medicalized psychiatry, would feel ever more part of an eccentric minority, and might choose not to enter a psychiatry residency in the first place.    So psychiatry would become even more "medicalized" with time, in a form of evolutionary selection process.  


Ideas for Positive Change:

1) Wait list management.
a)  The public health system in Canada, and possibly private insurers elsewhere in the world, could simply fund private non-medical psychotherapists.  Therapy visits with a psychologist or other counselor could be covered under the public medical services plan.  This could reduce psychiatry wait lists dramatically, while also helping the many psychotherapists who are ironically struggling to make a living, despite there being a massive population need for their services.  For a large institution such as a university, if there were extra funds to spend on mental health, these funds could be spent on providing service availability with local therapists, personal trainers, music & art therapists, pet therapists, gym memberships, etc., rather than spending money on expensive new buildings and other infrastructure.   People help people.  Buildings don't help people much, despite appearing to do so.  

b) Non-medical psychotherapists could be allowed to prescribe medication, at least in a very limited way.    I am not meaning to suggest this as a way to increase medication use!  I suggest this to defuse the power dynamic which currently exists among psychiatrists and other physicians.   The basics of psychiatric medication prescription do not require many years of medical education to understand and manage safely.  In fact, the many years of  education may simply consolidate a culture of medication use as an often unnecessary norm.  If there would be less pressure on psychiatrists and other physicians as the sole prescribers of medication, then there could be an opportunity for psychiatrists to be less focused on medication, and therefore more focused on therapeutic alliance.

2) Style of Practice
Here, I think it is very simple:  make time for people!  Doctors, make time for your patients!  Be willing to see them!  I am less concerned about what style of psychotherapy or other tactics.   I am more concerned about being present, collaborative, empathic, and available.   We should be well-informed about medications, and about therapy styles such as CBT, but we should focus most of our attention on very basic matters of building rapport, trust, and working alliance, without fear of the relationship being cut off. 

Cochrane Review: ADHD medications have lower-quality evidence than most people believe

A new Cochrane review, published on November 25, 2015 by authors Storebø and Zwi, looked at the use of stimulants to treat childhood ADHD (specifically, methylphenidate).  Their conclusions included:

1.  "the low quality of the underpinning evidence means that we cannot be certain of the magnitude of the effects."
2. "the general perception of methylphenidate as an effective drug for all children with ADHD seems out of step with the new evidence."  

The authors found a great deal of industry sponsorship in existing studies, and found that "all 185 trials" had a high risk of bias.   I would add that more recent ADHD studies, involving newer, more expensive medications, are most likely at an even higher risk of similar biases.  

In general, the weaknesses of existing data are similar to the weaknesses in much other psychiatric research:  studies are usually brief, rather than long-term, despite  treatments often being given for many years or permanently.  

Other authors, such as Hinshaw (2015)[http://www.ncbi.nlm.nih.gov/pubmed/26262927] have reached similar conclusions, including
"the diminution of medication's initial superiority [was apparent] once the randomly assigned treatment phase turned into naturalistic follow-up. The key paradox is that while ADHD clearly responds to medication and behavioral treatment in the short term, evidence for long-term effectiveness remains elusive"

How should this information inform our understanding or management of ADHD?

First, I do not think it is necessary to stop using stimulants as a treatment.  However, I do think it is necessary to step away from the assumption that long-term stimulant use is appropriate for every person with ADHD symptoms.   Other ways of using stimulant medication could often be more appropriate for many, such as using stimulants sporadically, to manage attentional symptoms for brief periods of time.  

The evidence also does not strongly support the long-term effectiveness of behavioural therapies.  This, too, is not really surprising to me.  

I think that the answer lies in moving away from a highly medicalized, reductionistic approach entirely.  Phenomena such as ADHD have broad biopsychosocial underpinnings:  some factors exist within the individual, while many others exist in family, social, and educational structures.   In some ways this is similar to other public health issues, such as obesity or addictions:  a single medication or behavioural treatment is very unlikely to be a remarkably effective strategy to help with these problems.    Yet, each of these strategies has a role, provided that the role is not overvalued by those offering it.  Other larger social factors are extremely important as well, including factors relating to poverty, economic equality, community supports, provision of justice & public safety, etc. 

So in conclusion, I see -- not surprisingly -- that we must not have exaggerated expectations of medication for treating ADHD or any other psychiatric phenomena.  I do think stimulants have an important role, however, for many people, provided that the expectations are modest, and provided that side effect risks are not discounted by an over-enthusiastic prescriber with biased beliefs about long-term effectiveness vs. risk. 

It is also important not to be biased against any particular treatment.  In some cases, for example, balanced medication treatment of ADHD could reduce various types of risks, including substance use problems and traffic accidents, etc.   It is just that the magnitude of such protective effects are likely to be exaggerated in most practioners' minds, due to the biases described above. 

 As with other life issues, I believe it is necessary to have a very broad view about helping strategies, which includes other types of therapeutic support if desired, as well as attention given to community, educational, cultural, and family resources--not in isolation, but in a comprehensive and holistic way.