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
Wednesday, March 25, 2009
St. John's Wort
St. John's Wort is a herbal antidepressant. Its mechanism is not well-understood, and at this point is in the realm of speculation, but may involve multiple compounds rather than just a single ingredient (one of the many ingredients in St. John's Wort extracts, for example, is hyperforin).
There is an evidence base in the research literature, supporting its use. However, I find many of the articles to be published in minor journals, and to be of questionable quality.
I will restrict my present survey to a few studies that I consider to be of higher quality:
Here is an article abstract discussing possible mechanisms of action:
http://www.ncbi.nlm.nih.gov/pubmed/12775192
This is a reference to a Cochrane review from 2008.
http://www.ncbi.nlm.nih.gov/pubmed/18843608
It supports the use of St. John's Wort for treating major depression, and concludes that response rates were similar, compared to SSRIs and tricyclic antidepressants. It also concludes that St. John's Wort was much better-tolerated than other antidepressants, with a greatly reduced risk of side-effects or of discontinuing the medication due to side-effects. The authors note that studies from German-speaking countries tend to report a greater benefit from St. John's Wort.
I note that this review was written by authors from a "Centre for Complementary Medicine Research" in Germany. It may be that researchers at such a site could have a biased view in favour of complementary therapies.
This review from the major journal BMJ in 2005 gives much less enthusiastic conclusions about St. John's Wort:
http://www.ncbi.nlm.nih.gov/pubmed/15684231
It gives a rigorous analysis of the data, and concludes that there is evidence, mainly from older, smaller, lower-quality studies, that St. John's Wort is beneficial compared to placebo, particularly for mild to moderate depression. More recent, larger, more rigorous studies, and studies including patients with more severe depression, show smaller treatment effects.
It does strongly emphasize that different preparations of St. John's Wort may differ in quality, especially since it is an over-the-counter product in most places, and therefore may lack the guaranteed quality control of regulated pharmaceutical products.
Here are links to 2 carefully done studies from 2001 and 2002, published in JAMA, showing no therapeutic benefit of St. John's Wort. The first study compared only with placebo, the second study also compared with sertraline, an SSRI--in the latter study the sertraline actually didn't do well against placebo either! I have to wonder if particular samplings of depressed patients are relatively less treatment-responsive compared to placebo, for a variety of reasons. Also, it may be that some preparations of St. John's Wort are more effective than others:
http://www.ncbi.nlm.nih.gov/pubmed/11308434
http://www.ncbi.nlm.nih.gov/pubmed/11939866
Here is a link to a recent German study showing that people who respond to St. John's Wort have lower rates of relapse, compared to placebo, if they continue to take it for a year:
http://www.ncbi.nlm.nih.gov/pubmed/18694635
There are some interactions St. John's Wort may have with other drugs; mainly the concern is that St. John's Wort induces the liver to metabolize other drugs more actively, therefore reducing the levels of other drugs. This could be a danger for some people. Here is a reference about this:
http://www.ncbi.nlm.nih.gov/pubmed/15260917
There are case reports of St. John's Wort causing mania, so it would need to be used carefully in persons with bipolar disorder. But there are no studies that I can find, which give clear estimates of risk for St. John's Wort to cause mania or rapid cycling, particular when compared to other treatments for depression in bipolar disorder.
There is a poor evidence base looking at the safety of combining St. John's Wort with other antidepressants, but there are a few case reports of possibly dangerous states such as serotonin syndrome.
I will add to this posting later, but for now I would say that St. John's Wort is probably quite safe for most people, and is probably easier to tolerate (in terms of side-effects) than prescription antidepressants. It may be effective, for some people, to treat or reduce symptoms of depression and anxiety. It may reduce levels of other medications, including contraceptives, and may interact with other drugs, so these possibilities have to be considered very carefully, and discussed with your prescribing physician.
Also, I should add that different brands of St. John's Wort may differ in quality, differ in the extraction method used, etc. So if you are going to give St. John's Wort a try, it may be worthwhile to try several different brands. Given the abundance of positive research studies from Germany, it might be worthwhile to try a German brand.
Wednesday, March 18, 2009
How to Quit Smoking
It is difficult to quit smoking.
Here is my summary of the evidence about things that help:
The single most effective treatment to help smokers quit is a new drug called varenicline. This drug works by mildly stimulating a nicotine receptor, while blocking nicotine itself from interacting with the receptor: in this way it is a "nicotine receptor partial agonist." Varenicline is quite well-tolerated, the most common side-effects being nausea and insomnia. Usually these settle with time, and are less a problem if the dose is started low, and built up gradually. There have been reports of adverse psychiatric side effects (e.g. agitation, worsened insomnia, worsened depression) so it would have to be used cautiously in those with mental illnesses. I have reviewed a few studies below which affirm its usefulness among patients with psychiatric problems.
Evidence shows that there is only about a 10% chance of being able to quit smoking on your own (by quitting, we mean staying abstinent for at least a year).
A 3-month course of bupropion (an antidepressant) approximately doubles your chance of being able to quit. However, this raises your chance only to about 20%.
Tricyclic antidepressants such as nortriptyline can increase abstinence rates, probably comparable to bupropion.
Nicotine replacement (e.g. gum or patch) is less effective than bupropion. But it does increase your chances of quitting to about 15%.
Varenicline is most effective of all; a 3-month course increases your chance of quitting to about 25%.
Probably, combinations of the above pharmacological treatments increase your chances further.
Also I should note that many of the studies looking at pharmacological treatments for smoking addiction only used the active treatment for three months. It seems to me that longer courses of treatment would be more likely to help people maintain sustained abstinence; addictions and other long-standing phenomena in the brain persist, or change, over a course of years, not just months.
Psychotherapeutic strategies (e.g. CBT and other behavioural therapies) may help, but the evidence is weaker. The evidence that is available suggests that if psychotherapeutic or motivational strategies are to be effective, they need to be maintained over the long-term (perhaps permanently). In this regard, it reminds me of a "12-step" philosophy, which emphasizes the permanence of an addictive problem, and emphasizes that lifelong vigilance is needed to prevent relapse.
The following study published in CMAJ showed 54% 1-year abstinence in a group of smokers who had suffered an heart attack (MI), and who were given an "intensive anti-smoking intervention" (advice, an hour of counseling, and 7 telephone follow-up sessions over 60 days). The counseling employed "Marlatt and Gordon's relapse prevention model." A similar group of smokers not receiving this intervention had a 35% 1-year abstinence rate. Interestingly, medications were permitted in this study, and were associated with markedly worse abstinence rates. But the medications were administered more or less ad lib, so the effect of medications would be very confounded and unclear (for example, perhaps only the patients struggling most would have opted for medications--the reason they didn't do as well is because they were more severely addicted in the first place, not because of the medications. Also, with a haphazard administration of medications, patients might not realize the need to continue medications longer-term to maintain a therapeutic effect).
http://www.ncbi.nlm.nih.gov/pubmed/19546455
In my opinion, the level of "intervention" here actually seems quite minimal, yet it seems impressive that an organized effort of any kind to help prevent smoking through counseling methods would produce good results.
This is the best review article about medication treatments to date, in my opinion; it is from The Canadian Medical Association Journal (July 2008):
http://www.ncbi.nlm.nih.gov/pubmed/18625984?ordinalpos=87&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
A current study by Michael Steinberg et al. in Annals of Internal Medicine (2009;150:447-454) shows that combination therapy with bupropion + nicotine patch + nicotine inhaler, increased abstinence rates at 26 weeks to 35% in a group of medically ill smokers, compared to 19% in a group receiving only a nicotine patch. Those in the combination group were encouraged to use the treatments as long as they felt necessary, then to taper and discontinue as they felt able. This instruction, in my opinion, would have discouraged the participants from considering that bupropion could work to prevent relapse in the long-term, therefore they would probably have chosen to discontinue the bupropion as soon as they felt free of their smoking habit for a short time. As I look at the study in detail, I see that most of the combination group indeed did not maintain the bupropion beyond the 3 month mark. I suspect that if people were strongly encouraged to continue the treatments longer, on a preventative basis, then the abstinence rates could have been much higher than 35%.
Here is a 2005 meta-analysis showing that the tricyclic antidepressant nortriptyline can be effective. Once again, the effects were significant but modest. Most of the studies used only a standard 3-month course of treatment, followed by a taper and discontinuing the nortriptyline. In the one study allowing a full year of nortriptyline treatment, the abstinence rate was much higher (40%):
http://www.ncbi.nlm.nih.gov/pubmed/15733245?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=4&log$=relatedreviews&logdbfrom=pubmed
Similarly, in a study maintaining varenicline for 52 weeks, the abstinence rate was 36.7%, compared to 7.9% with placebo. However, while the existing evidence about the safety of using varenicline on a long-term basis is generally reassuring, more long-term experience is necessary with this drug to know for sure. I think the potential risks would have to be weighed against the risks of continuing to smoke. Here is a link to the study:
http://www.ncbi.nlm.nih.gov/pubmed/17407636?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed
Similarly again, in the one long-term study of bupropion (a full year of medication), there were considerably higher abstinence rates:
http://www.ncbi.nlm.nih.gov/pubmed/11560455?ordinalpos=18&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
The following small study showed that varenicline helped reduce smoking in patients with schizophrenia, and appeared to have some beneficial cognitive effects in this group.
http://www.ncbi.nlm.nih.gov/pubmed/19251401?ordinalpos=6&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
The following small study showed possible increased abstinence rates when varenicline and bupropion therapy was combined:
http://www.ncbi.nlm.nih.gov/pubmed/19246427?ordinalpos=8&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
Another study supporting the idea that combination therapy (e.g. varenicline + nicotine replacement) is more effective than one treatment alone, for helping smokers quit:
http://www.ncbi.nlm.nih.gov/pubmed/18826906?ordinalpos=56&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
The following study shows that varenicline is similarly tolerated and effective in patients with depression, compared with patients without a history of depression. Stress and mood scores improved slightly with time:
http://www.ncbi.nlm.nih.gov/pubmed/19238488?ordinalpos=12&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
This 2009 study from Biological Psychiatry suggests that varenicline could also reduce alcohol consumption in heavy-drinking smokers:
http://www.ncbi.nlm.nih.gov/pubmed/19249750?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
This is a 2009 Cochrane review of smoking relapse prevention interventions; it supports extended treatment with varenicline to prevent relapse, and concludes that there is insufficient evidence at this point to comment one way or another on specific behaviour therapies:
http://www.ncbi.nlm.nih.gov/pubmed/19160228?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedreviews&logdbfrom=pubmed
This study looked at 20 weeks of adjunctive CBT, and found no significant difference in abstinence rates after a year. But it did find an advantage in the CBT group in the shorter term, during the course of CBT (45% abstinence in the CBT group vs. 29% in the control group, at the 20 week mark). This suggests that long-term, ongoing, continuous CBT may be helpful to boost abstinence rates, but the therapy loses its effectiveness if it is not maintained:
http://www.ncbi.nlm.nih.gov/pubmed/18855829?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
All of these studies support the idea that smoking addiction is a long-term problem. Short-term strategies (typically over a few months) definitely help, but long-term, continuing effort or treatment is needed to maintain abstinence for most people. These strategies could include medications such as varenicline, bupropion, or nortriptyline; and they could include psychotherapeutic approaches such as CBT.
Individuals with psychiatric illnesses such as depression, bipolar disorder, ADHD, and especially schizophrenia, have much higher rates of smoking. Here is a reference:
http://www.ncbi.nlm.nih.gov/pubmed/15949648?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=2&log$=relatedarticles&logdbfrom=pubmed
There is evidence that nicotine can acutely improve elements of cognitive performance and to reduce impulsivity, particularly in those with illnesses such as schizophrenia and ADHD. This may be one of the reasons why individuals with these problems are more drawn to cigarette smoking. Here is some evidence:
http://www.ncbi.nlm.nih.gov/pubmed/17443126?ordinalpos=6&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
http://www.ncbi.nlm.nih.gov/pubmed/18022679
Also there is evidence that nicotine can improve performance in attention tests in elderly people with dementia:
http://www.ncbi.nlm.nih.gov/pubmed/10326778?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=3&log$=relatedarticles&logdbfrom=pubmed
Yet, of course, nicotine has numerous harmful effects. And it is likely that nicotine could cause long-term harm to cognitive function, through several mechanisms, even if it causes short-term enhancement. A medication such as varenicline, due to its agonist effect on nicotine receptors, may be especially helpful to address some of the cognitive or attentional problems in persons with mental illnesses.
In terms of health care policy, I am puzzled about why effective therapies to improve smoking cessation are not publicly funded. Smoking is one of the largest public health problems in the world, and causes an enormous burden of premature disease and death, as well as an enormous financial drain on the health care system. I believe that all proven therapies for smoking cessation should be freely available.
Unfortunately, varenicline -- and other anti-smoking therapies -- are expensive, and they are often not covered by health plans.
Here is my summary of the evidence about things that help:
The single most effective treatment to help smokers quit is a new drug called varenicline. This drug works by mildly stimulating a nicotine receptor, while blocking nicotine itself from interacting with the receptor: in this way it is a "nicotine receptor partial agonist." Varenicline is quite well-tolerated, the most common side-effects being nausea and insomnia. Usually these settle with time, and are less a problem if the dose is started low, and built up gradually. There have been reports of adverse psychiatric side effects (e.g. agitation, worsened insomnia, worsened depression) so it would have to be used cautiously in those with mental illnesses. I have reviewed a few studies below which affirm its usefulness among patients with psychiatric problems.
Evidence shows that there is only about a 10% chance of being able to quit smoking on your own (by quitting, we mean staying abstinent for at least a year).
A 3-month course of bupropion (an antidepressant) approximately doubles your chance of being able to quit. However, this raises your chance only to about 20%.
Tricyclic antidepressants such as nortriptyline can increase abstinence rates, probably comparable to bupropion.
Nicotine replacement (e.g. gum or patch) is less effective than bupropion. But it does increase your chances of quitting to about 15%.
Varenicline is most effective of all; a 3-month course increases your chance of quitting to about 25%.
Probably, combinations of the above pharmacological treatments increase your chances further.
Also I should note that many of the studies looking at pharmacological treatments for smoking addiction only used the active treatment for three months. It seems to me that longer courses of treatment would be more likely to help people maintain sustained abstinence; addictions and other long-standing phenomena in the brain persist, or change, over a course of years, not just months.
Psychotherapeutic strategies (e.g. CBT and other behavioural therapies) may help, but the evidence is weaker. The evidence that is available suggests that if psychotherapeutic or motivational strategies are to be effective, they need to be maintained over the long-term (perhaps permanently). In this regard, it reminds me of a "12-step" philosophy, which emphasizes the permanence of an addictive problem, and emphasizes that lifelong vigilance is needed to prevent relapse.
The following study published in CMAJ showed 54% 1-year abstinence in a group of smokers who had suffered an heart attack (MI), and who were given an "intensive anti-smoking intervention" (advice, an hour of counseling, and 7 telephone follow-up sessions over 60 days). The counseling employed "Marlatt and Gordon's relapse prevention model." A similar group of smokers not receiving this intervention had a 35% 1-year abstinence rate. Interestingly, medications were permitted in this study, and were associated with markedly worse abstinence rates. But the medications were administered more or less ad lib, so the effect of medications would be very confounded and unclear (for example, perhaps only the patients struggling most would have opted for medications--the reason they didn't do as well is because they were more severely addicted in the first place, not because of the medications. Also, with a haphazard administration of medications, patients might not realize the need to continue medications longer-term to maintain a therapeutic effect).
http://www.ncbi.nlm.nih.gov/pubmed/19546455
In my opinion, the level of "intervention" here actually seems quite minimal, yet it seems impressive that an organized effort of any kind to help prevent smoking through counseling methods would produce good results.
This is the best review article about medication treatments to date, in my opinion; it is from The Canadian Medical Association Journal (July 2008):
http://www.ncbi.nlm.nih.gov/pubmed/18625984?ordinalpos=87&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
A current study by Michael Steinberg et al. in Annals of Internal Medicine (2009;150:447-454) shows that combination therapy with bupropion + nicotine patch + nicotine inhaler, increased abstinence rates at 26 weeks to 35% in a group of medically ill smokers, compared to 19% in a group receiving only a nicotine patch. Those in the combination group were encouraged to use the treatments as long as they felt necessary, then to taper and discontinue as they felt able. This instruction, in my opinion, would have discouraged the participants from considering that bupropion could work to prevent relapse in the long-term, therefore they would probably have chosen to discontinue the bupropion as soon as they felt free of their smoking habit for a short time. As I look at the study in detail, I see that most of the combination group indeed did not maintain the bupropion beyond the 3 month mark. I suspect that if people were strongly encouraged to continue the treatments longer, on a preventative basis, then the abstinence rates could have been much higher than 35%.
Here is a 2005 meta-analysis showing that the tricyclic antidepressant nortriptyline can be effective. Once again, the effects were significant but modest. Most of the studies used only a standard 3-month course of treatment, followed by a taper and discontinuing the nortriptyline. In the one study allowing a full year of nortriptyline treatment, the abstinence rate was much higher (40%):
http://www.ncbi.nlm.nih.gov/pubmed/15733245?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=4&log$=relatedreviews&logdbfrom=pubmed
Similarly, in a study maintaining varenicline for 52 weeks, the abstinence rate was 36.7%, compared to 7.9% with placebo. However, while the existing evidence about the safety of using varenicline on a long-term basis is generally reassuring, more long-term experience is necessary with this drug to know for sure. I think the potential risks would have to be weighed against the risks of continuing to smoke. Here is a link to the study:
http://www.ncbi.nlm.nih.gov/pubmed/17407636?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed
Similarly again, in the one long-term study of bupropion (a full year of medication), there were considerably higher abstinence rates:
http://www.ncbi.nlm.nih.gov/pubmed/11560455?ordinalpos=18&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
The following small study showed that varenicline helped reduce smoking in patients with schizophrenia, and appeared to have some beneficial cognitive effects in this group.
http://www.ncbi.nlm.nih.gov/pubmed/19251401?ordinalpos=6&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
The following small study showed possible increased abstinence rates when varenicline and bupropion therapy was combined:
http://www.ncbi.nlm.nih.gov/pubmed/19246427?ordinalpos=8&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
Another study supporting the idea that combination therapy (e.g. varenicline + nicotine replacement) is more effective than one treatment alone, for helping smokers quit:
http://www.ncbi.nlm.nih.gov/pubmed/18826906?ordinalpos=56&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
The following study shows that varenicline is similarly tolerated and effective in patients with depression, compared with patients without a history of depression. Stress and mood scores improved slightly with time:
http://www.ncbi.nlm.nih.gov/pubmed/19238488?ordinalpos=12&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
This 2009 study from Biological Psychiatry suggests that varenicline could also reduce alcohol consumption in heavy-drinking smokers:
http://www.ncbi.nlm.nih.gov/pubmed/19249750?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
This is a 2009 Cochrane review of smoking relapse prevention interventions; it supports extended treatment with varenicline to prevent relapse, and concludes that there is insufficient evidence at this point to comment one way or another on specific behaviour therapies:
http://www.ncbi.nlm.nih.gov/pubmed/19160228?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedreviews&logdbfrom=pubmed
This study looked at 20 weeks of adjunctive CBT, and found no significant difference in abstinence rates after a year. But it did find an advantage in the CBT group in the shorter term, during the course of CBT (45% abstinence in the CBT group vs. 29% in the control group, at the 20 week mark). This suggests that long-term, ongoing, continuous CBT may be helpful to boost abstinence rates, but the therapy loses its effectiveness if it is not maintained:
http://www.ncbi.nlm.nih.gov/pubmed/18855829?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
All of these studies support the idea that smoking addiction is a long-term problem. Short-term strategies (typically over a few months) definitely help, but long-term, continuing effort or treatment is needed to maintain abstinence for most people. These strategies could include medications such as varenicline, bupropion, or nortriptyline; and they could include psychotherapeutic approaches such as CBT.
Individuals with psychiatric illnesses such as depression, bipolar disorder, ADHD, and especially schizophrenia, have much higher rates of smoking. Here is a reference:
http://www.ncbi.nlm.nih.gov/pubmed/15949648?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=2&log$=relatedarticles&logdbfrom=pubmed
There is evidence that nicotine can acutely improve elements of cognitive performance and to reduce impulsivity, particularly in those with illnesses such as schizophrenia and ADHD. This may be one of the reasons why individuals with these problems are more drawn to cigarette smoking. Here is some evidence:
http://www.ncbi.nlm.nih.gov/pubmed/17443126?ordinalpos=6&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
http://www.ncbi.nlm.nih.gov/pubmed/18022679
Also there is evidence that nicotine can improve performance in attention tests in elderly people with dementia:
http://www.ncbi.nlm.nih.gov/pubmed/10326778?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=3&log$=relatedarticles&logdbfrom=pubmed
Yet, of course, nicotine has numerous harmful effects. And it is likely that nicotine could cause long-term harm to cognitive function, through several mechanisms, even if it causes short-term enhancement. A medication such as varenicline, due to its agonist effect on nicotine receptors, may be especially helpful to address some of the cognitive or attentional problems in persons with mental illnesses.
In terms of health care policy, I am puzzled about why effective therapies to improve smoking cessation are not publicly funded. Smoking is one of the largest public health problems in the world, and causes an enormous burden of premature disease and death, as well as an enormous financial drain on the health care system. I believe that all proven therapies for smoking cessation should be freely available.
Unfortunately, varenicline -- and other anti-smoking therapies -- are expensive, and they are often not covered by health plans.
Tuesday, March 17, 2009
Psychoanalysis & Neuroplasticity
This post is based in part on my thoughts regarding Doidge's book on neuroplasticity.
Psychoanalysis is a type of psychotherapy in which patients usually attend sessions almost every day (3-5 days per week, 50 minutes each time). The details of theory and practice vary, but in general psychoanalysts tend to believe that early childhood events and memories are very important to examine and understand, and that these events (e.g. relationships with mother) have direct causal links to adult personality traits and psychological symptoms. Also psychoanalysts tend to believe that the relationship with the therapist is a setting in which prior relationship dynamics recur, in the form of "transference." Most psychoanalysts assume a relatively quiet or passive stance, tending not to have active conversation or "problem solving" dialogs with patients. Also most psychoanalysts would tend to interpret various types of phenomena, such as dreams, behavioural habits, etc. as laden with meaning. A course of psychoanalysis might take years, and in general the model would be that the patient would "work through" various childhood conflicts, including as they might be transferentially manifest in the therapy, and that the patient might come to understand the various themes at play in their lives, as manifest in dreams, habits, and interpersonal behaviour. This process of understanding and "working through" is thought to lead to symptom relief and life change.
Doidge himself is a psychoanalyst. One of the chapters in his book describes psychoanalysis as a "neuroplastic therapy." (chapter 9, Turning our Ghosts into Ancestors). Part of the support for his claim comes from a case study (a type of evidence characteristic of psychoanalytic thinking). And part of his support comes from briefly describing the life and work of Eric Kandel, the great nobel laureate neuroscientist.
Kandel's work brilliantly demonstrated some of the specific anatomic and molecular changes that happen in neurons as memories are formed.
Kandel himself has been an advocate of incorporating recent biological scientific knowledge into the practice of psychiatry and psychoanalysis (see: http://www.hhmi.org/bulletin/kandel/), and had apparently planned to become a psychoanalyst himself.
I consider it not to be particularly relevant to mention Kandel at all, other than to quote someone important who probably considers psychoanalysis a good thing. It is a common sales tactic to mention an important person's name while trying to convince someone of something. Also it is common in medicine and psychiatry--but especially in alternative medicine--for there to be some mention of something that sounds "scientific" to bolster the public opinion of a product, while the science itself, if looked at closely, is only obliquely related. For example, many questionably effective naturopathic remedies, sold at quite a profit, include advertising laden with some kind of biochemical jargon, much of which, at close examination, lacks substance, but which sounds impressive.
I believe that psychoanalysis can be a powerful and transformative experience. However,I also strongly suspect that there are elements of dogma contained within the theory which are irrelevant to its beneficial effects, and which at times could make it an inefficient therapy.
Consider this thought experiment:
Suppose the beneficial effects of psychoanalysis are due to the following factors:
1) meeting with someone for an hour per day, who will listen and try to understand life problems
2) finding an "explanation" for symptoms. In the case of psychoanalysis this explanation tends to come from an examination of early life events.
Suppose that it is the belief in the explanation that causes symptom improvement, therefore that if some alternative "explanation" for symptoms could be developed, then it would lead to the same symptom improvement. Therefore, suppose that the psychoanalytic theory of character and symptom development is actually a fiction, akin to a dogmatic religious belief system, but that adherence to this belief system, and the resultant faith and conviction, would be the causes of symptom relief and character change.
A way to test this would be to conduct a randomized study of two types of intensive, long-term psychotherapy. Both would be 5 sessions per week, 50 minutes per session, lasting 5 years.
Group 1 patients would have psychoanalysis.
Group 2 patients would receive the same intensive, empathic, sessions, with intelligent and thoughtful, well-boundaried therapists. But let us imagine that some other belief system would underlie the therapy for group 2. For example, astrology. Or some form of religious fundamentalism (of any variety). Here, interpretations would be based on the positions of stars & planets, or on passages from religious texts.
A condition for this type of experiment would be that the patients in both groups would have to lack any differences in bias for or against the style of therapy. So, for example, patients in group 1 would have to have a similar level of belief that psychoanalysis is a valid and culturally-accepted system of thought, and have similar respect for the therapist, compared to the beliefs about therapist and therapy style of patients in group 2 (regarding astrology or fundamentalism, etc.).
In both groups, I suspect that subject matter would come up in the sessions, which would require the therapists to respond either empathically or interpretively. There would probably be dreams that would come up, probably interpreted quite differently--or not at all-- in both groups. The process of therapy, dream interpretation, feelings of closeness with therapist, etc. might well be experienced similarly between groups.
My hypothesis is that both the groups would show similar improvement in a 5 year course of therapy, with only a slight advantage for group 1. I believe this is because the core effect of such therapy is not from the theoretical belief system, but from the process, which is caring, consistent, empathic, understanding, and interpretive. Failed therapy experiences may happen in both groups, some of which because the patients do not like the style or belief system which is being introduced, some of which because life problems can be treatment-resistant at times, some of which because the patient did not feel well-matched with the therapist. I think group 1 would do very slightly better than group 2, because despite the dogma involved in psychoanalytic theory, the underlying process is more intellectually open (at its best).
Unfortunately, I think there is a substantial risk for people in both groups to come out of the experience with stronger dogmatic beliefs, irrespective of any therapeutic improvement. In a more mature psychoanalytic frame, I think this risk would be diminished, as the process would hopefully be more intellectually open.
I do believe that we as intelligent creatures should always seek the "truth" as best we can know it, and therefore we need to challenge our dogmas. The best therapies, in my opinion, need to seek such truths without being restricted by dogma. This is consistent with the underlying theme of psychoanalysis, which I think is about liberation (liberation from symptoms, liberation from past harms or traumas, etc.).
I am reminded now of Joseph Campbell, the comparative mythologist, who might argue that the different styles of therapy are something like different mythologies, none of which are literally "true", but perhaps all of which might contain core aspects of wisdom about the human condition. He might also argue that dogmatic, literalistic adherence to any system of belief could obstruct its underlying message. But he would also agree, I think, that one has to have "faith"--a sense of trust, engagement, and belief--in order to have a transformative experience from anything.
In psychoanalysis, I think it is immensely valuable to seek meaning by examining early childhood events, and by searching for meaning and themes in dreams and nuances of behaviour. But I think it can be can be obstructive to believe, literally, for example, that specific non-traumatic events or patterns of engagement with one's mother at the age of 2, are the causes of specific adult symptoms. I consider the greatness of psychoanalytic interpretation to lie in its focus upon a human life as though it is a great novel or work of art, and that the therapy is partly an experience of understanding, analyzing themes, interpreting, looking at context, in order to enrichen the experience of the art.
A weakness in psychoanalytic practice can, in my opinion, be due to its passive approach at times, which can render it less efficient. Another weakness can be due to a dogmatic or literalistic over-absorption with the theory, causing the therapy to digress--sometimes for years--into an examination of early childhood events, when the core elements of therapeutic need lie solidly in the present, or in the more recent past. I think modern psychoanalysis needs to much more actively incorporate ideas from cognitive and behavioural therapies, from social psychology, as well as from behavioural genetics, etc., and to actively question its dogma.
From a "neuroplastic" point of view, I think the immense advantage of psychoanalysis is in the frame, which is intense (5 days per week), long-term (over years), intellectually open (anything that passes through one's mind is encouraged to be spoken), and consistent. If one was taking language or music lessons, we would see MUCH more "neuroplastic change" in the brain (and, much more importantly, we would see much more language or music learning), if the lessons took place 5 times a week for 5 years, rather than just once a week for 6 months. The consistency and discipline of the psychoanalytic frame is powerfully motivational, just as is any other consistent and disciplined educational framework.
Psychoanalysis is a type of psychotherapy in which patients usually attend sessions almost every day (3-5 days per week, 50 minutes each time). The details of theory and practice vary, but in general psychoanalysts tend to believe that early childhood events and memories are very important to examine and understand, and that these events (e.g. relationships with mother) have direct causal links to adult personality traits and psychological symptoms. Also psychoanalysts tend to believe that the relationship with the therapist is a setting in which prior relationship dynamics recur, in the form of "transference." Most psychoanalysts assume a relatively quiet or passive stance, tending not to have active conversation or "problem solving" dialogs with patients. Also most psychoanalysts would tend to interpret various types of phenomena, such as dreams, behavioural habits, etc. as laden with meaning. A course of psychoanalysis might take years, and in general the model would be that the patient would "work through" various childhood conflicts, including as they might be transferentially manifest in the therapy, and that the patient might come to understand the various themes at play in their lives, as manifest in dreams, habits, and interpersonal behaviour. This process of understanding and "working through" is thought to lead to symptom relief and life change.
Doidge himself is a psychoanalyst. One of the chapters in his book describes psychoanalysis as a "neuroplastic therapy." (chapter 9, Turning our Ghosts into Ancestors). Part of the support for his claim comes from a case study (a type of evidence characteristic of psychoanalytic thinking). And part of his support comes from briefly describing the life and work of Eric Kandel, the great nobel laureate neuroscientist.
Kandel's work brilliantly demonstrated some of the specific anatomic and molecular changes that happen in neurons as memories are formed.
Kandel himself has been an advocate of incorporating recent biological scientific knowledge into the practice of psychiatry and psychoanalysis (see: http://www.hhmi.org/bulletin/kandel/), and had apparently planned to become a psychoanalyst himself.
I consider it not to be particularly relevant to mention Kandel at all, other than to quote someone important who probably considers psychoanalysis a good thing. It is a common sales tactic to mention an important person's name while trying to convince someone of something. Also it is common in medicine and psychiatry--but especially in alternative medicine--for there to be some mention of something that sounds "scientific" to bolster the public opinion of a product, while the science itself, if looked at closely, is only obliquely related. For example, many questionably effective naturopathic remedies, sold at quite a profit, include advertising laden with some kind of biochemical jargon, much of which, at close examination, lacks substance, but which sounds impressive.
I believe that psychoanalysis can be a powerful and transformative experience. However,I also strongly suspect that there are elements of dogma contained within the theory which are irrelevant to its beneficial effects, and which at times could make it an inefficient therapy.
Consider this thought experiment:
Suppose the beneficial effects of psychoanalysis are due to the following factors:
1) meeting with someone for an hour per day, who will listen and try to understand life problems
2) finding an "explanation" for symptoms. In the case of psychoanalysis this explanation tends to come from an examination of early life events.
Suppose that it is the belief in the explanation that causes symptom improvement, therefore that if some alternative "explanation" for symptoms could be developed, then it would lead to the same symptom improvement. Therefore, suppose that the psychoanalytic theory of character and symptom development is actually a fiction, akin to a dogmatic religious belief system, but that adherence to this belief system, and the resultant faith and conviction, would be the causes of symptom relief and character change.
A way to test this would be to conduct a randomized study of two types of intensive, long-term psychotherapy. Both would be 5 sessions per week, 50 minutes per session, lasting 5 years.
Group 1 patients would have psychoanalysis.
Group 2 patients would receive the same intensive, empathic, sessions, with intelligent and thoughtful, well-boundaried therapists. But let us imagine that some other belief system would underlie the therapy for group 2. For example, astrology. Or some form of religious fundamentalism (of any variety). Here, interpretations would be based on the positions of stars & planets, or on passages from religious texts.
A condition for this type of experiment would be that the patients in both groups would have to lack any differences in bias for or against the style of therapy. So, for example, patients in group 1 would have to have a similar level of belief that psychoanalysis is a valid and culturally-accepted system of thought, and have similar respect for the therapist, compared to the beliefs about therapist and therapy style of patients in group 2 (regarding astrology or fundamentalism, etc.).
In both groups, I suspect that subject matter would come up in the sessions, which would require the therapists to respond either empathically or interpretively. There would probably be dreams that would come up, probably interpreted quite differently--or not at all-- in both groups. The process of therapy, dream interpretation, feelings of closeness with therapist, etc. might well be experienced similarly between groups.
My hypothesis is that both the groups would show similar improvement in a 5 year course of therapy, with only a slight advantage for group 1. I believe this is because the core effect of such therapy is not from the theoretical belief system, but from the process, which is caring, consistent, empathic, understanding, and interpretive. Failed therapy experiences may happen in both groups, some of which because the patients do not like the style or belief system which is being introduced, some of which because life problems can be treatment-resistant at times, some of which because the patient did not feel well-matched with the therapist. I think group 1 would do very slightly better than group 2, because despite the dogma involved in psychoanalytic theory, the underlying process is more intellectually open (at its best).
Unfortunately, I think there is a substantial risk for people in both groups to come out of the experience with stronger dogmatic beliefs, irrespective of any therapeutic improvement. In a more mature psychoanalytic frame, I think this risk would be diminished, as the process would hopefully be more intellectually open.
I do believe that we as intelligent creatures should always seek the "truth" as best we can know it, and therefore we need to challenge our dogmas. The best therapies, in my opinion, need to seek such truths without being restricted by dogma. This is consistent with the underlying theme of psychoanalysis, which I think is about liberation (liberation from symptoms, liberation from past harms or traumas, etc.).
I am reminded now of Joseph Campbell, the comparative mythologist, who might argue that the different styles of therapy are something like different mythologies, none of which are literally "true", but perhaps all of which might contain core aspects of wisdom about the human condition. He might also argue that dogmatic, literalistic adherence to any system of belief could obstruct its underlying message. But he would also agree, I think, that one has to have "faith"--a sense of trust, engagement, and belief--in order to have a transformative experience from anything.
In psychoanalysis, I think it is immensely valuable to seek meaning by examining early childhood events, and by searching for meaning and themes in dreams and nuances of behaviour. But I think it can be can be obstructive to believe, literally, for example, that specific non-traumatic events or patterns of engagement with one's mother at the age of 2, are the causes of specific adult symptoms. I consider the greatness of psychoanalytic interpretation to lie in its focus upon a human life as though it is a great novel or work of art, and that the therapy is partly an experience of understanding, analyzing themes, interpreting, looking at context, in order to enrichen the experience of the art.
A weakness in psychoanalytic practice can, in my opinion, be due to its passive approach at times, which can render it less efficient. Another weakness can be due to a dogmatic or literalistic over-absorption with the theory, causing the therapy to digress--sometimes for years--into an examination of early childhood events, when the core elements of therapeutic need lie solidly in the present, or in the more recent past. I think modern psychoanalysis needs to much more actively incorporate ideas from cognitive and behavioural therapies, from social psychology, as well as from behavioural genetics, etc., and to actively question its dogma.
From a "neuroplastic" point of view, I think the immense advantage of psychoanalysis is in the frame, which is intense (5 days per week), long-term (over years), intellectually open (anything that passes through one's mind is encouraged to be spoken), and consistent. If one was taking language or music lessons, we would see MUCH more "neuroplastic change" in the brain (and, much more importantly, we would see much more language or music learning), if the lessons took place 5 times a week for 5 years, rather than just once a week for 6 months. The consistency and discipline of the psychoanalytic frame is powerfully motivational, just as is any other consistent and disciplined educational framework.
Drum Circles
Drum circles are groups where people gather to pound drums together: producing, hearing, and appreciating rhythms.
The perception of rhythm is one of the core elements of human experience.
Over hundreds of thousands of years of human evolution--even before the development of culture--the perception of rhythm must have been a very important part of daily life experience.
Here are some examples of rhythms that have been part of life experience for millions of years:
-The rhythmic pounding of ocean waves
-The beating of the heart (as perceived by feeling the pulses through touch, by feeling a throbbing, excited heart in the chest, or sometimes by hearing one's own or someone else's heartbeat)
-The rhythm of breathing (regular and soft in a calm state, rapid or erratic in anxious or excited states, irregular in various particular ways as a person is crying or sobbing; or when a person is dying, e.g. Cheyne Stokes respiration)
-The chirping of crickets or the croaking of frogs (these rhythms being affected by human proximity)
-The rhythm of work tasks (e.g. preparing some kind of meal or building some kind of structure would involve repetitively pounding, picking, or working with a material, and if this was a monotonous, laborious task, a rhythm would naturally form to help the person "get into it")
-The rhythm of human footsteps (steady and strong when feeling confident and certain, rapid or timid when frightened, stomping when angry)
-The rhythms of the human voice. Before the development of languages over 50 000 years ago, probably a great deal of communicative content between humans would have been based on "non-verbal" vocalizations, which would have emphasized tonal quality but also rhythm. Today vocal rhythms are most obviously part of the expressive content in poetry and song.
-Part of rhythm includes silence. It is the "empty space" between sounds. There was a lot more silence in pre-modern cultures.
Upon the development of human culture, starting perhaps 50 000 years ago, rhythms would have been generated spontaneously as a part of creative expression, as celebration, or as ritual.
In modern culture, perhaps a lot of the ancient, prehistoric aspects of rhythmic perception have been "drowned out". In urban environments, we have a lot of cacophonic, industrial sounds, or multiple sources of sounds all coming at us at the same time. There may not be very much silence at all. I suspect that this cacophony is a contributing factor to life stress, and one of the variables increasing the rate of mental illness (there are certainly many studies showing increased prevalence of various mental illnesses in urban environments). As a corollary, I believe that spending time developing one's musical and rhythmic experiences is beneficial to mental health.
As a therapeutic modality, drumming could help people in various ways:
1) as a form of meditative focus
2) it involves physical action: it is a form of exercise as well as a form of tactile stimulation
3) it helps to focus attention: it is a form of mental exercise, as well as a means to distract mental energy away from anxiety or other negative emotions
4) it can be an endless source of intellectual stimulation, with hearing or producing increasingly complex rhythms and cross-rhythms. This can evolve to become a source of esthetic enjoyment, also leading to appreciating rhythm in other aspects of life and music more richly.
5) it can be a social activity, in which other members of the group can be guides or teachers: in drum circles, individuals need not be skilled in drumming or in generating complex rhythms--exposure to the group permits a social learning experience
6) similarly, a drum circle could be a good setting to deal with performance anxiety or social anxiety, in the comfort of an encouraging and accepting group
7) it can simply be a healthy, enjoyable form of stress management
8) drum circles can be a means to build community: the experience combines elements having to do with conformity (maintaining the same rhythm together) and with individuality (each person may have a separate or special rhythmic role or task) -- both such elements are required to have healthy community life
In Vancouver, I know of one regular drum circle group, which has been open to anyone interested. The leader of this group, Lyle Povah, has done interesting work with drum circles as part of an inpatient eating disorders treatment program. Here's his website:
http://lylepovah.com/
There may be similar groups in other communities across the world, and I encourage people to research this, and to consider checking one out.
The perception of rhythm is one of the core elements of human experience.
Over hundreds of thousands of years of human evolution--even before the development of culture--the perception of rhythm must have been a very important part of daily life experience.
Here are some examples of rhythms that have been part of life experience for millions of years:
-The rhythmic pounding of ocean waves
-The beating of the heart (as perceived by feeling the pulses through touch, by feeling a throbbing, excited heart in the chest, or sometimes by hearing one's own or someone else's heartbeat)
-The rhythm of breathing (regular and soft in a calm state, rapid or erratic in anxious or excited states, irregular in various particular ways as a person is crying or sobbing; or when a person is dying, e.g. Cheyne Stokes respiration)
-The chirping of crickets or the croaking of frogs (these rhythms being affected by human proximity)
-The rhythm of work tasks (e.g. preparing some kind of meal or building some kind of structure would involve repetitively pounding, picking, or working with a material, and if this was a monotonous, laborious task, a rhythm would naturally form to help the person "get into it")
-The rhythm of human footsteps (steady and strong when feeling confident and certain, rapid or timid when frightened, stomping when angry)
-The rhythms of the human voice. Before the development of languages over 50 000 years ago, probably a great deal of communicative content between humans would have been based on "non-verbal" vocalizations, which would have emphasized tonal quality but also rhythm. Today vocal rhythms are most obviously part of the expressive content in poetry and song.
-Part of rhythm includes silence. It is the "empty space" between sounds. There was a lot more silence in pre-modern cultures.
Upon the development of human culture, starting perhaps 50 000 years ago, rhythms would have been generated spontaneously as a part of creative expression, as celebration, or as ritual.
In modern culture, perhaps a lot of the ancient, prehistoric aspects of rhythmic perception have been "drowned out". In urban environments, we have a lot of cacophonic, industrial sounds, or multiple sources of sounds all coming at us at the same time. There may not be very much silence at all. I suspect that this cacophony is a contributing factor to life stress, and one of the variables increasing the rate of mental illness (there are certainly many studies showing increased prevalence of various mental illnesses in urban environments). As a corollary, I believe that spending time developing one's musical and rhythmic experiences is beneficial to mental health.
As a therapeutic modality, drumming could help people in various ways:
1) as a form of meditative focus
2) it involves physical action: it is a form of exercise as well as a form of tactile stimulation
3) it helps to focus attention: it is a form of mental exercise, as well as a means to distract mental energy away from anxiety or other negative emotions
4) it can be an endless source of intellectual stimulation, with hearing or producing increasingly complex rhythms and cross-rhythms. This can evolve to become a source of esthetic enjoyment, also leading to appreciating rhythm in other aspects of life and music more richly.
5) it can be a social activity, in which other members of the group can be guides or teachers: in drum circles, individuals need not be skilled in drumming or in generating complex rhythms--exposure to the group permits a social learning experience
6) similarly, a drum circle could be a good setting to deal with performance anxiety or social anxiety, in the comfort of an encouraging and accepting group
7) it can simply be a healthy, enjoyable form of stress management
8) drum circles can be a means to build community: the experience combines elements having to do with conformity (maintaining the same rhythm together) and with individuality (each person may have a separate or special rhythmic role or task) -- both such elements are required to have healthy community life
In Vancouver, I know of one regular drum circle group, which has been open to anyone interested. The leader of this group, Lyle Povah, has done interesting work with drum circles as part of an inpatient eating disorders treatment program. Here's his website:
http://lylepovah.com/
There may be similar groups in other communities across the world, and I encourage people to research this, and to consider checking one out.
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