Blanco et al. published this study in the March 2010 issue of Archives of General Psychiatry. Here's a link to the abstract:
http://www.ncbi.nlm.nih.gov/pubmed/20194829
Patients with social anxiety were divided into four groups in this randomized prospective 24-week study: placebo; cognitive behavioural group therapy; phenelzine medication; combined CBT + phenelzine.
CBT was modestly effective, phenelzine only slight more effective, but the combination of CBT + medication was substantially more effective, more or less additively so, particularly in terms of total remission rates. There was a very low placebo response.
Findings of this type are not surprising. An interesting aspect to this particular study is that it makes use of phenelzine, an old MAO inhibitor. This shows that sometimes these old drugs can still be quite useful.
This study does not necessarily demonstrate that CBT is the only form of psychotherapy which would work adjunctively to help social anxiety. I do think that components of CBT, such as emphasizing exposure to anxiety-provoking situations, and practicing social initiatives in a systematic way, are necessary. But, other forms of psychotherapy might adjunctively help the CBT to work better!
Friday, March 19, 2010
Omega-3 update
Appleton et al. has published a recent review of evidence regarding the psychiatric effects of omega-3 supplementation.
Here's the link:
http://www.ncbi.nlm.nih.gov/pubmed/20130098
Basically, the conclusion is similar to my previous impression on this issue: there is more evidence coming out, generally supporting the possibility that omega-3 supplementation can be modestly beneficial for treating depression. But the existing evidence is somewhat shaky, heterogeneous, and probably influenced by publication bias.
The authors overstate some of the conclusions: for example, they claim that, based on the evidence, omega-3 supplements are unlikely to be useful to prevent depression in a healthy population. This is unfounded, since there were really no adequately long studies which aimed to show preventative effects.
Another of my usual complaints about the studies described is that they are of inadequate duration: many lifestyle changes or treatments that could affect depression (an illness with a periodicity which is often over years or decades) may require several years of disciplined adherence before significant benefits would become apparent. Most of the studies described were less than 3-6 months in duration.
Another study by Amminger et al. from the February 2010 issue of Archives of General Psychiatry (http://www.ncbi.nlm.nih.gov/pubmed/20124114) assessed subjects with signs of early psychotic disorder who were randomized to receive 4 capsules per day of fish oil (containing omega-3 fatty acids), or placebo daily, for 12 weeks. In the following year, substantially fewer individuals in the fish oil group, compared to the placebo group, went on to develop ongoing psychotic illness (5% vs. 28%).
I do encourage omega-3 supplementation, as it poses negligible risk, with a modest potential benefit, both with respect to mood and to some other areas of health.
Here's the link:
http://www.ncbi.nlm.nih.gov/pubmed/20130098
Basically, the conclusion is similar to my previous impression on this issue: there is more evidence coming out, generally supporting the possibility that omega-3 supplementation can be modestly beneficial for treating depression. But the existing evidence is somewhat shaky, heterogeneous, and probably influenced by publication bias.
The authors overstate some of the conclusions: for example, they claim that, based on the evidence, omega-3 supplements are unlikely to be useful to prevent depression in a healthy population. This is unfounded, since there were really no adequately long studies which aimed to show preventative effects.
Another of my usual complaints about the studies described is that they are of inadequate duration: many lifestyle changes or treatments that could affect depression (an illness with a periodicity which is often over years or decades) may require several years of disciplined adherence before significant benefits would become apparent. Most of the studies described were less than 3-6 months in duration.
Another study by Amminger et al. from the February 2010 issue of Archives of General Psychiatry (http://www.ncbi.nlm.nih.gov/pubmed/20124114) assessed subjects with signs of early psychotic disorder who were randomized to receive 4 capsules per day of fish oil (containing omega-3 fatty acids), or placebo daily, for 12 weeks. In the following year, substantially fewer individuals in the fish oil group, compared to the placebo group, went on to develop ongoing psychotic illness (5% vs. 28%).
I do encourage omega-3 supplementation, as it poses negligible risk, with a modest potential benefit, both with respect to mood and to some other areas of health.
Saturated fat not intrinsically harmful?
I'm intending to start a series of posts reviewing articles that I found interesting from a selection of journals published in the first months of 2010.
Here is the first, from The American Journal of Clinical Nutrition, March 2010, Vol. 91, No. 3, pp. 533-546. Here's a link to the abstract:
http://www.ncbi.nlm.nih.gov/pubmed/20071648
The authors, Siri-Tarino et al., show via meta-analysis that saturated fat intake is not actually positively correlated with heart disease risk.
Rather, the more important issue is the ratio of polyunsaturated to saturated fat in the diet. Higher ratios are protective against heart disease.
The authors cite evidence that ingesting the same number of calories as carbohydrate instead of saturated fat actually increases the risk of myocardial infarction (heart attack).
With respect to nutritional behaviour for optimal physical and mental health, I return again to the recommendation that there be a balance which includes adequate fat, carbohydrate, and protein as dietary macronutrients. Saturated fat need not be excluded or avoided, but should be balanced by a more abundant intake of non-saturated fats.
In a separate article, the same authors recommend maintaining balanced dietary fat intake, but avoiding refined carbohydrate in the diet:
http://www.ncbi.nlm.nih.gov/pubmed/20089734
In my opinion, adequate dietary carbohydrates are very important for brain health, as I believe low-carb ketotic diets are hard on the brain. Complex carbohydrates, with a lower glycemic index, are preferable.
Here is the first, from The American Journal of Clinical Nutrition, March 2010, Vol. 91, No. 3, pp. 533-546. Here's a link to the abstract:
http://www.ncbi.nlm.nih.gov/pubmed/20071648
The authors, Siri-Tarino et al., show via meta-analysis that saturated fat intake is not actually positively correlated with heart disease risk.
Rather, the more important issue is the ratio of polyunsaturated to saturated fat in the diet. Higher ratios are protective against heart disease.
The authors cite evidence that ingesting the same number of calories as carbohydrate instead of saturated fat actually increases the risk of myocardial infarction (heart attack).
With respect to nutritional behaviour for optimal physical and mental health, I return again to the recommendation that there be a balance which includes adequate fat, carbohydrate, and protein as dietary macronutrients. Saturated fat need not be excluded or avoided, but should be balanced by a more abundant intake of non-saturated fats.
In a separate article, the same authors recommend maintaining balanced dietary fat intake, but avoiding refined carbohydrate in the diet:
http://www.ncbi.nlm.nih.gov/pubmed/20089734
In my opinion, adequate dietary carbohydrates are very important for brain health, as I believe low-carb ketotic diets are hard on the brain. Complex carbohydrates, with a lower glycemic index, are preferable.
Friday, March 12, 2010
Intellectual Lineage & the Sources of Therapeutic Ideas
It was hard to think of a title for this post; really, this is a bit of a philosophical ramble. It's the type of title I might sometimes poke fun at, it sounds like something you might find in an overly serious scholarly journal. To some degree this post is a sequel to my previous one.
Psychotherapy, while not religious in a dogmatic sense (unless there is some form of religiosity infused into an individual practioner's style), contains many ideas which are dealt with or contemplated by philosophers or theologians. Many ideas in psychotherapeutic styles are inspired by religious or literary metaphor, which can be rich sources of insight about the human condition.
If there are borrowings from any type of religious thinking, we could in turn say that the religions themselves "borrowed" ideas (such as regarding compassion, altruism, meaning, etc.) from other thinkers or cultural influences of the day. Most religions finally have quite similar values in this regard, with stylistic variations from one culture to the next (even within the same religion). Much theological writing and thinking in this era is, in turn, influenced by secular philosophy, including such pragmatic secular philosophies as contained in cognitive-behavioural therapeutic theory.
The history of human creativity is deeply rooted in borrowing, or referring to, creative ideas generated by others. Mozart or Beethoven did this with music. Einstein did this in physics. Shakespeare did this with language. New religions are substantially influenced by "borrowings" from other religions. Art, architecture, engineering, etc. are all imaginatively influenced by work (either whole pieces of work, or mere fragments of a whole) that others have done before. There is a type of "family tree" with respect to ideas, in which we can trace the lineage or ancestry of most any creative or intellectual work. The degree to which a new thinker ought to give overt credit to the ancestry of his or her ideas is open to some debate, I suppose. Sometimes the ancestry might not even be part of the conscious awareness of the author.
The very language I am currently using has its origins in a type of linguistic family tree, in the Indo-European family of languages. The shape of the letters of our alphabet derives substantially from Egyptian hieroglyphics (a delightful area to learn about, see http://webspace.ship.edu/cgboer/alphabet.html or http://www.usu.edu/markdamen/1320hist&civ/pp/slides/17alphabet.pdf or http://members.peak.org/~jeremy/dictionaryclassic/chapters/alphabet.php ): for example, various letters of our alphabet derived from symbols the ancient Egyptians used, which resembled animals or objects in the environment; the letter A comes from a picture of an ox head; the letter m from waves in water; the letter o from an eye; the letter D from a symbol representing a door, etc.
Yet I do not feel compelled to include footnotes referring to Egyptian hieroglyphics every time I use letters of the modern alphabet.
I find most styles of psychotherapy to be helpful in particular ways, and in particular situations. One has to acknowledge the strong evidence base showing that CBT, for example, is useful, particularly for the treatment of specific anxiety symptoms. I find these ideas to be highly recommended in approaching most any life difficulty. However, I have found CBT on its own to be very unsuccessful in helping people with chronic, treatment-refractory symptoms. Research studies generating empirical support for CBT are geared towards showing rapid symptom improvement in non-refractory disorders. In fact, the very lack of success of CBT can magnify the sense of hopelessness and despair in chronic, treatment-refractory conditions. Tangible benefits in treatment-refractory conditions may sometimes be measurable on mood questionnaires, but many tangible benefits may come from a broader evaluation of finding a reason to live despite unchanging symptoms; such questions about "reasons to live" are rarely present on questionnaires, or at least would often not be weighted highly. Yet such an issue is often the most integral daily question faced by a person with a severe chronic illness.
An approach to being present with unremitting symptoms, as a therapist or as a patient, without losing a sense of meaning or connection, is very important, in my experience. Stories from those who have endured such suffering are relevant in encouraging a hopeful or life-affirming attitude.
Psychotherapy, while not religious in a dogmatic sense (unless there is some form of religiosity infused into an individual practioner's style), contains many ideas which are dealt with or contemplated by philosophers or theologians. Many ideas in psychotherapeutic styles are inspired by religious or literary metaphor, which can be rich sources of insight about the human condition.
If there are borrowings from any type of religious thinking, we could in turn say that the religions themselves "borrowed" ideas (such as regarding compassion, altruism, meaning, etc.) from other thinkers or cultural influences of the day. Most religions finally have quite similar values in this regard, with stylistic variations from one culture to the next (even within the same religion). Much theological writing and thinking in this era is, in turn, influenced by secular philosophy, including such pragmatic secular philosophies as contained in cognitive-behavioural therapeutic theory.
The history of human creativity is deeply rooted in borrowing, or referring to, creative ideas generated by others. Mozart or Beethoven did this with music. Einstein did this in physics. Shakespeare did this with language. New religions are substantially influenced by "borrowings" from other religions. Art, architecture, engineering, etc. are all imaginatively influenced by work (either whole pieces of work, or mere fragments of a whole) that others have done before. There is a type of "family tree" with respect to ideas, in which we can trace the lineage or ancestry of most any creative or intellectual work. The degree to which a new thinker ought to give overt credit to the ancestry of his or her ideas is open to some debate, I suppose. Sometimes the ancestry might not even be part of the conscious awareness of the author.
The very language I am currently using has its origins in a type of linguistic family tree, in the Indo-European family of languages. The shape of the letters of our alphabet derives substantially from Egyptian hieroglyphics (a delightful area to learn about, see http://webspace.ship.edu/cgboer/alphabet.html or http://www.usu.edu/markdamen/1320hist&civ/pp/slides/17alphabet.pdf or http://members.peak.org/~jeremy/dictionaryclassic/chapters/alphabet.php ): for example, various letters of our alphabet derived from symbols the ancient Egyptians used, which resembled animals or objects in the environment; the letter A comes from a picture of an ox head; the letter m from waves in water; the letter o from an eye; the letter D from a symbol representing a door, etc.
Yet I do not feel compelled to include footnotes referring to Egyptian hieroglyphics every time I use letters of the modern alphabet.
I find most styles of psychotherapy to be helpful in particular ways, and in particular situations. One has to acknowledge the strong evidence base showing that CBT, for example, is useful, particularly for the treatment of specific anxiety symptoms. I find these ideas to be highly recommended in approaching most any life difficulty. However, I have found CBT on its own to be very unsuccessful in helping people with chronic, treatment-refractory symptoms. Research studies generating empirical support for CBT are geared towards showing rapid symptom improvement in non-refractory disorders. In fact, the very lack of success of CBT can magnify the sense of hopelessness and despair in chronic, treatment-refractory conditions. Tangible benefits in treatment-refractory conditions may sometimes be measurable on mood questionnaires, but many tangible benefits may come from a broader evaluation of finding a reason to live despite unchanging symptoms; such questions about "reasons to live" are rarely present on questionnaires, or at least would often not be weighted highly. Yet such an issue is often the most integral daily question faced by a person with a severe chronic illness.
An approach to being present with unremitting symptoms, as a therapist or as a patient, without losing a sense of meaning or connection, is very important, in my experience. Stories from those who have endured such suffering are relevant in encouraging a hopeful or life-affirming attitude.
Wednesday, March 10, 2010
Man's Search for Meaning
Man's Search for Meaning, by Victor Frankl, is one the great books of the past century.
Frankl (1905-1997) was an Austrian psychiatrist who developed a style of therapy which he called "logotherapy," a style which focuses upon the identification and nurturance of meaning as a primary therapeutic goal. While this style affirms the importance of symptom relief, it focuses on the idea that meaning is available even in the context of extreme unremitting symptoms or suffering.
The gravity of his ideas must be taken very seriously, because of Frankl's own personal experience between 1942-1945: he survived almost three horrific years in Nazi concentration camps including Auschwitz and Dachau. His parents and wife were killed in the concentration camps, and his only surviving immediate relative was one sister. So Frankl approaches these questions with the perspective of one who understands the extremity of suffering, profound loss, and domination by oppressive forces outside of one's control. In this way, Frankl has a deep empathic understanding of what it can be like to experience severe, torturously unremitting psychological illness.
The first half of Man's Search for Meaning is a description of life in the concentration camps. The second half is a brief description of the author's meaning-based psychotherapy style.
As a style issue, I do wish there was more attention to gender-inclusive language, as humans are always referred to as "man," and the pronoun "his" is always used instead of "her." But this is a very small complaint, given the profoundly moving, inclusive, and life-affirming nature of this writing.
This is another of the books I've read recently, which I really ought to have read 20 years ago...
Frankl (1905-1997) was an Austrian psychiatrist who developed a style of therapy which he called "logotherapy," a style which focuses upon the identification and nurturance of meaning as a primary therapeutic goal. While this style affirms the importance of symptom relief, it focuses on the idea that meaning is available even in the context of extreme unremitting symptoms or suffering.
The gravity of his ideas must be taken very seriously, because of Frankl's own personal experience between 1942-1945: he survived almost three horrific years in Nazi concentration camps including Auschwitz and Dachau. His parents and wife were killed in the concentration camps, and his only surviving immediate relative was one sister. So Frankl approaches these questions with the perspective of one who understands the extremity of suffering, profound loss, and domination by oppressive forces outside of one's control. In this way, Frankl has a deep empathic understanding of what it can be like to experience severe, torturously unremitting psychological illness.
The first half of Man's Search for Meaning is a description of life in the concentration camps. The second half is a brief description of the author's meaning-based psychotherapy style.
As a style issue, I do wish there was more attention to gender-inclusive language, as humans are always referred to as "man," and the pronoun "his" is always used instead of "her." But this is a very small complaint, given the profoundly moving, inclusive, and life-affirming nature of this writing.
This is another of the books I've read recently, which I really ought to have read 20 years ago...
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