Health Tips for the new school year

Here are some suggestions for maintaining your health during the new school year:

1) Have a healthy study schedule.  You will learn much more efficiently and enjoyably if you study regularly, in a disciplined schedule.  I don't believe it is possible to master any subject, much less build up an enjoyment of it, by procrastinating or cramming.  Each full-year course probably deserves about 200 hours of study, to be spread out as evenly as possible.   Mastery of a specific field of study probably requires about 10 000 hours of work, which would be full-time for 5 years.   Even if you can get good grades without working hard, I would emphasize to you that doing the bare minimum is an extremely harmful habit--the consequence is that your potential will remain unrealized, also your enjoyment and respect for your subject will never be fully developed.   
2) Have a healthy leisure schedule.  Time must be reserved for pleasure (outside of the hoped-for intrinsic pleasure of studying or working).  A type of "meta-subject" at university is learning to have a pleasurable and healthy lifestyle, with a sense of friendship and community, in the midst of working hard.
3) Be physically active.  Exercise & sports will help you maintain your strength, sharpen your mind, relieve stress, and offer potential sources of community & friendship.  A common problem, however, is excessive exercise, which drains time and energy away from other activities, and which can cause an addictive pattern leading to a psychological dependence on fitness activities alongside a diminished capacity to manage stress in other ways.
4) Don't binge drink.  There is an illusion that binge drinking is an essential part of university social culture.  While it may be a common phenomenon, I think many people minimize its extremely negative health impact.  Anything more than 2 drinks per 24 hours is, from an epidemiologic point of view, harmful to health.    For those dealing with anxiety, depression, trouble fitting in, etc., alcohol can lead to an illusory sense of relief or social belonging while insidiously deepening and entrenching the problems.
5) Eat well.  It's easy to neglect this one, particularly if you're living on your own for the first time.  Basic nutritional advice is not hard to find.  Unfortunately, I think that unhealthy food choices are too easy to find on university campuses.  I think that university cafeterias should not sell junk food, soft drinks, etc. (I also think such items should be taxed heavily, in the same way that cigarettes are).   It's always disappointing to see soft drink companies or fast food restaurants as major food sponsors, with vending machines all over the place, including in hospitals and gyms, etc.   Two simple changes for most people would be to increase vegetables in the diet, and to eliminate junk food.   Allowing oneself to go hungry, or to be carbohydrate-deprived, is likely to substantially impair academic performance, attention, and mood.
6) Make cultural choices with care.  Developing personal culture is very important, and deserves time and energy.   I don't think it is healthy to make a particular cultural choice (e.g. "let's go clubbing!") just because everyone else seems to be doing it. I see a lack of personal culture, with an ensuing lack of a sense of meaningful community, to be one of the leading problems driving loneliness and perpetuating depression on university campuses.
7) Seek medical help if you have symptoms.  There are treatments and supports to be connected with, which can help address anxiety, mood problems, physical symptoms, etc.  It can be better to connect with resources early, rather than wait for things to get worse.
8) Be wary of viral contagion.  A single banal respiratory infection could substantially reduce your enjoyment and learning for a week or more at a time.  The best preventative strategy is to wash your hands frequently, especially if handling objects which thousands of other people have handled or coughed on.  It's important not to go overboard with this--which could be an obsessive-compulsive symptom-- but basic infection control techniques could save you a lot of headache.
9) If you tend to get tired or depressed in the winter months, consider trying a light box.  This is an easy, safe physical treatment which can help with seasonal depression.  Daylight is diminishing rapidly in September, so this is probably a good time to get out your light box.
10) Nutritional supplements.  Women should have ferritin levels checked, and in general should take iron supplements if ferritin is below 50 ug/L.  A daily multivitamin/mineral supplement is a good idea, especially if having abundant fruits and vegetables in the daily diet is not happening consistently.   Harmless at worst.  Extra vitamin D is indicated, I'd suggest 2000 IU extra per day.  DHA/EPA supplements could be useful (omega-3 fatty acids, typically from fish oils). I have some references about this in other entries.  
11) Addiction inventory.  I'd encourage everyone to take an inventory of all addictive or compulsive behaviours, and take steps to stop or moderate them all.  Alcohol or drug use are obvious examples, but other activities could include internet use, gambling, exercise, self-injury, phoning or texting, etc.  Many habits consume so much time and attention, that there is much less time, energy, or enthusiasm left for other things that may be more deeply important to you.

Dopamine Agonists in Psychiatry

The dopamine agonists pramipexole and ropinirole are drugs used in the treatment of Parkinson Disease.

These drugs are now well-established in treating restless legs syndrome (RLS) and periodic limb movement disorder of sleep (PLMS), which are frequent problems afflicting about 10% of the population, and which can negatively impact quality of life & mood symptoms.

There is a small body of evidence showing possible benefits of dopamine agonists in the treatment of depression.

Unfortunately, dopamine agonists can exacerbate addictive/compulsive behaviour: http://www.ncbi.nlm.nih.gov/pubmed/20484726 

Here are some references about the role of dopamine agonists in RLS and PLMS:

http://www.ncbi.nlm.nih.gov/pubmed/20120624

Here's a good review article on the use of ropinirole to treat these conditions: http://www.ncbi.nlm.nih.gov/pubmed/20421915
Here's a recent review of dopamine agonists in general to treat RLS: http://www.ncbi.nlm.nih.gov/pubmed/20206780
Here's a 2008 meta-analysis comparing ropinirole with pramipexole for treating RLS.  Pramipexole is shown to be slightly superior:
http://www.ncbi.nlm.nih.gov/pubmed/18226947

In this 2010 study, gabapentin was compared to ropinirole for treating RLS.  While ropinirole was superior in reducing objective measures of periodic limb movements, subjects taking gabapentin had a higher subjective benefit:
http://www.ncbi.nlm.nih.gov/pubmed/20049491


Here's a case study showing remission of depressive symptoms with ropinirole used as an augmenting agent:
http://www.ncbi.nlm.nih.gov/pubmed/20188777 

Here's a 2005 study looking at ropinirole augmentation in treating depression:
http://www.ncbi.nlm.nih.gov/pubmed/15999953
This 2010 review in Lancet showed a direct antidepressant effect of pramipexole in Parkinson Disease patients:  http://www.ncbi.nlm.nih.gov/pubmed/20452823
Here's a rather weak but positive 2010 paper describing a group of patients with bipolar depression who appeared to benefit from longer-term pramipexole treatment; doses averaged about 1 mg/d:  http://www.ncbi.nlm.nih.gov/pubmed/20425143


The side effects from these drugs include frequent nausea and dizziness, possibly some daytime sleepiness.  Psychiatric adverse effects can include hallucinations, and increased compulsive or impulse-control problems.

In summary, I think dopamine agonists have a role in selected psychiatric conditions, particularly if there are restless-legs symptoms contributing to insomnia or nocturnal discomfort.  They may help treat refractory depression, but there is a risk of causing impulse control problems or hallucinations in predisposed individuals. 

Potential adverse effects of group therapy

I encountered an article today about a subject I've often thought about:  does group therapy actually have a risk of worsening underlying problems?

Here's a link to the article:
 http://www.time.com/time/health/article/0,8599,2003160,00.html

The mechanism could typically occur in the treatment of addictions, which is the subject of this article.  The same mechanism might operate in the treatment of behavioural problems, including conduct disorders, eating disorders, maybe even mood disorders.

Basically, the concern is that the individuals in the group might actually "teach" others in the group about tactics to engage more deeply in the problem behaviour.  The social bonds formed in the group might expand a person's network to engage in addictive behaviours.  If some members of an addiction treatment group are severely involved in the addiction, are perhaps ambivalently committed to therapy, and may be connected to convenient resources in the community to access their addiction, this may facilitate other less severely involved members of the group to broaden their access to addictions.

In eating disorders, members of the group might "compete" with each other to some degree with eating disorder behaviours.  If there are social leaders in the group who are still highly involved in the eating disorder, this may cause a negative peer pressure on others who are starting out.  

On the other hand, an opposing, positive force in group therapy is encountering others who have understanding and personal experience of similar problems.  This can be especially important for problems where a person often feels judged or misunderstood.  Also, members of the group can teach others tactics to deal with moment-to-moment manifestations of the addiction.  In order for these positive forces to be manifest, the group itself needs to be composed of individuals who are probably similar in terms of problem severity, and where there are individuals members of the group who are progressing.  This introduces a social learning effect, in which an individual can see and emulate another individual with similar problems who is starting to make progress.  The similar problem severity among members of the group would hopefully reduce the likelihood of mildly afflicted group members being drawn into more severe illness behaviours.

Since progress through problems is always a dynamic, individualized process, it may be that involvements with groups ideally need to change dynamically as well.  If  individuals are moving quickly away from addictive behaviours, they may ideally need to nurture group connections which are similarly healthy.

This poses another problem for many with long histories of addiction or other socially dynamic health problems:  relationships which have been strongly associated with the addiction may need to left behind, or at  least boundaried very carefully.

Naturalistic study comparing quetiapine, ziprasidone, olanzapine, and risperidone

This study caught my eye recently (here's a link to the abstract:)

http://www.ncbi.nlm.nih.gov/pubmed/20334680

It's a naturalistic study, published in BMC Psychiatry in 2010, prospectively following 213 patients with symptoms of psychosis, who were randomized to receive one of four antipsychotic medications (quetiapine, ziprasidone, olanzapine, or risperidone), then apparently followed for up to 2 years.  

My prediction with such a study would be that all four medications would have similar effectiveness, with a slight edge in favour of olanzapine.

In fact, the results showed a slight edge in favour of quetiapine.  There were no substantial differences in tolerability.

The problems with this study, though, include the following:

1) Most of the data was actually for patients who had only been followed up for 6 weeks (not 2 years!).  Only 8 of the 213 patients were followed up for 2 years.  Of these 8, 5 were taking olanzapine, 2 were taking ziprasidone, and 1 was taking risperidone.  Perhaps one might be tempted to conclude that olanzapine is the drug that has the highest chance of being acceptable for long-term use.

 2) The results were presented in a type of "refined" fashion, for example the changes in symptom scores for each drug over time were presented as graphs with a single straight line for each drug, plotted over a 300-day period.  This type of graph omits a tremendous amount of relevant data:  first of all, there were very few patients who were actually followed for 300 days, most of them were only followed for 6 weeks.  A graph like this implies that there are strong data points stretching out over the entire period.  Secondly, the linear plots do not show the degree of scatter in the data points.  There were no direct reports of the raw data in the study, only refined statistical distillations.  It would be much more informative to show all of the data points plotted out over time:  then one could see the times where most of the data were derived, the various courses of symptom change for each individual in the study, etc.  It would be a messier graph! -- but it would not mislead the viewer to immediately conclude that one medication is obviously better than the others.

In conclusion, the study really grabbed my attention when I first looked at it, but I found it to be much weaker than I thought, after reading it closely.

It does, however, provide a little bit of support for the idea that any one of these four antipsychotic medications are reasonable to try, in the treatment of psychotic symptoms.  I agree that quetiapine is a reasonable first choice, though the others could be reasonable also, depending on personal preference, past experience, side effect risks, etc.  I would still lean towards olanzapine for anticipated long-term treatment of severe symptoms.

A Learning Model of Psychological Change: the necessity of work & practice

It requires a great deal of work to bring about psychological change.

The brain is a dynamic organ, its development influenced by genetic predisposition combined with environmental experience.  Repeated environmental experience sculpts the brain, altering the strength of neuronal connections, neuronal activity, neurochemistry, and even neuronal growth or survival.

Various environmental adversities obviously predispose the brain to generate psychological symptoms, including specific incidents of trauma or neglect.

The manner in which adversity changes the brain is similar to the manner in which the brain changes in response to any other sort of experience:  sometimes there is sudden, intense change which can happen in an instant (e.g. a traumatic brain injury), but most often the brain changes gradually, after many repetitions of similar stimuli or similar inner processes.

Some environmental adversities are repetitive over months or years.  But often times the repetition which does further harm is generated by the brain itself:  in response to a problem, the brain's repetitious analysis and revisiting of the problem ends up causing consolidated change and ongoing symptoms. A great deal of the harm caused by specific instants of trauma is caused by the brain's reaction months or years after the trauma is over.  This reaction is akin to an autoimmune disease, in which the body's attempts to fight off disease end up causing inflammation, pain, and tissue damage. 

A symptom, such as anxiety or depressed mood, once generated from any cause, may lead to a cascade of brain changes which perpetuate and intensify the symptom.  The behavioural withdrawal which results from anxiety or depression changes the potential experiences the brain may incorporate in order to heal itself.  Even without overt behavioural withdrawal, an anxious or depressive state may cause the brain to perceive normal or pleasurable stimuli as dangerous, negative, boring, or unpleasant.   Each time this experience occurs, the brain changes further into a state of more deeply consolidated anxious or depressive disorder.  The theory of cognitive-behavioural therapy insightfully recognizes the role of thoughts as part of a cascade of phenomena perpetuating psychological illness.  Recurrent hostile, reflexively critical, cynical, pessimistic or negative thinking may at times have intellectual or philosophical validity; however, such thoughts, if highly recurrent, teach and sculpt the brain to make such a style of thinking an entrenched habit.  Such habits of thought are obvious causes for depression and diminished quality of life.    

My point here is to describe the brain as a "teachable" organ.  It is changed and sculpted by experience.  The source of this experience may be from the external environment or from the self-generated inner environment of the brain.   The degree to which the brain is sculpted by experience depends on the intensity of the experiences, multiplied by the time or frequency the experiences repeat themselves.

 In this regard, as I've stated before, the brain and its experiences are analogous to a growing garden, or a forest:  changes require time, care, knowledge about requirements, and energy.


Therapeutically, it is very clear to me that much work must be done in order to effect significant, lasting brain change. Likewise, a growing garden requires frequent care, particularly if there are adverse conditions caused from within (e.g. depleted soil, weeds) or from without (e.g. harsh weather, vandalism).  

The neurochemical environment can be an obstacle to brain change, in the same sense that abnormal soil chemistry may thwart the most earnest efforts of a gardener.  The "abnormal soil chemistry" may itself have been caused by an imbalanced garden ecology over many years, perhaps by genetic predispositions of the plants, and may conceivably be remediated and prevented in the long term by healthy gardening practices, yet an immediate external aid could be an immensely helpful catalyst to help these changes occur more easily and quickly.   Likewise, psychiatric medications can often be helpful catalysts for change.

But the key ingredient for brain change is experiential.  The type of experience capable of changing the brain substantially must be strong enough (i.e. it must employ a significant degree of the brain's capacity for attention, thought, feeling, and sensation, rather than simply being a passive or background activity), and must be frequent enough (i.e. it must occur regularly over a long period of time).

These requirements for experiential change are, as I've claimed before, similar to the requirements needed for learning a new language, or a musical instrument.

Without daily practice, therapy experiences which involve only one, or a few, appointments per week, are unlikely to cause significant psychological change, for the same reason that a language or music class once or twice a week will not lead to much language or music learning without doing daily homework.   The classes may be helpful or inspiring guides, but most of the change or learning will occur due to many hours of hard work, practicing, in-between classes.

Studies of different therapeutic strategies for treating psychological symptoms usually neglect to assess the most obvious and powerful source for change:  the amount and quality of the practice done.  It seems to me that most any style of therapy could work quite well (some slightly better than others, depending on the situation), provided that a great deal of disciplined work and practice takes place to learn new skills, and to effect change in the brain.

The analogy of musical practice leaps to mind again, in which quantity and repetition are important for learning, but also "quality."  To practice something passively, carelessly, or inattentively is often ineffectual, or sometimes even counterproductive, since one may be inculcating an unwanted habit.  Also, some types of practice may be excessively mechanical, or may be veering off a desired course too easily.

I am reminded of the "Suzuki" method of music education, which I think is wonderful, for the following reasons:
1) it encourages one to start young (i.e. at any age or level of ability)
2) it strongly encourages "playing by ear", listening frequently to recordings with strong attention to perceiving sound and tonal quality; this leads to a stronger and more rapidly developed appreciation for esthetics, as well as less dependency on external cues such as printed music.   The therapeutic analogy could be of  inviting frequent indirect involvement from a therapist or therapeutic system, rather than doing all "homework" completely on ones' own.
3) it strongly encourages group practice & performance, right from the beginning. This teaches not only solo musicianship, but also following and playing well with others, enjoying others, cooperation, being in a leadership role, having confidence with performance, and sharing one's gifts with others.   Also, practice is encouraged to be not just a solitary activity, but something which can be done with family or loved ones.  Therapeutically, I think it is strongly desirable to incorporate psychological work into group, family, and community settings.  
4) it emphasizes the importance of good posture.  Therapeutically, I think a fairly strict and disciplined framework to practice psychological techniques is healthy and reduces the likelihood of acquiring unhelpful habits.  On a literal level, I think a balanced exercise routine is psychologically healthy, including cardiovascular or strength training, sports, or a "postural" exercise such as yoga. 
5) it emphasizes the need for a lot of repetition.  Therapeutically, it may be necessary to practice techniques thousands of times, over a period of months or years, in order for them to become fluent.   Repetition should never be undertaken in a dull, mechanical way -- it needs to be infused with careful, reverent attention -- but it is absolutely needed in order to master anything. 

I challenge all those wishing to change longstanding psychological problems to frequently renew commitments to work hard, and to translate these commitments into a disciplined schedule of daily practice.  It may be that there are symptoms of  tiredness, amotivation, apathy, or a very negative or painful reaction to a broad variety of daily life experiences; these symptoms can prevent engagement with commitments, and can hinder the capacity to engage in disciplined work habits.  Also, the life stressors (work, money, relationship problems, etc) can take up so much time and energy that there is not much left to do regular psychological work.  Perhaps part of the therapeutic process at this stage is to problem-solve around ways to reduce stresses, reduce some of the symptoms, bolster energy, etc. as prerequisites to establishing a work plan.  Another view of this issue is that the "work" alluded to here could take place within any type of life stressor, it does not necessarily require a lot of extra time separate from other activities of daily living.

"Brain Training" ineffective?

Adrian Owen et al. published a letter in Nature this week, summarizing the results of a study examining the effects of playing "brain training" computer games.  Here is the link:
http://www.ncbi.nlm.nih.gov/pubmed/20407435


The format of the study is interesting, involving the BBC website, inviting mass public participation in ongoing on-line research projects (here's a link to that site, which has a variety of other entertaining surveys you can do: http://www.bbc.co.uk/science/humanbody/mind/index_surveys.shtml).

In this case, over 11 000 subjects did various types of computer games on-line, aimed at developing various cognitive skills.  The subjects had to practice for at least 10 minutes per day, at least 3 days per week, for 6 weeks.  Some subjects practiced much more than others. 

The results are not very surprising to me:  basically, they showed that the skills developed while practicing a computer game do not "transfer" : they do not lead to generalized improvement in cognitive ability.   Even the subjects who practiced much more than the minimum requirement did not end up improving in a set of generalized cognitive tests afterwords.

Subjects improved significantly only in the specific tasks which were practiced.  This is intuitively obvious.   If you practice Tetris, you will become much better at Tetris, but are not likely to improve your mastery of French vocabulary!  Practicing volleyball will not help your guitar skills very much -- in some cases, such practice may in fact interfere with other skills acquisition, because one is procrastinating or redirecting energy away from one skill while practicing another.    Certainly it is true that computer games can be quite addictive:  if someone is spending many hours per week playing computer chess, or some other game, instead of reading, then overall educational performance is likely to decline rather than improve.

For participants in this study, it may be true that benefits occurred in "process" which were not adequately measured by the benchmark tests administered before and after the 6-week trial.  For example, playing a game which improves reflexes or visual memory might not immediately or directly "transfer" or  lead to improved performance in another reflex-based or memory-based benchmark test--but it might cause improvement in the rate at which another reflex-based or memory-based test, task, or game would be learned or mastered.  Analogously, if you have played a lot of volleyball, you might not immediately perform well in soccer--but you might learn to play and master soccer more quickly.  Or, if you have learned French and Spanish, you might not immediately perform well in a German vocabulary test, but you might be able to learn German much more quickly.  These types of benefits would not be picked up by the testing administered in this study. 

Here are some further ideas:

1) Is it possible that some particular cognitive games are more useful or generalizable than others?

-I think this is very possible.  I think that one should consider what type of gain is desired from the exercise you are doing.

A game which helps you practice learning and remembering faces and names could be quite helpful if such memory issues are problematic in your daily life.  Such a game would be inherently generalizable, since the daily behaviour and experience outside of the game would be similar to the game challenges. Lumosity.com has examples of such games.

A game which helps you pay attention to reading texts closely, while monitoring and testing your speed, accuracy, memory, and comprehension of the text, could be very useful if you are having trouble reading or studying.

Games which teach and test general knowledge subjects could be obviously useful to gain general knowledge -- e.g. learning vocabulary, facts about nature, etc.

So, I think one should choose games carefully, with the knowledge that the game will train you to improve in a particular skill.  Is that particular skill likely to be useful or generalizable in your daily life?

2) Is it possible that some of the specific games used in this study could be generally useful to some particular individuals, even though they were not helpful to the group as a whole?

-I think this is very possible as well.  There are three main issues that leap to my mind about this:

First, the study looks at a large general population of volunteer subjects.  A great many of these subjects were probably already in pretty good shape cognitively, and were motivated and enthusiastic to participate in such a research project.  This would be like asking a bunch of fitness enthusiasts to do 10 minutes of calisthenics 3 times per week, and then checking to see if their overall fitness improved 6 weeks later.  It would not be surprising to see an absence of any effect.  However, if the participants were chosen because of having cognitive weaknesses, due to learning disabilities, dementia, other illnesses, or environmental deprivation, then perhaps there could have been a much more substantial and relevant improvement with such a regime.  People with a lower fitness level would be expected to benefit much more substantially from a simple calisthenic routine than those already in good shape.  Many people with depression might have low motivation or engagement with intellectual tasks -- in this case, games of this type might help people get their minds more active again, as a prelude to other types of learning or intellectual engagement. 

Second, I am reminded of some other requirements for change in the brain: an immersive or highly intensive environment can be required for the brain's plasticity to be harnessed.  This might require many hours per day, over many months.  These hundreds of hours of training would contrast with the total of 3 hours' minimum training which this study evaluated.   

Third, some of these game types could be useful, diagnostically, for evaluation or identification of particular cognitive or perceptual strengths and weaknesses.  If these problems are identified, then a specific recipe for improvement could be mapped out.

I do wish the authors of this study, given their interest in computer-based learning & cognitive testing, would invent some games which could help people develop ability in reading, comprehension, general knowledge, etc.  Also, there are game-like computerized exercises which can help people develop skills in recognizing emotions, empathizing, etc.  (examples can be found at the BBC site).   These exercises could be useful for dealing with social anxiety, relationship problems, Asperger's Syndrome, etc.

A good site for free cognitive training games

I found this free site which offers exercises which you can use to practice memory, concentration, and reasoning skills:

http://www.cambridgebrainsciences.com/ 

There are a variety of basic memory exercises, mainly testing visual/spatial immediate memory.  Many of the tests are on a timer, for 90 seconds to 3 minutes, so the exercises are designed to help develop speed and accuracy.  Unfortunately, there is not much at this site for practicing verbal memory skills, verbal comprehension, calculation, longer-term memory, or other practical cognitive skills such as remembering faces or names.  But for a free site, it is quite good.  It also shows you a graph of your score improvement over time, which can demonstrate to you that your skills are improving with practice.

The authors of the site are two British professors who do research into web-based assessment and development of cognitive skills.

Optimal Learning & Training Schedules

An interesting question I have often considered has to do with the most efficient way to use time, in order to prepare for something, or to learn.  This is relevant in psychotherapy, in terms of helping therapeutic change progress at the most optimal pace.

To formalize the question, consider the following:

1) If you had 100 hours to learn something (e.g. to memorize a text; to learn a foreign language; to learn a musical instrument; to understand a set of complex ideas; to learn a new sports skill; or overcome a psychological symptom), how would you distribute these hours, so as to optimize the therapeutic change?  Would it be 10 hours per day, for 10 days in a row?  Or 1 hour per day, 100 days in a row?  Or 1 hour twice per day, for 50 days?  Or 1 hour per week, for 2 years (!?) 

2) Another set of constraints on this problem would be this -- if you had 10 weeks to learn something, a maximum of 10 hours per week to learn it, and a maximum of 10 hours on a single day to spend, what would be the best way to work?  Would it be 10 hours every Monday, for 10 weeks?  Or 2 hours every weekday? Or 1 hour twice a day on weekdays? 

It interests me to note that answers to this type of question come from different fields of research, from cognitive psychology to education to athletic training.

The most sophisticated piece of research I found regarding this issue is described in the following article:

Pavlik et al., "Using a model to compute the optimal schedule of practice," Journal of Experimental Psychology: Applied, v14 n2 p101-117 Jun 2008

The research shows that, in general, "spacing" is far superior to "blocking" in terms of time management or study scheduling.  That is, if you have 10 hours to learn something, it is better to split the time up into short blocks, with rest periods in-between, rather than spending all 10 hours at once.

Pavlik's article includes a much more sophisticated analysis:  for a memory task, items which were more difficult to remember were reviewed with a shorter interval, whereas easier or more well-learned items were reviewed with longer intervals.  As each item became more well-learned, the spacing increased gradually.  To review something too soon would not be using time well:  not only could that moment be used more efficiently to review something more difficult, it also does not develop the longer-term memory of the item as well.  It is most optimal to review something just as its memory is starting to decay.  These memory decays take place over a longer and longer time, the more you have learned something.    To review something with too long an interval between study trials would also be inefficient, as too much forgetting will have taken place, and an inefficient investment of time will need to be spent re-learning the same material.

Common practices in studying or practicing  include the following:
1) familiar or easy material is revisited too much:  it is often inefficient to review something you already know well, unless this causes you to  develop some new insight about it.
2) unfamiliar material is reviewed in large blocks of time (cramming) -- this is profoundly inefficient, and does not allow for long-term learning.

Pavlik's experiment also confirms that high levels of accuracy should be sought, right from the beginning, so as to maximize efficiency.

In summary, Pavlik's work shows that one should space learning efforts.  When just starting out, the spacing interval should be brief, with enough frequent review to master what you have just learned.  With the material mastered on a short-term time scale, the spacing interval can be extended, just enough to make the review slightly challenging.  This process continues, with gradual expansion of spacing intervals, until the material is permanently learned.   Once the spacing interval extends for days, weeks, or months, the learning will probably be permanent. 

The research is very incomplete on this matter, for a number of reasons:

1) the complexity of each individual learning task needs to be taken into account.  For example, if one is trying to solve a complex physics problem, or to comprehend a difficult concept in philosophy, it may be necessary to invest many solid, continuous hours of effort in a "block."  In this sense, each individual "trial" of learning takes place over many hours, rather than over seconds (as in memorizing a foreign-language word).  So, for more complex tasks, fragmenting one's study time could decrease efficiency.  But in a general sense, it will be extremely inefficient to try to "cram" in order to learn how to do complex physics problems.  The "spacing" needs to take place generously, but with each space over a period of days--allowing you to complete individual problems--rather than hours.

2) It remains true that action is required in order to learn.  If accuracy is valued so highly as a priority that action does not take place, than learning cannot occur.  So, for example, in order to learn a new language, one must practice speaking it, or using it.  If one is excessively meticulous about accuracy of vocabulary or grammar right from the beginning, and therefore one is silently contemplative in a conversational language class,  then the action cannot proceed, and instead a stifling self-critical process will inhibit learning and engagement. 

3) The existing research does not account for the powerful effects of "constraint-induced" neurologic change.  Immersive processes may permit the brain to develop new pathways much more efficiently -- anything less than immersion allows a continuing neural pathway of least resistance.  The Taubian ideas about stroke rehabilitation exemplify this phenomenon:  neurological recovery may be much more complete if the brain is not allowed to by-pass or compensate for the disabled body part:  in this way the brain's energy and capacity  and plasticity may be directed towards regaining lost function.  So, in this sense, a continuous "immersion" in a study process may be more effective than any sort of "spacing" regime.  The immersive experience would be a "block" lasting months at a time, continuously.  Of course, there could be smaller spacing effects within this.  Addiction recovery requires similar "immersion" in an abstinence process.  The neurological recovery from the addictive process could then proceed over months or years (typically a year being a significant milestone).   

4) Sometimes, large blocks of time can be useful.  Even though it is not the optimal schedule for using time, in terms of memory formation, it may be optimal on other levels, such as with developing the ability to maintain longer periods of attention in the subject matter, with developing deeper insights about patterns within the subject, or with developing a richer sense of community or identity around the activity.  Thus, a "weekend retreat" experience of something can be educationally powerful, even if the same number of hours spread over several weeks might be a more optimal use of time, if simple memory is the only consideration. 


Here are some references to other  research which addresses this question:

http://www.ncbi.nlm.nih.gov/pubmed/19122053
Extinction more effective if spaced rather than in a block of time.


http://www.ncbi.nlm.nih.gov/pubmed/19831094
Variable practice (involving several versions of a skill) has advantage over constant practice


http://www.ncbi.nlm.nih.gov/pubmed/17326522
Random training in basketball has better retention after 1 year


http://www.ncbi.nlm.nih.gov/pubmed/12831284
Contextual interference improves learning skill

http://www.ncbi.nlm.nih.gov/pubmed/19093603
Blocked practice better for immediate acquisition, random practice better for retention (long-term).

http://www.ncbi.nlm.nih.gov/pubmed/17037668
blocked practice better for acquisition, random practice better for retention (long-term) --pistol shooting

http://www.ncbi.nlm.nih.gov/pubmed/16383091
variable practice better in tennis


http://www.ncbi.nlm.nih.gov/pubmed/1989009
knowledge of results (KR) -- more is not necessarily better.  less KR improves results after a delay, especially if tested without KR


http://web.ebscohost.com/ehost/detail?vid=7&hid=3&sid=04efbc76-6010-4987-ab5f-353b00504841%40sessionmgr13&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=ehh&AN=26941729
 shuffled practice of math problems vastly superior to standard blocked practice, when measured 1 wk later

http://web.ebscohost.com/ehost/detail?vid=7&hid=3&sid=3588cd73-af26-475d-81e9-6186d4241292%40sessionmgr10&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=ehh&AN=47668545
spacing better, in general; but if the learner prefers a block strategy, then spacing less advantageous



http://web.ebscohost.com/ehost/pdf?vid=3&hid=3&sid=902d9a70-de9b-4441-835b-2fddc6ff0698%40sessionmgr14
1988 psychology article reviewing spacing as optimal memory strategy



http://web.ebscohost.com/ehost/detail?vid=8&hid=3&sid=3588cd73-af26-475d-81e9-6186d4241292%40sessionmgr10&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=ehh&AN=37193344
1 day per week courses -- much inferior to 3 days per week


http://en.wikipedia.org/wiki/Spacing_effect

The Nature of Happiness - book review

The Nature of Happiness by Desmond Morris, is a brief little book describing the author's beliefs about various types of happiness.

I think it's worth including in a list of books to read about happiness, though I find it to be quite a superficial opinion piece.  There are a few interesting observations; some sound, simple advice;  and a collection of nice quotations from famous authors, but otherwise the book really lacks substance.  There is almost no reference to research;  there are many sweeping statements, such as about evolutionary underpinnings of happiness-related behaviour, yet without a rigorous development of these ideas, and perhaps without a sense of understanding the voice or perspective of those to whom he is referring.

It is always surprising to me how a minor text of this type could warrant a glowing review from a major newspaper:
"At last, a highly intelligent, serious exploration of a subject as universal as it is mysterious...an illuminating and fascinating read."  The Times

 

Antidepressant + CBT superior to either treatment alone for treating social anxiety

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!  

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.

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. 

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.

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...

Losing at the Olympics

This subject has come up many times in conversation, over the past month.

The comments go something like this:

(referring to someone who has lost at the Olympics, and therefore did not get a gold medal, or any medal at all, etc.):

"What an incredible waste -- a waste of time, a waste of effort, to train all those years, to get all the way to the Olympics, to base your whole life on excelling in your sport, only to lose at the end!"

It seems to me that children or adults who have grown up being involved with athletics, and who have had good coaching over the years, have gained a good understanding of this issue (at best, I think athletic involvement can help considerably with personal growth).  Their response might be something like this:

"It is a joy and an honour to participate in the sport.  To play at all is meaningful.  To train for something is an intrinsic joy.  To be part of a community event, whether at a local community arena, or at the Olympics, is exciting, fun, and meaningful.  The meaning of all those years of training does not depend on winning a medal (although a medal would be nice!) -- all that training was an act of love, my life has been better because of it, regardless of any medals."

Most of the Olympic competitors were very gracious and honorable in their wins or losses.  The occasional individuals who were not gracious were really the only ones who "lost."  

Of course, there are issues about financial compensation, future career opportunities, etc. which may depend on winning, in one form or another.  And it could be deeply disappointing if a particular goal is not reached, and may not ever be reachable again (e.g. to make the Olympic team, to win a medal, etc.).


But psychological health cannot depend on such things.  I don't believe that Olympic athletes experience significant depressions due to losing...because the joy & meaning do not depend on winning or losing, they depend on the process.

Few of us are Olympic athletes, but we all have analogous life pathways...many of us view life success as dependent on some external "win" such as getting high grades, getting into the right school or program, getting the best job, having money, car, house, relationship, being a certain body type or weight,  etc.

Provided that an individual is not in an impoverished state (financially,  nutritionally, neurophysiologically, psychosocially, etc.), I claim that success in life is dependent on process, not on winning anything.  While the pursuit of excellence is itself a healthy and enjoyable process, it ironically cannot proceed if the pursuit of excellence becomes frozen into a pursuit of "winning."  Winning will happen, on multiple levels, if a joy of process is nurtured.

Book Review: Mad, Bad and Sad

Mad, Bad, and Sad: A History of Women and the Mind Doctors from 1800 to the Present, by Lisa Appignanesi (2007) is quite a good history of psychiatry, particularly regarding the period between 1800 and about 1950.

It was interesting and valuable to look at some of the life histories of individual women from previous eras, and to speculate about what helped them and what did not. Some of the biographical sketches are about famous women such as Sylvia Plath, Virginia Woolf, and Marilyn Monroe.

The author approaches the subject matter with a broad vision to include social and cultural context, and particularly feminist issues such as the role constraints and expectations imposed upon women by the prevailing culture, in communities, in families, and also in the therapeutic relationships (which often had a paternalistic quality, or one which reinforced restrictive cultural stereotypes about women).

Many of the stories are strong critiques against various elements of therapeutic philosophy and practice, especially biological psychiatry.

An important thesis is of the limitations of "therapy": her closing statement is

...the mind doctors--whether they're GPs on the front line, therapists of an increasing number of varieties, psychoanalysts, psychiatrists or psychopharmacologists -- trudge along, doing what they can, which is sometimes all that can be done. The danger, perhaps, comes when we ask them to do too much. (p. 484)

Certainly, through all the stories mentioned, the benefits of therapy were often tangible but limited--some compelling "success stories," others particularly tragic in their ending (e.g. Plath, Woolf, or Monroe).

An underlying thesis seems to be very supportive of psychoanalysis as an important form of therapy, which may nurture a sort of freedom in self-development and personal growth.

I find that she is excessively dismissive of cognitive-behavioural therapy. While I agree that such "shorter term" therapy styles may well be designed to improve symptom scores, such that an insurance company would be more willing to fund this therapy for a short time, then cut people off--I also think that many psychological ailments can be products of simple symptoms which can be treated in a very direct, matter-of-fact way, rather than through years of philosophical rumination on a psychoanalyst's couch. Panic attacks, OCD, social anxiety, etc. can be approached as symptoms which can be mastered through behavioural practice. It could be a tremendous disservice to individuals seeking "freedom" or "liberation" to neglect these practical and philosophically simple techniques.

I do agree that complex existential and relational issues can usually not be addressed in a shorter course of therapy, especially if the therapist is dogmatically attached to a particular style (e.g. in formal CBT, there may be no time to talk about any transferential issue or existential problem). Yet, many people may feel empowered to develop their existential and relational life on their own, provided that symptoms are not obstructing their efforts.

Some of her comments can be quite dismissive, for example:

But what young person doesn't feel depressed?--particularly perhaps after a week of student exams, or a split with a boyfriend, even after a little use of recreational drugs and forgetting to eat...A sense of hopelessness, a teenage irritability, may be a phase, even if one that lasts several years...One of the effects of such tools as the Beck's [sic] Depression Inventory and the DSM's chartable diagnoses is that they can produce the very results they are looking for. (pp. 468-9)

In response to this quote, I would say that we are dealing with semantics to some degree. Actually, most young people do not feel depressed after their exams. They do not have a sustained change in behaviour after relationship disappointments, do not have a prolonged sense of hopelessness, irritability, insomnia, weight loss, suicidality, etc. These feelings may well be "phases," but the question is, should we simply treat these as "normal," (which is a semantic construct itself), and therefore not "do" anything (i.e. not offer companionship, support, advice, mentorship, etc.)? I agree that labeling and medicalization may unreasonably guide people into reflexive and sometimes unhelpful or inappropriate treatments (e.g. if a certain Beck score or life disappointment would automatically necessitate antidepressant drug therapy without any opportunity for dialog).

The author appears to have a particularly narrow view of some psychiatric treatments, such as ECT, which she describes as "barbarism." (p. 480) Perhaps thoracic surgery could be judged barbaric as well--most types of medical treatment were truly barbaric in many previous points of history, and only became less so through understanding and careful research as to how to perform the treatments more safely. Undoubtedly, even today, many people have negative experiences with thoracic surgery--or ECT--but in order to evaluate the humane usefulness of such invasive procedures, we need to do careful research trials. In order to assess whether something is "barbaric" or not, perhaps it is important to examine the stories of those who have had a profound, life-saving experience of something, alongside the stories of those who have had ambivalent or negative experiences.

She attempts to be fair in her analysis of medication treatments, but I think most readers unfamiliar with the issue would read her analysis, and conclude that medications to treat depression are a dangerous sham perpetrated by drug companies, with the collusion of paternalistic and impatient physicians.

There is little discussion of vast areas of research about the human mind: the entire field of academic & research psychology is barely mentioned. This research is so very important in challenging the dogmas associated with various therapeutic theories. Psychoanalytic theorists may have been, and still are, very wise and very talented listeners or shamanic figures, but the theories themselves were, and are, often very weak if taken too literally, and sometimes cultishly dogmatic, with therapeutic gains or inferences being illusions caused by the primitive logic of association leading to an assumption of causation. Also, the field of neuroscience is barely mentioned. The author uses the term "Big Science" as a kind of pejorative epithet, alongside "Big Pharma", a kind of ad hominem style of argument which seems to suggest that research findings from "Big Science" must be biased, and that the lack of research findings which support her position must have to do with the scientists being inadequate, rather than her position in fact being weak. One piece of "Big Science"-style research she does cite, in support of psychoanalysis, is upon closer observation a single study, with no adequate control group, little critical review. Yet she seems to aggrandize these findings in a way similar to how I have seen "Big Pharma" reps market medications based on a single, fairly weak research study.

The strength of this book lies in the biographical stories of suffering individuals, and of the descriptions of how people attempted to help them. Some of the most effective strategies are clearly based on common sense: humane social and community support, minimizing iatrogenic harm, promotion of the greatest degree of freedom possible. She argues effectively that Freudian ideas were quite liberating, permitting discussion of subjects previously held under a veil of taboo in the Victorian era, such as the nature of sexual drives. Also, these Freudian notions tended not to pathologize the drives themselves, but rather considered the drives to be innately normal, hence inviting frank, uncensored dialog as a pathway to greater freedom. The book highlights, importantly, some of harms done to people by misguided therapists and theories. And the book highlights the fact that symptoms generated by the mind can present in different ways, according to cultural influences. She argues that classification schemes can follow a fashion, and that ailments may present to follow the classification scheme, rather than the other way around.

So, in conclusion, a book with some interesting biographical sketches of patients and therapists. And some good discussion about the dangers of over-medicalizing human nature. But she does not convey a good understanding of psychological or neuroscience research, and certainly does not lay out evidence in a balanced or comprehensive way.

Olympics & Psychiatry

The Olympic games cost billions of dollars to prepare for, and to host. Therefore, it has been a subject of controversy, particularly because so many people (both globally, and in the local communities near the Olympic sites) are suffering with homelessness, poverty, lack of opportunities for therapy, education, recreation, healthy community, etc. There is understandable criticism that those billions could have been better spent addressing these serious social problems directly.

A few things in particular bother me about the Olympics: one main corporate sponsor is a soft-drink company; another is a fast food company. These companies, in my opinion, contribute to the health problems of millions of people. It is like having cigarette companies as sponsors. The Olympic torch was preceded by a truck with neon lights and dancers boisterously advertising soft drinks...I think this was contrary to the spirit of the event--certainly in bad taste-- and I hope future Olympic organizers can be more health-conscious in considering whom to allow as corporate sponsors.

Overall, however, my opinion is that the Olympics are very healthy, for the following reasons:

1) In these games we have an opportunity for nations of the world to display a type of excellence, and to come together in serious, spirited, but friendly competition. It is a model of sublimating competitive conflict through sport or play, rather than through war. And it is an opportunity for multicultural celebration, in a setting which encourages sportsmanship, generosity, and hospitality.

2) The ethical problem of spending extravagantly while many do not have basic needs met is a very serious one. Here are a few ideas about this:
-Almost any activity could be considered extravagant spending (in terms of money, time, or attention) : much university education does not address the needs of impoverished, displaced, or other suffering individuals. Much in medicine (e.g. transplantation surgery) could be considered expensive extravagance, benefiting a small number of people while others have inadequate basic health care. A great deal of scientific exploration (e.g. the space program) is very expensive, yet doesn't help directly with poverty or world hunger. Investment of time, attention, or money in the arts (e.g. music, theatre, literature, visual arts) could be considered wasteful, since it does not directly help with poverty or homelessness. People could be directed to stop spending time reading novels, going to plays, going jogging, having pets, etc. because they should better be volunteering to assist with dire social problems.
-Regarding the above examples, I think most would agree that these "extravagant" aspects of human endeavour are healthy...it is part of human nature to strive for excellence and for new frontiers (whether this be in space travel, advanced surgery, mathematics, theatre, or sports): it is part of healthy civilization that we allow our attention, time, and money to be invested in these activities. It would induce a type of global psychosocial impoverishment to suppress these activities. The development of a culture which is advanced in terms of arts, sciences, and sports, and which shares its advances with other cultures, is healthy. While these activities may not directly help with social problems, they are part of building a healthier society, which in turn can address its social problems with greater ease and morale.

This social issue has a metaphorical parallel, I think, in individual cases of depression, anxiety, or other psychological symptoms: in a depressed or anxious state, a much greater portion of energy may be invested to meet basic needs. Energy itself may be in short supply, and it may require most of this energy just to prepare food, or to make it through the day. It makes sense to budget energy in such a way that few "extravagances" are allowed. Yet, if this budgeting practice persists for years, it may lead to a perpetuation of a grey, depressed status quo. "Extravagance" may be a necessary part of energy budgeting in depressive states--this extravagance might take the form of energy expenditures which may not seem affordable (e.g. exercising, taking up a new activity, involving oneself in a new community, socializing, taking time away from a hard-to-maintain work schedule in order to volunteer, etc.)---and indeed, such extravagances may sometimes not work out (e.g. efforts to socialize may fizzle, the new activity doesn't work out due to depressive fatigue, etc.). But allowing for extravagances is a type of balanced risk that can permit growth from a depressive status quo.

Suppose a room-mate invites a whole bunch of people to your home, for a lavish celebration. Suppose you are very opposed to this event, perhaps in the context of your room-mate not having done his share of chores regularly for the past 4 years (etc.) ...But suppose also that the guests are themselves honorable, noble people who come from many lands, who are polite, respectful, talented, and interesting. Perhaps in this context it is healthier to set aside one's differences, and to welcome the guests with a spirit of hospitality and celebration.

I think it is great to have the Olympics in Vancouver: I wish all the athletes and spectators a happy, healthy, spirited few weeks of enjoying our community, of enjoying vigorous competition and good sportsmanship. Afterwards, I hope that all of us in the community may enjoy the resources constructed for the games, and that special effort may be made to include those in greatest need.

Sleep, Hormones, and Obesity

Here are some excellent references about the interaction between sleep, hormones, and obesity. They were contributed by a reader (thank you very much!):


http://www.ncbi.nlm.nih.gov/pubmed/16459757

http://www.ncbi.nlm.nih.gov/pubmed/18591489

http://www.ncbi.nlm.nih.gov/pubmed/19056602

http://www.ncbi.nlm.nih.gov/pubmed/15531540

http://www.ncbi.nlm.nih.gov/pubmed/18564298

Lastly a good review paper and shows the basics (along with some fun diagrams)
http://www.jpp.krakow.pl/journal/archive/1205_s6/articles/01_article.html


Comments:

These references make it very clear that inadequate sleep increases the likelihood of obesity.

The last article was interesting, but oddly lacked any discussion of culture or psychology with respect to eating behaviours or obesity.

In terms of advising a fixed, early wake time, I believe this is entirely consistent with a plan to get adequate, optimal sleep. In fact, I believe that when individuals who are struggling with insomnia have a habit of sleeping in, the overall sleep quality diminishes, the insomnia pattern is exacerbated and perpetuated, and the health problems associated with inadequate sleep are likely to worsen.

Therefore, I believe that sleep quality and the restorative health benefits of sleep are most optimal if wake times are consistent and early. Possible exceptions to this could occur in adolescents, who probably need more sleep (but even then, it would be better for them to get that additional sleep by sleeping longer hours but getting up at the same time every day, rather than by sleeping in on weekends). Another exception could be in the setting of a physical illness, in which case one might need to stay in bed longer to recover.

Self-help books

There are a lot of self-help books to choose from, dealing with almost anything including mood problems, anger, anxiety, body image, obesity, shyness, relationship or marriage problems, etc.

There are others that might aim to help a person develop creativity, or guide one with respect to some other life pursuit, such as building a sense of purpose, meaning, balance, simplicity, etc.

I think it is worthwhile to familiarize yourself with the self-help literature. I think it can be something like getting a textbook for a course at school...while some textbooks may not be very well-written, I think having a textbook at all can at least allow some extra tangible structure in therapeutic work.

Most self-help books have exercises to work through, often requiring you to write things out with pen and paper. I think it is important to actually do the exercises, as opposed to just leafing through the book, or thinking that you've done all those things in your mind before anyway. Working through exercises strengthens the mind, even if the exercises themselves are not very well-constructed. It is something like working through arithmetic or grammar problems. Even if the exercises are boring or trite, the earnest effort spent working through them will strengthen your ability and insight about the subject matter. Also, most self-help books, even if they are poorly written, can act as structures to develop your own personalized insights about the subject matter--the workbooks can be a frame to do the work, as opposed to being an intrinsic source of insight.

Many self-help books are organized with cognitive-behavioural ideas in mind. Once again, even if you don't care much for cognitive therapy, the exercises remain useful, provided you engage in them earnestly (it is possible to do these exercises in a half-hearted or sarcastic way, etc. -- which would minimize any possible benefit, just as with any other exercise in life).

What does evidence have to say about self-help books? So-called "bibliotherapy" (yes, someone had to designate an awkward piece of vocabulary to describe "reading") has an evidence base--here are a few references:

Gregory et al. published this 2006 meta-analysis showing cognitive bibliotherapy was effective for depression: Professional Psychology: Research and Practice 2004, Vol. 35, No. 3, 275–280. They concluded that bibliotherapy had an effect size of about 0.77, which is substantial, and comparable to effect sizes from medications and psychotherapy.

Here is a reference to a 2003 meta-analysis by Newman et al. showing that bibliotherapy was effective in the treatment of various anxiety disorders:
http://www.ncbi.nlm.nih.gov/pubmed/12579544

Here is a 2004 reference showing that guided self-help is effective in treating bulimia:
http://www.ncbi.nlm.nih.gov/pubmed/15101068

In conclusion, I do strongly recommend working through self-help books. I find that it can be important to look at several different ones, as there can be style or content differences causing you to prefer one over the other.

The main word of caution I have about self-help is that some authors may have a very biased point of view (perhaps influenced by dogmatic or eccentric beliefs regarding politics, religion, health care, etc.), and may therefore lead a vulnerable individual towards an unhelpful set of beliefs or actions.

So my main recommendation is for standard cognitive-therapy style self-help, as a place to get started. There need not be any bias in cognitive therapy, since it is merely a neutral frame for your own therapeutic work.

Rating Scales: limitations & ideas for change

A visitor's comment from one of my previous posts reminded me of an issue I'd thought about before.

In mental health research, symptom scales are often used to measure therapeutic improvement. In depression, the most common scales are the Hamilton Depression Rating Scale (HDRS), the Montgomery-Ashberg Depression Rating Scale (MADRS), or sometimes the Beck Depression Inventory (BDI). The first two examples involve an interviewer assigning a score to a variety of different symptoms or signs. The last example is a scale which is filled out by a patient.

Here are examples of questions from the HDRS, with associated ranges of scoring:
depressed mood (0-4); decreased work & activities (0-4); social withdrawal (0-4); sexual symptoms (0-2); GI symptoms (0-2); weight loss (0-2); weight gain (0-2); appetite increase (0-3); increased eating (0-3); carbohydrate craving (0-3); insomnia (0-6); hypersomnia (0-4); general somatic symptoms (0-2); fatigue (0-4); guilt (0-4); suicidal thoughts/behaviours (0-4); psychological manifestations of anxiety (0-4); somatic manifestations of anxiety (0-4); hypochondriasis (0-4); insight (0-2); motor slowing (0-4); agitation (0-4); diurnal variation (0-2); reverse diurnal variation (0-3); depersonalization (0-4); paranoia (0-3); OCD symptoms (0-2)

One can see from this list that depressive syndromes which have many physical manifestations will obviously score much higher. The highest possible score on the 29-item HDRS is 89. It is likely that physical manifestations of acute depression resolve more quickly, particularly in response to medications. Therefore, the finding that more severe depressions have better response to medication could be simply an artifact of the fact that physical symptoms respond better and more quickly to physical treatments.

A person who is eating and sleeping poorly, is tired, feels and looks physically ill, who is not working, who is not seeing friends as much, and whose symptoms fluctuate in the day, would already get an HDRS score of up to 30 -- without actually feeling depressed or anxious at all! A person feeling very depressed, struggling through life with little pleasure, meaning, satisfaction, or joy -- but sleeping ok, eating ok, and forcing self through daily routines such as work, social relationships, etc. -- might only get a score of 4-6 on this scale.

I acknowledge that the many questions on the HDRS cover a variety of important symptom areas, and improvement in any one of these domains can be very significant.

But -- a big problem of the scale, for me, is that the relative significance of the different symptoms is arbitrarily fixed by the structure of the questionnaire. So, for example, are the 4 points for fatigue of equivalent importance to the 4 points for guilt, or social withdrawal, or depressed mood? Would different individuals rate the relative importance of these symptoms differently? Maybe some people might prefer to sleep better, rather than socialize with greater ease. Also, perhaps some of the symptom questions deserve to be "non-linear," or context-dependent. So, for example, perhaps mild or intermittent depressed mood might deserve a score of only "1". Moderately depressed mood might warrant a score of "5". Severe depressive mood might warrant a score of "20". Or, relentless moderate symptoms over a period of years might warrant a score of "20", while only short-term or episodic moderate symptoms might warrant a score of "5".

It would be interesting to change the weighting of these symptom scores, on an individualized basis.

Also, it would be interesting to see the results of depression treatment studies portrayed with all the separate symptom categories broken down (i.e. to see how the treatment changed each item on the HDRS). Many researchers or statisticians would complain that to portray, or make conclusions, about so many results at once, would reduce the statistical significance. Statistically, a so-called "Bonferroni correction" is necessary if multiple hypotheses are being made simultaneously: if n hypotheses are made, the statistical significance is reduced by a factor of 1/n. Based on this statistical idea, most researchers prefer to analyze just a single quantity, such as the HDRS score, instead of looking at each component of the score separately.

But, this analysis dilutes the data from any study, in the same way that the analysis of artworks in a museum would be diluted if each piece were summarized only by its mass or area.

A more complete analysis would portray every category at once. A graphical presentation would be reasonable, perhaps taking the form of a 3-d surface (once again). The x-axis could represent the different symptom areas (or scores on each item on the HDRS); the y-axis could represent time; and the z-axis could represent the severity. With this analysis, we could say that we are not actually making n hypotheses--we are making a single hypothesis, that the multifactorial pattern of symptom results, manifest as a 3-d surface, is changing over time. Each individual patient's symptom changes, in every symptom category, could be represented on the graph. In this way, no data, or analytic possibility, would be lost or diluted. The reader would be able to inspect every part of the data from the study, and perhaps notice interesting relationships which the original researchers had not considered.

Some patterns of change with different treatment could present in the following ways, as shown in such as 3-d surface:
1) some symptoms improve dramatically with time, while others are much slower to change, or don't change at all. In depression treatment studies, sleep or appetite might change very quickly with a potent antihistaminic drug...this would immediately lead to pronounced improvement on the overall HDRS score, but might not be associated with any significant improvement in mood, energy, concentration, etc.
2) some symptoms might improve immediately, but deteriorate right back to baseline or worse after a few weeks or months. Benzodiazepine treatment would produce such as pattern, in terms of sleep or anxiety improvement. A medication which is sedating but addictive might cause rapid HDRS improvement, but only a careful look at individual category changes over a long period of time would allow us to see the addiction/tolerance pattern. Some people drink alcohol to treat their anxiety symptoms -- such a behaviour might rapidly improve their HDRS scores! But of course, the scores would return to worse than baseline within a few weeks or months. And the person would probably have new symptoms and problems on top of their original ones. So, we must be cautious about getting too excited about claims of rapid HDRS change!
3) some treatments might cause a global change in most or all symptoms...this would be the goal of most treatment strategies. Such a pattern would imply that the multi-symptom syndrome (in this case, the "major depressive disorder" construct) is in fact valid, all components of which improving together with a single treatment.
4) some combined treatments might work well together...for example, a treatment which helps substantially with energy or concentration (such as a stimulant), together with a treatment which helps with mood, socialization, optimism, or anxiety (such as psychotherapy, or an antidepressant). These treatments on their own might appear to be equivalent if only the total HDRS score is considered (since each would reduce symptom points overall); the synergistic effect would only be apparent by looking at each symptom domain separately.

Finally, I think it is important to look at very broad, simple indicators of quality of life, or of general improvement. The "CGI" scale is one example, although it is awkward and imprecise in design, and most likely prone to bias.

Quality of life scales are important as well, in my opinion, since they look at overall satisfaction with life, rather than merely a collection of symptoms.

In practice, only a discussion with the person receiving the treatment can really assess whether it is worthwhile to continue the treatment or not. In such a discussion, the subjective pros and cons of the treatment can be weighed. Even if the treatment has had a minimal impact on a rating score, it might be subjectively beneficial to the person receiving it. And even if the treatment has produced large rating score changes, it might not be the person's preference to continue. I suppose the role of a prescriber is mainly to facilitate such a dialog, and contradict the patient's wishes only if the treatment is objectively causing harm.

Health benefits of dietary nut intake

Dietary nut intake is strongly associated with a variety of health benefits, particularly a lower risk of developing cardiovascular disease. Here is a link to a recent review of the subject:
http://www.ncbi.nlm.nih.gov/pubmed/19321572

This 2009 article describes a carefully controlled, inpatient, 4-day randomized study in which subjects were given a breakfast containing walnuts; or a "placebo" breakfast containing the same number of calories, and the same amount of carbs & fat, but no walnuts. The results showed that a breakfast containing walnuts leads to a significantly greater feeling of satiation (contentment and satisfaction with respect to food), at lunchtime:
http://www.ncbi.nlm.nih.gov/pubmed/19910942

Therefore, eating walnuts, as part of a balanced diet, is likely to maintain a feeling of satiation, and therefore reduce some of the physiological drives which can contribute to unhealthy eating behaviours.

This is a reference to a large prospective study of over 50 000 women followed over 8 years. The results included a multivariate analysis controlling for many other factors, such as physical activity, smoking, other dietary habits, etc. There was a slight reduction in weight gain or obesity in those who included more nuts in their diet, and in fact the more frequent the nut intake, the lower the risk of obesity:
http://www.ncbi.nlm.nih.gov/pubmed/19403639

With respect to mental health, I think that a balanced, healthy diet is important. Lifestyle habits, including nutritional choices, which reduce risk of cardiovascular disease, are likely also to reduce risk of degenerative brain disease. Walnuts are a source of omega-3 fatty acids, for which there is modest evidence of beneficial effects on mood.

Treatment of eating disorders requires deliberate attention to healthy, regular nutritional habits. Many individuals with eating disorders exclude certain types of food from their diets, based on an unfounded belief that the exclusion would lead to improved control of appetite or caloric intake.

Nuts in particular clearly deserve to be part of a healthy diet, unless there are issues such as food allergy.

Antidepressants only effective in severest depression?

A recent article in JAMA by Fournier et al. is a meta-analysis of antidepressant treatment effects assessed in relation to depression severity. Here's the reference:
http://www.ncbi.nlm.nih.gov/pubmed/20051569

The results show that antidepressants work significantly well, compared to placebo, only for very severe depression (corresponding to Hamilton Depression Rating Scale scores of at least 25).

The analysis is quite well-done, and the results are also presented in a graphical form clearly showing a linear increase in antidepressant effect as baseline depression scores increase.

The authors observe that antidepressants are most commonly prescribed to people who have milder depressions--a population in which they show that medications arguably do not work.

Here are a few of my criticisms of this study:

1) the duration of each trial included in the meta-analysis was between 6 and 11 weeks. In my opinion, depressive disorders are long-term, highly recurrent problems, which have a natural period over at least 6-11 months, not 6-11 weeks. Treatments to address mood disorders of any severity require much longer durations. The short duration could cause a significant under-estimation of treatment effects.

2) the study, like many, looks at "depression alone." In most real-life situations, outside of a research study, individuals have several different problems, such as mild depression + social anxiety, or mild depression + panic attacks, etc. The presence of other symptoms, particularly anxiety symptoms, most likely would increase the likelihood of antidepressants helping.

3) Milder depressions, just like more severe depressions, may actually improve more consistently with a "second step" such as combination with psychotherapy, or combining two different antidepressants. The mildness of a medical syndrome does not necessarily mean that the effective treatments need only to be "mild."

4) Milder depressive syndromes may be more prone to misdiagnosis.

5) current "resolution" to measure treatment effects in depression is quite poor. "Depression" is a very broad category. An analogy could be considering "abdominal pain" to be a diagnostic category. If "abdominal pain" is the only category, and is simply rated on a severity scale (rather than subcategorized to obtain a precise diagnosis), and the treatment offered for "abdominal pain" is appendectomy, then we would probably see no difference in treatment effectiveness between appendectomy and placebo. This is because appendectomy is only effective to treat appendicitis (a subset of the abdominal pain population), and is either ineffective or harmful in treating abdominal pain patients without appendicitis (except, perhaps, for those patients who have a placebo improvement of psychosomatic or factitious abdominal pain, an improvement which they attribute to having surgery).

We currently do not have the science to subcategorize depression in a more clinically meaningful way (there are subcategorization schemes, but they don't have much relevance in terms of treatment).

But we do have a research method which could improve "resolution":
-instead of comparing two populations of depressed individuals, one group receiving antidepressant (or some other treatment), and the other receiving placebo (or some other alternative), the study design could instead be to offer every individual courses of placebo, alternating with antidepressant (or "treatment one" alternating with "treatment two"). Each course of treatment would have to last an adequate length of time. The analysis would aim to show whether there is a subset of individuals who respond to the antidepressant, or a subset of individuals who do better with placebo. The averaged results over the whole group might show that antidepressant effects do not differ from placebo (just like appendectomy might not differ from placebo in treating "abdominal pain"), but the individualized result could show that some individuals improve substantially with the antidepressant (just like appendectomy would save the lives of the small group of "abdominal pain" patients who have appendicitis).

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In the meantime, though, I think it is reasonable to recognize that antidepressants are less consistently helpful when symptoms are less severe.

A Gene-Environment-Phenotype Surface

I've been thinking of a way to describe the interaction between genes, environment, and phenotype qualitatively as a mathematical surface.

In this model, the x-axis would represent the range of genetic variation relevant to a given trait. If it was a single gene, the x-axis could represent all existing gene variants in the population. Or, the idea could be extended such that the x-axis could represent all possible variants of the gene (including the absence of the gene, represented as "negative infinity" on the x-axis). The middle of the x-axis (x=0) would represent the average expression of the relevant gene in the population.

The y-axis would represent the range of environmental variation relevant to a given trait. y=0 would represent the average environmental history in the population. y="negative infinity" would represent the most extreme possible environmental adversity. y="positive infinity" would represent the most extreme possible environmental enrichment.

The z-axis would represent the phenotype. For example, it could represent height, IQ, extroversion, conscientiousness, etc.

In my opinion, current expressions of "heritability" represent something like the partial derivative dz/dx at x=0 and y=0; or perhaps, since the calculation is based on a population sample, heritability would be the average of derivatives dz/dx over various sampled (x,y) points near x=0 and y=0.

Conventional heritability calculations give a severely limited portrait of the role of genes on phenotype, since it condenses the information from what is really a 3-dimensional surface into a single number (the heritability). This is like looking at a sculpture, then being told that the sculpture can be represented by a single number such as "0.6", based on the average tilt on the top centre of the artwork.

A more comprehensive idea of heritability would be to consider that it is the gradient, a component of which is dz/dx. This gradient would not be a fixed quantity, but could be considered a function of x and y.

It is particularly interesting to me to consider other properties of this surface, such as what is the derivative dz/dy at different values of y and x? This would determine the ease with which environmental change could change a phenotype regardless of genotype.

A variety of different shapes for this surface could occur:

1) z could plateau (asymptotically) as y approaches infinity. This implies that the phenotype could not be changed beyond a certain point, regardless of the degree of environmental enrichment.
2) z could appear to plateau as y increases, but this is only because we do not yet have existing environments y>p, where p is the best current enriched environment. It may be that z could increase substantially at some point y>j, where j>p. I believe this is the case for most medical and psychiatric problems. It implies that we must develop better environments. Furthermore, it may be that for some genotypes (values of x), z plateaus as y increases, but for other genotypes z changes more dynamically. This implies that some people may inherit greater or lesser sensitivity to environmental change.
3) dz/dx could be very high near the origin (x,y)=(0,0), leading to a high conventional estimate of heritability; but at different values of (x,y), dz/dx could be much smaller. Therefore, it may be that for some individual genomes or environmental histories, genetic effects may be much less relevant, despite what appears to be "high heritability" in a trait.
4) dz/dx could be very low near the origin, but much higher at other values of (x,y). Therefore, despite conventional calculations of heritability being low, there could be substantial genetic effects on phenotype for individuals with genotypes or environmental histories which are farther from the population mean.

The idea of x itself being fixed in an individual may also not be entirely accurate, since we now know of epigenetic effects. Also, evolving technology may allow us to change x therapeutically.

In order to describe such a "surface", many more data points would need to be analyzed, and some of these might be impossible to obtain in the current population.

But I think this idea might qualitatively improve our understanding of gene-environment interaction, in ways that could have practical applications (current heritability estimates are typically 0.5 for almost anything you can think of--this fact seems intuitively obvious, but is not very helpful to inspire therapy or change, can sometimes increase a person's sense of resignation about the possibility of therapeutic change, and can distort understanding about the relative impacts of genes and non-genetic environment).