Wednesday, December 17, 2008

Social Learning Therapy

Here's another style of therapy probably under-utilized:

This is based on Bandura's work on social learning theory and self-efficacy.

The best examples along this line involve the treatment of phobias. Many approaches to phobias involve graded exposure (i.e. practicing the feared activities), cognitive therapy (examining and challenging thoughts which are associated with the fears), relaxation training, and medication (sedatives and antidepressants).

A neglected but extremely important component of therapy for phobias includes a social learning, or social modeling approach.

For example, a person afraid to swim would simply watch others swim, as a component of treating the fear. But, of course, this could just lead to the frightened person feeling left out, and heighten the sense of alienation or futility. A more effective social modeling experience would be for the person with the phobia to watch OTHER people with the same phobias learning successfully to swim. This could start off with watching videos, and move on to working directly with other people. It may not be convincing evidence that swimming phobia can be overcome just by watching a bunch of swimmers; but it may well be much more convincing evidence to watch other FEARFUL swimmers successfully learn.

If we see someone we feel is similar to ourselves do a difficult task successfully, we are more likely to be able to try or do that task.

I think this is one of the advantages of group therapy, provided there are abundant examples of individuals in the group who are beginning to cope well with their problem. Social modeling of this sort is a particular strength of 12-step groups, where individuals can see others struggling, sometimes slipping back, but finally succeeding, in a way that they can relate to and see themselves in.

Here are a few links to some sites dealing with Bandura's theories:
(this link summarizes some of Bandura's opinions about the influence of media violence, etc. on children's behaviour -- an important subject which could be generalized in many ways)
(a nice biographical sketch of Bandura and his ideas)

An introductory experience to something like a social learning therapy approach could involve looking at videos or documentaries showing individuals struggling with and resolving longstanding mental illnesses. This could be a source of inspiration, motivation, and hope. I would like to find some examples of documentaries of this type; if any readers are aware of good examples, please let me know.

I've just found one site that has a few videos (actually the site seems pretty mediocre to me, but I can't find a lot of other better stuff right now); I think the most pertinent videos to look at from here are in the "programmes" section and would be the case studies on page 3 about phobias (you have to log in to this site as a guest to get into the videos):

Relaxation Training

Here's another example of a therapy style that is probably under-emphasized.

Relaxation techniques are simple, straightforward, and intuitive. There is evidence that they work; here is a reference to a Cochrane review on relaxation techniques for treating depression:

As with most any other strategy to deal with psychological symptoms, I do believe that a lot of practice is required.

Many people abandon relaxation techniques because they do not work when they try them. I encourage persistence--it could take months of daily practice for these skills to become more effective, effortless, and automatic.

There are different styles of relaxation training out there, and I encourage people to do a bit of research, and try a few different types. There are self-help books on the subject, as well as audio CDs and videos. Joining a group or taking a course can be a good way to learn and practice as well.

The beauty of relaxation therapy is that there is no risk of harm, it is side-effect free. However, some people with panic or psychotic symptoms can feel uncomfortable with certain types of relaxation experiences. If this happens, I think it is a technical problem to work around, rather than necessarily a reason to abandon the technique altogether.

Neuroimaging Research

I think modern technology is wonderful.

We now have machines which can image the living brain and measure activity in different parts of the brain as events are happening.

Whenever there are interesting new measuring devices, there will be many research scientists who will compete for time on the machines, to conduct experiments.

In psychiatry, brain imaging has been an active area of research. Most every week there is something in newspaper headlines about brain imaging findings pertaining to human emotion, perception, personality, or behaviour.

I think such studies will eventually help guide us to understand and help a greater variety of problems, perhaps in a more proactive and specific way.

But, in my opinion, we are not nearly there yet. Functional imaging has few practical applications. And, in the excitement about seeing something light up on a computer screen, people are suspending common sense at times.

For example, the other day I was reading an article in the paper, which was citing an imaging study apparently showing that people had less empathy for those struggling with addiction, compared to those with other problems.

I would not doubt that many people truly do have less empathy for addicted indididuals. But in the article, the "proof" that people had less empathy was that some area of their brains, when scanned, showed less activity, when contemplating scenes depicting individuals with addiction problems. This imaging finding was used as a rhetorical device in the article.

This reminds me of trying to determine if people outside believe it is daytime or night-time, by making them wear hats that have solar panels on top, and measuring the intensity of light picked up by the solar panels during the day.
--i.e. such measurements are indirect, imperfectly correlated, and absurdly unnecessary--
People may certainly believe it is daytime when the solar panel is picking up the strongest signal. But does that mean that this evidence from the solar panel data is somehow more intellectually superior to simply asking the person what they think? The most direct measure is to ask the person outside "do you think it is day or night"? The solar hat is just silly. However, it might at times pick up a situation in which someone is lying or unaware. Even then, such a finding would merely warrant further investigation, and would hardly constitute proof of anything.

It is an obvious truth that changes in thought, emotion, and behaviour, will correlate with, or be the result of, changes in brain activity. Yet it is NOT an obvious truth that a change in regional brain activity--particularly with the relatively crude spacial and temporal resolution permitted by today's technology-- proves that there is a particular change in thought, emotion, or behaviour, or that such measures of brain activity have higher levels of validity than simply having a conversation with someone.

I worry that findings from machine-generated data may so dazzle the audience that it causes unwarranted persuasion to occur, despite the findings being vague or associative. People tend to be impressed by colourful pictures made by expensive machines. We can't let this kind of phenomenon cause us to suspend critical judgment.

A related example of this leaps to mind, in pharmaceutical marketing. There has been a lot of competition out there, in past decades, for companies selling antidepressants and antipsychotics. Typically, in a sales spiel, for a given drug, there would be information given such as:

"most receptor-specific"
or "dual mechanism of action"
or "highest potency"

These facts would certainly be true, and they would have the evidence to prove it. But -- the evidence does not actually exist that these facts are clinically relevant. Whether a drug is "receptor-specific" or not may not really matter at all in terms of how well the drug works. In fact, some drugs such as clozapine, are not "receptor specific" at all, yet work better than the others in its class. "Dual mechanism of action" actually refers to a drug affecting two different receptors (hence, actually it would be less "receptor-specific" yet the phrase is still used as a selling point). Venlafaxine is often marketed this way. Whether or not venlafaxine is a superior antidepressant because of its "duality" is hardly proven, yet the marketing catch-phrase can be compelling to many. And "highest potency" is almost always clinically irrelevant. A drug with smaller "potency" can simply be dosed differently, so that it produces the same effect as a "high potency" drug.

I wholeheartedly support ongoing imaging research, yet I think we need to be careful about inferring too much from the findings at this point.

Thursday, December 11, 2008

Finding Help

It can be hard to find help that suits you well.

Individuals seeking help sometimes ask me directly if I will see them. At this point, I am not able to see very many new patients; those new patients I do see have often been waiting a very long time, and because I work as part of the staff in a university clinic, I need to restrict new assessments or psychiatric follow-up to the university student population.

Here is some general advice about finding psychiatric care in the Vancouver area (maybe some of these suggestions could apply to other parts of the world too):

1) Find a primary care physician you are comfortable with. Many gp's (general practice physicians) are at least as capable as a great many psychiatrists, in terms of providing good, thorough, compassionate psychiatric care. A good gp should be a good listener, have a good knowledge of psychiatric conditions, be comfortable dealing with psychiatric problems, and be comfortable with some psychotherapy principles as well as with medications.

It can be hard to find a gp you are comfortable with. But it is probably a much easier task in most cases than finding a psychiatrist or other therapist.

2) Be familiar with other mental health resources in the community. In Vancouver this would include the community mental health teams and specialty clinics such as the Mood Disorders Clinic. Some of these resources may not offer follow-up but could at least offer some advice to help you and your gp move on with some new therapeutic ideas.

3) Be well-informed yourself, so that you can communicate your problems clearly to any new physician or therapist. If there is a past medical record, it can be helpful to have copies of this information yourself, which can speed up the process of a new person understanding your history.

4) Be open to alternative resources: other types of therapy or counseling outside of the medical or psychiatric system can sometimes be very helpful.

5) Be open to therapeutic ideas that might not necessarily be your first choice. For example, you might be referred to some kind of group therapy program, instead of to a 1-on-1 therapist (sometimes groups are more readily and immediately available). This kind of experience can sometimes be very helpful, and also help you become more connected with other resources. Many people are so insistent on wanting 1-on-1 therapy that they will not consider a group.

6) Be reminded that the hospital emergency rooms are always open, and help is available at any time. In most hospitals a psychiatrist would be available to see you for an urgent or life-threatening problem. Also, most hospitals would have other resources, such as social work, which could be useful to help with other circumstantial difficulties accompanying your symptoms. The emergency room experience can be chaotic and frustrating, though.

More links to some different Vancouver-area resources:

Friday, December 5, 2008

Antipsychotic Medications

Antipsychotic medications are frequently prescribed by psychiatrists. They help directly to reduce symptoms such as hallucinations, extremely disorganized thinking, suspiciousness, agitation, or delusions.

The first conventional antipsychotic medication was chlorpromazine, which began to be studied in the treatment of schizophrenia in the early 1950's. Many other antipsychotics were developed afterwards.

There is not much evidence that any one of the conventional, or "typical" antipsychotics works better than another. But there are differences in side-effects: some of these drugs--such as chlorpromazine-- are more sedating; others are less sedating but more prone to cause muscle stiffness--such as haloperidol.

All of the older antipsychotics cause an increased risk of developing a movement disorder called tardive dyskinesia, in which there is abnormal, involuntary muscle activity, often involving the mouth or tongue. Sometimes tardive dyskinesia can be irreversible. The risk is approximately 20-30% for individuals taking older antipsychotics long-term; the risk is probably higher in women, in the elderly, and in those with mood disorders.

I have not prescribed an old "typical" antipsychotic in years. But some people may have taken them for years, and may prefer to continue with them, especially if they are benefiting from the medication without having side-effect problems. They are still used quite frequently in hospitals, since they come in an injectable form which can more rapidly help to calm some extremely agitated patients who are unable to take oral medication.

In recent years, a new class of antipsychotics has appeared on the market; these are usually called "atypical antipsychotics". These include risperidone, quetiapine, olanzapine, ziprasidone, and clozapine (there are a few other newer ones, less commonly used in Canada).

Initial enthusiasm for these new antipsychotics led to various claims about their superiority over the older drugs for treating symptoms of schizophrenia. There is a lot of marketing money being spent on the atypicals. But there is more evidence right now that they actually don't work very much better than the old drugs, if at all. However, the evidence is quite clear that the atypicals have a smaller likelihood of causing movement disorders, especially tardive dyskinesia. For this reason, I consider them to be the drugs of choice to use when prescribing antipsychotics.

Because they are safer than the older drugs, the atypicals have been used quite liberally to treat other psychiatric symptoms aside from those of schizophrenia. They are probably useful mood-stabilizers to treat or prevent manic episodes in bipolar disorder, and there is also evidence that they can be useful adjuncts to treat symptoms of depression. Many of my patients, who may have mixed symptoms of anxiety, depression, primary insomnia, and emotional lability under stress, benefit from small doses of atypical antipsychotics, at least for short periods of time.

There is not much evidence showing that any one atypical antipsychotic is superior to another, with a few exceptions:
1) olanzapine may be slightly superior to other antipsychotics except for clozapine. However it has worse side-effects, including weight gain, which can sometimes be severe.
2) clozapine is without a doubt the most effective antipsychotic. For the majority, it works about as well as any of the others. But for a significant minority (maybe 30% of people) it is markedly superior, and leads to a vast, sometimes miraculous, improvement in symptoms and quality of life. However, clozapine has serious side-effect problems, including a small life-threatening risk that white blood cell levels can drop dangerously (agranulocytosis). Also there is a small but significant risk of seizures. So, at this point, the standard practice is to reserve clozapine for those who have attempted several other antipsychotic medications without adequate benefit.

Antipsychotic medications are imperfect. For the majority of people, they are helpful in reducing psychotic symptoms, and are tolerated reasonably well. For some, they almost instantly and completely relieve symptoms. For many others, they do not reduce symptoms very well, and may merely cause a type of unwelcome sedation. The sedation can feel like sleepiness, but often the most bothersome type of sedation from antipsychotics is a feeling of indifference, or emotional restrictedness. A common phenomenon among people struggling with schizophrenia or bipolar disorder is of stopping medications against medical advice -- often people stop the medications because they don't like the side-effects, and they don't feel feel that the medication is helping with respect to quality of life.

In any case, it is certainly true that it can take time for antipsychotics to work best. There is some evidence that a full therapeutic effect may accumulate over a period of at least 6 months. So I encourage people who are giving these drugs a try to be patient with them, to give them a chance. Also, there are a variety of options to choose from, and sometimes one drug can suit a person better than another. Dosing is another matter; sometimes larger doses deserve a thorough try; other times it can be worth trying a much smaller dose, which may work as well, with fewer side-effects, provided it can be stuck to consistently for a long trial (e.g. at least 6 months).

--a study summarizing the expected effects of a standard antipsychotic (in this case, chlorpromazine) in schizophrenia; in general, the evidence supports that relapse rates are reduced by at least 50%, with a modest improvement in quality of life and symptom control--
--an important study showing no advantage to quality of life among those using atypical antipsychotics, compared to those using older, typical antipsychotics, in fact the data from this study show a slight advantage for the older drugs--
--a summary of an important study showing a slight advantage of olanzapine over several other atypicals, and with the older typical antipsychotic perphanazine working as well as these other atypicals--
--a study showing no significant difference in effectiveness between risperidone and olanzapine--

--another large recent meta-analysis showing a slight advantage for olanzapine and clozapine--

--another major European study showing a slight advantage for olanzapine and clozapine over other antipsychotics--
--a study showing that extremely high doses of olanzapine (over 30 mg/day) may work as well as clozapine for treatment-resistant patients with schizophrenia; but the olanzapine caused more weight gain--
--a very recent study showing that clozapine is markedly superior to high-dose olanzapine for treatment-resistant adolescents--
--a study showing a reduced rate of tardive dyskinesia in patients taking atypical antipsychotics, compared to those taking typical antipsychotics. Of note, this study showed a risk of tardive dyskinesia in patients not taking any antipsychotic at all, and this rate was actually slightly higher than the rate in patients taking atypicals. This is consistent with some evidence that atypicals such as olanzapine and clozapine may actually be used to treat tardive dyskinesia--

--a nice long-term study showing that antipsychotic+mood stabilizer (in this case, fairly low-dose quetiapine plus either lithium or valproate) was much superior to antipsychotic alone or mood stabilizer alone in preventing relapses in bipolar disorder--
--a study showing that an atypical antipsychotic (in this case, risperidone) can reduce suicidal ideation and other symptoms when added to an antidepressant in treating depression--

It should be noted that the results of these studies, as with those from most studies, give us ideas about how groups of people with specific diagnoses respond to certain treatments. The studies rarely tell us how a particular individual would respond to a given therapy; I find that in clinical practice, sometimes one particular medication or therapy suits an individual much better than another, regardless of what the studies show. In this case I think the studies show that a whole variety of different medications--including the older ones--have a decent chance of working, and so I think this could instill some hope that it can be worthwhile for an individual to keep searching for the one that works best.

Friday, November 14, 2008


The ancient Greeks described three different forms of love:

1) Eros -- sensual desire; attraction and appreciation of beauty; passion
--In describing eros we need not assume that it only refers to sexual passion; I think there is a component of the "erotic"-- in a broad metaphorical sense--in all moments of life, all motivations, all experiences of beauty in all its forms--

2) Philia -- virtuous, loyal, attachment between friends or family members; dispassionate but balanced, stable, reciprocal, equal.

3) Agape -- this term was adopted by early Christian theologians, referring to unconditional, giving, selfless love for all. In this type of theological view, agape was felt to be the feeling of the divine towards humankind. Psychiatrically I might say that agape was a projection of a feeling onto the projected character of "God" that fit with an idealized philosophy of life which was prescribed by religious leaders to the rest of the community.

I have to wonder if the "agape" idea was a bit of a defensive construct, since people with conservative religious beliefs or values might not want to be using a "love" term associated with eroticism or sexuality in their description of the divine, or in a prescription for ideal behaviour to espouse.

--since I am neither a scholar in Greek, nor well-versed in theological debate, I recognize that my above introduction may contain inaccuracies--

I do think love is one of the great joys of life, a requirement for happiness, a requirement for life itself to continue. A life without love can be intolerable.

But many of the experiences of love can lead to exquisite suffering. Love can be unrequited. Love can lead to obsession and despair. Love can fade and disappear. Love sometimes can throw off our judgment.

I do think that love is an ingredient of the psychotherapy experience. The struggle with "love problems" is one of the most frequent themes bringing people to psychotherapy.

If love occurs between patient & therapist, this love exists within the boundary of the therapeutic frame. Actions associated with this love--according to the rules of psychotherapy--take place through dialog. Actions outside of dialog (such as gift-giving, etc.) may or may not be allowed within the therapeutic frame, but if they do occur certainly would require careful attention or discussion through dialog. In many cases I feel that to reject a gift would be akin to rejecting a handshake--at times it could be humiliating--and that it may sometimes be part of the development of a healthy relationship to permit gifts in psychotherapy. I realize that many of my colleagues would disagree with me (all kinds of talk about boundaries would arise, I'm sure). I do realize that accepting gifts could give rise to a variety of problems in some cases (e.g. anger at generosity not perceived to be reciprocated, or gift-giving "getting out of hand" with more and more financial expense involved, etc.); in some cases I will gently let people know that their presence is a gift, and that other types of gifts can't be something I can accept. Gift-giving can be a much subtler theme, as many times patients may "try harder" in their therapy as a gift to the therapist, etc. Such gifts should not be rejected, yet of course it is important therapeutically to understand this motive, and to find ways to expand the range of motivations for "trying harder".

I affirm strongly that I have--and aspire to maintain-- a feeling of agape towards my work as a psychiatrist, and towards all of my patients.

I feel it is important to convey this positive feeling directly at times, and that it is often a fear of impropriety, or of boundary-crossing, etc. that prevents many therapists from openly pronouncing positive regard for their patients. As a community of therapists, I think this fear stems in part from recognition of many disturbing examples of boundary-crossing behaviour(e.g. therapists having affairs with patients, often with components of exploitativeness, and often causing complex harmful consequences for the patients). Or some therapists may have been taught to believe that the therapist should not "meet a patient's dependency need" but should rather interpret such a need, or help problem-solve around it, to help the patient meet that need outside of the therapy. Well, in many cases I feel that depriving a patient -- in this case, let's use totally frank language: depriving a patient of love -- is merely a tactic that keeps the therapy less personal, more frustrating, and less helpful. Also it fosters greater detachment in therapists, which I think fuels a broader phenomenon of therapists not really enjoying their work, leading to increased cynicism, less appreciation for the beauty and potential of their patients.

I believe all three types of love exist in every human dynamic, in some mixture. This is normal and healthy, a fact of life. This includes patient-therapist interaction. Yet these other varieties of love dynamics may only colour the dialog or the narrative in a therapy setting, they cannot cause the therapeutic frame to change.

Having said this, I think that in many cases, the patient-therapist relationship is much more distant. It can be like the relationship between "homeowner & electrician" or "shopper and retail clerk". This kind of distance may work just fine, the therapy itself doesn't have to be a specific setting to work out "love problems". The therapy may simply be about obtaining advice to relieve a symptom.

There are some cases -- such as in patients who have a history of dangerous interpersonal behaviour, or in cases of psychosis which may involve the therapist in a delusional system -- where the therapeutic relationship has to be much more distant. It is still not without agape though. A truly loveless relationship cannot be of much help; in situations like this it is often necessary to refer the patient to a different therapist.

In some cases, the therapy itself becomes a setting to "work through" love problems, and the love dynamics present in non-therapeutic life may show up in the therapy itself. In the psychoanalytic community, this would tend to be called "transference". The idea of transference is extremely important, since feelings or dynamics in a person's personal or past life may very well appear in the therapy, towards the therapist, and this phenomenon may epitomize a recurrent relational problem in the patient's life. Yet the term "transference" may also be part of a defensive language on the part of the therapist, to negate "true" feelings which may exist between patient and therapist. So I feel that both "transferential" and "non-transferential" feelings can be present, may be something to acknowledge--and sometimes to affirm--in the therapy, provided the boundaries are clear and consistent.

The world needs to devote more of its energy and resources to solving its "love problems", and to celebrating its many examples of powerful, healing, healthy love.

Tuesday, November 11, 2008

The Tragedy of the Commons

In 1968 (just before I was born) Garrett Hardin published an article in the journal Science called "The Tragedy of the Commons" [Vol. 162, No. 3859 (December 13, 1968), pp. 1243-1248].

It is a metaphorical--and sometimes literal--illustration of how groups of humans behave, specifically when individuals are using a shared resource. It is a wonderful example of an academic area studied in the field of social psychology. But the ideas have been studied in other fields such as political science and economics.

In the metaphor, "the commons" could refer to a common pasture or field in a town of farmers. Each farmer would be entitled to use the pasture to feed his cows. With this system, each individual farmer will immediately profit most by allowing his cows to graze on the pasture for as long as possible. But, if each farmer does this, the pasture will quickly become overgrazed, and everyone loses. The question is, how long does it take between the time when individuals are "winning" and the time when everyone is "losing"?

Of course, the world has many examples of this situation. Pollution of all sorts is like this.

Proposed solutions to this problem have included the idea of privatizing everything (i.e. to eliminate any "commons"). The trouble is, part of the tragedy of the commons lies in an individual profiteer having a short-term motive. "Short-term" in an ecological sense could sometimes be considered to be 50-100 years. The profiteer may maximize his wealth by relentlessly exploiting a natural resource, whether he owns the resource privately or not. During his lifetime, there may not actually be overt negatives to this practice. But over several generations, this practice will destroy the environment.

So, privatization is not a rational solution (besides, carrying privatization to an extreme would yield such absurdities as individual private ownership of the atmosphere or the sky, etc.).

Shared resources must be managed. The management must be from a point of view of the community as a whole (hence it must be communal or governmental), and not only that -- the management must be from a point of view which encompasses the distant future as well as the present. So we must have a government, and a set of values, which makes substantial consideration for what happens even after every currently living person on the earth has died -- i.e. we must consider future generations of life.

I wonder if the common religious stories regarding the notion of an "afterlife" may touch metaphorically upon the importance of literally considering what comes after our own lives. In this practical case, though, we are considering our currently living role in caring for the lives of those who are yet to be born. We may exact such care by protecting "the commons." We may consider this a sacred act.

Such a perspective goes beyond what the mind has been evolutionarily programmed to do -- yet such a highly cultured perspective is what we are called to espouse, if we are to save ourselves, and to save "the commons." The most obvious example of such need is, once again, relating to pollution (of which the "global warming" issue is one of many facets).

The human mind has an innate difficulty with sharing, and it requires culture and a legal structure around the human individual's drives and yearnings, in order to prevent "the tragedy of the commons" from playing itself out.

In a modern society which allows a high degree of individual freedom, and highly advanced, unique forms of living out this freedom (e.g. the internet, telecommunications, rapid and convenient transportation almost anywhere in the world), we may be serving and developing those parts of our mind -- those parts we have evolved over millions of years -- which are most apt to "deplete the commons".

The parts we must strive to attend to are those which require us to use our intelligence, empathy, and imagination, in the process of learning how to share.

I think the modern conservation movements are just the tip of the iceberg, in terms of people making more deliberate, conscious, inspired efforts to protect the present and future environment. These efforts will not only literally protect the earth -- but they will protect our minds. The practice of empathy, and of sharing, of planning to protect something we will not even be around to see -- these are the crowning qualities of human culture, made possible by the human brain, but often thwarted by inherited aspects of the carniverous greed which our species required to survive for millions of years.

It is interesting that many dreams about fear, terror, and death feature wild creatures such as wolves. The wolf is an apt symptol for such frightening emotions--wolves and humans co-existed in a wild state prior to the development of a modern moral culture. In those prehistoric days, there might not have been much room for empathy and sharing in an average
human "household." Since that time, humans have befriended and domesticated wolves, (some of them at least) such that we have a type of wolf we keep in our homes, which we call a"dog." Perhaps to some degree me may remember in our dreams that dogs, or wolves, have been symbols of the terrors of the wild, of a simple but cruel kill-or-be-killed existence.

Our mind reverts to such "wild" states easily--after all, hundreds of thousands of generations of humans evolved under such wild conditions, and those traits in our minds have a strong genetic background. It is like a long war, which is finally over. We don't have to be wild anymore. It is no longer necessary--at least no longer in the peaceful parts of our world--to devour prey; to hunt; to kill our enemies before they kill us; to prepare for a panicked escape in the event of possible attack, etc.

In fact, as the tragedy of the commons metaphor illustrates, it is necessary to set aside aspects of our genetically programmed heritage, to over-ride this with a learned culture of love, sharing, and compassion, with the leadership offered in the culture (e.g. in the form of government or law) to ensure that moral excellence is favoured.

From a psychiatric point of view, I remind you that your mind is partially "wild", it strives for immediate safety, satiation, or relief. You may need to over-ride the wildness, using your intelligence, imagination, and culture (derived both from within yourself and from your community), in order to protect, or "conserve" your mind -- to protect your future mind from the wild emotional instability that may be seething in the present. Cognitive-behavioural therapy is a concrete example of this kind of idea. But more subtle -- and possibly more powerful -- examples include all imaginative, intelligent acts that are rooted in compassion, altruism, generosity, and protectiveness towards self & others.

Sunday, November 9, 2008

Biases associated with Industry-funded research

There is evidence that research studies sponsored by pharmaceutical companies produce biased results. Here is a collection of papers supporting this claim:
This paper from the American Journal of Psychiatry reports that industry-sponsored studies are 4.9 times more likely to show a benefit for their product.

In this paper, an association is shown between industry involvement in a study, and the study showing a larger benefit for the industry's product (in this case, with newer antipsychotics).
In this study, the findings suggest that the direct involvement of a drug company employee in the authorship of a study leads to a higher likelihood of the study reporting a favourable outcome for the drug company product.
This is a very important JAMA article, showing that industry-funded studies are more likely to recommend the experimental treatment (i.e. favouring their product) than non-industry studies, even when the data are the same.

I do not publish this post to be "anti-drug company". I think the pharmaceutical industry is wonderful. The wealth of many of these companies may allow them to do very difficult, hi-tech research with the help of some of the world's best scientists. The industry has produced many drugs that have vastly improved people's lives, and that have saved many lives.

Even the profit-driven-ness of companies can be understandable and may lead to economic pressure to produce treatments that are actually effective, and that are superior to the products of the competitors.

Sometimes the research trials necessary to show the benefit of newer treatments require such a large scale that they are very expensive...sometimes only a large drug company actually has enough money to sponsor trials of this type.

BUT...the profit-driven orientation of companies may cause them to take short-cuts to maximize profits...
-marketing efforts can distort the facts about effectiveness of a new treatment
-and involvement in comparative trials by eager, profit-driven industry, very likely biases results, and biases the clinical behaviour of doctors

A solution to some of these problems is a requirement for frank transparency always, when publishing research papers, in terms of industry involvement.

Another solution is to have more government funding for independent, unbiased large-scale clinical trials.

And another solution is for all of us to be better informed about this issue!

Wednesday, November 5, 2008

Assisted Suicide

I am intending this discussion to be focused specifically on the theme of suicidal thoughts which occur in chronic depression. While I think some of these ideas generalize to other areas of human suffering, I cannot claim to have a great deal of experience working with people outside the area of primary psychiatric illness, and so I don't want to sound preachy about an area outside my knowledge and experience.

When struggling with the question of whether to live, or whether to die, often there is longstanding ambivalence. The struggle with this question may have been going on for years. Reasons to live may lie in small or large connections with other people, other meaningful activities, other small pleasures, other small moments of relief, other hopes that things might get better in the future. Reasons to die may involve observations that things aren't getting better, that positive connections are disappearing or absent, that treatments aren't working, that hopes are fading or gone. Sometimes the ambivalence progresses to the point that one more bad, disappointing, enraging, or painful life event can "tip the balance".

While struggling with this kind of longstanding ambivalence, it can be an annoyance to hear many of the standard encouragements to live, such as:

1) "depression is a treatable illness!"
[well, yes it is, but often times the treatments don't work so well--and if they aren't, it can leave the person suffering from a refractory depression feeling even more alienated, hopeless, and irritated by someone sharing the cheerful news about treatability]

2) "it's wrong to kill yourself"
[while moral qualms can deter many people from killing themselves, moralisms can also sound irritating, preachy, and the product of a perspective which doesn't really understand the nature or intensity of depressive suffering]

3) "it will hurt or devastate your family or friends"
[this may be a deterrent for many, but often times with advancing chronic suicidal ambivalence, this thought may change to something like "my family will accept my decision in time", or "they're better off without me", etc. ]

...there are probably many other examples...

I understand that life can be intolerable. Maybe your life has been intolerable for a long time.

I encourage all of those who suffer to know that there is relief available in life. Always. There is connection available in life. Always! --either improvements of existing or past connections, or development and growth of new or future connections. Loneliness need not ever be permanent.

Some problems cannot be solved or fixed, but regardless of this, it is always possible for things to be better--in some way--than they are. It is always possible for pain to be relieved. It is always possible for a new connection to be made, or for meaning to be found and nurtured. No matter how bad things are, or have been, and no matter how long things have been bad (weeks, years, decades...), a new path can be forged today. If mistakes have ever been made, things can be mended, starting today.

I realize that the above advice may also be, for some, an annoyance to hear, perhaps the same old trite, easy-for-me-to-say attempt to console, or to instill hope. I deliberately say this, though, not as a person wanting to enter into an ethical debate about "right-to-die" issues, etc. but just so that a person researching suicide may encounter a consoling point of view. I do see that many with chronic illness can recover, or have a good quality of life, despite what can seem like a grim or intolerable prognosis.

Some people may be researching "assisted suicide" in their state of suffering and ambivalence. In today's world, such research may yield all kinds of advice about how to kill oneself. There was a front-page article in the newspaper the other day about this. I note that there was no article on the other side of that front page which was devoted to reasons NOT to consider assisted suicide. Therefore, despite the accuracy of the article, the newspaper did not give a truly balanced presentation of the subject. Therefore, if an ambivalent person were to read such an article, it could be an event leading to "tipping the balance."

While I support freedom of speech, I also recognize that research, especially on the internet, can cause an ambivalent person to become immersed in a highly biased information environment. What may be seen as research can become persuasion. A huge persuasive element in the world is social pressure (for a person researching assisted suicide, it may influence a person to choose suicide if they find an online community of others who are also choosing suicide). The presence of a positively-toned newspaper article on assisted suicide may encourage suicidal actions in people who are acutely struggling, but who may not be receiving good treatment yet for their underlying problem.

I encourage people to be wary of biased external persuasive factors. These may be altering your judgment, sometimes without you even knowing it. A guiding principle of many who espouse the idea of "assisted suicide" has to do with freedom, with human rights. However, biased persuasive factors are obstacles to free choice. The solution is for information to be fair, balanced, and thorough, with adequate presentation of multiple points of view. Most research on the internet does not offer such rigor. Most newspapers--unfortunately-- do not have a balance of articles having different points of view.

If you have searched for information on "assisted suicide" on the internet, and landed on this blog entry, I hope to remind you that connection and relief are possible, even if they seem unavailable to you. You deserve respect and support, given the very heavy burden you have been carrying, and I remind you that others are available to share the burden and to help you. It may be a difficult journey, though, to find the support and help that is best suited for you. I wish you the continued strength and courage to carry on.

Tuesday, November 4, 2008


It is therapeutic to laugh. Humour is therapeutic.

Laughter can be practiced deliberately, and it is probably very healthy to do so.

Humour is important in psychotherapy as well. Psychotherapy need not always be serious, grave, or have an air of hard work or formality. But of course, it would be important for any humour initiated by a therapist to be gentle, sensitive, careful, and not excessive.

Here are a few links to references about laughter & humour in health & psychotherapy:
Here's a link to the website for the "Association for Applied and Therapeutic Humor"--it contains a lot of links to other interesting and funny sites (the fact that there is an association with this title is itself funny to me):

Another relevant link:

Pets are Therapeutic

It can be beneficial for mental and physical health to have a pet, for the following reasons:

1) pets offer companionship, and therefore may help people to cope with loneliness. At times I have seen relationships with pets be strong protective factors against suicide.
2) many pets, particularly dogs, may help their owners get outside regularly for exercise
3) dogs in particular may act as social catalysts, making it more likely to meet and converse with new people (this could happen while dog-walking).
4) the requirements of caring for a pet may add some structure and an external focus to daily activities, which can be healthy

For some people, having a pet can be more problematic, particularly if it is not possible, for health or economic reasons, to care for the pet adequately. And some people may have pets for unhealthy reasons (e.g. acquiring a large, vicious dog, encouraging its aggressiveness, or failing to train it adequately for safety).

The evidence on health benefits from pet ownership is actually a bit weak. I think part of this is due to inadequate studies on the subject. Also, in order for a pet to have a healthy emotional effect, there would have to be a good "match" between pet & owner, and adequate support for a healthy relationship to develop. Just as in human-human relationships, some people may choose a type of relationship that is not healthy or sustainable for them.

Here's a link to a review on pet ownership and human health:

Contact with animals can be therapeutic in other ways. There is a lot of anecdotal evidence about the merits of therapy animals. Dogs and cats are examples, but so are large animals such as horses.
Here are references to papers describing the benefits of "animal assisted therapy" with larger animals:

Here are some references about the benefits of therapy dogs:

I could not find very much in the research literature about "therapy cats"--but I think having a pet cat can be therapeutic.

Sunday, November 2, 2008

How to make friends

There are many reasons why a person could have trouble making friends; here are a few:

1) shyness (social anxiety)
2) depression (with resulting lack of energy & motivation)
3) difficulty with social skills (in initiating contact or communication with new people, with continuing on after an introductory contact, or with maintaining healthy ongoing friendships)
4) difficulty finding a community of accepting peers, despite having addressed other factors, such as #1-3 above. So, for example, a person with a particular lifestyle or cultural interest may not be able to find many people with whom to share this in the local community.
5) sometimes there may be qualities about a person's behaviour that cause others not to want a friendship (e.g. recurring temper tantrums or other overt manifestations of hostility).
6) lack of time, energy, or money

Here are some ways to address the problem of making friends:

1) treat shyness. Pharmacologically and psychotherapeutically. Strong effort needs to be spent on practicing cognitive-behavioural techniques. I encourage all who believe they may be shy to start by reading some of the many books on the subject of shyness.
2) treat depression
3) Learn about social skills. This can start with reading. A therapy group of almost any sort can be a good resource. Psychotherapy can be a setting to practice social skills. Other activities can be great places to practice, such as taking a class, joining a group, Toastmaster's, etc. Skills have to be practiced. The skills need to be practiced in all three domains (initiating communication with new people, continuing on to the next step following an introduction, and maintaining ongoing positive communication and activity within existing friendships).
4) Identify individual lifestyle and cultural interests, and deliberately seek out groups that can share in this (for example, regarding music, the arts, orientation/identity issues, hobbies, sports). Be willing to at least slightly expand your horizons of cultural interest & involvement. If you have a healthy solitary interest, try to make it a healthy group interest.
5) Identify factors within oneself that may make it hard for someone to befriend you (e.g. temper problems, refusal to allow closeness, etc.) Be very honest with yourself about this. The gentle feedback or support from a therapist can help. It needs to be emphasized, though, that in a depressed state, many people believe they are unattractive for a variety of reasons, and this type of thinking about self can be a symptom of the depression. If you falsely believe that people don't like you -- for any reason -- then your social actions may lead you to become more isolated and alone.
6) Time, energy, and money may need to be set aside, to allow for the development of a social life. There are many community resources that are free, or that may specifically welcome and try to help those in economic need. Maybe your community does not have enough of these types of resources--if this is the case I hope there is the possibility that you can find a different community that does have enough.

In today's world, we of course have access to "virtual communities" and other types of relationship-building that can be done on the internet. I think the internet is a powerful resource, and can be very helpful for making friends, or practicing social skills. But the medium of the internet can itself be addictive, so this needs to be watched for. Some people may spend so much time on internet relationship sites that their non-internet relationship life may be shrinking rather than growing.

A brief google search on the internet with the name of your city or town plus "social networking" or "meetup" may yield a variety of possible real-life social groups to consider joining, some of them geared towards simple friendship, others may be oriented towards a particular activity, others especially for people who are shy, etc.

Here are some of the explanations people have given me about their difficulty making friends:

1) "I'm not attractive enough"
2) "This city is unfriendly"
3) "I can't be bothered"
4) "It's not worth the risk"
5) "I'm too busy"
6) "I'd rather be alone"
7) "I would be/am a burden on other people"

All of these explanations need to be addressed and challenged.
1) Beliefs about unattractiveness are a powerful social obstacle, because they cause the person who feels unattractive to withdraw, assume in advance that others don't like them, etc. Also a belief about innate unattractiveness can cause a person to be resigned to this false belief, such that actual esthetic enjoyments--including superficial but important things such as choice of attire, "spa treatments", etc.--may be unnecessarily avoided
2) While it may well be true that certain cultures or parts of the world have more or less social opportunities and a more or less socially engaging style, I find most complaints about the "unfriendly city" to be projections of one's own social frustrations onto the fairly neutral ground of the geographic city. I would encourage people to do what they can, with an open heart and mind, right where they are geographically, rather than contemplate a move right away to some supposedly more friendly place.
3 - 5) Friendship-building requires energy, and can be frustrating. There is a component of risk, at the very least of being disappointed. I stand by the advice that friendship-building is a necessary health activity for everyone, as is daily exercise of some sort. So it is necessary for your health to bother with it.
6) We all require solitude. Some of us are most comfortable alone. Many of us desire more closeness or intimacy, but have become resigned, such that we tolerate having very little. It can be a symptom of depression to become more and more isolated. Isolative resignation is a problem that needs to be worked on in the treatment of depression.
7) Belief in being a burden is another depressive assumption, just like feeling unattractive. It is time to let go of this kind of belief. Every relationship does require give and take, though, and it can be part of the process of practicing social/relationship skills to be observant of the general balance in your friendships, so that no one feels that the relationships are one-sided.

Tuesday, October 28, 2008


Most research findings include a lot of statistical analysis of data, and many of the conclusions or assertions made in research papers are based on the statistical analysis.

This is a major advance in the science of analyzing and interpreting data.

Yet, there are a few complaints I have about the way statistical analyses are reported:

The application of statistics is meant to give the reader a very clear, objective summary of what data show, or what data mean. The spirit is neutral objectivity, without the biases of arbitrary subjective opinion or judgment, of people "eyeballing" the data and concluding there is something meaningful there, when in fact there is not.

Yet, in most statistical summaries of research data, the words "significant" and "not significant" are frequently used. The criterion for "significance", however, is arbitrarily determined. It is part of the research, or the statistical, culture, to consider that a "significant" difference means that the data shows a difference that could be due to random chance only 5% of the time or less. If the data show a difference which could be due to randomness with a probability of 6%, then the difference would be reported as "non-significant".
This is an intrusion of human-generated arbitrariness into what is supposed to be an objective, clear analysis of data.

What I feel is a much more accurate way to report on a statistical analysis in a research paper is the following:

the probability ("P value") of a difference being due to chance, rather than to a real difference, should always be given prominently in the paper, and in the abstract, rather than the words "significant" or "non-significant". The reader can then decide whether the finding is significant or not.

As far as I'm concerned, any P value less than 0.5 (50%) carries some degree of significance to it, and the reader of a paper or abstract deserves to see this value prominently given. And it seems absurd to me that results showing a P value of 0.06 would be deemed "non-significant" while results with a P value of 0.05 would be "significant".

**note: there are more rigorous and precise definitions for the statistical terms above, I use a somewhat simplified definition to make my general point more clear and accessible; I encourage the interested reader to research the exact definitions.

Another thought I've had is that, when it comes to clinical decision-making, "eyeballing" the data-- provided the data are fairly represented (for example, on a clear graph which includes the point {0,0} ) --can often lead to more intuitively accurate interpretations than some kind of numerical statistical summary. There is more information represented visually in a graph than in a single number which summarizes the graph, in the same way that there is more information in a photograph than in a number which summarizes some quality about the photograph.

The biggest advantage of sophisticated statistical summaries lies in optimizing research resources, such that we can re-direct our attention away from treatments that work less well, and focus instead on treatments that work better, particularly if there are limited resources, and if a given treatment could determine survival (or not). Also, if there is abundant data, but little way of understanding the data well, then a good statistical analysis can guide treatment decisions. It may help to choose the best chemotherapy drug for cancer, or the best regimen to manage a heart attack. For depression, though, and perhaps other mental illnesses, the statistical analyses can often add more "fuzziness" and distortion to clinical judgment, unless the reader has a sharp eye to recognize the many sources of bias.

Monday, October 27, 2008


Many people believe that sugar (sucrose) intake causes behavioural problems. The two most common specific beliefs are that eating sugar causes worsened hyperactivity; or that eating sugar causes a rush of energy, followed by a plunge into fatigue as the sugar level "crashes".

In fact there have been a lot of very good studies looking at this, and the evidence is quite clear that sugar does not cause hyperactivity. There is an association between high sugar intake and antisocial behaviour, but the relationship is probably not causal. It is much more plausible that those with more antisocial behaviour in the first place happen to choose to consume more sugar.

In some of the prospective, randomized studies, in fact, individuals consuming sugar (instead of a placebo) did better, particularly in terms of learning tasks.

The evidence is also very clear that so-called "reactive hypoglycemia" is very rare, even in people who insist that they have it. However, there may be some individuals who become more irritable as their blood glucose level drops, even if the drop is not down to clinically hypoglycemic levels.

There is evidence that some individuals may respond adversely, in terms of their behaviour, to certain foods, but actually sugar is not a common such food, according to well-controlled studies.

I do affirm that moderating sugar intake, and also eating meals with a lower glycemic index, is part of overall good long-term health.

But most of the claims about sugar influencing behaviour adversely are part of a myth, not supported by clear evidence.

For an excellent review of the evidence on this matter, see this article by David Benton (May 2008):

Friday, October 24, 2008

Chocolate is Good for You

There is evidence that dark chocolate is healthy for you in a variety of ways:

1) May reduce high blood pressure and improve other cardiac risk factors:

Here's a reference to an article in JAMA, one of the world's leading medical journals:

2) Here's a whimsical reference to a study suggesting that pregnant women who eat chocolate end up having babies with more positive temperaments, also these women may be more resilient to stress during the pregnancy

However, it should be acknowledged that many people have trouble moderating their chocolate intake. For some people with atypical depression or eating disorders, excessive chocolate consumption can be part of their unhealthy eating behaviours. Yet, it pleases me to know that chocolate (dark chocolate, or cocoa, in particular) is good for you (in moderation of course)

Saturday, October 18, 2008


Cymbalta (duloxetine) is one of the newer antidepressants on the market. It is being quite aggressively marketed. I notice various lecturers speaking enthusiastically about its merits.

I am immediately wary of this phenomenon:
-new drug enters the market
-lots of advertising
-lots of money to pay for psychiatrists (some of whom, to my embarrassment, are mood disorders specialists) to give educational lectures about the new drug


-down the road, it is often found that the new drug is not quite as spectacular or good as everyone was thinking...
-most often, the new drug is effective and useful, but not qualitatively better than any other related drug
-the new drug becomes simply another option to try, that might work, or might not, for someone struggling with depression
-the new drug otherwise does not become a "first choice" for someone wanting to start a medication, because the many other drugs in its category (e.g. antidepressants) work just as well, on average

--my reading of the evidence is that duloxetine IS an effective antidepressant. It is an appropriate option for treatment-resistant patients who have tried many other medications. But it is no more effective than its competitors on average. I also do not see any compelling advantages with respect to side-effect profile. And it is more expensive! (of course it has more marketing dollars behind it right now, but should this be a reason to consider it first?)
--it is also being marketed for treating pain syndromes -- yet there are few studies comparing duloxetine with other existing antidepressants, for treating these pain syndromes -- so its apparent advantage may simply be due to the fact that no one has done adequate comparative studies including other treatments.

When looking at references regarding a new treatment, the interested reader should take a look at who the authors are, who sponsored the research (was it the drug company?), how often the authors have been involved by industry-funded research, and how frequently the authors have received money for giving lectures supporting the use of the new treatment. Also, look carefully at what the paper is saying as a conclusion vs. what the data from the paper shows: do the authors try to aggrandize the new drug using words (e.g. "this verifies that... is effective and safe, ... ") while the data from the very same study actually show that the new drug is not actually any better than the old drug?
Also, if the study is comparing one drug with another, are the results biased? For example, did the study protocol only allow a limited, less-than-optimal dose of the comparison drug?

Here are some references:

Friday, October 17, 2008

Vitamins & other nutritional supplements

There are many people who believe that nutritional supplements can help with a variety of health problems. There is a field called "orthomolecular psychiatry", in which the practioners believe that vitamin supplements and other nutritional adjuncts can treat mental illnesses. I consider many of these beliefs to be spurious, and to be lacking a significant evidence base. I think many of those who benefit from these treatments are experiencing a combination of a placebo effect, and are perhaps benefiting from the psychotherapeutic care involved as well. Perhaps some of these individuals are also benefiting from not having the side-effects of other conventional therapies that were not working for them.

Here is a look at the evidence regarding vitamin supplementation; I restrict any references to journals that I consider to have a high professional standard:

1) Folic acid. There are a few studies which suggest that folic acid supplements may help augment the effectiveness of antidepressants. Here are a few references:
(in this study, adding 0.5 mg of folic acid daily to the antidepressant fluoxetine, improved depression severity, in women only)

(In these studies, low folic acid levels were strongly associated with resistance to fluoxetine treatment and more frequent depressive relapse. However, I am curious to know if this is merely an association--that is, whether the low-folic acid level group had other factors such as generalized poor nutrition or self-care, etc. that caused them to be more treatment-resistant.)

2) Thiamine (vitamin B1)
Thiamine can treat and prevent an extremely severe neurological syndrome called Wernicke-Korsakov encephalopathy; this syndrome occurs in nutritionally-deficient alcoholics, and causes devastating, permanent, sometimes total inability to form short-term memories. But there is not a lot of evidence about using thiamine to help other psychiatric disorders. Mind you, it hasn't been studied much. There are a few studies in the elderly, which suggest that thiamine supplementation helps with energy and well-being:

3) Other B vitamins:

Here's a study showing a relationship between folic acid levels--but not any other B vitamins or omega-3 fatty acid levels--and depressive symptoms in a group of Japanese adults.

Vitamin b-6: High doses may cause damage to sensory nerves, and I would not recommend taking more than 10 mg daily. Most daily multivitamins have about 3 mg. The toxicity is quite clear for doses over 100 mg/d.

Here is a reference to a new study including over 5000 women, over 7 years of follow-up, from Archives of Internal Medicine. It showed significantly reduced rates of macular degeneration in a large cohort of people taking high-dose b-vitamins (2.5 mg/d of folic acid; 50 mg/d of b-6; 1000 mcg/d of b12):

4) Vitamin D
There is accumulating evidence that higher doses of vitamin D are beneficial for a variety of health variables. Also, it is becoming apparent that many people are vitamin-D deficient, especially those who live in northern climates. Most supplements contain 400 IU, but probably a dose of at least 1000 IU daily could be recommended. Doses less than 10 000 IU have not been associated with toxicity, according to my review of the evidence, but we could conservatively say that doses up to 4000 IU daily are very likely to be safe, unless there is some medical disorder present (e.g. sarcoidosis) that causes a disturbance in calcium metabolism. Here is a very interesting and promising recent study suggesting beneficial mood effects from higher-dose vitamin D supplementation; the study is from a major, highly respected internal medicine journal:

It should be emphasized that more is not always better! Many vitamins cause toxicity if they are taken in excess. Also, some of the studies are showing that groups who took certain vitamin supplements (such as vitamin E and beta-carotene) actually fared more poorly, rather than better.

5) Omega-3 fatty acids
There is some evidence that omega-3 supplementation (containing the fatty acids EPA & DHA) can help reduce depressive symptoms, particularly in those with bipolar disorder. Omega-3 fatty acids can be found most abundantly in fish such as salmon. Plant sources include canola oil, flax, and walnuts (however, the plant sources only have one of the 3 types of omega-3 fatty acids). Here's a link to recent Cochrane Review abstract:
Here are some links to other reviews:
However the evidence appears to be fairly weak at this point, there may be some publication bias (i.e. studies showing no effect may not have been published) so more research really needs to be done. In the meantime, though, omega-3 supplementation (usually in the form of fish oil capsules) appears to be harmless, and potentially beneficial. The dose corresponding to what many of the studies used is about 3-6 grams of salmon oil daily (usually 3-6 capsules, each of which containing 1 gram).

Omega-3 supplementation may be beneficial in other ways--it may help protect against macular degeneration (vision deterioration during old age). Also there is some data showing that higher omega-3 intakes, or fish consumption, may slow the rate of cognitive decline in old age. Here's the best such study I could find showing this:

I suspect that some of the benefits from increasing omega-3 intake could be augmented by consuming a diet in which other unhealthy lipids are minimized--this would involve reducing omega-6 intake, eliminating trans fatty acids, and moderating the intake of saturated fats. I invite the interested reader to research this subject further.

Tuesday, October 14, 2008


Sleep problems can be frustrating and exhausting. Sometimes a person can have trouble sleeping for no apparent reason, and with no other associated symptoms.

More commonly insomnia is a symptom associated with another medical or psychiatric problem. Here are some of the causes of insomnia:

A) Physical Medical Problems
Here's a partial list:
  • any painful condition
  • infectious diseases (anything from a common cold to any more severe disease)
  • endocrine disorders (e.g. hyperthyroidism)
  • respiratory diseases
  • bladder or kidney problems (e.g. causing a need to use the bathroom in the night)
  • heart disease (e.g. in heart failure it may be very uncomfortable to lie flat)

B) Psychiatric Problems
  • depression
  • anxiety
  • psychotic disorders
  • mania
  • situational stress
  • substance use disorders
  • specific sleep-related disorders such as sleep apnea or narcolepsy
  • post-traumatic stress disorder (e.g. in which the past trauma occurred at night)

C) Environmental Problems
  • uncomfortable bed, bedding, or pillow
  • noisy bedroom at night
  • too much light in the bedroom (e.g. street lights shining through a window)
  • too hot, too cold, poor air quality, etc.
  • sleeping next to someone who snores loudly or moves around a lot during sleep

In the management of insomnia, it is important to consider all of the above categories. A medical check-up to rule out or start treatment for physical diseases will be important. All possible improvements to the bedroom environment should be made. Evaluation and treatment of other psychiatric symptoms or conditions is important. If there is any question of breathing problems during sleep, or of a specific sleep disorder such as narcolepsy, then other tests may need to be done, such as an overnight sleep study.

For some people with allergies, I have found at times that a simple measure--such as starting a nasal spray at night which allows for easier breathing, or starting an antihistamine--can be a remarkably effective relief for insomnia and resulting mood/energy problems.

Beyond this, there are specific ways to manage sleep problems:

1) Careful documentation of exactly what is happening with sleep:
A sleep log can be very useful. In the sleep log, you can keep the following records for each day:
a) what time you went to bed
b) what times you were actually asleep
c) what time you got out of bed
d) what times you spent in bed or asleep during the daytime
e) your assessment of how good the quality of your sleep was
You can keep your log in the form of a chart, with sleep times indicated by a solid bar going across the chart, and times spent awake represented by interruptions in that solid bar. Here are some examples of a sleep log:

2) Behavioural treatments:
  • maintaining a constant wake time: it may be impossible to control when you fall asleep, but it is possible (even if difficult) to control when you wake up and get out of bed. If you are out of bed at the same time every morning, you will be more sleep-deprived after a night of insomnia, and will therefore have an easier time sleeping the next night. If you allow yourself to sleep in after a night of insomnia, you will not be as sleepy, and will have a harder time sleeping the next night.
  • If you have a hard time waking and getting out of bed at the same time every morning, external stimuli can help, such as a timer circuit which turns on a bright light next to your bed in the morning, or even an automated coffee machine which starts at the same early time.
  • leaving the bedroom if you are having a hard time sleeping. Otherwise there is a conditioning effect in which your brain associates your bed with being awake. Go back to your bed when you feel more sleepy.
  • avoiding wakeful activities in the bed, such as watching TV or reading. Do these things in another place.
  • avoid or minimize napping. If you must nap, keep it earlier in the afternoon if possible, and as brief as possible.
  • sleep restriction: for example, if you are in bed for 9 hours per night, but are only asleep for 5 of those 9 hours, then you can try going to bed exactly 5 hours before your planned wake time. This strategy is intended to cause you to become more sleepy before you go to bed, to have deeper sleep while you are in bed, and to spend less time lying awake in bed. If this strategy works, a next step can be to gradually start going to bed earlier in order to extend the total number of sleep hours. It is harder to adjust to an earlier bedtime, so this process has to be very slow, perhaps trying a bedtime 15 minutes earlier than your previous bedtime, then sticking with it for a week or so, before adjusting again.
  • morning exercise -- here's a link to a study showing this: (

3) Cognitive Treatments
  • There are many thoughts which occur in the midst of insomnia; some of these thoughts can perpetuate the insomnia, or be part of a vicious cycle. For example, as you lie awake you might think:
  • - "oh, no, not again! I'm still awake! I'll never be able to function tomorrow!"
  • -"It's 3:21. I've been awake for 57 minutes. I have only 3 hours and 39 minutes before I have to get up."
  • -"I can't slow down my thoughts! I'll never fall asleep!"
  • -"No matter what I do, I still can't sleep."
  • In working on insomnia cognitively, it is important to "talk back" to all of these thoughts in a way which is brief, without becoming an inner intellectual debate (this would be another example of a cognitive process which would keep you awake). Much of the "talking back" might involve reassuring yourself, accepting the thoughts and then letting them go, letting go of the need to control your thoughts, and accepting that sleep will happen on its own without your intellectual input, or regardless of whether your thoughts are active or not.
There is some solid evidence that cognitive-behavioural techniques are effective in treating insomnia. Here are some references:

4) Other physical treatments
  • Light therapy: use of a 10 000 lux light box for 45 minutes in the morning can help with night-time insomnia. Here's a reference:
  • There is some evidence that using a light box in the EVENING can help "early morning awakening insomnia". In depressed states, waking too early in the morning is a frequent sleep disturbance. It could be an interesting and low-risk therapy for this to use evening bright light. Here's a reference:
  • There is a lot of evidence that sedative medications are effective short-term treatments for insomnia. Mind you, some of the evidence is not as robust as one might think it should be. Unfortunately, most of these sedatives tend to be habit-forming or addictive. And tolerance tends to develop to the sleep-promoting effects.
  • Sedating antidepressants (e.g. trazodone, amitriptyline, doxepin, mirtazapine) could be useful in selected cases. Sedating antipsychotic medications in low dosages can also help sometimes (e.g. quetiapine). There is some current interest in very low-dose doxepin for treating insomnia, because it appears to have a very selective antihistamine effect at these doses; here's a link to an abstract about this-
  • Melatonin: There is some modest evidence that melatonin can help with insomnia, with few side-effect problems. Here's a link to a study, in which they were looking at the effectiveness of 2 mg of prolonged-release melatonin:

Tuesday, October 7, 2008


I think it is beneficial to journal.

A journal can become a sort of relational experience, in which the journal becomes your confidant; in this way the journal experience becomes something similar to a psychotherapy experience (e.g. the journal may become a non-judgmental, accepting, well-framed safe place for exploring ideas, feelings, joys, and problems).

As with all other relational experiences, some tactics can work better than others:

A psychotherapy experience is likely to be quite limited if the only things spoken are descriptions or repetitions of problems, with no response from the therapist.

Likewise, I believe that a journaling experience will be very limited if it involves only the documentation of problems or sorrows.

I think the experience of journaling can be much more powerful and therapeutic if "the journal" can offer empathy, support, or advice. Here, the "point of view" of "the journal" would need to be composed by you, the author.

A cognitive-behavioural model of journaling can include this idea more clearly: here, every problem or issue related in the journal would be written in one column, with the adjacent column devoted to "talking back" to the problem or issue, either through reassurance, empathy, advice, analysis, problem-solving approaches, etc. It may seem not to be very genuine to "force" such a "talking back" when you may not feel in any mood to write down a supportive comment about your journal entry. But as an exercise, frequently repeated, it can start to train your mind always to "talk back" to various symptoms, recurring negative thought patterns, or "negative self-talk".

So I encourage such a style of journaling, in which every sorrow or symptom is always "talked back to" in the next column.

Another role of journaling can be as a creative outlet, which I think is independently therapeutic. Here, the journal could include descriptions of your day, but also other creative forms such as poetry, drawings, photographs, video, audio recordings, other media, etc.

It can be satisfying to have an experience of your journal as a place to do work and have a sense of accomplishment. The beginning of the accomplishment can be simply to maintain the frame of keeping your journal regularly. Further accomplishment comes from your journal becoming a place in which problems are addressed, examined, worked through, and solved. Or a place where the joys of your life can be celebrated.

Wednesday, October 1, 2008

Politics & Economy in the Mind

Different political styles, views, and beliefs could be considered different strategies or algorithms to solve problems.
So-called "right-wing" beliefs may include the following features:
1) strict rules
2) a clearly polarized distinction between "right" and "wrong"
3) perhaps an emphasis on facilitating the progress of the most "elite" members of the group (whether this be in an economic sense, or in terms of other types of accomplishment). The thinking could be that if the "elite" are flourishing, then the entire society will ultimately flourish, either through a "trickle-down" effect, or through a type of "natural selection" process.

Disadvantages of the right-wing strategy include the following:
a) the "elite" groups may be "elite" for unfair reasons (e.g. luck; born into a rich family, despite a lack of earned merit). Or the "elitism" may be founded upon a skill which benefits merely the individual but which may have a detrimental effect on the community as a whole (e.g. an unscrupulous businessperson who may maximize profits through narcissistic and bullying disregard towards others, towards the environment, towards the law, etc.)
b) the "trickle-down" effect may not actually work in all cases. The rich may simply get richer, and the poor get poorer.
c) The strict rules may cause a rigidity to the culture which leaves various groups feeling excluded, marginalized, or persecuted.
d) The so-called "natural selection" may either occur at the cost of great suffering for many individuals, and therefore be morally intolerable--or the "natural selection" may not occur at all, paradoxically (here, the literal example would be that birth rates in highly advantaged groups are usually lower than birth rates in disadvantaged groups).

So-called "left-wing" beliefs may include the following features:
1) more flexible rules
2) an emphasis on investing society's energy in all members of the group, so as to directly support those who are struggling most. The thinking here is that if everyone is supported equally, then the entire society will flourish.

Disadvantages of the "left-wing" strategy include the following:
a) the strategy may be inefficient, and in some cases may discourage excellence. For example--by analogy but perhaps also literally--if there is a group of athletes wanting to train for the Olympics, but there are only a few trainers or facilities, the "left-wing" model might give every athlete equal training time. The star athletes would get only a mediocre ability to train, and therefore would never excel as they could have. Or, entire areas of human excellence might never be developed: space travel to the moon, heart or brain surgery, organ transplantation, etc. might never happen because they are expensive, might not be seen as efficient ways to invest energy, time, and money, and they would require the formation of a type of "elite" group (e.g. astronauts, heart surgeons, etc.). This inefficiency may certainly happen in some forms of "left-wing" economic management.

Most groups, be they nations, cities, clubs, or families, have some mixture of strategies, between the extreme "right wing" and "left wing". Perhaps part of the choice of style is determined by the cultural history of the group, though part of it could be determined by the active choice of the group.

Mind you, it seems to me that many people's positions on these matters are highly influenced by factors such as what their parents or peers think, or even by inherited predisposition--see the following twin study :

Alford, John R., Carolyn L. Funk, and John R. Hibbing "Are Political Orientations Genetically Transmitted?." American Political Science Review, 99 (2005, May): 153-167.

The study shows a significant contribution of inherited factors which influence a person's ideological stance.
There are some subtleties to the findings which make the article worth a look.

An advantage to a "democratic" system is that the style could be more changeable, and that individuals don't have to be stuck permanently in a style that they don't like. A disadvantage of democratic systems is that most groups and most individuals vacillate a lot, and are often almost equally divided between "left" and "right" (e.g. look at the U.S. electorate). This can result in leadership which is itself ambivalent and unstable.

The above comments are a prelude to a metaphor I've been considering, about how the mind, or how strategizing about life, works.

A "right-wing" approach in the mind or in one's life might be to develop one's strengths, and to pay little attention to one's weaknesses, with the belief that optimizing one's strengths will optimize success in life. So if you are a talented musician but have weaker math skills and social skills, the strategy would be to practice music 12 hours per day, to skip out on math, and not to bother socializing.

A "left-wing" approach might be to divide one's day up into 30 minute blocks, and devote equal attention to music, math, socializing, knitting, soccer, cooking, etc.

Both the above approaches, in their extremes, would probably not work out very well, or whatever successes would result would come at a high cost. In the first case, we might have a brilliant but isolated, depressed, and autistic musician. In the second case, we might have a pretty well-rounded person, who however would never be able to make a career out of music, and who might carry a lifelong frustration about never having had the chance to fully develop gifts or potential.

I think most of us would agree that a moderate position between those two extremes would be most beneficial in the above example. The theoretical musician described above probably ought to practice a lot -- much more than most others -- but probably ought to spend some time struggling through some math, and trying to get involved in social activities. In the long term, such a mixed model would probably lead to even more excellence, since a well-rounded person with good morale and multiple strengths is likely to have more energy to share with society, and is less likely to be sidelined by depression. Furthermore, there can be unexpected synergistic benefits from having a broad range of experiences.

So, in my opinion, from a psychological point of view, I believe that a "moderate" position in the "political spectrum" of the mind is healthiest and most beneficial, perhaps a position which is able to flexibly assimilate ideas from both sides of an ideological spectrum.

Another phenomenon that occurs in political debate is intense polarization: opposing groups merely fight and argue with each other. The fighting and arguing rarely seem to resolve anything, but may in fact further entrench the polarization of the opposing points of view. I think it is healthy -- in the politics of the world, and the politics of the mind -- to always be on the watch for polarization, and to take active steps to diminish it. Groups of individuals tend to separate, polarize, and compete -- sports fans or athletes are one example. In can be fun to playfully feel polarized into "us" and "them" at a sports event. But it isn't fun when the polarizing occurs automatically, and interferes with problem solving, whether it be in political debate, in an argument with a loved one, or within one's own mind.

In the internal "politics" of the mind, I think it is healthy to have a clear sense of identity, to develop your positions, ideas, beliefs, values, etc. But I think it is important to watch for polarization. This may require an openness to sometimes respectfully consider ideas that seem opposed to your position.

Likewise, in world politics, I think it is important for opposing parties to work at affirming or considering the validity of their opponents' positions, to find common ground, to even find some wisdom or inspiration -- once in a while -- in the opponents' ideas.