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.

Making it through a difficult day or night

It can be hard to make it through the next hour, if you are feeling desperately unhappy, agitated, empty, worthless, or isolated, especially if you also feel disconnected from love, meaning, community, "belongingness," or relationships with others.

Such desperate places of mind can yet be familiar places, and a certain set of coping tactics may evolve. Sometimes social isolation or sleep can help the time pass; other times there can be addictive or compulsive behaviours of different sorts. These tactics may either be distractions from pain or distress, or may serve to anesthetize the symptoms in some way, to help the time pass.

Time can become an oppressive force to be battled continuously, one minute after the next.

I'd like to work on a set of ideas to help with situations like this. I realize a lot of these ideas may be things that are already very familiar, or that may seem trite or irrelevant. Maybe things that are much easier said than done. But I'd like to just sort of brainstorm here for a moment:

1) One of the most important things, I think, is to be able to hold onto something positive or good (large or small), in your mind, to focus on it, to rehearse it, to nurture its mental image, even if that good thing is not immediately present. The "good thing" could be anything -- a friend or loved one, a song, a place, a memory, a sensation, a dream, a goal, an idea. In the darkest of moments we are swept into the immediacy of suffering, and may lose touch with the internalized anchors which might help us to hold on, or to help us direct our behaviour safely through the next 24 hours.

In order to practice "holding on" I guess one would have to get over the skepticism many would have that such a tactic could actually help.

In order to address that, I would say that "covert imagery" is a well-established technique, with an evidence base in such areas as the treatment of phobias, learning new physical activities, practicing skills, even athletic training (imagining doing reps will actually strengthen muscles). The pianist Glenn Gould used covert imagery to practice the piano, and preferred to do much of his practice and rehearsal away from any keyboard; he preferred to learn new pieces entirely away from the piano. There is nothing mystical about the technique -- it is just a different way of exercising your brain, and therefore your body (which is an extension of your brain).

In order for covert imagery to work, it really does help to believe in it though (skepticism is highly demotivating).

Relationships can be "covertly imagined" as well -- and I think this is a great insight from the psychoanalysts. An internalized positive relationship can stay with us, consciously or unconsciously, even when we are physically alone. If you have not had many positive relationships, or your relationships have not been trustworthy, safe, or stable, then you may not have a positive internalized relationship to comfort you when you are in distress. You may feel comforted in the moment, if the situation is right, but when alone, you may be right back to a state of loneliness or torment.

The more trust and closeness that develops in your relationship life, the easier it will be to self-soothe, as you "internalize" these relationships.

Here are some ways to develop these ideas in practical ways:

-journaling, not just about distress, but about any healthy relationship or force in your life which helps soothe you and comfort you

-using healthy "transitional objects" which symbolize things which are soothing or comforting, without those things literally being present. These objects may serve to cue your memory, and help interrupt a cycle of depressive thinking or action.

-if there is a healthy, positive, or soothing relationship with someone in your life, imagine what that person might say to comfort or guide you in the present moment; and "save up" or "put aside" some of your immediate distress to discuss with that person when you next meet.

2) Healthy distraction.
e.g. music (listening or performing); reading (silently or aloud, or being read to); exercise (in healthy moderation); hobbies (e.g. crafts, knitting, art); baking
-consider starting a new hobby (e.g. photography)

3) Planning healthy structured activities
e.g. with community centres, organized hikes, volunteering, deliberately and consciously phoning friends

4) Creating healthy comforts
e.g. hot baths, aromatherapy, getting a massage, preparing or going out for a nice meal

5) Recognizing and blocking addictive behaviours
-there may be a lot of ambivalence about this, as the addictive behaviours may have a powerful or important role in your life; but freeing oneself from an addiction, or from recurrent harmful behaviour patterns, can be one of the most satisfying and liberating of therapeutic life changes.
An addictive process often "convinces" one that its presence is necessary and helpful, and that its absence would cause even worse distress.

6) Humour
-can anyone or anything make you laugh?
-can you make someone laugh?

7) Meditation
-takes a lot of practice, but can be a powerful tool for dealing safely with extreme pain
-could start with a few Kabat-Zinn books & tapes, or consider taking a class or seminar (might need to be patient to find a variety of meditation which suits you)

8) Being with animals (dogs, cats, horses, etc.). If you don't or can't have a pet, then volunteering with animals (e.g. at the SPCA) could be an option.

9) Caring for other living things (e.g. pets, plants, gardens)

10) Arranging for someone else to take care of you for a while (e.g. by friends, family, or in hospital if necessary)

11) Visiting psychiatry blogs
-(in moderation)


...I'm just writing this on the spur of the moment, I'll have to do some editing later, feel free to comment...

Drum Circles

Drum circles are groups where people gather to pound drums together: producing, hearing, and appreciating rhythms.

The perception of rhythm is one of the core elements of human experience.

Over hundreds of thousands of years of human evolution--even before the development of culture--the perception of rhythm must have been a very important part of daily life experience.

Here are some examples of rhythms that have been part of life experience for millions of years:

-The rhythmic pounding of ocean waves
-The beating of the heart (as perceived by feeling the pulses through touch, by feeling a throbbing, excited heart in the chest, or sometimes by hearing one's own or someone else's heartbeat)
-The rhythm of breathing (regular and soft in a calm state, rapid or erratic in anxious or excited states, irregular in various particular ways as a person is crying or sobbing; or when a person is dying, e.g. Cheyne Stokes respiration)
-The chirping of crickets or the croaking of frogs (these rhythms being affected by human proximity)
-The rhythm of work tasks (e.g. preparing some kind of meal or building some kind of structure would involve repetitively pounding, picking, or working with a material, and if this was a monotonous, laborious task, a rhythm would naturally form to help the person "get into it")
-The rhythm of human footsteps (steady and strong when feeling confident and certain, rapid or timid when frightened, stomping when angry)
-The rhythms of the human voice. Before the development of languages over 50 000 years ago, probably a great deal of communicative content between humans would have been based on "non-verbal" vocalizations, which would have emphasized tonal quality but also rhythm. Today vocal rhythms are most obviously part of the expressive content in poetry and song.
-Part of rhythm includes silence. It is the "empty space" between sounds. There was a lot more silence in pre-modern cultures.

Upon the development of human culture, starting perhaps 50 000 years ago, rhythms would have been generated spontaneously as a part of creative expression, as celebration, or as ritual.

In modern culture, perhaps a lot of the ancient, prehistoric aspects of rhythmic perception have been "drowned out". In urban environments, we have a lot of cacophonic, industrial sounds, or multiple sources of sounds all coming at us at the same time. There may not be very much silence at all. I suspect that this cacophony is a contributing factor to life stress, and one of the variables increasing the rate of mental illness (there are certainly many studies showing increased prevalence of various mental illnesses in urban environments). As a corollary, I believe that spending time developing one's musical and rhythmic experiences is beneficial to mental health.

As a therapeutic modality, drumming could help people in various ways:
1) as a form of meditative focus
2) it involves physical action: it is a form of exercise as well as a form of tactile stimulation
3) it helps to focus attention: it is a form of mental exercise, as well as a means to distract mental energy away from anxiety or other negative emotions
4) it can be an endless source of intellectual stimulation, with hearing or producing increasingly complex rhythms and cross-rhythms. This can evolve to become a source of esthetic enjoyment, also leading to appreciating rhythm in other aspects of life and music more richly.
5) it can be a social activity, in which other members of the group can be guides or teachers: in drum circles, individuals need not be skilled in drumming or in generating complex rhythms--exposure to the group permits a social learning experience
6) similarly, a drum circle could be a good setting to deal with performance anxiety or social anxiety, in the comfort of an encouraging and accepting group
7) it can simply be a healthy, enjoyable form of stress management
8) drum circles can be a means to build community: the experience combines elements having to do with conformity (maintaining the same rhythm together) and with individuality (each person may have a separate or special rhythmic role or task) -- both such elements are required to have healthy community life

In Vancouver, I know of one regular drum circle group, which has been open to anyone interested. The leader of this group, Lyle Povah, has done interesting work with drum circles as part of an inpatient eating disorders treatment program. Here's his website:
http://lylepovah.com/

There may be similar groups in other communities across the world, and I encourage people to research this, and to consider checking one out.

Volunteering Improves Mental Health

Altruistic volunteering is beneficial for mental health.
There are several mechanisms by which this could happen:

1) the experience of giving one's time and energy for another in need is an intrinsic life joy
2) there are opportunities to build new friendships, with others who also are "practicing altruists"
3) the experience may allow you to discover new aspects of yourself, in terms of skills, pleasures, ambitions, etc.
4) the structure of the volunteer experience may be a "benevolent structure" motivating action in your day, challenging depressive symptoms which might keep you inactive or alone

Here is some evidence from the literature:

http://www.ncbi.nlm.nih.gov/pubmed/18381833
{this 2008 study from a gerontology journal, shows that people in their 60's who volunteer moderately have higher levels of well-being, after controlling for variables such as educational level, physical health, etc. People who didn't volunteer, or people who volunteered "too much", had lower levels of well-being}

http://www.ncbi.nlm.nih.gov/pubmed/18321629
{a 2008 study from the London School of Economics, showing that there is a direct causal relationship between volunteering and happiness; weekly volunteering increases the likelihood of being "very happy" by 16%, independent of income level--the data also suggest that the effect is more pronounced for people who volunteer more frequently}

http://www.ncbi.nlm.nih.gov/pubmed/11467248
{a 2001 study looking at data from 2681 people, showing that volunteering is associated with increased well-being in numerous domains, including happiness, life satisfaction, self-esteem, sense of control over life, physical health, and depression}

http://www.ncbi.nlm.nih.gov/pubmed/9718488
{a 1998 study showing that volunteering bolsters well-being in elderly persons who volunteer; also the people who are helped by the volunteers had reduced amounts of depression}


I think there should be some more prospective, randomized studies of volunteering and other altruistic activity in the treatment of mental illnesses.

If you are interested in volunteering in Vancouver, here is a place to start looking:


http://www.govolunteer.ca/cgi-bin/page.cgi?_id=16

Singing

There are a number of reasons why singing (out loud!) can be beneficial for mood:

1) the parts of the brain, as well as the facial and pharyngeal muscles, involved in singing, are similar to those most active in positive mood states. This may seem a trite or ridiculous association, but it is supported by evidence, namely that voluntary actions associated with happiness, even if unconsciously initiated, lead to more positive mood. Here's a link to the abstract of a classic, amusing, 1988 paper by Fritz Strack, published in The Journal of Personality and Social Psychology (another great journal that I recommend following), demonstrating that changing the position of facial muscles leads to a change in emotional response:
http://psycnet.apa.org/journals/psp/54/5/768/

2) singing is active, yet relaxing; potentially social, yet individual; creative, yet structured

3) Fellow singers--if singing is done in a group--are likely themselves to be emotionally positive and encouraging, leading to a positive social environment.

Here's a link to an abstract demonstrating that choir singing leads to improved mood and reduced stress hormone levels:
http://www.ncbi.nlm.nih.gov/pubmed/15669447

Of note, actively singing music -- not merely listening to music -- was required to produce a beneficial effect.

Bipolar Depression

The depression which occurs in the context of bipolar disorder may have a variety of unique features (sometimes such a depression may occur BEFORE a clear manic episode has ever happened, so a depression with these features can sometimes be a warning sign of latent bipolarity, or a risk sign that bipolar disorder may develop in the future):

1) excessive sleep (rather than insomnia), along with marked physical lethargy
2) depression beginning early in life (during teenage or young adult years)
3) depressive episodes of short duration
4) depressive episodes having psychotic features (e.g. delusions)
5) other "atypical" depressive features, such as increased eating
6) Sometimes a very rapid response to antidepressants (e.g. within one or two doses)

Nevertheless, these features are not invariably present in bipolar depression; and many people may have depressive episodes with these features, who do not have bipolar disorder.

Conversely, in my opinion, there is one significant element from a person's history which points strongly away from a diagnosis of bipolar depression:

If a person has taken an antidepressant, especially at a high dose, and especially for a long period of time (over 3 months), and especially a tricyclic antidepressant or venlafaxine -- if a person has taken such an antidepressant on its own, without a mood stabilizer, and WITHOUT developing overt symptoms of mania, this is fairly strong evidence against underlying bipolarity.

Some of the recent evidence about treating bipolar depression leads us to question the role, value, or safety of antidepressants in the bipolar population.

http://www.ncbi.nlm.nih.gov/pubmed/18727689
(a 2008 review, showing little effect of antidepressants when added to mood stabilizers in treating bipolar disorder over at least 6 months of follow-up)

http://www.ncbi.nlm.nih.gov/pubmed/17392295
(this is from the New England Journal of Medicine--one of the world's leading medical journals--in 2007, and it showed, over 26 weeks of follow-up, that adding antidepressants to a mood stabilizer regime did not improve outcome, in fact the antidepressant group did not do quite as well)

Which treatments have an evidence base in bipolar depression?

1) Lamotrigine. It has the advantage of helping modestly with depressive symptoms with a low risk of causing mania. It may be true that some of the studies over the past few years have exaggerated the benefit of lamotrigine, however. In any case, it appears quite safe, and can be helpful for some people. There is a small risk of a very serious skin rash with this drug, otherwise it is quite safe and well-tolerated.

http://www.ncbi.nlm.nih.gov/pubmed/19200421
(a recent study looking at Lithium + Lamotrigine vs. Lithium + Placebo over 8 weeks of follow-up; the benefits of lamotrigine are significant but modest)

http://www.ncbi.nlm.nih.gov/pubmed/15003074
(this study also showed a benefit from lamotrigine, over a whole year, but there was no placebo group, so the results carry much less weight)

2) Other mood stabilizers, e.g. lithium, valproate, and carbamazepine. Unfortunately these drugs are probably more effective for preventing manic episodes than for preventing or treating depression. Yet, the combination of a standard mood stabilizer with another agent such as lamotrigine could be a valid step.

3) Atypical antipsychotics, e.g. olanzapine, quetiapine, and risperidone. These drugs undoubtedly are beneficial as mood stabilizers, possibly more so than the standard mood stabilizers such as lithium or valproate. There is evidence that antipsychotics + other mood stabilizers are additively effective in combination. They can be worth a try for treating bipolar depression. Unfortunately, if the bipolar depression is already characterized by excessive sleep, tiredness, and appetite, antipsychotics can sometimes make these symptoms worse. But if there are psychotic features with the depression, an antipsychotic can be an essential part of the treatment.

4) Omega-3 supplements : see my previous post

5) Light therapy: I have seen this be helpful at times. The light exposure may need to be carefully titrated (e.g. just a few minutes at a time), to prevent overstimulation or agitation. Light therapy requires the purchase of a 10 000 Lux light box, which could cost about $200-300.
http://www.ncbi.nlm.nih.gov/pubmed/18076544

6) Cognitive-behavioural therapy. Elements of CBT help with most anything, it seems to me (from learning to play the violin, to doing mathematics, to treating anxiety or depression from any cause). CBT can be adapted so as to be more tolerable and interesting (some of the workbooks can be hard to get through). I think its core features require daily written work, journaling, conducting a dialog with oneself about thoughts and emotions (hopefully to work at identifying forms of depressive thinking, and being willing to challenge such thoughts if they occur), and deliberately challenging oneself behaviourally to face fears, a little at a time. In bipolar disorder CBT may work best in conjunction with ideas that help to stabilize or structure daily behavioural rhythms (e.g. getting up regularly in the morning, having a routine, eating regularly, exercising, doing some intellectually challenging work, doing some creative work, going to bed around the same time, etc.). Of course, in depression of any sort, it can be extremely hard to initiate or maintain such lifestyle habits--if there is too much fatigue or lack of motivation to get started with very much, I encourage getting started with the very smallest of tasks or daily structures, and building from there; consistency is more important than amount.

http://www.ncbi.nlm.nih.gov/pubmed/18324665

7) Other psychotherapy: basic supportive care can be very important, provided there is a resilient, trusting therapeutic relationship

8) Antidepressants: despite the negative results of late, there are selected individuals for whom antidepressants may be very helpful. Over the past decade, bupropion has perhaps been the first antidepressant to consider, due to its lower rate of causing a manic switch, and possibly its higher likelihood of helping with the low energy states characteristic of bipolar depression. SSRI antidepressants have been the second-choice agents. MAOI's are probably lower risk with respect to causing manic switch, and the reversible MAOI moclobemide could be a good option. Venlafaxine and tricyclic antidepressants have been agents to avoid, due to their high risk of causing a manic switch.

References:
http://www.ncbi.nlm.nih.gov/pubmed/16449476

http://www.ncbi.nlm.nih.gov/pubmed/16880481

9) Stimulants: I have found that stimulants can be quite useful in bipolar depression, provided that they are not increasing psychotic symptoms or agitation. They have the advantage of working quickly, helping immediately with energy and attention, and often helping with mood. Furthermore, they can be withdrawn quickly if manic symptoms or agitation arises; if stimulants are withdrawn quickly, it causes a relative state of sedation. (Note that there is some evidence from a few older studies that stimulant treatment can actually reduce symptoms of mania) There are several older stimulants, such as methylphenidate (Ritalin), and dextroamphetamine (Dexedrine), and several newer formulations of these older drugs (e.g. Adderall). A newer, atypical stimulant called modafinil can be an option as well. However, modafinil is quite expensive and often not covered by medication plans in Canada.

References:
http://www.ncbi.nlm.nih.gov/pubmed/15383134
http://www.ncbi.nlm.nih.gov/pubmed/18980736

http://www.ncbi.nlm.nih.gov/pubmed/16974196

http://www.ncbi.nlm.nih.gov/pubmed/367183

http://www.ncbi.nlm.nih.gov/pubmed/3312177

(the above two references are to older, interesting studies showing that stimulant treatments actually helped REDUCE manic symptoms acutely--I cite this as evidence that stimulants are reasonable to use in bipolar patients, however I would not go so far as to recommend stimulants in the treatment of mania, as other anti-manic treatments are much more effective and accepted as a standard of care)


10) ECT:electroconvulsive therapy is unequivocally effective for treating both depression and mania. However, there may be a higher risk of mild but persistent cognitive side-effects in the bipolar population:
http://www.ncbi.nlm.nih.gov/pubmed/17653292

If there are "borderline" phenomena occuring in the context of bipolar depression, once again some of Dawson's ideas may be helpful (see my previous postings about borderline personality); these involve emphasizing the role and competence of the individual patient in choosing treatment options, and avoiding an authoritarian stance on the part of the therapist.

Other references:

http://www.ncbi.nlm.nih.gov/pubmed/18992784
(A recent study correlating early age of onset for depression with bipolarity, severity, recurrence, etc.)

http://www.ncbi.nlm.nih.gov/pubmed/18199233
(A review of diagnostic issues regarding bipolar depression)

Noise Pollution

Peace and quiet are important for mental and physical health.

Here are a few links to references:

http://www.ncbi.nlm.nih.gov/pubmed/14757721

http://www.ncbi.nlm.nih.gov/pubmed/15936421
(A 2005 study published in Lancet which showed that noise causes increased irritability, and a negative impact on cognitive development in school-aged children)

On a related note, the use of music players such as iPods can cause permanent hearing loss, particularly if people have the volume turned up very high. People are more likely to use higher iPod volumes if the background noise level is also high. Here are some links to information and evidence:

http://www.hearinglossweb.com/Medical/Causes/nihl/mus/ipod/ipod.htm#fast

http://www.ncbi.nlm.nih.gov/pubmed/19124629

http://www.ncbi.nlm.nih.gov/pubmed/17430434

http://www.ncbi.nlm.nih.gov/pubmed/17711774

Also, the sound volume at a rock concert or a nightclub is sufficient to cause hearing damage, especially if this is an activity done regularly without hearing protection. I recommend using earplugs at rock concerts (yes, I'm serious!) Here is some evidence:

http://www.ncbi.nlm.nih.gov/pubmed/8499785

http://www.ncbi.nlm.nih.gov/pubmed/16825883

http://www.ncbi.nlm.nih.gov/pubmed/12176760

Anxiety Hierarchies

The idea of an "anxiety hierarchy" is simple and powerful.

It is an application of behavioural therapy, and is analogous to a well-designed educational or athletic training program.

In education--for example, learning to read, or learning arithmetic--a well-designed workbook would call for you to start with some exercises that you would find very easy. If the initial exercises are too hard, then it would be necessary to go to the previous workbook, and try something easier. If you can do the easier ones fluently, you can move on to the next page, and try some exercises that are just a little bit harder, and so on...the pace could be self-directed; some people might want to leap ahead quickly, others might want to linger on the easier pages, or practice doing them faster, etc.

In athletic training--for example, training for a marathon--one might have to start with just a few minutes of jogging, alternating with a few minutes of walking, a few times per week--once this feels comfortable, the intensity and duration could be increased.

An anxiety hierarchy is basically a "workout schedule" or "curriculum" for overcoming a phobia or an inhibition.

A prerequisite to engaging in this process is a clear wish to overcome the anxiety. It may well be possible to practice the skills necessary to become a skydiver, but unless you really want to skydive, you probably shouldn't do the training!

If the anxiety is social phobia, for example, the prerequisite for this approach is that you truly want to be able to interact socially with greater ease. If you have a phobia of bridges, you have to truly want to be able to cross bridges easily.

To do an anxiety hierarchy, it is necessary to consider tasks which involve your anxiety in some way, and rank them in difficulty, say from 1 to 100.

For social phobia, a rating of 100 might be warranted for the task of showing up for a group function, consisting of strangers, introducing yourself to everyone, striking up a conversation with the person who interests you most, and asking for that person's phone number. A rating of 50 might be for the task of asking a stranger in a crowded cafeteria for the time. A rating of 10 might be for reading a book in a crowded place, instead of at home. The details of how you do the ratings are up to you and how you feel.

It helps to think of as many tasks as you can along the "hierarchy", covering as many numbers as possible from 1 to 100.

The next step is--just like learning arithmetic or training for the marathon--to start with the easiest task, and practice it daily until you feel comfortable with it.

Then move on to the next harder step, and continue gradually working your way up the hierarchy. It is important to do the work every day, if possible; consistency and regularity are extremely important, just as in other learning tasks.

It is important to really take this seriously, and to put in your hours of work and practice. Just like marathon training or language learning, it won't happen unless you do it regularly, at a moderate level of difficulty, for solid blocks of time (e.g. one hour every day).

The pace of change may be quite similar to an educational or athletic task--after all, it is your brain that is changing, just the same way as your brain changes with learning anything else. Also your body learns to change--when you are more physically fit, the same athletic task can be done more efficiently, with less effort, and with less physiological stress. With anxiety tasks, your body will learn not to react with the same anxiety symptoms (e.g. racing heart, sweating, shortness of breath), as you train yourself.

Procrastination

I've been putting off publishing this post.

But to follow some of the behavioural advice about solving procrastination problems, I realize that I have to just publish what I've got, and maybe finish it or tune up the posting a little bit later.

Procrastination is often paralyzing. The motivational force to initiate an action is just not there, or there seems to be a lot of "friction" keeping things stalled. So, time passes, guilt about inaction increases, or denial is engaged in, as though the task to do doesn't even exist. UNTIL -- the day before something is due, or until some deadline approaches -- then there is a frantic pressure leading to a frenzied, exhausting all-nighter.

Some people actually produce good work this way -- or at least they claim they do -- but I think for most of us we produce less work, both in quantity and quality, and we condition ourselves to experience the process of work as negative, frenzied, stressful, or exhausting.

I'm pretty sure that if people who do interesting work despite procrastinating were to actually work on changing or improving their procrastination habit, they would end up doing even more interesting work. It may not necessarily be true that some kind of manic-depressive pattern is a key to creative inspiration.

Yet we may also condition ourselves to require high external pressure as a motivator.

This cycle needs to be broken, in order to solve the problem of procrastination.

Simple behavioural tactics include always doing a little bit of work every day -- especially the types of work that you are putting off. The key is consistency and daily regularity, rather than amount. If there is more continuity of effort, it makes the task much easier. Not only does more work get done, it also gets done more enjoyably. Once again, it is like learning a language or a musical instrument ( tasks which really cannot ever be procrastinated).

David Burns has a chapter on procrastination in The Feeling Good Handbook. Someone recently recommended to me a different resource--see what you think of this website:

http://www.procrastinus.com/


Addendum:

In response to some of the comments, here are a few more points to add:
-different people may have different reasons for procrastinating, or different patterns of procrastination. It is important to look at, and address, the underlying reasons, whatever they may be. Part of a "cognitive therapy" or "psychodynamic" approach would certainly involve examining this closely.

-Other phenomena, such as anxiety, depression, ADHD, and OCD, may be strong contributing factors to a pattern of procrastination, and in fact may lead to procrastination being a more effective, tolerable, and comfortable strategy for completing tasks under these conditions. It is important to address these other issues. Medical and psychological strategies to treat anxiety, depression, OCD, etc. may be necessary in order for strategies addressing procrastination to be helpful.

-I do stand by the claim that daily work (as opposed to "last minute work") on anything leads to a deeper, more enjoyable, and more lasting effect on the brain and on learning, for the same reason that language learning requires daily work, and cannot be done on a last-minute basis. But I agree that there may be numerous reasons why this type of daily work could be difficult or not feasible for different individuals or circumstances.

-I suppose one exception to this would be if the "learning" has already been done, and if the individual's personal style is such that intensive bursts of activity are enjoyable. Some people may like to immerse themselves in one particular thing for days or weeks at a time (while procrastinating a whole bunch of other things, I guess), and this strategy may work very well for them. Some artists or authors like to work this way, for example. I don't think it would work well, though, unless the people were already skilled at the area in which they were immersing themselves.

-Another proviso about the "daily work" idea is that there needs to be some focus on joy in the activity itself. If the daily work is merely a burdensome, unrewarding chore, from beginning to end, then the mind gets consistently conditioned to hate the activity (this is one reason, for example, why many children learn to hate piano lessons or math -- they are made to practice or study joylessly and alone--though consistently-- by parents who may have well-meaning ideas about daily discipline, etc.). Finding ways to experience an activity with some element of joy is a particular therapeutic challenge -- conventional behaviourism neglects this. I think that more "Eastern" systems of thought and practice have a little more wisdom to offer in this area, with respect to finding ways to teach ourselves to experience, or rediscover, some joy and contentment in a seemingly or previously joyless moment or activity.

Happiness and Economics

I just finished reading an excellent book called Happiness: Lessons from a New Science, by Richard Layard (Penguin, 2005).

His main points are in synchrony with ideas that I have alluded to in previous posts:

-Economic growth is a numerical measure which does not correlate consistently with well-being or health. Except for people who are living in poverty. $100 to relieve one person's poverty goes much, much, much farther to improve well-being (for both the individual and for the world) than $100 to increase a wealthy person's leisure budget.
-Despite large increases in wealth in many parts of the world, people are not any happier (in fact, they are often less so, particularly in the U.S.)
-Pursuit of wealth has an addictive quality: it produces short-term satisfaction, but the mind habituates to any short-term external satisfaction. The mind is more satisfied with stability, and is more averse to perceived loss than it is satisfied with material gain.
-If economic growth is optimized, it leads to "pollution" of various sorts. Literal, environmental pollution is one type (actually Layard could do well to include more ideas about environmental care in his thesis). Most economists do not measure this "pollution" in their calculations. But there is other "pollution" as well: a culture which values accumulation of financial wealth as the main priority may do so while "polluting" its social fabric. For example, optimal financial output may require longer workweeks and more worker mobility, which then becomes a social norm, leading to everyone spending less time with family & friends & culture, leading to declining morale and a declining sense of community, increased crime, etc. Once again, this type of social "pollution" from maximizing financial performance in society is often not included in economists' calculations.

The wisdom of his book lies in his attempt to combine the field of economics with psychology and the other social sciences, a combination which I think is badly needed. He encourages economists' calculations to be "weighted" by consideration of emotional well-being, not simply by optimization of simple financial measures.

Some of his specific ideas could be challenged (e.g. see the following paper: http://bpp.wharton.upenn.edu/jwolfers/Papers/EasterlinParadox.pdf). He advocates increased taxation as a deterrent to over-work, as a cost to pay for "pollution". I think the idea deserves attention, but it has certainly been challenged as a specific policy (the "cost" of feeling more burdened by the state may be a different psychological factor to include; furthermore, I think one of his stronger points is that motivations should be best drawn from inner sources, rather than from external incentives or disincentives).

However, the spirit of his ideas encourages us to do the following, as individuals, and as a society, for the sake of improving our lives & happiness:
1) avoid the "rat race" -- i.e. be wary of choosing a lifestyle in which you have to do more and more, to get more and more stuff, in the name of supposedly improving your life, when in fact you are sacrificing not only your own personal, family, social, and cultural life, but also participating in establishing a competitive social norm which others will want to follow, at their own expense, and at the expense of society itself. Let hard work be done for its intrinsic satisfaction, and as a satisfying way of life, rather than as a means to "get ahead" or to "get rich".
2) Pay close attention to nourishing aspects of personal culture which improve personal and collective happiness:
-be involved in helping others & be involved in your community
-avoid making choices just to keep up with someone else
-avoid criticizing or judging yourself in comparison to someone else; the modern world is set up to make you feel needlessly bad about yourself, or needlessly competitive to change something about yourself that needs affirmation rather than change
-educate oneself, and participate in the education of others, about emotional self-care
3) Watch less TV. The TV is a specific device which has clearly been shown to reduce happiness, through a similar process by which wealth itself can reduce happiness: it is an external source of pleasure, to which we become habituated, at the expense of relationships, community, physical fitness, and personal culture. Also it desensitizes us to violence, which is a further factor leading to increased aggression. Also it feeds, through advertising, the rat-race mentality of acquiring more and more stuff; much of this advertising is directed at children. He quotes an interesting study which supports his view: http://jcc.sagepub.com/cgi/content/refs/16/3/263). I might add the internet is another example of something similar.

Addendum: actually, as with many things, I think modern technology can have positive influences too. I remember many experiences of joy, humour, and togetherness watching movies or good TV series. Sometimes the TV can enhance education about the world, history, nature, current events, etc. And TV can introduce us to new aspects of personal culture, and therefore be a cultural enhancement. But I do think that TV can become an addictive and isolative habit; I guess the key is moderation, choosing wisely when and what you watch, and considering carefully why you're watching it.

I especially agree with Layard's ideas about encouraging children to learn from an early age about ways to manage and understand emotion, to practice compassion and empathy (yes, compassion and empathy can be "practiced" and "learned"), and to be involved in community-building. It often concerns me that many supposed community-building activities involving children (e.g. sports, academics, or even music lessons) end up being subverted into yet another rat-race or competition. Ideas from cognitive therapy could be introduced in elementary school, and I'm pretty sure that this could help prevent, or lessen the severity of, many cases of mood and anxiety disorder.

I also especially agree with certain other public policy points: for example, I think it is unconscionable that governments encourage gambling as a form of revenue. To encourage, and advertise, an addictive behaviour which takes individuals away from their families, loved ones, and communities, and leaves some in a miserable state of addiction, just because it is an efficient source of revenue, is extremely poor public policy. It is poor economic policy too, since more people spending more time gambling surely does not lead to increased economic success for individuals or communities, except for the people running the casinos.

I think his ideas about limiting commercial advertising directed at children warrants serious attention. Apparently Sweden has banned such advertising; the Scandinavian countries appear to be a good example to follow in terms of public policy which considers well-being above mere economic optimization.

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:

http://www.stanford.edu/dept/bingschool/rsrchart/bandura.htm
(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)

http://www.des.emory.edu/mfp/bandurabio.html
(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):
http://www.mentalhealth.tv/index.php?mod=page&page=Home

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:

http://www.ncbi.nlm.nih.gov/pubmed/18843744

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.

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.

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.

Journaling

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.

Real vs. Perceived Alcohol & Drug Use in University Students

I always ask patients about drug and alcohol use.

Often times, someone will tell me that they drink alcohol or smoke marijuana "socially" or "on weekends" or "average". I always follow this up with more questions about how much this really amounts to.

Often times, this amounts to a pattern of either daily use, or quite frequently of having binges at least once a month, sometimes once or more per week.

It is quite clear from a medical point of view that binge drinking is psychologically harmful: not only does it place someone in a position of higher risk for physical accidents (I do not have to search my memory far to think of tragic alcohol-related deaths or severe head injuries among young students in the prime of their life), the pharmacological effect of this type of usage will exacerbate all mood and anxiety problems. It will interfere with normal sleep for long periods of time after the binge is over, and if there is a mood-related or anxiety-related sleep problem already, it can push the symptom intensity up much higher and make it much more difficult to treat.

I have found that many people, upon describing their pattern of binge drinking or marijuana use, will say that their behaviour is part of normal, ubiquitous university culture, i.e. "everyone does it."

Here is what some statistics show from a local part of a large recent continent-wide survey of university students:

Percentage of students who actually have never used marijuana: 63%
Students' belief about what percentage of fellow students have never used marijuana: 16%

Percentage of students who actually use marijuana daily: 1 %
Students' belief about what percentage of fellow students use marijuana daily: 16%

Percentage of students who have actually never used alcohol: 16%
Students' belief about what percentage of fellow students have never used alcohol: 3%

Percentage of students who have used alcohol daily: 0.1%
Students' belief about what percentage of fellow students have used alcohol daily: 30%

All of these above figures show that students greatly overestimate how much their fellow students are drinking and using marijuana. Because of how powerful the influence of social pressure is, especially to young people, it is important to be reminded of the facts. It is much more the "norm" for students to drink or use marijuana rarely, if at all. And it is common -- not rare -- to be completely abstinent.

However, one concerning figure from the same study shows that about 40% of male students, and 30% of female students, have had 5 or more drinks in one sitting at least once in the past month. This is a binge. And this is associated with the greatest risk of physical and psychological harm. For almost 10% of students, binge drinking occurs 3-5 times per month, which is more or less on a weekly basis. This type of behaviour is certainly a prelude to a more severe future of alcoholism, with all its physical and psychological sequelae.

Based on my reading of epidemiological studies, it is clear to me that 2 drinks per 24 hours is the maximum quantity of alcohol reliably consistent with good health (it may be that this level of alcohol consumption actually confers health benefits compared to abstinence, at least for some people).

I am not convinced that any amount of marijuana use is consistent with good health, except perhaps for some people who may have used it just a few isolated times in their lives, in a good mood, in a pleasant environment, which may have helped them relax some of their inhibitions or gain some other insight about themselves or the world. It is more often the case, though, that such experimentation leads to negative health effects.

Boredom

The feeling of boredom may be a signal to change what we are doing, to seek something more stimulating or pleasurable.

Many signals that the brain gives us are helpful guides, which lead us to make better decisions.

Other times, the signals the brain gives us are misleading.

In the case of boredom, the brain may be conditioned to expect a lack of stimulation or pleasure in a given activity. And it may be conditioned to expect stimulation or pleasure by leaving this activity. If this behavioural pathway is followed, it may further lead to a conditioning effect, in which the initial activity feels even more boring the next time round. It is like the forest path again, and each time you go down the path, it becomes more established.

I believe that in many cases the brain causes us to leave experiences prematurely. There might be much more pleasure, stimulation, and meaning in activities that are felt to be boring, but the brain is too habitually eager to get us out quickly, to the alternate activity.

As an exercise, I encourage practicing ways to discover interest, stimulation, meaning, and pleasure, in activities that you have pronounced to be boring (e.g. working through a textbook for school; getting through a work shift; commuting; conversing with someone who isn't your favourite person, etc.). It may require looking at the experience in a different way, with an eye to find significance, meaning, and interest, rather than focusing on the aspects that you find tiresome.

One very specific way to discover this change of perception is to take a class in drawing, painting, or photography -- often part of the experience is of learning to see things in a different way, to become absorbed with interest in something you thought was mundane. Another technique is to take courses in meditation, in which one can learn to be more at peace with the present moment, even while sitting quietly with almost no external stimuli.

In my work with students, I believe this is an extremely important issue. Many students have enrolled in a course of study that may last at least four years, or may lead to a lifetime career. Yet they are bored with what they are doing. I strongly encourage choosing courses (or other life decisions) that have a hope to be interesting, and coming to the work with an attitude of finding significance, meaning, and interest, rather than expecting or continuing an experience of boredom. Boredom leads to disengagement, a fractured relationship with what you are doing, and can be the beginning of lifelong unhappiness with the present moment.

While you may need to make external changes, it is important to make a strong effort to direct internal changes too.

Reading List

Here is a set of books that can be worthwhile to read, dealing with mental health & self care issues. I think I will try to update this list regularly as I stumble upon new titles.

1) The Feeling Good Handbook by David Burns. An overview of cognitive therapy ideas, with lots of exercises to work through, pertinent to anxiety, depression, relationship conflict management, procrastination, among other things. Sometimes the book may come across as saying (imagining the smiling face of the author on the cover of the book): "if only you did my exercises properly or more thoroughly, you too could have a happy life". I think this is a weakness of the book--it is important to acknowledge that cognitive techniques can help, and they require a lot of work, but they may not help all symptoms, sometimes they may not work at all, the exercises often may not be pertinent, some of the content may seem trite; and the style of the book may be annoying to some. Yet I do think it is quite a comprehensive overview of some cognitive techniques, and it is worth looking at; the author validly challenges you to actually work through all the exercises with pen and paper, cover to cover, before judging the book. While cognitive therapy can help during a bout of severe depression, I think it is most useful when you are actually feeling better already, or only feeling mildly symptomatic. The cognitive therapy can help prevent relapses, help you stay well.

2) Against Depression by Peter Kramer. A very good defense of biological psychiatry. Also some interesting ideas about how quite severe depression, with its associated severe suffering, may have been "normalized" in current and past culture, in the arts, etc. It is an interesting and thought-provoking idea. I personally agree with many of his points.

3) An Unquiet Mind by Kay Jamison. Her other books are also worth looking at. She tells her personal story of dealing with manic depressive illness. From an interesting perspective, in that she is a famous research psychologist who has co-authored one of the major textbooks on the subject of manic depression.

4) various of the books by Irvin Yalom. Enchanting and delightful at times. Some might find him annoying. But an example of what psychotherapy experience can be like. He has a very open and liberal style (perhaps too liberal for some).

5) various of the books by Oliver Sacks. Interesting to learn about the different experiences and phenomena associated with the brain and its disorders. In this way a commentary on the human experience in general.

6) I encourage people to visit an academic library, and browse through some of the major psychiatry and psychology journals. Look through them as you would copies of waiting-room magazines. You'll get a sense of what's going on in research, what some of the new treatments are, and how psychiatrists and psychologists think. Many of the articles are pedantic and questionably relevant, but others are more readable, pertinent, and interesting. The biggest psychiatry journals are The American Journal of Psychiatry and Archives of General Psychiatry. Another good large journal is The British Journal of Psychiatry (more of a European perspective). Journals devoted specifically to the latest medications and other technologies for treating mental illness include The Journal of Clinical Psychiatry (this journal seems quite influenced by industry, but has good updates about medication treatments), The Journal of Clinical Psychopharmacology, and Biological Psychiatry (this journal can be very technical). There are lots of interesting journals devoted specifically to psychotherapy as well, and in the psychology literature there is a wealth of other perspectives to look at (however, many psychology journals contain articles that are full of technical jargon).

7) Read a textbook of social psychology. A wonderful field, very interesting. The textbooks are easy to read. And presents a rich body of evidence about social factors in personal psychological experience that we often neglect to consider in managing emotional problems.

8) Yoga for Depression by Amy Weintraub. This was recommended to me. As I scan through it I see good things. If not this particular book, I do think that at least something in this genre deserves an important place on your bookshelf.

9) The How of Happiness by Sonja Lyubomirsky. The author is a psychologist who has researched happiness, and the factors that contribute to it. An important subject, often neglected by the majority of us who focus on the factors that contribute to negative states or disorders, rather than the factors that contribute to health. However, the book, in my opinion, while having some good practical suggestions in it, is fairly weak and limited in its usefulness in its approach towards managing major mental illnesses. It is most useful for those who well, or who are recovering from their illness already, and want to consider some changes that could help them stay healthy and happy. It is also helpful, I think, for those who are chronically demoralized, moderately unhappy, but not clinically depressed.

10) Influence: the psychology of persuasion by Robert Cialdini. A useful book by a social psychologist, looking at the factors that persuade us to buy something, do something different, or change our mind. I think that being more aware of these factors -- often used in advertising or by salespeople -- can protect us from being persuaded to do things that we don't really want or need, and can therefore help us to make healthier decisions.

11) How to Start a Conversation and Make Friends by Don Gabor. So many of us struggle with shyness, or find it difficult to make new friends, or hold a conversation, etc. Here's a book that gives a lot of practical suggestions on how to approach these things more easily. I realize that many people believe a "how-to" book would not do much for them, or that the ideas in the book are things that are already very familiar or obvious to some, but I think that working through the book can only help, at least as a frame to contemplate and plan ways to make things better. There is a wide variety of books on this subject, and I invite people to check out numerous different titles--some people may need to check out numerous titles to find a book whose style and content suits them best. A search on a bookselling site such as Amazon, looking for "social anxiety" or "shyness" books will yield a nice variety to choose from.

12) Find a newspaper with a large collection of daily cartoons. Read them regularly. If you have a favourite cartoonist or humourist, get an anthology (e.g. I always liked The Far Side). A lot of other stuff in newspapers has a negative impact on mood, in my opinion, since newspapers focus on disaster and conflict in the world, rather than on things that are going well. We have to find a balance between staying well-informed and involved in debate or activism, etc. while not allowing the terrible stresses of the world to damage us. Of course, when depressed, it may be that nothing seems funny at all--and reading cartoons may just be an irritation; if this is the case, I'd advise you to give it a break until you're feeling better.

Healthy Eating

-lots of fresh vegetables & fruits (except for root vegetables), in amount and variety
-lots of high-fiber foods
-less meat, if any
-fish is healthy, especially fatty red fish such as salmon (an omega-3 source)
-but this has to be moderated due to the unfortunate risk of heavy metal contamination from eating a lot of fish, and due to the environmental problem of worldwide overfishing
-tea is good, in moderation (green & black), unless the caffeine is interfering with sleep
-dark chocolate is good for you; but it has to be in moderation, since it contains a lot of saturated fat
-carbohydrates (carbs) are probably important and necessary for mental health; low-carb ketotic diets are probably hard on the brain. But it is important to choose complex carbs that are released more gradually into your body. Sprouted whole grain breads are better. White bread or rice is almost like pure sugar, in terms of its rate of digestion into simple carbohydrates. Sugar itself should be cut down substantially (it has addictive properties; once you have gradually weaned sugar from cooking and baking, perhaps to 1/3 or 1/4 of what most recipes recommend, you will enjoy the intrinsic flavour of the baking more, and find the higher-sugar recipes unpleasantly sweet).
-components of the "Mediterranean" diet in which there is abundant use of olive oil, is probably healthy
-eliminate trans-fatty-acids from the diet (e.g. hydrogenated oils, often present in many packaged foods to prolong shelf life -- remember this may prolong the oil's "shelf life" on the inside of your arteries as well).
-there is some evidence that there is an excess of omega-6 fatty acids in the typical North American diet; this can be addressed by reducing use of omega-6 rich oils such as sunflower and corn oils, and instead using oils such as canola. Walnuts and flax are other natural sources of healthier omega-3 oils.
-1 to 2 glasses of wine (125-250 mL) per day may improve health compared to abstainers, and compared to those who drink more. But some individuals may have health problems as a result of drinking even small amounts of alcohol. In this case it is best to abstain.
-drinking water is great, but you really don't have to drink huge amounts. Keep yourself well-hydrated, but you only need to drink if you're thirsty.
-I do encourage people to leave all soft drinks behind -- the sugary ones are obviously bad for you. The ones with artificial sweeteners are probably not great for you either, and are also training you to expect sweetness while you hydrate yourself--this conditioning may exacerbate an unhealthy dependence upon simple carbohydrates and sweets, and cause you to be perceive the simple joy of drinking pure water to be unpleasantly mundane. Also do you really want to financially support the big soft-drink companies, with their expanding presence in children's schools, developing countries (many of whose people are dying from starvation), etc.?
-minimize the use of salt
-high-temperature cooking such as barbecuing adds flavour to food, but may result in higher levels of unhealthy chemicals, so it is probably best to reduce the intake of charred food.
-if you are a vegetarian or have other dietary restrictions, make sure you get an adequate intake of vitamins and minerals. A simple daily vitamin supplement should usually be sufficient. I do not see compelling evidence that "megadose" vitamins are beneficial.
-but there is some evidence that the RDA for vitamin D ought to be higher, perhaps up to 1000 IU per day or more.
-extra calcium supplementation may also be needed for many people on a long-term basis, to maintain bone health

While much of this advice is part of basic general health, I think that basic general health is also beneficial to mental health. And there may possibly be specific direct benefits to mental health from a very healthy diet.

I do qualify the above remarks, by saying that extremely clear, direct evidence linking healthy nutritional habits to improved mental health, is lacking. Much of the evidence is indirect or anecdotal. Many exaggerated claims are made in the advertising found in health-food stores. There are a few small studies looking at specific supplements, such as omega-3 supplements, which show some modest evidence that this can improve mood.

Some useful links:
1) the USDA nutrient database (detailed nutritional data about different foods):
http://www.nal.usda.gov/fnic/foodcomp/search/

2) the Cornell University food psychology page:
http://www.foodpsychology.cornell.edu/

The American Journal of Clinical Nutrition is a good academic journal to browse through, to get a good sense of what is going on in food & nutrition research. You can head to an academic library, and leaf through the past year's issues.

Addendum:

After reading the excellent comment on this entry, I feel compelled to add a few things to what I now recognize has been a very dry and pedantic set of comments:
I forgot to mention that I think food is one of the great joys and pleasures of life!
As with other joys, it is wonderful and healthy to develop and nurture a rich culinary experience.
Not only are food, cooking, and eating sources of sensual pleasure, they are also part of a rich and healthy culture (and a way to introduce oneself to new cultures), a part of a social and community life, and a part of an active intellectual life. It is a delight of human nature that we can start with something basic (e.g. an onion, or a grape), and keep refining it, transforming it, and using it in new ways, until we derive more and more art and pleasure from it. There is something very basic about the meaning of life itself in this kind of dynamic.

So I wholeheartedly endorse the idea of embracing and developing a rich culinary culture as part of healthy living. I do still maintain, however, that every culture ought to be informed by science and evidence, and perhaps adaptations can be made to certain cultural practices if we learn that they are harmful (to ourselves, to others, or to the environment). Sometimes the symbolic or esthetic value of a cultural practice can be preserved while the unhealthy aspects can be minimized.

Dietary Extremism

This is a sensitive topic, as many people feel badly about their weight, body image, and dietary habits. And many people have eating disorders, in which difficult relationships with food and with body image lead to a variety of behaviours that can do severe physical and emotional harm.
In this post, I wanted to address the specific phenomenon of what I call "dietary extremism". I consider the phenomenon to be similar to dogmatic religious belief.

Dietary extremism occurs as a result of people struggling to find some change in their lives that truly makes a difference for the better. They may have tried a wide variety of "standard routes" but continue to struggle with the same problems.

Extremism can often yield results for people, because it involves a radical change in lifestyle. It is something like joining a monastery. The lifestyle becomes more sustainable because of the community of fellow extremists (the other "monks in the monastery"), and because the community sets itself apart from the mainstream. The extremist beliefs are entrenched within the community, especially when members of the community are seeing significant changes within themselves for the first time.

Yet, the beliefs themselves are often extremely dogmatic and inaccurate. While I am a fan of permanent, positive life change, I believe that we must always stay attuned with the truth, always be open-minded to hear the facts, always be willing to question and challenge, always be wary of being told what to do by a guru-like figure (who, incidentally, may be making a lot of money and enjoying a lot of attention from fans, by selling books or running retreats).

A specific example that has come to my attention is the "raw food diet". Adherents have made substantial changes to their lifestyle. And, in my opinion, they are usually healthier for it. There is quite a bit of evidence that eating more fruits & vegetables, eating less meat, eating fewer animal products, etc. is part of good self-care. Furthermore, it is better for the environment, better to address world hunger (since raising animals instead of plants on agricultural land produces less nutritional energy per acre), and more humane (fewer sentient creatures need to be killed).

But most informational tracts about "raw food" are filled with claims that sound "scientific". The use of false or misleading pseudo-scientific claims is a typical tool used in charlatanism. This is one of the pathways that makes this potentially healthy dietary idea stultified by dogma. If you encounter statements about various types of nutritional degradation caused by heating, or about the miraculous virtues of some kind of oil (e.g. coconut oil), or about the advantages of choosing foods that are "less acidic", etc. I encourage you to be aware that there may be some dogmatic, charismatic salesmanship going on. The fact that these statements sound "scientific" may simply be fooling you. If you really want to know the truth, or what the evidence shows, then I think it is important to look closely yourself, at primary sources in reputable research journals.

The concern I have about the dogma doesn't necessarily mean that I think "raw food" (or some other diet) is a bad thing. I think it is a cultural practice, which has healthy aspects to it. Like other cultural practices, there may be a well-developed estheticism within it, leading, for example, to some really good recipes with raw food ingredients. The cultural practice crosses the line, though, into dogmatism, when it pronounces itself better than all other practices, and starts to support this claim using spurious or misleading information. All the while, many people are probably making quite a profit by marketing these ideas.

One of the phenomena often described in extremist groups is a collection of testimonial accounts from people whose lives have been radically changed for the better (e.g. cured of cancer, reached their ideal weight, felt healthy for the first time in their lives, etc.). While it may well be true that these individuals are genuinely thriving as a result of their new cultural practice, the mechanism of this change may be the result of very different factors than what they believe. Most any radical life change that leads to a sense of purpose, community, consistency, and meaning can have a transformative positive effect on an individual's health. I encourage such quests for purpose, community, and meaning -- but I encourage people to keep an open mind and to avoid dogma.

There are some good journals of scientific nutrition, such as the American Journal of Clinical Nutrition, and others. Abstracts are available on-line for free, and you can search on medical databases for information. Once again I encourage you to explore the evidence first-hand. When you read a claim about the nutritional virtues about this or that food, or this or that diet, be aware that you may be reading an ad, or an "info-mercial", and be prepared to search further yourself to clarify this kind of information before you make a needless change in your health behaviours.