Thursday, February 18, 2016

Mental Health Care Organization & Advocacy

A grave problem in the world today is the lack of timely access to mental health care.

The roots of this problem are located in basic societal factors, such as poverty, political oppression, crime, and lack of educational opportunity. 

These social factors influence the prevalence, severity, and prognosis of mental health problems.  Mental health problems still occur frequently, even in affluent, safe, free environments, but it is important in health care to address the core societal needs as the first, most important, and most powerful rung of care.

These issues are very "political," since changes in poverty and social freedoms, etc. require the involvement of a community's leadership on all levels.

What is the role of the existing community of therapists and other mental health workers to improve quality and timely access to mental health care?

A common pathway nowadays is to employ a type of  "corporate" model to improve efficiency.  In industry, it is very clear that an assembly line is much more efficient, to produce the largest quantity of goods, with good quality control, in a very consistent, standardized way, with the least possible amount of money and time.    Such an approach requires teams of workers, supervised by managers, with each individual worker having a particular area of specialization.

In many corporations or businesses--such as banks--there are also regular efforts to evaluate employee performance, so as to enhance productivity.   There may be performance reviews done by management, or perhaps quotas to meet, or quantified analysis of productivity which is then reviewed regularly. 

The mental health analogy of an assembly line would be a type of corporate structure, with various members of a team involved in care.  So one might deal with a clerical worker to organize appointment times, a social worker, an occupational therapist, a nurse, a primary care physician, a clinical counselor, and a psychiatrist.  Even prior to entering this structure, one could deal with friends, family, peer support volunteers, or in a university setting it could be professors, residence workers, etc.

In order for such a system, with multiple rungs of care involved, to work smoothly and helpfully, there would need to be a sense of warm, harmonious collaboration, allowing the experience of being supported by a community.

The risk of such a system, particularly if it is not running smoothly, is that a person could feel like their care was divided or pigeon-holed.  It could indeed feel like interacting with a corporation, in the negative sense of the word.  (For a particularly critical set of insights about this, I am reminded of the documentary book and film by UBC law professor Joel Bakan, entitled The corporation). 

Performance reviews often could lead to a dramatic reduction in morale in an organization, even if the short-term goal of increased "productivity" is reached.  Generally it is stressful for workers to feel scrutinized in a hierarchical system.  Another consequence of a highly monitored work environment could be subtle changes in the pattern of practice:  workers may avoid more difficult, chronic cases, since these would be more likely to lead to negative "productivity ratings."   Creative initiatives in the workplace could become inhibited, since it would be "safer" from a productivity point of view to stick with established practices.  Also, this type of environment would lead to a type of natural selection process, in which workers with a greater tolerance for such scrutiny and stress would become more abundant in the worker population.  Those workers with less tolerance for this would become less prevalent in this system, due to burnout, and due to such a person not wanting to apply for work in such a system.  

In some parts of the world, psychiatry is reserved only for "medication consultation," thus leading to atrophy of clinical skills among psychiatrists, as well as overuse of medications, all in rushed, highly medicalized brief appointments. 

While I applaud efforts to improve efficiency, I am aware of serious risks.

I see a rise in bureaucratic activities in health care.  I see more people, including talented, warm-hearted clinicians, spending their time in front of computers, attending meetings, doing research, or doing some kind of administrative task, instead of dealing on a personal level with people in need.   More people are hired, while a smaller proportion of workers' time is spent helping people on a personal level. 

Some types of bureaucracy are unavoidable, and necessary for excellence.  For example, in hi-tech manufacturing, we absolutely must cooperate with specialists, many of whom across the world, to share the task of creating something amazing or world-changing.  The creation of a modern computer or airplane requires hundreds of highly specialized steps, starting from the mining and processing of rare earth metals, to metallurgical processing, to specialized manufacturing of countless components, to involvement of mathematicians, physicists, engineers, and other designers.  The finances for such projects need to be organized by people with expertise in commerce and business.

Mental health care does have some aspects in common with airplane manufacturing!    But in many ways I believe that it is quite different.

Most patients I see have not really benefited from bureaucratic involvements, but rather have been stressed by them.   Hi-tech therapeutic "tools" have often been tried, ranging from trials of "manualized" therapy to computer apps, to sophisticated combinations of medications.    

I do not claim that such "tools" are unimportant (actually I think many of them are interesting, clever, imaginative, and uniquely helpful for many),  but rather that they must not become the sole focus of a network of health care,  that is becoming increasingly impersonal, bureaucratized and corporatized.

The foundations of mental health care are personal empowerment, through economic and educational freedom, followed by the opportunity to have a reliable, stable personal relationship with a helping figure if desired.   Physical treatments should be available but not pushed upon people as a default approach, or because personal care was not an option. 

If the system is preoccupied with technical and bureaucratic aspects of care, at the expense of personal relationships, then I believe we are facing a steep decline in the quality and availability of mental health care for those most in need.

A particularly insidious part of this problem would be that an assembly-line type of mental health care bureaucracy could most certainly allow more people to be seen, to shorten wait lists, etc.  This could lead an external observer to assume that the system had improved.   But the decline in quality -- which could risk becoming part of a cultural norm, just as fast-food restaurants or donut shops have become a community norm -- may not be noticed or addressed.  

In order to protect the quality of mental health care, I encourage those who have had a positive experience of their own care to be sure to speak up, to offer feedback and advocacy if possible, so as to guide the system towards providing similar positive care experiences for others.  

Personal care is expensive to society, in terms of time and money.  Bureaucratic care is undoubtedly less expensive, at least in a shorter-term view.   At present, many people in dire need have no care at all.  Arguably, economically efficient bureaucratic care is preferable to no care at all.

But another option is for our society to invest much more attention and time to offer high-quality, personal care for everyone.   For this to occur, or to continue, it is likely that advocacy is needed.


Bakan, J. (2004). The corporation: the pathological pursuit of power and profit. New York: Free P.

Thursday, February 4, 2016

CBT Therapists prefer Psychodynamic for themselves

Last summer a professional colleague quoted a research finding, that CBT therapists, if they had to choose a style of therapy for themselves personally, preferred psychodynamic therapy.  I haven't been able to locate the exact source of  this finding-- perhaps it was a survey at a conference. 

Here, by "psychodynamic" I mean an open style of therapy, which is based on empathy, exploration, reflection, consideration of interpersonal patterns, consideration of existential issues, building insight, and particularly on attending to the relationship between therapist and patient or client.  Psychodynamic therapy is much less focused on symptom questionnaires, "psychoeducation,"  prescription of exercises, reviewing worksheets, etc.

During a subsequent discussion I had with a leading CBT specialist, this theme recurred--about how  meaningful and helpful it was for that person to have had a long-term personal experience with psychodynamic therapy.

CBT is a very much more "data-driven" style.  Psychodynamic styles are less so.   While I find CBT approaches extremely important, it is also true that because they are "data-driven" it will be naturally much easier to generate certain types of data from trials of CBT.  There would be a built-in bias favouring CBT in research.  Those therapists who are very inclined towards "data gathering" would likely be much more inclined towards CBT, and in turn would probably be more inclined to spend time publishing in research journals.  Psychodynamic therapists, on average, are simply less interested in publishing research papers. 

Those studies comparing CBT with other styles of therapy sometimes show advantages of CBT -- but many do not.   And most comparative studies are very brief in duration.

The meaningful, positive elements of psychodynamic styles of therapy are likely to require longer periods of time to evaluate.  Such long time periods are more difficult to measure in a study, due to technical limitations.

The inefficiencies of psychodynamic therapies, as manifest in some of the research, have often stemmed from applying old-fashioned psychoanalytic ideas in a dogmatic or highly passive way, and from offering long-term psychodynamic therapies to all patients, without any attention to shorter-term CBT-style work.  A "blended model" could involve attending to CBT ideas with most patients, but also offering longer-term psychodynamic therapies at the same time, according to patient wishes.    This type of blending is already a natural part of the approach of most therapists on both sides of the "CBT vs. psychodynamic spectrum."  The key feature which is required, in any case, is for the therapist to be kind, patient, empathic, engaging, and available.  

Another related factor, emerging in society in general, is that much of CBT is simply psychoeducational.  Ideas about basic psychological self-care tactics are a major part of every formal CBT course or manual.  The thing is, it is becoming much more prevalent now that people are already educated about CBT ideas.

Therefore, to offer only CBT would be, more commonly, to offer educational material that more and more people are already well-versed and experienced in.

I completely support the idea of increasing the availability of CBT, and of fostering education about self care based on these ideas, starting in childhood.  A lot of CBT could be "taught" as a university or high-school style course.  The manuals for them are similar in size to the workbooks for a typical 3 month course.

But the role of psychodynamic styles is likely to become even more important with time, since more people will already have been well-versed in CBT. 

Monday, January 11, 2016

Light therapy for non-seasonal depression

Lam et al. have published a study this month in JAMA Psychiatry  ( ) in which they show that people with non-seasonal major depressive disorder may have improvements in their mood with daily use of a light box alone.  Previously, light boxes have been used mainly in the treatment of seasonal depression or "SAD."

One of the reasons light therapy is attractive is that it is not a medication:  it is far less likely to cause side effect problems, and therefore it could have a much broader appeal, especially among people who are not comfortable using psychotropic medications.  

In the study, there were four groups:
1) 10 000 Lux light box exposure for 30 minutes as soon after waking as possible (the standard regimen of using light therapy), plus a placebo medication.
2) A "sham" or "placebo device" condition of sitting in front of a buzzing box (an inactive ion generator),  plus a placebo medication
3) 20 mg/day of fluoxetine +  placebo device
4) 20 mg/day fluoxetine + 10 000 Lux light box

The treatment duration was 8 weeks. 

 At the end of the study period, there were no significant differences between the fluoxetine+placebo device and the placebo medication+placebo device groups.   We could conclude from this that monotherapy with 20 mg/d of fluoxetine for 8 weeks had no benefit for treating major depression in this cohort! 

The light box+placebo medication group showed much more improvement (about twice as much change from baseline as the placebo-placebo group), with response rates typical for effective antidepressant therapies.   The combination group did best of all, with a response rate of 76% and a "remission rate" of 59%.

So this study supports the use of a light box alone as a viable therapy for depression, even if the depression does not have a seasonal pattern.
However, here are a few possibly cynical queries about this study:

1) while people in the study had to be medication-free for 2 weeks before the study commenced, I would suspect that many people in the study had tried other antidepressants.  This was not clearly documented.  By far the most common antidepressants that they would have tried would have been SSRIs.  Obviously, any SSRI trial would not have led to satisfactory improvement in these people, otherwise they wouldn't still be depressed!   In general there is not a lot of evidence that one SSRI is very different from any other, in terms of effectiveness.  Therefore, the study would have been biased against the medication group, in favour of the outcome which I presume the authors desired (which is to show that "light therapy is good").  If the authors wanted to control more powerfully for this factor, it would be necessary for them to assemble a cohort of depressed patients who had no prior history with antidepressants.

2) it is not hard to imagine that bright light could be a healthy, wholesome way to start the day.  It is much harder to imagine that sitting in front of a buzzing dark box could be beneficial.  The study demonstrated that the "expectancy scores" were the same for each of the four groups, i.e. that people in each of the 4 groups had a similar belief that the treatment they were receiving could be beneficial.   Yet, I question how compelling it would be for a modern person to believe that sitting in front of a buzzing box daily for 8 weeks would lead to a positive mood change or health benefit.

Furthermore, the treatments were absolutely not "blinded."  It would be obvious to the person sitting in front of the light box that they were receiving light therapy!  The person sitting in front of the buzzing box would be fully aware of not receiving light therapy!

3) people in the study were apparently told not to "spend an excessive or unusual amount of time outside" during the study!   If you are told not to go outside, do you not think that you might benefit even more from bright light indoors?   What if the effect of time outside exceeds the effect of the light box?!  In this case, how about prescribing that people just go outside for a half-hour in the morning after sunrise?   I'd be curious to see a study comparing a half hour walk outside with a half hour sitting in front of a light. 

Is a commercial 10 000 Lux light box really necessary?   How well can a person tell the difference between light intensities?    In various prior studies, the "sham" light therapy was a dim red light.  Here again, such a "device placebo" is not truly blinded!  Being stuck in front of a dim red light for half an hour sounds depressing just to think about!

The most interesting study I have come across looking at some of these questions was published by Riemersma-van der Lek et al in JAMA in 2008.
They had different lighting levels in nursing homes, followed for over a year.  People living in the homes could not guess accurately whether they were in the bright light condition or not (the intensities were approximately 1000 Lux vs 300 Lux, all day).  The brighter light seemed to cause some positive effects, and also eliminated negative effects caused by nightly melatonin administration.

To have a truly blinded study, we would need to use a light box of the same size, with the same colour of light, but with a lower intensity (for example, 5 000 Lux), but such that the person exposed to this light would not be able to guess the intensity level correctly.  That is, if you sat in front of the lower intensity light box, you wouldn't be able to tell that you were in the "dim light" group. This is reasonable to expect, since the visual system adjusts remarkably to different lighting conditions, causing wide ranges of measured illumination to be perceived similarly unless they are contrasted directly with each other at the same time. 

It would also be useful to more carefully assess the relationship, if any, between light therapy duration and intensity with clinical symptom changes.  What about 20 minutes vs. 30 minutes?  Or 7 000 Lux vs 10 000 Lux?   I suspect that the 10 000 Lux, 30 minute regimen is more arbitrary than one might expect. 

I have little doubt that bright light first thing in the morning is beneficial for mood--it seems like an obviously wholesome thing, which could also help regulate behaviour and sleep-wake patterns etc.  It could also be an opportunity to structure a type of meditative or study time in the morning.

But is a commercial product really necessary?  A typical "light box" costs about $200.  The electrical components inside are probably worth no more than perhaps $20-40.  It is just a fluorescent light!
It would be reasonable to conduct studies with "home made" light therapy, including just turning on a few extra lamps, or even just sitting in front of a bright east-facing window!  While the 30-minute treatment could be enjoyable and meditative for some, or a time to start the day with a bit of reading, it may be that the sedentary nature of light box exposure could be unhelpful for at least some people.  For these others, perhaps they could use that 30 minute time more healthily to get outside for a walk, instead of sitting in front of a box. 

One of the other applications for a light box that I have recommended to people is to help with morning sleep habits.  Many people have trouble waking and getting up out of bed at a regular hour (this regularity being a cornerstone of healthy sleep habits!).  Using a light box next to the bed, connected to a timer circuit which turns it on at the same hour each morning, could be used to help consolidate a regular sleep routine.  It would be like an "artificial sunrise."  (Of course, a natural sunrise would be much better still, but in our modern indoor world, it is hard to arrange this; also in a northerly latitude, the sun rises very late during the winter months, which is most likely a factor in causing seasonal mood and sleep changes).    So, using bright light as an "alarm clock" could be an idea worth trying, especially in the winter months. 

Thursday, January 7, 2016

Omega-3 supplements: update

 A number of negative studies have come out in the past year or two, regarding various types of supplements.  

I think it is good to be wary of claims about supplements, just as we should be wary of biases related to pharmaceutical marketing or to therapists touting particular styles of psychotherapy.  

Here is a review of some recent research regarding omega-3 supplementation: 
A simple 12-week study by Fristad et al (2015), published in the Journal of Child and Adolescent Psychopharmacology, showed that omega-3 supplements, given over 12 weeks,  had a modest antidepressant effect in children with bipolar-spectrum symptoms.  The effect size was greater than placebo, but less than that of "psychoeducational psychotherapy." 

In a very recent meta-analysis by Cooper et al (2016), it is concluded that omega-3 supplements given to children with ADHD do not cause large symptom improvements.  But there is enough evidence, including from high-quality studies, to believe that omega-3 supplementation could lead to small improvements in emotional lability and oppositional behaviour.

Bos et al (2015) compared omega-3 supplements (650 mg/day EPA+DHA) with placebo, in a 16-week study of 79 boys with ADHD.  They found improved parent-rated attention scores in the omega-3 group.   The effects they report appear to be clinically significant.

Widenhorn-Muller et al (2014) showed an improvement in working memory in children with ADHD given 720 mg/day of omega-3 supplements for 16 weeks.

In a JAMA article by Chew et al (2015), the authors show that omega-3 supplements, given daily over 5 years, do not slow down the rate of cognitive decline in elderly people.

For a recent review, Mischoulon and Freeman's 2013 chapter in Psychiatric Clinics of North America is a good contribution.

Animal Studies
Gonzales et al (2015) showed that omega-3 supplements, given to rats, led to "increased adaptive coping with stressful events."

In this interesting article by Bondi et al, they suggest from their findings that omega-3 deficiency, continued over several generations, can cause "impairment in cognitive and motivated behaviour" in adolescent rats.  This may speak to the importance of the dietary quality through the entire lifespan, as a factor in psychological resilience.  The typical western diet is often described as progressively omega-3 deficient. 


I continue to recommend omega-3 supplementation.  It is a reasonable supplement for those with symptoms of depression, ADHD, or bipolar disorder.   The dose to aim for is between 1 and 2 grams per day of EPA+DHA combined, usually with the EPA:DHA ratio at least 3:2.

I base this recommendation on the fact that there is reasonable evidence of a slight improvement, not only in measures of psychological health, but also in various other aspects of physical health (such as inflammatory diseases). 

I think the magnitude of any improvement due to omega-3 supplements is likely to be very slight.  But in combination with other factors, such as healthy lifestyle and responsible use of medication, it could be a component of balanced, holistic health care, particularly if continued regularly for long periods of time.  

One of the weaknesses of many of these studies is the lack of consideration for other lifestyle elements.   Considering diet alone, it is unlikely that omega-3 supplements would help very much if the rest of a person's diet is unhealthy.    A healthy, balanced, "Mediterranean" style diet, with lots of vegetables, healthy oils (such as olive), fish, and nuts, with minimal processed foods, minimal sugar, minimal simple carbs, is likely to be much more important in terms of nutritional care of mood, compared to any supplement alone.  However, omega-3 supplements could be a safe and possibly useful adjunct to an already healthy diet.

Parenting & Psychotherapy

There are many books out there about how to be a better parent.  The fact that this genre is popular is, in my opinion, a good sign of societal health:  perhaps part of parenting well is being interested in learning about ways to parent well!  It speaks to a cultural change as well, in which quality of parenting is considered important as a societal theme.

Demographics have changed over the centuries, in a way which bodes well for the earth's future:
 At this point, there is about 1.1% of population for each year of age, up to 1.6% per year for people in their 50's (the baby-boomers), then declining gradually for elderly.  In general, the population pyramid now looks more like a "solid bar" rather than a triangle, indicating that people of all ages are more equally represented in the population, rather than young children being most common.

This means that each family with children, on average, can invest more time, attention, and resources, with each individual child. 

What is the evidence about the merits of different styles of parenting?

Here we have the very surprising finding that differences in "shared family environment" have a much smaller impact on most phenomena, such as personality traits, intelligence, and mental illnesses, compared to differences "non-shared environment" (i.e. the environmental factors unique to the individual) and to differences in genetics.

 Yet, these findings refer to population averages. It is obvious that extremes of environmental experience will obviously influence outcomes much more.  An atmosphere of severe abuse and neglect is likely to have a damaging effect, while smaller differences in home environment within the "average" range in the society are much less likely to have significant effects.

People tend to focus excessively on the "smaller differences" side of things, with respect to parenting and home environment.  Provided that the home is secure, safe, relatively stable, with access to reasonable social and educational resources, it is probably true that variations within one or two standard deviations of the mean of parenting style are unlikely to make very much difference, in terms of subsequent illnesses, intellectual achievement, or overall well-being among children who grow up in such family environments.    The key thing is the avoidance of extreme negatives such as abuse or neglect.

Is there any other parenting variable that clearly matters?

I believe it is simply time, involvement, and availability.  Better parenting does not necessarily require parent education groups, expanded community resources and collaboration, better activity groups for the children, more efficient time-management strategies, etc.

Rather, better parenting simply involves being joyously, affectionately present for your children!

Presence and availability alone are not enough.  The availability has to be provided with a spirit of joy and delight.  Child-rearing cannot merely be a chore or a technical skill -- it must be nurtured as a joy of life.  Children who see that their parents actually enjoy parenting, enjoy laughing and playing and working together, are much better off than those whose parents spend equal amounts of time, but with a spirit of stress, negativity, or conflict.

I wish to make an analogy between parenting and psychotherapy.  I know it is an imperfect comparison, in many cases at least.  Some patients do not desire or need any such dynamic with a therapist, and it could be intrusive or presumptuous for the therapy relationship to have some kind of unwelcome "parental" quality.    For other patients, there is a more overt "parental" dynamic in therapy frames.  In any case, I think that there is a direct analogy between optimal "parenting strategy" and optimal "psychotherapeutic strategy."

Most of us, examining evidence of psychotherapy, emphasize technical differences in the therapy style or actions (e.g. using CBT vs. psychodynamic approaches).  Yet, evidence about relative advantages of one technique vs another is actually very minimal.

I do think there are technical elements which are important.   For example, I think principles of behavioural therapy must be called upon for management of any condition or problem -- it is like prescribing exercise to strengthen a muscle -- all the talking in the world cannot replace the need to actually practice something actively to become stronger or more skilled.   Similarly, a parent does need to literally teach a child to speak, to throw a ball, to ride a bike, to read, etc.  Time and togetherness alone are not usually enough to help a child acquire these skills.  

However, the biggest factor of all, in psychotherapy, is just like with parenting:   it is all about being available, and offering time and attention.  But just like with parenting, time and attention are not enough:  the time and attention must be provided with a spirit of joy, interest, and engagement, and with stable, healthy, safe boundaries. 

Nowadays, we have pressures upon medical and mental health care which seek to "optimize" care delivery.  Evidence is gathered about efficiency of care.  This tends to push medical and psychotherapeutic practice towards shorter visits, less frequent visits,  limited numbers of visits (for example, 6 month limits on courses of therapy), and indirect visits (e.g. through video links).    Most of the evidence supporting such methods is short-term. 

Imagine instructing a parent to become "more efficient,"  encouraging briefer interactions with children, less frequently, and for no more than 6 months at a time, particularly if it was found that the children's "symptom scores" had reached a particular threshold.

Optimal psychotherapeutic care requires time, patience, and availability.  In a setting of impoverished resources, there may be less time and availability to be shared.  But sometimes, such as in Canada, we do not actually have an impoverishment of resources.  It is "pseudo-impoverishment."  If it is difficult to access resources, the solution does not need to involve spartan rationing or obsessing about "efficiency."  It may mean that it is worth considering, for society as a whole, that it is good to invest more of our nation's vast wealth to offer personalized, patient, ongoing empathic care to those who desire or need it.