Monday, April 9, 2018

Steven Pinker's optimistic new book

I'm a Steven Pinker fan...I really appreciate his optimism about the state of the world, and the future of the world, an optimism which he supports with a lot of engaging evidence.

So I encourage having a look at his book, Enlightenment Now.  It is a sequel to another of his books (Better Angels of our Nature) which I have reviewed earlier on this blog.

I don't agree with everything he says, but I do also embrace a spirit of optimism about things, and an attitude that the many problems we have in our lives, or in the world, can be solved or at least improved with continued care and effort. 

This type of book is a good accompaniment to a study of behavioural economics and social psychology (such as the works of Daniel Kahneman), as well as optimistic data analysts such as the late Hans Rosling.

The strongest section of his book is the middle part, in which the reader is barraged with many graphs showing positive changes in the world over time.  I found the other sections, with a lot of philosophizing about the enlightenment, etc. less important and engaging. 

As to this book's relevance to mental health?  I hope we might all embrace a spirit of optimism about the pathways of our lives.   Past adversity in life does not necessarily predict a guaranteed future life of suffering.  There is work to be done, to build a better, happier life, regardless of the hardships of our origins.

In the cognitive theory of depression or anxiety, we understand that thoughts may specifically focus on pessimistic or even catastrophic interpretations of observations; much information in our modern world is distilled to emphasize catastrophe or adversity (non-catastrophes are less likely to become headlines), so this information is natural fuel to a depressive or anxious state.  An optimistic but highly rational book such as Pinker's could be understood as a type of cognitive therapy for a modern consumer of news.

Progress in the world may also translate overall to improved mental health...but I suspect we would see the most robust improvements in those areas which have the least current services.

A peril of such a strongly optimistic text can be that it fails to empathize sufficiently with those who continue to suffer...or that it can seem insensitive when there continues to be horrible tragedy in the world.  But I think that we are best able to help and heal from tragedy if we are not depleted, pessimistic, or even hopeless about the ongoing problems in our lives or in the world.  So this book is a much-needed infusion of optimism into public debate.

Tuesday, March 6, 2018

Depression Treatment Guidelines

I encourage having a look at the September 2016 issue of The Canadian Journal of Psychiatry, which summarizes treatment recommendations for major depressive disorder, based on a thoughtful review of the evidence available at the time.  The authors spent many hours of careful work preparing this authoritative set of articles, and I think they did a good job. 

Here is a brief summary:

1) Various antidepressants are beneficial for treating depression.  They may help with an acute episode, and may help prevent relapses if continued.  Some may work better than others, but the differences are small, and there are likely to be individual cases in which a so-called "second-line agent" works better than the first-line choices.    Some things are classified as "second-line" not because they are necessarily inferior, but because they have not been researched as much as the "first line" things.

2) Various types of psychotherapy are beneficial for treating depression.  These, too, can be helpful for acute episodes, as well as for preventing relapses, even after discontinuation.  CBT has particularly strong evidence for being effective. 

3) As to specifics, such as "which medication is best under which circumstances?" or "which type of psychotherapy is best under which circumstances?", the evidence often does not guide us clearly, aside from CBT in general being favoured. 

4) Various other types of treatment, including ECT, TMS, exercise, and light therapy, have evidence supporting their use.

I am concerned that there was not a lot of critical debate about these claims.  Many authors of review articles are proponents of a particular type of therapy (e.g. light therapy, CBT, etc.), and the content therefore may be biased, or at least lacking input or commentary from different points of view.   It could be argued that "the data speaks for itself," but often the verbal conclusions resulting from the data can be coloured significantly by the author's opinion.

There are some useful specific pointers:  for example, there is a lack of evidence that combining two different antidepressants is consistently helpful.  But "augmenting" strategies, such as adding an atypical antipsychotic medication to an antidepressant, are better supported by evidence. 

In general, for me, these guidelines are most useful as a very general introduction, to get an overview of common treatments, and of up-to-date research evidence.

Here are some ideas of my own to add about "treatment guidelines":

A very thorough understanding of a person's history is most important for care.  In many cases what appears to be "major depressive disorder" ends up being a more complicated story, upon spending time learning the history.  Many treatments such as antidepressants can be dangerous if given without thorough understanding of the history (for example, if there is a history of bipolar symptoms).  Obtaining a good history is not necessarily possible with a single visit, with a standardized interview, etc.  It takes time and a good therapeutic relationship to know a person's story.

There is some question about the validity of "major depressive disorder" as a construct.  Eiko Fried has a good summary of this issue on Twitter:
As I have written before, a great many patients do not have only one diagnosis (assuming we are focusing on a DSM-style diagnostic scheme).   It is therefore limited to focus only on the treatment of depression alone.  I realize that it is a convenience in research to define syndromes in this way, which can then help us to measure the effectiveness of treatments systematically.  But for a given individual, it is often necessary to step away from diagnostic constructs, and help the person in the specific ways they desire or need. 

There are many pathways towards nurturing mental health.  Finally it is reasonable for most people with depression to try various treatments, including medications, provided there is a good understanding of risks and potential benefits.  Psychotherapeutic ideas (such as CBT, but also other styles) are beneficial for most anyone, even those who do not have formally diagnosed mental illness.  Lifestyle and psychosocial factors are very important: exercise, healthy nutrition, healthy social, family, and community development, physical safety, career, education, stable finances, and the pursuit of meaning, should be an invited focus for everyone.    There is relatively little attention given to these issues in most published treatment guidelines (sometimes I get the feeling that some authors in the field are embarrassed to even approach them) yet for many people these issues are the most important of all.

In the 102 pages of this journal, which are devoted to approaching and treating depression--a disease of emotional and often existential suffering, loneliness, joylessness, and a crisis of meaning--here is a tally of individual words used in these pages:

1) love:  0 times.  The search engine found a reference to the author J. Glover as the only occurrence of "love"
2) compassion: 1 time
3) nutrition: 1 time
4) cooperation: 0 times, except as part of 7 references to an agency (the "Asia Pacific Economic Cooperation") which gave money to one of the authors
5) healing: 1 time
6) friendship: 0 times
7) encouragement: 1 time
8) pets: 0 times
9) nature: 1 time (referring to "nature of risk")
10) joy: 0 times
11) humour, laugh, laughter, smile, happy, happiness:  0 times for all
12) art, hobby, hobbies: 0 times
13) patience: 0 times
14) drug: 86 times
15) intervention: 91 times

While I love science (my alternative career would have been a mathematician or a statistician!) it is necessary in mental health care to also discuss issues or words that do not fit neatly into a science or data-based analysis.  These issues include compassion, meaning, love, and patience.  Another issue is finding ways to cope with, live with, or accept unremitting chronic illness or pain, while continuing an evidence-based, but uncertain and frustrating, search for relief or cure.  Algorithms and guidelines tend not to help very much with this existential struggle.    Educationally, I think it is more valuable to present case studies, with group engagement, perhaps with references made to treatment protocols, rather than to make the protocols themselves the subject of the lesson.   

I prescribe a lot of medication.  In some cases the medication appears to be incredibly helpful.  In many other cases, there is a small but significant benefit.  And in others still, there is not much benefit at all despite many, many trials of different medication.  And in a few cases, the medications are harmful.   Many of my patients benefit most from medications that are considered "second line." I can't think of any examples in my practice where guidelines of this type have been useful in determining the most helpful course, aside from being a very general roadmap to remind us of available options or the occasional new finding in the research.   But this roadmap would already be very familiar to most mental health professionals, part of an academic focus over years of training.   Specific treatment issues (such as choosing the best medication or psychotherapy combo etc.) are part of professional development: this requires ongoing familiarity with the broad research literature, and with experience in clinical practice, rather than reliance upon review articles.    Review articles of this type are  authored by research experts, whose work deserves respect; however, the authors represent a limited subset of expertise within the population of mental health workers.

My therapeutic style has included more and more ideas based on CBT, over the past 15 years.   Many of my patients work on structured CBT elsewhere as well.  As with medication, this is incredibly helpful for some, slightly helpful for many, and has little or no effect for a few others.  Arguably, some CBT groups could even be harmful for a few, if there is a large mismatch between what the person desires and needs and what is actually offered.   In many cases, people are familiar with these therapy styles, but have not yet really done the work necessary to derive benefit from them.  This lack of work is usually due to the depression or the psychosocial situation itself, but also can be due to a lack of continuity of care.  It can be a little bit like trying to learn a foreign language, and dabbling in it for a few months, learning a bit of grammar and vocabulary, but never really gaining fluency due to a lack of immersive focus,  and a lack of someone to speak the language with on a regular, long-term basis.

Many people, I think, simply benefit from knowing that they are being cared for, by a person or system which has time and attention for them as they need and desire, sometimes on a long-term, open-ended basis.  It is helpful for mental health care providers to be well-versed in a wide variety of therapeutic techniques, and to be able to adjust or tune the care to what each individual patient or client wants or needs.   Within a system, it is good to value the unique styles and abilities of different individuals within the group, rather than compelling everyone to follow an identical protocol.  Some caregivers are better-suited to using a CBT style, while others are naturally suited to IPT, meditation, or psychodynamic styles.    Some psychiatrists have a particular expertise and interest in medication management.  Most research protocols do not look at this issue in groups or systems.  These individual variations should be respected, but I do think it is also good for everyone to come together to learn from each other.  For example, psychodynamic therapists can adopt interesting, useful ideas from CBT therapists, and vice-versa.

Most of my patients would say that it was not some medication combo or therapeutic style or adherence to guidelines that ended up helping them, but was a combination of many factors, in conjunction with a system of care (such as a therapist, psychiatrist, or other support network) which was stable, consistent, compassionate, and long-term.

Wednesday, October 11, 2017

Mindfulness: is the evidence exaggerated?

Mindfulness-based techniques are now mainstream in psychotherapy.

A recent review and look at the evidence, published by Nicholas Van Dam et al. (Perspectives on Psychological Science, October 10, 2017, doi 10.1177/1745691617709589) is worth reading.   This article is discussed by Bret Stetka in Scientific American Mental Health today.

I believe there are very important points to consider:

1) Mindfulness itself could mean different things to different people.
2) People are earning a lot of money from mindfulness education, groups, books, etc.

We come to a theme that I have often found, in so many other areas of life, and specifically in psychiatry:  "dogma."

In a therapeutic encounter, or in a long-term course of therapy, the patient or client may feel better.   In the process of this therapy, the client or patient may adopt new ideas, habits, or beliefs, based on the subject matter of therapy.  We see this in CBT, in psychodynamic therapy, and in meditation-based therapies.  In other areas of life, such as in religion, in exercise training, in education, and in nutritional change, we also see people adopt new ideas, habits, or beliefs.  The benefits of these experiences are often attributed to the specific changes in ideas, habits, or beliefs.

But I believe that in many cases, the specific ideas, habits, or beliefs are less important (sometimes totally unimportant, or at worst even harmful) than the process.

In meditation, people adopt a quiet behavioural habit, which is then practiced diligently.  Time and effort is committed to learning the skill, perhaps paying money take lessons, and to meet others who share the same practice.

The process here is of diligent commitment, daily behavioural practice which differs from the status quo, and often different social affiliation.

The actual theory or literal practice of the meditation might sometimes not be important at all.  These details are part of the dogma of the practice, and may not be required for the practice to be helpful.  Yet, we humans can become more committed to a practice if we believe there is some strong theoretical foundation behind it.

I see this phenomenon in other therapeutic styles.   CBT has a strong theoretical foundation, yet I have to wonder if much of the benefits from CBT occur irrespective of the theory, but rather simply because of the diligent practice of exercises.  Psychodynamic theory features many dogmatic beliefs (such as about the impact of certain childhood events), but yet the process of the therapy (of warmth, communicative freedom, invitation to reflect) is probably the key factor in its benefits, irrespective of the theoretical dogma.

In this post, I am not meaning at all to be critical of meditation-based techniques.  I actually think that meditation could be quite a wonderful and transformative practice.  But I do encourage people to question the theoretical dogma.  Your own personal version of meditation may be equally effective or better than some other formally prescribed method, provided you are engaging with it in a way which feels comfortable, meaningful, useful, and enjoyable.

Another implication is that positive disciplined activity can be very therapeutic, but perhaps we can be free to choose the specifics according to our interests and proclivities.  So it may be that a Tango class or art lessons or nature photography or horseback riding could be more therapeutically "meditative" than an actual mindfulness or yoga class.  But others might prefer the mindfulness class.  I encourage us to be open-minded.  I also encourage us to have a little bit of healthy skepticism about therapeutic trends, especially when there is a lot of money and salesmanship involved.

Wednesday, June 14, 2017

Twitter in mental health

I wanted to learn a little bit about Twitter recently, so I started a Twitter account (@DrGarthK).

In past years I assumed that the Twitter format would be very limiting, and would tend to favour very superficial chatter.

But despite this issue, I have found Twitter to be an interesting way to connect a little bit with people in the world whose ideas and wisdom you admire.   There are leading theorists, researchers, poets, authors, therapists, and scientists who contribute to Twitter regularly.  Of course, there are political leaders as well (one of my favourite contributors is the Dalai Lama, @DalaiLama).  

The very brief format of tweets does constrain expression very much, but on the other hand there can be a sort of concise poetry to them, at their best.  Furthermore, it is possible for your tweets to introduce a piece of lengthier writing.

Positives about Twitter

Here are some of the positives with Twitter I have discovered so far:

1) Interesting to hear what some famous people or great scholars are saying or doing.  It's possible to actually participate in a conversation with them, and give feedback about their ideas.

2) It is easy to engage with Twitter over a very short period of time, such as during a break.

3) The 140-character limit makes you practice framing ideas in a brief, concise manner.

4) It is interesting to appreciate Twitter as an art form, which some people have done very creative things with.

Negatives about Twitter

Here are some of the negatives or problems I have seen:

1) Even some famous people or leaders in a scholarly community contribute posts which can be rambling smalltalk, ranting/complaining, or disparaging other people, which I think is less enjoyable and makes less of a positive impact.

2) I realize that Twitter is commonly used for self-promotion, but an overtly self-promoting agenda comes across like an unwelcome sales pitch.  I find it a bit tiresome to see a lot of  tweets trying to market a new book or seminar etc.  I think I'd be more interested in someone's book if it wasn't advertised so directly.

3) Twitter, like many other forms of social media or electronics, can have an "addictive" quality, which might make you spend more time on it than is healthy for you.  Also the brevity of the content may condition people to expect morsels of knowledge or conversation that only require a few moments of attention.  I worry that this would make people gradually more impatient with a deeper, lengthier conversation.

 Uses of Twitter for mental health:

There are many people who post psychoeducational material, affirmations, meditations, encouragements, testimonial accounts about recovery and healing, etc.  In many cases, a person with psychological symptoms may have only the time or attention to spend reading something very brief.  So it is good that there is a medium favouring such brevity.


So far, after using Twitter for a few weeks, I am not quite sure if it has been worthwhile.  There's been some interesting content and discussion about things, but I have had a tendency to check it a little too often, at the expense of reading more substantial things...  Maybe a little too much time spent absorbed on a device, instead of enjoying the present moment, going outside,  or enjoying the scenery.

But it's been a learning experience, and I may continue to use it a little bit, in moderation.

Monday, March 13, 2017

Helping Patients with Schoolwork

In my clinic, I mainly see university students.  I believe it is important, and therapeutic, to invite students to bring their schoolwork to their psychiatry appointments, so that we can sometimes look at it together and discuss it.

Last year, I mentioned this practice to a reviewer, and I suspect it was considered an inappropriate use of time in a medical appointment, and a waste of resources -- a psychiatrist "helping with homework."

I would like to make a case for why "helping with homework" is useful, and part of a good therapy relationship:


In order to help with a mental health issue, it is good to understand what your client, patient, or friend is doing with their time.   University students often spend thousands of hours studying, writing, and thinking about academic subjects.  Sometimes this work is experienced as a joy of life, a passion, or as a source of meaning.  For others, the work can be experienced as a burden, a chore, or as meaningless "jumping through hoops."   In many cases, a student's academic work is a reflection of health status (both mental and physical),  For many students, academic performance affects self-esteem:  low grades can cause a person to feel like a failure.  Perfectionism in schoolwork can cause almost any grade to feel like a sign of failure or inadequacy.

In order to understand another person's emotional life, it is very important to learn about how he or she is spending time.   Is the schoolwork a meaningful life pleasure?  Is it only a chore, a burden, or a stress?

It deepens understanding of this issue to explore it in more than a superficial way.  I believe it is valuable for understanding and rapport to encourage patients to show their notebooks, textbooks, and assignments, to talk about them a little bit.  Often this leads to a much better understanding of a whole range of other issues, including mood, attention, motivation, anxiety symptoms, learning disabilities (often never previously recognized), relationship problems, and existential uncertainty about direction in life.

Shared Interest

Many students I have seen have been passionately engrossed in their studies for many years, including at a graduate level.  But sometimes, they have almost no social conversation about their studies, with a person who shows interest.  The academic study becomes an insular, lonely experience, rather than a source of potential social interest.  Sometimes this lack of social sharing is due to an entrenched habit...the therapy setting can be a place to change this.    Not only does such a conversation boost rapport, it is also a practice for the patient to be able to converse with other people about their work, for the benefit of their social life.

Also I believe it is psychologically beneficial for a patient or client to have an experience of sharing their own expertise, and learned scholarship, rather than only being on the "receiving end" of such expertise.  It is a humble and respectful position for the therapist to take, which can only improve a therapeutic alliance.


All mental health issues affect cognitive functioning and academic performance.  A direct discussion about academic matters is relevant to the assessment of overall mental health.  Sometimes cognitive and academic function is good, but a person's feelings about this functioning is very negative.  In this case, looking together at academic work leads to a very direct focus on an active set of symptoms.

What do Notes Look Like? 

The manner in which a person might keep notes, or organize essays, or surf the internet doing research, gives us better understanding of psychological health.    Are notes tidy, meticulous, or disorganized?  Do the notes fluctuate a lot from one week to the next?  Are the notes clear for someone else to read and understand?  Are there gaps where notes are missed entirely?  Is writing fluent once started, but just difficult to start?  Is there evidence of tremor or other neurological symptoms manifest in handwriting?

Cognitive Testing

If cognitive testing is to be done, it is most useful to refer to subject matter that the person is actually interested in, and experienced with.  A mathematician or engineer might not show any decrement on a simple arithmetic test (such as "serial sevens") despite having significant cognitive problems.  It would be more appropriate to ask them to solve a complicated mathematical problem having to do with their current work.    A literature student might not show any decrement on a simple verbal test (such as memorizing words, or reading a sentence) but might have difficulty describing the themes or dynamics of a current novel on the curriculum.    Another benefit to "testing" this way is that it can highlight unusual strengths and talents, which can then be a subject of positive feedback and encouragement.

Practical Therapy

Cognitive therapy is a type of "academic" process:  it requires note-taking, reflection, analysis, and homework.  Many students might not have time for diligent cognitive therapy.  But they do have time for their schoolwork!   Cognitive therapy can take place while doing schoolwork!  It could be rewarding in a therapy session for a patient to have a successful experience of completing an academic task, while having a chance to reflect on the emotional changes or barriers happening at the same time.   A creatively constructed regime of cognitive therapy could involve combining it with academic study.

Behaviour Therapy for performance anxiety

Many students have anxiety about sharing their work, being called on by a professor, speaking out loud in class, presenting in front of others, etc.  The therapy session is a chance to directly practice these things, in a supported setting.  It is a simple CBT exercise!

Therapy for Procrastination

Procrastination is one of the most common problems faced by almost all students.  This is often much worse when there are other mental health issues going on.  The increased stress, and decreased grades, caused by procrastination, often cause further worsening of mental health symptoms.  Procrastination is sometimes even a critical part of a deteriorating cascade of events, leading to leaving school unsuccessfully.    The core necessity in treating procrastination is to do the procrastinated thing as soon as possible!  In a therapy session, if this subject comes up, I believe it is optimally therapeutic for the patient to have an opportunity to do the procrastinated activity right in the session, immediately!   It is an incredibly simple way for a therapy hour to be directly helpful.  Otherwise, sometimes visiting a therapist can be yet another way to procrastinate work, and feel even worse!   If a patient of mine does agree to do some procrastinated schoolwork during a session, it is my goal to help the patient enjoy the activity, feel supported and encouraged, and to have an experience of success.

Study Techniques

Many students work or study inefficiently, which is an underlying cause of worse academic stress, then leading to worse mental health.  Discussion and practice of better studying techniques is directly relevant to mental health therapy.  I like to discuss various memory and time-management techniques with patients, and try them out right in the session.  These ideas are applicable to other life activities, including CBT exercises.

Reading and Oration

It has been remarkably common to find students who have trouble reading.  Often they have other cognitive strengths, which have allowed them to manage with this reading difficulty all their lives, while still doing well in school.  But in advanced academics, a reading difficulty can greatly slow down the rate at which a student can study.  Reading textbooks becomes a gruelling chore.   Reading out loud, or giving presentations, can become a source of dread.

The most effective therapies for reading difficulties are very similar to therapies for mental health issues:  it involves practice, in a safe setting, with tasks that are easy enough to be enjoyable and easily mastered, but challenging enough to foster growth.    Reading out loud is very literally an exercise to strengthen one's voice.  Such voice-strengthening is a metaphorical cornerstone of all progress in psychotherapy.  Practicing this literally, in a psychotherapy session, is simple, relevant, enjoyable, diagnostically informative, and therapeutically useful, often in a very immediate way.

Study as Mood Therapy

I believe that studying and other intellectual work can be intrinsically therapeutic for mood.  It can be a meditative and meaningful experience, and a healthy coping technique or psychological defense.  But some students have study practices which are far from meditative.  The therapy session can be a chance to help people regain a sense of meaning and meditative joy in study, to recapture "flow."

Oliver Sacks

I am reminded of the famous neurologist, Oliver Sacks.  He spent time really learning to know his patients well, and in doing so became not only a great therapist and physician, but also a wise and insightful scholar about the ways of the mind.   Part of his technique was to always engage deeply with his patient's work and study interests.   In doing so, often he would discover phenomena that would never have otherwise been noticed or attended to.   I would hope to be a clinician more like him.

Other Work (not just study)

I think it is important to discuss other areas of work, with patients, and to be willing to look together at the work very directly at times, if desired.  I like to see examples of some of the work my patients do, and I think this relates to health in a similar way.

Benefit for the therapist

If a therapist takes sincere interest in a patient's work, study,  and other activities, it is also beneficial for the therapist.  What a delight it is to vicariously be part of an educational journey!   The therapist's health will therefore also be better.  This, in turn, will improve care within the system as a whole.  And this goodness will "bounce back" to the clients or patients, and continue a cycle of interpersonal positivity.