Sunday, April 5, 2020

COVID-19 update April 5 2020

The main advice about COVID-19 is just the same as before:  very strict social distancing (stay at least 2 metres, or 6 feet away from other people at all times), stay at home as much as possible,  wash your hands very thoroughly after touching anything that someone else might have touched, and do not touch your face unless your hands have been very carefully washed.

Please keep in mind that the 2 metre or 6 foot social distancing guideline is an arbitrary recommendation.  It would clearly be more effective to have 4 metres of social distancing!  The 2 metre recommendation is a starting point, but it would be best of all to avoid all crowds entirely, and even to avoid places which have been crowded in the previous hours (especially indoor places). 

These measures alone are helping to contain the spread of the disease, but we need to keep this up for many more weeks or months.

It has become clear (unsurprisingly) that disease spread can be significantly reduced if as many people as possible are wearing masks, especially in crowded places such as grocery stores or public transit.  Masks probably are most effective to prevent a person with COVID, including the many people without active symptoms, from spreading it.  Therefore, mask usage, if it is to be optimally effective, has to be used on a massive scale.

However, we have a terrible shortage of medical masks.  So it will be necessary to make home-made masks, or use scarves, until we have an abundant supply for the public of medical masks.  Medical masks need to be prioritized for medical workers, community workers, transit drivers, and grocery store staff.

It is valuable to look closely at what China, South Korea, and Taiwan have done to get their COVID-19 infections under good control.  We should be well-informed about their strategies, and copy.  Generally, my impression is that their strategies are similar to what we are doing here, but much more strict and enforced.

One of the issues of the week has to do with hydroxychloroquine and azithromycin as possible treatments for COVID.  The only evidence for these comes from so-called "in vitro" experiments; there is not yet any supportive evidence for their use in people with COVID.  But it is still important to study the question, which has to be done in a randomized controlled fashion.  Results of this research will take weeks.   I am neutral on this question, as we have no good evidence to guide us one way or the other on it, except for a recent negative study showing that it is not useful in severely ill patients.  It remains to be studied whether they could be effective if given early in the disease process, or prophylactically.   It is very clear that these drugs should not be endorsed, as they have potentially dangerous side effects.  And the public focus on this issue in the U.S. may distract people from focusing on what actually IS proven to help, which is social distancing, staying home, hand washing, and mask use.

I have thought of a modification of my "COVID hotel" idea, (see which is much less controversial.  It would seek participants for the hotel from a cohort of people working in high-risk zones, such as hospital staff, emergency response workers, and grocery clerks.  A cohort of several thousand such people would be followed closely, with a COVID test being given daily.  There would be no inoculation--each person who ended up with COVID would have acquired it in the course of their work.  Every person with a positive test would be promptly enrolled in the COVID-hotel study.  The advantage of this technique compared to present research studies, is that we could be guaranteed that every participant had become positive within the previous 24 hours, therefore would all be in an equivalently early stage of infection.  I hypothesize that any treatment intervention (such as an antiviral drug) would have the best chance of working if given as early as possible in the infection process.  Since everyone in the study would begin treatment at the exact same stage of infection, it would greatly reduce variability in outcome simply due to giving the drug at a different stage.

Friday, April 3, 2020

Mental Health care during COVID-19

With COVID-19, we are all likely to experience great hardships:  social isolation, cramped living quarters, severe financial problems, daily anxiety about going outside, difficulties with simple activities such as getting groceries or basic supplies, and of course the awful horror when we learn about what is going on elsewhere.  "Elsewhere" for now may be an abstraction about some city far away, but at some point "elsewhere" will get closer to home, to our families, to our loved ones. 

Symptoms of all mental illnesses have a high chance of becoming more severe.  

What can we do?  

I don't have the answers.  I'm scared myself.  

But here are some reminders about the basics: 

1) to the best of your ability, eat well, sleep well, and get some exercise, every day.  Try to have a schedule about doing these things.  It may not be possible to get these things done.  Normal sleep may be impossible due to anxiety.  But try.  Have a schedule.  Do your best.  Avoid things that make you worse emotionally, such as too much caffeine, too much junk food, etc.  

2) Try to focus on something else other than COVID news.  Read.  Study.  Clean.  Play video games.  

3) Have social contact.  This would have to be on the phone, by email, by Skype or FaceTime.  Or you could talk or sing to people who live nearby, as they are doing in Italy.  

4) Plan for what you'd like to do when this is all over.  It could be brief, over months, but maybe this could drag on for a year or more.  Think of the great celebration we will have then.  

COVID update April 3, 2020

As the pandemic progresses, we see more and more abundant evidence that very strict social distancing is effective.

2 metres (or 6 feet) of social distancing means that if both you and a person next to you have your arms extended, stretched out as far as you can reach, you should not be able to touch the other person's fingertips.

As expected, mask use is gaining more clear evidence.  Probably the greatest benefit of wearing a mask is to prevent the mask-wearing COVID-positive person (including the many people who are carrying the virus but not yet showing obvious symptoms) from spreading the virus to others.  Therefore, to be most useful, everybody should be wearing masks, particularly in crowded places such as grocery stores.

I have updated my idea about a voluntary inoculation technique:
The risk of this technique would be that some of the volunteers would face a risk of death or permanent injury.  But the benefit of the technique would be that a cohort of people would leave the technique in a proven immune state; and the technique would allow much more rapid research (done in the most perfectly rigorous blinded randomized-controlled manner) to establish clearly and in the quickest possible way whether proposed antiviral treatments work or not.  I suspect most antiviral treatments would be much more effective if given in the earliest stages of infection, rather than after severe symptoms have developed.  This is true of other antiviral treatments, such as acyclovir for HSV.  This technique would allow a guaranteed method of testing whether such antivirals would make a difference for people guaranteed to be infected but who are in the earliest pre-symptomatic stage.  In getting these answers quickly (saving weeks to months of time), tens of thousands of lives could be saved as we determine much more quickly which treatments actually work and which do not.  Not only could it identify effect sizes of effective treatments rapidly, it could also give us the information which would lead us to stop  offering putative treatments that may actually be harmful.

Meanwhile, I continue my advice to keep up social distancing.  Wash your hands very thoroughly and frequently, with an extra time whenever you have touched anything that anyone else might have touched.  Learn about good hand-washing technique.

Mask use has strong evidence.  But there is a shortage of masks for those who need them most.  So people will have to improvise their own home-made masks.

I encourage keeping some disinfecting cloths with you.  Clorox wipes are in short supply, but you can make your own by cutting up some old clothes into rags, and storing them in a glass jar containing a strong antiseptic such as Mr. Clean.

Avoid going out unless it is absolutely necessary.  I do consider daily exercise necessary, but if you do this, choose a time when fewest people are around, and a place where there is the least crowding.  I suggest sunrise or midnight.  Of course, be mindful about other safety risks.

Monday, October 7, 2019

Indistractable: Book Review

 Indistractable, by Nir Eyal, is an instruction manual, teaching us how to make healthy choices with our attention and activities, in the midst of the many addictive distractions of the internet age.

It is a good book,  but most of  its content could be acquired through a brief surfing of the net.

Eyal wrote another book in 2014 called Hooked: How to Build Habit-Forming Products. Ironically, this earlier book uses his knowledge of persuasion and behavioural psychology to foster the very addictive distractions that Indistractable tries to rescue us from.  In some ways I guess we could compare that to the management of a casino organizing its own addiction treatment program for customers.

The book itself is well-written, and its format is an example of how to keep a reader engaged: the chapters are short, the language is simple and clear, and the main points are summarized at the end of each chapter, then once again at the end of the book.  There is even material provided to get started on a CBT-style program to become "indistractable."  The "indistractable" language is based, I'm sure, on a marketing idea of encouraging an identity-based slogan as a motivational tool.  If one were to wear a t-shirt with the "indistractable" logo it might help motivationally.

The book itself is a product, and I suspect that it will lead to profits for the author.

Yet, the ideas contained within are useful, and worth knowing about.  Aside from simple behavioural techniques (e.g. decluttering your home screen, scheduling in advance, etc.) there is appropriate attention given to identifying the emotions accompanying distracted behaviour, and to identifying core values (e.g. of being a good parent or a good friend) as a primary motivating force to choose relationships or meaningful work rather than surfing Twitter, playing a distracting video game,  or having a text conversation.

This is another example of how therapists or physicians can learn important lessons from people who have expertise in marketing.  It often requires an inspiring persuasive message to help someone who is struggling with depression, anxiety, addictions, or other problems to make positive, sustained engagements with meaningful life change.

Saturday, September 21, 2019

Review: "The Coddling of the American Mind" by Lukianoff and Haidt

The Coddling of the American Mind:  This is another book I recommend as an important, timely review of contemporary issues relating to modern culture, parenting, free speech, and university education.

I respect what I think Haidt is trying to do, as a persistent theme in his career:  to be a peacemaker, to encourage intelligent, harmonious, respectful dialogue among people with different viewpoints or political leanings, and to reduce or mend hostile polarization.  This theme comes across once again in this book.  I could not support this goal more strongly.   Haidt is probably one of the few psychologists who would have a respectful audience among people right across the political spectrum.

But there are many areas where I disagree.

Safetyism -- A Culture of Fragility

The initial section discusses how in a well-meaning quest for "safety" we can create a culture in which people are weaker, less capable, and more fragile.  For example, if we are so afraid of a child falling down and getting hurt, we might not allow bike riding, climbing, gymnastics, etc.  But this lack of exposure to challenging, slightly risky activity would lead to a failure for the child to develop normal physical skills, and might also lead to the child learning to fear and avoid challenges, rather than to face them and master them. 

Ironically, this would sabotage the goal of improving safety. 

Intellectually, according to the authors, if we teach fear, avoidance, or suppression of disagreeable ideas and of the people who express them,  it may likewise lead to a failure to develop normal resilience or problem solving, and may foment unnecessary, destructive societal conflict.

So the authors are saying that just as we must allow children to try riding bikes or climbing, even though there is a risk of falling, we must encourage a cultivation of resilience and respect when exposed to disparate ideas, including those which offend us.

Cognitive-Behavioural Therapy (CBT) as an approach to modern life

The authors make frequent mention of cognitive-behavioural therapy (CBT) ideas, as a model for approaching these social and political issues.  The principles of CBT call for us to study our thoughts, assess them for possible distortions, be open to challenge them and test them behaviourally, and also to face our fears.

Extreme Examples, Case Studies

They describe a variety of unsettling stories of extreme cases, where so-called "safetyism" led to excessive negative consequences for scholars, for free speech, even for university culture in general.  The authors argue that these conditions cause intellectual freedom to be dampened, replaced by an atmosphere in which some professors may be reluctant to speak their minds or share their research, for fear of causing offense and a resulting protest or scandal. 

A decline in teen and young adult mental health?  

The authors move on to describe their theory that teen and young adult mental health is declining, and that a combination of  "safetyism," overprotective parenting and internet use (especially social media) are responsible.    One of their prescriptions for this (which they advise strongly near the end) is for parents to encourage so-called "free play" with a restriction of internet or smart phone use for children.


Here are some of my misgivings:

 As is often the case, one can make a general prescription for a cultural change based on knowledge or experience with a limited group (sometimes a group of just one, when we recommend to everybody what worked for us individually).   Haidt is a respected, famous academic leader who has a fair bit of influence.  His book is marketed extensively, as I suspect are the public lectures across the world.  It would be consistent with one of the better themes of this book to welcome some balanced and thorough debate about it.  One insight from social psychology is that once a person has publicly announced a position or opinion (especially in the form of a well-selling book) they are more likely to be biased in favour of this position, despite contrary evidence.

It may well be true that cultivating intellectual resilience through exposure to disparate intellectual ideas, exposure to risk, free play, etc. are in general good things, which would be reasonable public health measures or aspects of a healthy policy about parenting or education.  But such cultivation may require a different approach for different people, just as cognitive-behavioural therapy would need to be approached differently depending on where the individual person is at.

In CBT, as with any therapy, the process cannot be pushed if the person does not consent to it.  Exposure therapy (e.g. exposure to fears, challenging safety behaviours) cannot occur without informed consent, otherwise it would often be traumatic and counterproductive.  And exposure usually needs to occur in a controlled, gradual manner, which is quite different from the way stress occurs in the environment (such stress outside of a therapy room is usually random and uncontrolled).    And not every mental health problem is amenable to exposure therapy; in some cases exposure makes things worse.  Humans are not always "antifragile."

One of the reasons why I think there is more stress about conflictual issues on university campuses is not because the students are less resilient at all.  I think it is because universities in general have become more accepting and accommodating to individuals whose concerns would have been more dismissed and marginalized in previous years and decades.

It is possible now to attend university while having more serious mental health problems, and most modern universities are more accommodating than they were in the past. 

There are also movements for previously marginalized groups to speak out, and insist on their rights.  Such insistence, as we see from all previous civil rights advances through the ages, often does not happen without social stress and conflict. 

So actually I think students are at least equally, if not even more,  resilient, courageous, and brave than they were in the past.  They are not merely "coddled." 

It is not clear to me that there is a large change in rates of mental illness, over a long span of time.  There may be, but it is debatable.  There can be transient ups and downs over the span of years or decades.  Causes for these changes are probably complex, regionally variable,  and multifactorial.  Economic factors, such as poverty,  are probably very important and underappreciated.  Different rates may be due to different rates of reporting, more awareness in the population, different trends or fashions of diagnosis, etc.

And if there is a change in the prevalence of mental illness, it is by no means clear to me that internet or social media use is responsible (there are some important recent studies disputing the impact of the internet on youth mental health).   There are good alternative viewpoints--here's a link to one good article: *   Przybylski, an Oxford researcher, has published a recent study worth reading on this subject: **

It is certainly not clear that parental "coddling" is responsible for changes in teen or young adult mental health.    There is evidence on both sides of this.  Common sense would dictate that, just as with any other human behaviour, we should be careful with our habits, our parenting, and with how children are spending their time.

I do more strongly agree about one of the authors' points about modern parenting:   it is not healthy for children to be overscheduled, to lack free time, and to be forced at a young age to start academic preparations for admission to a prestigious university.  Childhood should be a time of relationship development, play, and freedom.  However, some individual children may greatly enjoy and appreciate extra academic focus instead of more "free play" -- I know I was one of those children myself.

About "coddling."   The authors include this word in the title of their book.    It is meant as a pejorative of course.   I don't like it.  "Caudle" is a thick, sweet, warm drink which is meant to be  digested easily or enjoyed by someone who is unwell.  The authors use the word to mean that we are overprotective of others, including our own children, to the point that we are causing harm, as though feeding "caudle" to people who aren't ill.

I agree that such overprotection can occur.  But many children actually do need more protection and parental supervision. "Caudle" is often useful and good.  Different kids develop at different rates.  Some individuals, for various reasons, never attain, and are unable to attain, the full set of skills they need (physically, emotionally, or socially) to function independently, despite maximal "CBT."    Such individuals have often been neglected, left behind, and excluded by the majority.  One cannot just make a blanket prescription to "let the kids play more."   As a specific example, various types of learning disorders and developmental variants (such as autism-spectrum phenomena) are permanent, and they cannot be resolved simply by pushing the students to face their fears; remedial help and accommodation are needed (I guess we could call this "coddling").    Social anxiety disorders, which are extremely common,  should be approached using CBT techniques, but it is unlikely that any therapy can "cure" social anxiety -- we also need to accommodate ("coddle") and value shyness, rather than just try to "treat" it. ***

"Safetyism" should not be criticized too much.  Accidents and injuries are among the most common causes of death and permanent disability for children and young adults.  Basic improvements to safety are an obvious, reasonable societal advance.   People complaining about "coddling" as an impediment to healthy development might criticize safety features at playgrounds, or of signs recommending safe practices or rules for games.   I don't think these things deserve criticism.  Safety features and play instructions can be helpful for many people.  For those of us who don't want or need these safety features, we can just ignore or defy them, unless they are incorporated into law (such as regarding seat belt or helmet use).

With respect to parenting, the most common situation I see in my clinical practice is of people who have not been "coddled" too much, but who have been neglected or mistreated by their parents.   This has nothing to do with how much "free play" has occurred.

A common cause of such neglect is of a modern lifestyle where parents are too busy or disconnected to play with their children.   The causes for this phenomenon include cultural trends in work and parenting; economic stress; and mental illness.  Most children can accommodate to this, and even thrive, but some cannot.   Some children would find endless hours of free play to be a torment.    It need not be considered some kind of parenting triumph to allow your child to walk to school alone at an early age.   (I do not consider walking alone to be risky--the authors are correct in observing that risks of abductions, etc. are extremely low, and should not rationally lead to walking children to school just for their physical safety.)  But physical safety is not the point.  Enjoying time and relationship with your child is the point!  If you have the opportunity to play with your child, or walk him or her to school, this is not some kind of harmful "coddling"!  It is one of the joys of life, leading to memories that both of you will savour for the rest of your lives.     And some children may need to be walked to school, to help them negotiate their anxiety or build their social strengths alongside a trusted adult.  This is ok too, and is not "coddling" except in the best sense of the word.

I in general support the authors' recommendations for being open to hearing and respecting opposing points of view, as opposed to shutting down opposing voices using angry protest.  However, perhaps this recommendation deserves some questioning as well.  For example, if one has signed up to learn genetics, and if there is a space and time for a visiting lecturer once per week, I think most would consider it bothersome to reserve this precious lecture time and student attention on entertaining speakers who deny the existence of genes or DNA.  Free speech may not require that every point of view should have equal access to a reputable and influential public forum.    Of course, this would lead to a question of who has the power to decide who gets access to this forum.  A default answer would be to say that in a democracy, it is the people who would decide, hopefully guided by the wisdom of experts.   But sometimes the experts could be wrong.  Or sometimes population trends could be unreasonable.   In these cases, I do agree very much with the authors in affirming a principle of calm, reasonable openness to dissent to be enshrined as a guiding principle, as it is in many nations' constitutions.  And it is also reasonable for everyone in the population to be acquainted with rational techniques for self-questioning, such as CBT.

I actually do find that CBT ideas are so prevalent now, that many college students are aware of the theory already.  Young people are intelligent and well-informed, for the most part.

My own recommendations:

First of all, I question my right to make any sort of recommendation.    I think it is better to be a little more humble and admit that there is quite a bit of uncertainty about all of these things.

For parenting, I think different children have different needs.  For some it is ok or necessary to "coddle."  For others, it is best to encourage a lot more "free play."  For many kids it probably doesn't make a whole lot of difference either way, and there could be leeway to simply choose the strategy that is possible for you, and that you and the kids enjoy the most.  I am a big fan of spending a lot of time with one's children, to cultivate a close relationship, to build strong, positive, happy memories.  Such memories are, in my opinion, strongly protective of lifelong mental health, and one of the most powerful sources of resilience that experience can offer (other sources of resilience are inherited, and have nothing to do with parenting).   They are also very satisfying for a parent, and probably are associated with healthier, happier aging.   In many cases, though, the memories have nothing at all to do with mental health per se.  They are just memories of time together.  In general, I prefer to have them rather than not.