The Country Shrink

Blog Moved

2008-06-25T03:58:00.000-07:00

I've moved my blog over to Wordpress.com. It's just a better blogging system.

I have my own domain now too.

http://thecountryshrink.com

Do you still need more evidence on antidepressants?

2008-04-30T08:14:00.000-07:00

And the studies just keep coming. This time with Paxil showing that it was no better than placebo in adolescents, plus a relative increase in adverse events compared to placebo.

John Grohol, PsyD has a writeup on PsychCentral.

Antidepressants for Children Continued

2008-04-10T18:49:00.000-07:00

After I ended my last post, I got to thinking that maybe Irving Kirsch already had something to say on the matter of the effectiveness of antidepressants for children. Turns out, he did.

Basically, on the very limited number of studies that were available, he found the same thing for SSRIs that he found with adults--75% of the effects of SSRIs was duplicated by placebo. For tricyclic antidepressants, it was 98%. He concluded that SSRIs did not offer a clinically significant difference over placebo, and TCAs were completely ineffective.

So, my advice would be to first consider psychotherapy, unless the depression is very severe to the extent that the child or adolescent has a great deal of difficulty in functioning. Certainly, you want to have a thorough physical examination with a physician as the first step to rule out any physical causes.

Now, there are many (probably most) psychotherapists will recommend antidepressants anyway, because that is the way they've been trained. But there are those out there who will support your efforts to overcome your mild to moderate depression without medication. I would want to try that first with children for two reasons. The first is that we do not know what the long-term effects of these medications are on the brain. The second is a philosophical communication (or unconscious communication) that occurs when you take medication versus participate in psychotherapy. I think the communication with medication can often be that there's something wrong with your brain. You needn't bother changing anything in your life, just take this pill. At least with psychotherapy there can be the communication that something is wrong in your life, in your relationships, in the way you think, in internal conflicts that need to be resolved, or in your activity level that needs to change. It's a matter of teaching people to be in control of their lives versus teaching them they are controlled by their biology.

FDA Testimony of Dr. Irving Kirsch and Dr. David Antonuccio on the efficacy of antidepressants with children. February 2, 2004.

Prozac: Good for Children with Depression?

2008-04-10T17:00:00.001-07:00

That's what the latest study published in the American Journal of Psychiatry says. In a nutshell, they initially selected their subjects based on whether they were depressed and were excluded based on a number of factors (one of which was previous failure to respond to prozac or adverse reactions to prozac). All of the participants were initially tried on prozac, with dosage increases in waranted. Those who didn't respond to prozac were excluded from the continuation phase. Then they were randomly assigned to continue on prozac or placebo. So, the placebo group is abruptly taken off of prozac and put on sugar pill while prozac group experiences no such disruption. The authors thought this was okay because of prozac's "long half-life."

The study found that 42% of the prozac group relapsed within 6 months, whereas 69% of the placebo group relapsed. With an even stricter measure of relapse, only 22% of prozac group relapsed, whereas 48% of the placebo group relapsed.

This makes prozac sound pretty good for kids, does it not?? It does....

But there's a catch. I'll just focus on the "stricter" measure of relapse for now. This was based on scores on a scale that measures sympoms of depression the CDRS-R. Scores >= 40 over two sessions with a psychiatrist (separated by 2 weeks) were considered to be relapses, whereas scores under 40 were not considered to be relapses. How do we know whether 69% of the prozac group didn't have scores of 39 (not relapsed), whereas 69% of the placebo group had scores of 41 (relapsed)?? We don't know, because we don't know any scores. We don't know if the differences are truly clinically significant, because we don't know what the differences in the actual scores were.

Also, the fact that the study was set up to only include people who respond to prozac, we know nothing about how this would work if applied to the general population of children who are depressed. In other words, the deck was stacked in prozac's favor. The authors, in my opinion, just seemed to gloss over the possibility that the increased "relapse" in the placebo group could have been caused by the abrupt discontinuation of prozac.

I suppose we'll have to wait another 10 years for Irving Kirsch to publish an analysis on whether antidepressants provide any clinically significant benefit over placebo. I, for one, am not convinced by this poorly designed and written study.

Anger and Responsibility

2008-04-07T14:36:00.000-07:00

Be ye angry, and sin not (Ephisians 4:26).

If you do not wish to be prone to anger, do not feed the habit; give it nothing which may tend to its increase (Epictetus).

If you are patient in one moment of anger, you will escape a hundred days of sorrow (Chinese Proverb).

We have our emotions for a reason. They tell us things. They help us understand what we like and what we don't like. They help motivate us to make changes in our lives and environments. They help us form and maintain relationships, and motivate us to address problems in those relationships.

Anger, like the rest of our emotions, is part of life. You can't rid yourself of anger. You might think that you would like to, but without it you'd be missing out on an important signal and motivator. However, many people have problems with how they respond when angry, or have anger that is too intense to the point of rage. Anyway, your stuck with feelings of anger, but what you do when you are angry is a choice. This is difficult to understand for some people who have for so long thought that they have no control over their anger and what they do when they are angry. But it is the truth.

Some people view their anger as something they are born with. While there may be some support for a genetic component to the range or intensity of emotions that people feel, how you respond when angry is learned. For many men, they learned how to express their anger during childhood, from family members or other important people in their life. For men, if dad is angry and abusive, they sometimes learn that this is the way that men respond when angry. Others in the same circumstances learn to fear and suppress their anger, which can come out as anxiety or indirectly (such as the silent treatment). For many women, they learn not to express their anger, and again, this can come out in a variety of ways.

So there are two major problems with anger that people develop. They either can become violent, abusive, destroy things, yell and scream, or they can bury their anger and seethe on the inside or to the point that they are not consciously aware they are even angry. Both of these patterns are problematic.

The most important thing to know about anger and emotions in general is that they are temporary. They will subside on their own whether you do anything about them or not. So, if you have a problem with what you do when you are angry, you need to plan to isolate yourself when you have those intense feelings so that they have time to dissipate. One of the best descriptions of emotions that I have heard is that they are like waves breaking on a beach. The wave comes in to the shore, and then it goes back out again. This is true of anger. So, plan to remove yourself from the situation when you find your anger becoming overly intense. If you are in a relationship, you need to make it clear to your significant other ahead of time that you have a problem with anger and that there may be times when you need to be alone to "cool off." Be sure to work this out ahead of time, because not doing so can lead to misunderstandings and further arguments.

Now, one of the most significant aspects of what determines how angry we get about something is what we think about something. It's not true to say that someone else made you angry, such as "My boss made me angry." The truth of the matter is that your boss may have done something, and you perceived it in a certain way. The way you perceived it determined how angry you became over it. For example, if you think, "My boss is such a jerk. All he ever does is put me down. I'd like to knock him in the head." Now, if you think about it that way, you're going to become very angry, and depending on your history, you may or may not do something you regret as a result of those thoughts. If you perceived things in a different way, such as, "My boss is disrespectful to me and I don't appreciate that. I need to either discuss this with him or start looking for another job." When you think about it this way, you may also feel some anger, but it will not be as intense as the first way of thinking. It also makes it more likely that your actions as a result of your anger will be constructive and beneficial.

So, one of the first tasks is becoming aware of the situations that trigger your anger, and then examining how you think about those situations. You need to work on changing how you think about those situations in order to experience less anger and to avoid negative consequences that would occur if you express your anger inappropriately. It can be difficult work to change the way you think, and you may need the help of a psychotherapist to help you in this process. The reason is that we often have blind spots, things that we are unaware of, and need another person to be able to help us discover those blind spots. In a nutshell, the type of thinking that leads to inappropriate anger has been called "distorted thinking." It is thinking that ignores, magnifies, minimizes, or in some way filters information about the situation in a way that distorts the reality of the situation. You can do a Google search on distorted thinking if you would like to learn more about the various types of distorted thinking.

Another fallacy about anger is that doing something like hitting a punching bag, pillow, or breaking something of little importance will help to diminish your anger. The fact is, that these actions actually increase your anger, and are a form of 'anger practice.' In other words, you are practicing responding to your anger with aggression. The more you do this, the more it becomes automatic and begins to feel more comfortable. Also, many many people think that yelling and screaming is a good way to "release" their anger. The truth is, that the louder your voice becomes, the angrier you become. Most people think this is the other way around. "The angrier I am, the louder I yell." But the truth is, that yelling and screaming increases anger. You want to pay attention to how loud your voice is becoming and lower the volume of your voice if you want to become less angry. It really does work! So, don't hit pillows, and don't yell and scream to release your anger. If you feel like you are losing control, immediately remove yourself from the situation (count to 10, go to another room, take a walk). Then you can return to the discussion when you are in a calmer state of mind.

And as you begin to become more aware of when you are becoming angry, you can use your thoughts to help yourself become less angry. One way I have heard this described is "using cool thoughts." Some examples are to think to yourself, "This is not that big of a deal, I just need to calm down. I am blowing this out of proportion. I don't need to get bent out of shape about this. I just need to chill out." Now, you'll probably have your own thoughts that may help you to reduce your anger, and what I provided is just an example. The example may not be the ideal thing to use for everyone.

Another aspect of anger are the physical and non-verbal aspects. You want to begin to pay attention to these things when you become angry. You might notice that your fists are clenched, your jaw is clenched and your muscles are tense. When you notice these things, you'll want to unclench your jaw, open your fists, and focus on relaxing your muscles. Some people find progressive muscle relaxation techniques to be helpful here. You can also do a search on that to learn more. The point is, by changing this physical response in your body, you will become less angry. Pay attention to your non-verbal behavior such as intense angry stares, or your body posture. When you notice you are staring aggressively, breaking this stare will help you to become less angry. There are also aggressive body postures, which can be handled by changing your posture, or leaning up against a wall, putting your hand of a chair, etc...

It's good to establish some ground rules for yourself.

Some that I would suggest are:
1. Never hit anyone, break anything, throw anything, or hit anything when angry.
2. Do nothing at all. The feeling will pass with time. One of my patients described this as "riding the wave."
3. Do not yell or scream.
4. Do not curse when angry (this actually increases the intensity of your anger).
5. Immediately remove yourself from the situation when you feel your anger is too intense.
6. Do not make any big decisions when extremely angry.
7. Develop some strong personal beliefs about anger, "Whatever is happening, it's never worth getting bent out of shape over."

Above all, plan to practice responding appropriately to your anger. After something happens and you become angry, think back about what happened and try to figure out how you could have responded differently or thought about the situation differently. The most important thing to remember, is that you will require a great deal of practice in learning to respond more appropriately when you are angry. And don't hesitate to seek professional help if you find yourself having a significant anger problem that you have struggled with for many years. If the psychotherapist tells you to hit a pillow, fire him or her, and find a psychotherapist with more experience and knowledge about anger.

I plan to post more in the future on the other side of this equation, anger that is suppressed or repressed, and finds it's outlets in unconscious ways.

More Evidence that Antidepressants are Duds

2008-02-27T07:55:00.001-08:00

Well not actually duds. Just good placebos. I've posted on this before and the data keeps coming in (See this article). The previous studies were extended to include the newer generation of antidepressant medication (fluoxetine, venlafaxine, nefazodone, and paroxetine).

All studies are biased and have an agenda. The Last Psychiatrist thinks that reporting on this story in the press is a move to promote antipsychotics for depression. I'd say that'll probably happen.

The fact is, there is a large proportion of people who are depressed, and don't want to think about psychotherapy or go through the process. They would prefer to take a pill. So, don't worry, the pills will still be there. Only now, they've got worse side effects....

I'm a psychologist, and so my bias is towards psychotherapy. Very few of my patients, want, or take, medications. That said, I believe a signfiicant portion of people who take antidepressant medication would prefer psychotherapy if they were given the option. The majority of antidepressants that are prescribed in the nation are prescribed by the family doctor. Even though I work in "the sticks," I am not hurting for business. However, there are a lot of psychologists in the field who struggle to build a practice. This is good news if it leads to more people recieving psychotherapy instead of medication; however, I don't think this is very likely to occur. What's more likely is a new set of biased data promoting the next wonder drug.... And again, this is OLD news. Studies like this have been around for 10 years, and now with the antidepressant patents running out... Suddenly, everybody takes notice....

Electroconvulsive Therapy ECT, does it work?

2008-02-26T09:29:00.000-08:00

Electroconvulsive therapy has a long controversial history in the treatment of psychiatric disorders. In its heyday, it was used much more comonly for a wide range of difficulties. One person told me about being given ECT as punishment for being "incorragable" as a child in a way that appeared to be punishment for unruly behavior. Now, ECT is typically used only in the most severe cases of depression.

I have no doubt that ECT has some efficacy in the treatment of emotional disorders; however, to me the bigger issue is should it be used? Not everything that works is humane. Consider the case of the Russian substance abuse treatment program. People involved in the program were given two hundred lashes with a whip if they relapsed. Amazingly, this program had a 80% recovery rate. Something that is unheard of in the treatment of substance abuse problems. I read about this probably 8 years ago, and could not find any information about it today. So, they may have stopped the program.

I feel pretty certain, that if you were hit with a whip every time you had a negative thought, you'd probably stop having negative thoughts that lead to depression. Would that be humane? No way!! So does ECT differ from a severe punishment? Lets see. The people that I have seen who underwent ECT completely lost 6 months of their lives. In other words, they could not remember the last 6 months and were perpetually in a daze for several months after the treatment. That does not seem to be humane to me, and I have difficulty differentiating ECT from any other type of severe punishment.

I remember thinking increduously about the patients I have known who received ECT. They were so very depressed and desperate. Yet they were unwilling or unable to follow through with suggestions that would help them to make progress with their depression (increasing activity, exercising, healthy diet, etc...). It would have made more sense to me to have a family member take them to a gym and encourage them to exercise, or to even hire a personal trainer. I was not in charge of their treatment at the time they received ECT, so I was powerless to influence the process.

You can address some of the physical aspects of depression with exercise and diet (low energy, low motivation, apathy, and poor sleep). Once you get the ball rolling, you can begin to address the psychological aspects. In my opinion, if you are going to do something extreme, make it extremely positive or extremely beneficial. Don't fry someone's brain because it has been labeled a "medical treatment."

The idea of self-harm is not displeasing to some who are severely depressed...thus the higher suicide rates. When someone volunteers for ECT, I would speculate about the desire for self-harm. In other words, this harmful treatment becomes a more compelling option if you are willing to harm yourself in other ways. A patient with such an extreme desire for a radical procedure should be given the option of trying something radically positive that will not damage their brain.

I know there are some out there that credit ECT with saving their lives. I have never met one of these people. In my experience, I've only seen harm come from ECT.

Gun Laws and Discrimination Against the Mentally Ill

2008-02-19T06:32:00.000-08:00

And when he was gone forth into the way, there came one running, and kneeled to him, and asked him, Good Master, what shall I do that I may inherit eternal life? And Jesus said unto him, Why callest thou me good? There is none good but one, that is, God.
Mark 10:17

Ah yes, but we are separated right? Good people and bad people. In this case, the bad people are the mentally ill. I would not be incorrect in saying that there are only bad people. Only God is good. But is there a need to protect ourselves from people who would do us harm? Certainly. But look at the statistics. Are you more likely to die from a spree killer or a car accident. What about a heart attack? I suppose it wouldn't make a good headline to say, "1000 people died yesterday from a heart attack." Or..."150 people were killed yesterday on the nations roadways." It's only the things that are novel or unusual that make headlines. It's only things that are unlikely to actually occur.

Sensationalist media reporting increases both suicidal and homicidal behavior (see The Copycat Effect). But it seems that law makers and the media want to talk about how we can stop these "mentally ill" people from acquiring guns. Having a mental illness does not necessarily make a person any more likely to commit violence than the general population. In fact the research shows that individuals discharged from psychiatric institutions are of roughly the same risk of being violent as others in their community. They are more likely to engage in violence than others in their communities if they are abusing substances. The same is true for others who abuse substances (they are more likely to be violent). If the media are truly concerned about these spree killers, they'll change their reporting practices.

In rural America, a lot of people take their rights seriously. It scares them to seek help if they know they could lose their right to bear arms. The state of Illinois wants to extend state reporting on mental illness to include outpatient settings. So, if a patient has exhibited violent or suicidal behavior they must be reported. Furthermore, there are proposed links to the federal database so that people reported to the state, would automatically be entered into the federal database. It's difficult to imagine how I, in good conscience, could comply with this requirement. I can see it now, I tell a patient if they have recently engaged in suicidal or violent behavior that I must report them. They won't tell me, and the problem won't be addressed. Result....dead bodies.

Also, I wonder how far this extends. Does it extend to thoughts??? "I'd like to stangle Bob. He really gets on my nerves!" Does this fall under the mandatory reporting rule? Who hasn't had a thought like that. Wait....I never have!! Please don't report me. No, the difference between violent and non-violent people is a history of violence. There's already a reporting system in place for that...it's called a criminal record. Would that have caught Kazmierczak before he was able to purchase guns and kill 5 students?? No, but neither would any of the reporting laws. We don't know what caused this guy to unravel, but don't blame the mental health system and don't think we need more restrictive laws. People have free will, and there is no way to legislate against that. I do think the recent reportings of multiple spree killings could have played a role. I'm sure there are other newsworthy events out there in the world, like the spree killings of tornados in recent months. Maybe we should pass a law against high winds and thunderstorms....but that would be ridiculous right??? Just saying...

Since substance abuse seems to be an actually important variable, maybe there should be mandatory reporting for people undergoing treatment for substance abuse problems. I don't actually think that, but at least it is risk factor that makes more sense. I'm saying that just to emphasize the point that these laws are not based on protecting people from violence, but that there is an incremental political agenda based stereotypes of the mentally ill with the ultimate goal of limiting the rights of all people.

Ecopsychology...What??

2008-02-18T06:20:00.000-08:00

It seems some psychologists are bored... They must be. Recently, a new movement towards treatment of worry about the future of the planet has emerged. Psychologists and therapists are having groups and treating individuals who are anxious about the future of the planet. There are plenty of legitimate difficulties out there for psychologists to treat, and I suppose this helps certain psychotherapists keep their practices simple, easy, and on the surface. In other words, "lets work with something that's not too difficult and we'll feel good about ourselves for addressing this major social concern."

I suppose this appeals to the by-and-large liberal sentiment of psychologists in the field. Or it's another fad for largely academic psychologists who magnify the importance of their personal interests. Although I must admit, there's a certain appeal to adding "Simple Phobia, Ecological Type" to the DSM-V as a disorder that needs to be a focus of treatment. Then we'd have a label for people with ideology like Al Gore. Cogtive-behavioral psychologists could address the catastrophizing and psychoanalysts could examine the potty training conflicts of people worrying about "poluting the environment."

For more on Ecopsychology and treatment, the New York Times, has an article.

Antidepressant Medication and the Placebo Effect

2008-01-21T17:11:00.000-08:00

Back in graduate school, I began to speculate about the nature of the placebo effect and psychotropic medication. I did many literature searches and read as many articles as I could find on the subject. What I discovered was the placebo effect is a powerful demonstration of the interaction between mind and body, and that the effects of many medications can be largely explained by this effect despite attempts at experimental rigor with double-blind experiments.

The review article by Kirsch and Sapirstein (1998) comparing the efficacy of antidepressant medication to placebo. One of their findings was that 75% of the effects of antidepressant medications could be explained by the placebo effect. Indeed, it was further suggested that the remaining 25% of the effect could be due to an active placebo effect. Meaning that because of side effects, the participants figured out they were in the active drug group, which enhanced their beliefs that they would benefit. Because of my research on cognitive dissonance, I speculated an additional possibility for why side effects enhance the placebo effect. When people suffer as a result of something that they believe will be helpful, this sets up an inconsistency of beliefs that must be resolved ("I'm taking this antidepressant medication, but I have trouble with sexual functioning now....But you know it's worth it, because this is really helping me!") So, the medication comes to be more valued because of the side effects, not in spite of them.

My dissertation was on cognitive dissonance (how people react and change their beliefs unconsciously when they are inconsistent). Cognitive dissonance theory might predict that people might believe that they are being helped more by a medication that actually has a slightly negative effect as opposed to a true placebo (such as a sugar pill). Additionally, dissonance would be increased by paying for the medication. Therefore, I would expect that people who pay for medication out of their pockets might have a somewhat better effect with medication. Generally, enhanced placebo effects from medications would need to a nuisance and not extremely negative. In other words, it's difficult to develop a positive attitude about a medication with a serious negative effect. However, the more serious the condition, the greater the negative side effects could be, and the person could still come to the conclusion "I have these horrible side effects, but you know, it's worth it because I feel better."

Beliefs are powerful in all emotional disorders. If you truly believe something is beneficial, it usually will be. This also applies to some extent to a lot of physical disorders. Kirsh and others recommend that experimental procedures for medication be revised to include an active placebo group (a group that takes medication that causes some similar side effects), so that the true effectiveness of medication can be determined. I support this idea wholeheartedly.

Promising Treatment for ADHD

2007-02-26T18:44:00.000-08:00

Many children are on medication for Attention-Deficit/Hyperactivity Disorder. In many cases, medication can be avoided. There are a number of promising alternative treatments to medication, which I plan to discuss in future posts. In this post, I plan to discuss a most unusual and unexpected treatment.

The cerebellum is a part of the brain that lies roughly at the back of the brain and underneath the visual cortex. Early research found the cerebellum to be involved in balance, motor coordination, equilibrium, and posture. More recent research has implicated the cerebellum in a more broad range of cognitive and mental functioning, particularly attention, language and music processing, and other sensory processing.

Astronauts are known to develop a form of temporary dyslexia as a result of prolonged weightlessness, which is treated with having the astronauts perform a number of tasks involving balance and motor coordination. These techniques are thought to have their effects of cerebellar processing. The techniques were adapted for use with children suffering from dyslexia. A recent study provided astonishing evidence of the programs effectiveness, although future research remains to be conducted to validate the technique. Notably, the study found a great improvement in concentration for children with ADHD who were being treated for dyslexia. Improvements were found in 80% of the children involved in the program.

http://www.dore.co.uk/cure.aspx