Online Courses and CE: We offer a series of online educational programs for professionals and the public. Visit us here for previews and discounts on our online programs.

Follow PsychologySalon on Facebook: Become a fan of the PsychologySalon page; updates will appear in your news feed.

Looking for a therapist? We have eleven registered psychologists in our clinic, and we are accepting new clients. For information, visit

Friday 30 December 2011

PsychologySalon 2012: A 100% Discount

Library Square in Vancouver
PsychologySalon has allied with Vancouver Public Library to present our monthly talks at Library Square on Robson Street downtown in 2012.

This new relationship allows us to eliminate all fees for our talks, which henceforth will be free! It has been our goal to make these talks as accessible as we can, and VPL is helping us reach this goal. No more tickets, no more reservations, no more costs.

We'll be in the VPL Central Branch's Alma VanDusen & Peter Kaye Room, beneath the concourse at Library Square. I'll be away for part of early 2012, so the first talk will be in March.  Here's the lineup:

Monday March 26. Out of the Blue: The Nature and Treatment of Clinical Depression. Speaker: Dr Randy Paterson.

Tuesday April 24. Learning to Love Your Emotions. Speaker: Dr Lindsey Thomas.

Beneath the concourse, stairs at left.

Tuesday May 22. Overload! Create a Less Pressured Life. Speaker: Dr Randy Paterson.

Tuesday June 26. Put Off Procrastinating! Speaker: Dr Ekin Blackwell.

All talks run 7 pm to 8:30.  Come and join us.

And  Happy New Year, everyone!

Tuesday 27 December 2011

New Year's: Not Just for Getting Drunk Any More

Someone has to steer.

End of the year. Christmas has passed, and it’s time to think about the next holiday. So what do you do?

One option, indulged in by millions, is a drunken blowout with champagne and cardboard horns. What better way of beginning the new year than being unable to recall the last night of the previous one?

New Years parties have a thread of dissatisfaction that goes beyond the overconsumption. It’s possible to detect more than a hint of artificiality in the date, and if it truly is the end of one year and the beginning of the next, then surely something of greater import should take place.

It’s like standing in a crowded, tinsel-filled room, chatting about the weather, our jobs, our last holiday - and attempting to stave off the boredom that such conversations eventually bring. We look down and see that the floor is made of thick glass; and in the depths beneath there are more significant events taking place, interesting currents, candlelight, silence, clarity. But at this party there doesn’t seem to be a staircase leading down there. It’s inaccessible.

Perhaps rather than a loud, shouting revel, we should spend at least part of the time thinking. We should sit quietly on the border, gazing back over the year just finished, then swing our legs over the fence and look forward at the year to come.

Many such rituals are best done with paper and pen, and time to think, and solitude. Find a quiet space where you will be undisturbed for at least half an hour, preferably more. But if all you have is half an hour, you can still spend it well.

First, the year just past. Write the year at the top. Answer these questions:

  1. What were the most personally significant events of the year? Emphasize the things you chose to do, not just the things that happened to you.
  2. How satisfying a year was that? Would you rate it as one of your life’s best years? One of the worst?
  3. If an observer sat watching your actions for the entire year, what would he or she say were your top priorities – regardless of what you think they should have been?
  4. If there are dissatisfactions with how you spent the year, what are they and what would you like to have done instead?

Next, on a separate sheet, write the number of the year to come. Spend most of your time on a single task.

  • What do I want to do this year?  What would make me look back at the end of the year and rate it as one of my best?

Let your mind roam freely, and don’t edit. Don’t try to categorize or, if you do, have only two or three headings (like “Work” and “Life”).  Don’t worry if your ideas seem to be of various magnitudes (“Visit India”, “Finally watch ‘The Seven Samurai’”, “Clean out hall closet”).  Emphasize things that are under your control; that you might be able to bring about.  “Buy pencils” is better than “Win the lottery” or “Have a more romantic spouse.”

If you find yourself running dry, sit back. Consciously relax. Breathe deeply. Repeat the word “Anything” as you exhale. Don’t grab at ideas; let them come to you.

When the flow slows again, place your mind gently in the various rooms, or realms, of your life.  Some common ones include: Work, Family, Social, Romantic, Avocation/Hobbies, Creative, Learning, Home, Read/Watch/Buy, Daily Routine, Health, Finances, and Spiritual. There are others. Even if a room seems empty, stay there with the emptiness for at least a few minutes. Ideas may begin to emerge from the walls.

Give it time, and consider carrying your page around with you for a few days. Having stirred up your mind, new thoughts will pop into your head when you are on the bus, or in the bath, or waking up. Add them to your list.

Finally, remind yourself that the new year has begun. Ask yourself what you will do this week to begin the process of living the year you want. Don’t wait for the impulse. Don’t wait to want to exercise, or to call your estranged sibling, or to clean out the attic. The goal is to do these things, not to wait until they seem fun. You won’t act on everything on your list this week, but if you don’t act on any of them ask yourself why not. What are you waiting for? Who are you hoping will take charge of your life, if not you?

Our lives are like sailboats. It’s fun to sit back and look up at the sky, chat with friends, and even break out some wine (or a cardboard horn). But every now and then, we need to put a hand back on the tiller and steer.

Friday 23 December 2011

Are You Unsafe or Just Uncomfortable?

A recent workshop by a fellow psychologist reminded me of a useful principle in working with the emotions.

Nothing to worry about.
As humans, we routinely feel the full range of emotions, some of them enjoyable and others less so. When we experience sadness, anxiety, fear, or general unease, the temptation is generally to withdraw.  Fear, for example, almost always shouts the same thing in our ear: get away, get away, get away.

So what should we do? To a great extent, the answer depends on the situation in which we find ourselves.

If we are actually in physical danger, then we should probably obey the temptation and retreat.  The apartment balcony really is shaking as though it is about to collapse, so perhaps we should step inside.

If we know from past experience or from the magnitude of the feeling that we are in some very real psychological danger, then we can sometimes do the same. For example, if I know that the situation is definitely beyond my coping ability, or will put me into a week of emotional recovery that I can’t afford, then I can ease away. If being at a drunken party will put your long-fought-for abstinence at risk, then leave.

But if, as is more often the case, I am simply uncomfortable, but not unsafe, then I need to think more carefully. The route to an expanded life is almost always in the direction of our fears. If I am uncomfortable but not really in any objective danger, then the choice to stay and sit out the discomfort will probably be a more productive one.

If, since being caught in crossfire during a robbery, I have been fearful of shopping malls, then I will almost certainly feel uncomfortable when I enter a mall. I need to examine my fear. Am I really in danger? Is there any reason to think that the mall will once again be robbed today? Will I really lose my mind if I become anxious in the mall? Or will I simply be uncomfortable and unhappy? If I will just be unhappy, then the best course of action is to go to the mall and to stay there for an extended time – long enough for the anxiety to fade.

If I dislike speaking in public, I might ask myself “Am I unsafe, or just uncomfortable?” If it is simply discomfort, then perhaps I can use this as my cue to move toward my fear, volunteering to give talks and pushing myself to ask questions in meetings or propose toasts at dinners.

It has become a part of the cultural vernacular of late for people to say things like “I don’t do that – not in my comfort zone.” But perhaps if something is not in our comfort zone it is where we need to go – or can benefit from going.

We also hear “I didn’t feel safe there” when what is really meant is “I didn’t feel comfortable there.” We have misconstrued comfort with safety. In fact, there are situations that are safe and comfortable, safe and uncomfortable, and unsafe and uncomfortable (as well as a few that feel comfortable but aren’t really safe).

If we confuse safety and comfort we will, almost inevitably, live smaller and more restricted lives.  We will use our discomfort as a cue to close yet another door to larger experience.

So: Am I unsafe, or just uncomfortable? The distinction is important. They point me in opposite directions.

Thank you to Steve S.

Tuesday 20 December 2011

Resources: The single best thing you can do for your health

Staying healthy can seem a bit overwhelming. I have to work on my diet, boost my social network, meditate, find my passion, manipulate my sleep schedule, drink less coffee, drink more coffee (depending on the study), and on and on.  

Maybe you worry about your weight. You have bad knees. You want to avoid age-related cognitive decline. Uncle Frank had heart disease and you want to avoid it.

To avoid all of these different hazards seems like a full-time job. It's easier just to give up and let the fates do their worst.

But what if you didn't have to do all those things? What if there was just ONE thing you could do that would reduce your risk of dying from most causes? And what if the same thing would reduce your risk of an anxiety disorder or clinical depression and boost your quality of life? 

And, damn, you're not a smoker, so just giving up cigarettes isn't an option for you.

Well, actually, there IS one thing that can help prevent the most common emotional problems and chronic illnesses, as well as age-related cognitive decline. And you can guess what it is.

But here's a short video that makes the point clearly, concisely, with reference to the research:

It'll take you 9 minutes, and you already know what it's going to tell you.

But it really puts the ball back in our own court. Something we've wanted, something we might have wished for, has been discovered. So: Are we willing to make use of it?

You can extend your life, and have more fun living it. Want to? If not, why not?

Friday 16 December 2011

Medications: What Would a Selective Serotonin Reuptake ENHANCER Do?

In recent years there has been considerable controversy about the Selective Serotonin Reuptake Inhibitors (SSRIs) like citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), and the like.
These drugs are widely thought to operate by reducing the reuptake of serotonin into the sending neuron, thereby leaving more serotonin available in the gap between neurons so that enough can get across and cause the next neuron in line to fire.

Irving Kirsch and others have called this explanation into question, acknowledging that about 60% of people taking SSRIs seem to improve, but questioning whether the popularly-accepted explanation is correct.

If an SSRI helps mood by inhibiting serotonin reuptake, then what if we had a drug that promotes reuptake? Such a drug would open the reuptake pumps wider, reduce the amount of serotonin in the gap between neurons, and reduce the likelihood that the next neuron in line would fire. Presumably, such a drug would increase depression or, at minimum, have no antidepressant effect.

Fine. But is there such a drug?

Yes. It’s called tianeptine. It is a selective serotonin reuptake enhancer (an SSRE). It has been used in Europe and elsewhere for over ten years, and has been the subject of considerable study, including a number of double-blind trials.

Oddly enough, it’s sold as an antidepressant.

In 2002, a meta-analysis (a statistical reanalysis of multiple previous trials) examined five studies of tianeptine versus SSRI. The SSRI was fluoxetine (Prozac) in two cases, paroxetine (Paxil) in two cases, and sertraline (Zoloft) in one (Kasper & Olie, 2002).

The results indicated that there were no significant differences in effectiveness between SSRE and SSRI, except for one measure that leaned in favour of tianeptine. Most studies and reviews considering tianeptine concur that there is ample evidence that tianeptine is approximately as effective as SSRIs (eg., McEwan & Olie, 2005, Brink et al., 2006) and there are scattered reports that it is better tolerated with fewer side effects.

What’s missing from this picture?

What's missing is a nice medication crossover trial. Perhaps people who are given an SSRI and do not respond well will respond better to an SSRE than to another SSRI. As far as I can tell, this hasn’t yet been done.

So what’s up? 

How can tianeptine possibly work? One option is that both SSRI and SSRE are simply placebos, and that it doesn’t matter what you give people, some of them will get better – even if the drugs have opposite chemical effects.

Another option is that the reuptake effect doesn’t really explain the antidepressant effect, and that one or both of these medications works against depression at some other level. And indeed, there are hints that in addition to the SSRE effect, tianeptine operates elsewhere in the brain: on glutamate transmission, on the hippocampus, and possibly by reducing the damaging effects of stress (Kasper & McEwan, 2008).

What the tianeptine data does do is cast the popular explanation of antidepressant action into serious question. It’s hard to claim that antidepressants work by reducing reuptake when an equally effective drug increases reuptake. This is just one line of evidence nailing down the coffin lid of the monoamine hypothesis of depression.

It will be interesting to see what comes of the research into tianeptine. What we can already conclude is that our traditional explanation to patients about how SSRIs work is simply not supported - not by this data, nor by other lines of evidence. To the extent that we continue to give out the story, we are spinning fairy tales.

The truth is: We just don’t know how these medications work on depression – apart from the action of expectancy (the belief that one is receiving an active treatment), which seems to account for a large proportion of the effect.

Is there an additional biochemical margin, an organic benefit to these medications? Perhaps. But at this point there is no consensus about what it is.


Brink, CB, Harvey, BH, & Brand, L (2006).  Tianeptine: A novel atypical antidepressant that may provide new insights into the biomolecular basis of depression.  Recent Patents on CNS Drug Discovery, 1, 29-41.

Kasper, S, & McEwan, BS (2008).  Neurobiological and clinical effects of the antidepressant tianeptine.  CNS Drugs, 22, 15-26.

Kasper, S, & Olie, JP (2002).  A meta-analysis of randomized controlled trials of tianeptine versus SSRI in the short-term treatment of depression.  European Psychiatry, 17, 331-340.

Kirsch, I, et al., (2008).  Initial severity and antidepressant benefits: A meta-analysis of data submitted to the Food and Drug Administration.  PLoS Medicine, 5(2), e45.

McEwan, BS, & Olie, JP (2005).  Neurobiology of mood, anxiety, and emotions as revealed by studies of a unique antidepressant:  Tianeptine.  Molecular Psychiatry, 10, 525-537.

Online Course

Is there an alternative to a medication-based approach? If someone takes medication, is there more they can do in order to maximize the effect? Consider seeking the help of a qualified psychotherapist trained in cognitive behaviour therapy.

In addition, our clinic has developed a cognitive behavioral guide to self-care for depression. Though not a substitute for professional face-to-face care, UnDoing Depression may be a useful adjunct to your efforts.  The preview is below. For 50% off the regular fee of $140 USD, use coupon code “changeways70” when you visit our host site, here.

We also have courses for professionals and for the public entitled What Is Depression, What Causes Depression, Diagnosing Depression, Cognitive Behavioral Group Treatment of Depression, How to Buy Happiness, and Breathing Made Easy. For the full list with previews and substantial discounts, visit us at the Courses page of the Changeways Clinic website.

Tuesday 13 December 2011

Gifts For The Needless

"Everything is better in Gears of War 3... Four player co-op, new multiplayer modes, bajillions of unlockables, retrolancers, stuff that blows up, and perfect controls make this a top pick for the holiday season." - Metro News, Nov 25-27 2011, written with no apparent sense of irony.

Last week I posted some survival strategies for the holidays, and I mentioned that one of the biggest stresses for some people is trying to decide what to get for the person who has everything they need.
How about giving a mountain?

People often tell me they like the parties, the dinners, the decorations, and even the weather at Christmas. They just don’t like the shopping. They don’t know what to get, the people on their list don’t really need anything, and they’re uncomfortably aware of the discrepancy between the supposed point of Christmas and what it has become. We are one of the wealthiest societies the planet has ever known. The last thing most of us need is more stuff.

So stop buying people objects they do not need or, in most cases, want.

“Oh, but I have to give them something,” you say.

Fine. Give them eye surgery.

Not on them. On someone who needs it.

It’s possible to give great gifts to people who already have everything. Because the one thing they don’t have is a world in which others aren’t suffering.

What if you could give someone an HIV clinic, or an urban greenbelt, or a passport for a border-crossing bear, or eye exams for an entire village, or an acre of Canadian habitat, or an elementary school education, or a microfinance bank? Wouldn’t that be better than yet another sweater they won’t wear?

An increasing number of people are taking the opportunity of Christmas to give gifts that fit with their values and that have greater meaning than a new cordless drill.

Here are just a few suggestions. Your values and preferences may vary, so investigate your favourite organizations to see what they offer.

The Nature Conservancy

When you give a gift they send the recipient a calendar and certificate.  For $40 you can give a gift representing an acre of habitat. Larger donations represent habitat areas for more wide-roaming species ranging from owls ($55) to caribou ($400). You can also give any amount of money to support the activities of the Conservancy.

Trans-Himalayan Aid Society

TRAS, a local Vancouver charity, funds projects in India, Nepal, and Tibet, including child education sponsorships at a variety of schools in the region.

Seva Canada

SEVA focuses on the prevention and cure of blindness in the third world. They conduct educational, preventive, and surgical programs to deal with treatable blindness (the most common cause of which is cataract).  For $25 you can provide eye exams for 25 children, for $50 you can pay for cataract surgery, and for $150 you can pay for eye surgery for a child.

The Stephen Lewis Foundation

SLF supports community-level organizations focused on HIV/AIDS in Africa by providing care and support to women, orphans, grandmothers, and people living with HIV/AIDS.  Stephen Lewis is the former Special Envoy for HIV/AIDS in Africa for the United Nations.  You can gifts of any amount and you can order Christmas cards from the organization.

David Suzuki Foundation

An environmental organization, DSF engages in scientific, educational, and advocacy related activities to highlight a wide variety of issues.  This year they have a tongue-in-cheek set of symbolic gifts based on the idea that the North Pole (site of a certain workshop) is melting. You can buy water wings for reindeer ($20), elf-sized hockey sticks ($20), an abominable snowmaker ($50), and a variety of e-Cards (ranging from Critter Passports to Green Belts) that help fund the organization’s activities.


You’ve heard about microcredit in developing countries. You may not know that you can be a microcredit bank yourself. Kiva allows you to deposit money with them, and then issue loans of $25 or more to projects and individuals of your own choosing. You look through the photographs and stories of people seeking funding, and simply click to loan a specific amount to the projects you want to support. Kiva sends you updates on the repayment of these loans. When your loan is repaid, you can lend the money to another project. This is a perpetual gift that allows you to help any number of people over time.

Canada Helps

Want to contribute to a group not on the list? The website makes it easy to contribute to any registered charity in Canada. You can browse the available charities and donate right on the site. You can also create your own “Cause Wish List” that others can look at when they want to give you a gift – kind of like a wedding registry.

*     *     *

Don’t like any of these options? No problem. They’re just examples. There are thousands of ways of giving gifts to those who have no real needs – gifts that can benefit people and causes that fit with your values and those of your recipient.

What easier last-minute gift can you think of?

Friday 9 December 2011

Medications. Comparing Antidepressants to Placebo

Listening Closely to Prozac…

In the mid-1990s, psychologist Irving Kirsch (and his colleague Guy Sapirstein) wanted to determine the size of the placebo effect in clinical depression. The result was an explosion of literature that has been calling some of our most widely-accepted practices into question.

Recently Kirsch published a book, The Emperor's New Drugs, that summarizes the work from his perspective (which is unabashedly skeptical about the antidepressants, as the title suggests).

In his original study, Kirsch collected published studies of depression treatment that included a pill placebo condition – studies originally intended to examine antidepressant medication effectiveness.

Once you get a lot of similar studies on a subject, you can combine them and perform a meta-analysis.  In effect, this is like treating the participants in all of these separate studies as though they were in one giant study. A meta-analysis has a tendency to smooth over irregularities between trials and can show the general trend of results. On the other hand, they can also obscure some of the nuances of individual trials.

Fortunately, some of the trials included a no-treatment condition. This allowed Kirsch to compare the response to placebo to the response associated with just the passage of time. Some people get better on their own, after all, and there are a few other factors (reviewed in a recent post, here) that can otherwise inflate an apparent placebo effect.

Sure enough, Kirsch found that no-treatment groups had a small tendency to improve (Kirsch & Sapirstein, 1998). The placebo groups improved much more, however, indicating that the belief that one was receiving an active treatment had a significant therapeutic effect.

The surprise for Kirsch was that patients receiving antidepressant medications did not improve much more than those receiving placebo. In fact, the placebo group improved about 75% as much as the medication group. Put another way, about ¾ of the medication effect could be accounted for by expectancy or by spontaneous recovery with the passage of time. The active ingredient in the medication didn’t seem to add much potency.

In addition, Kirsch knew about the problem discussed a few weeks back: antidepressants have side effects and placebos do not, so patients receiving the antidepressants in such studies often figure out which study condition they are in. Suspecting they are getting the active drug, their expectancy effect may be greater. Kirsch raised the possibility that even the small difference between placebo conditions and active antidepressant conditions may be partly an expectancy effect rather than being attributable to the medication’s active ingredient.

This study created quite a stir when it was published, as it called the effectiveness of antidepressants into question. These are some of the most widely prescribed medications in North America, and it has been generally accepted that they work.

But what about the unpublished studies?

Kirsch had easy access to all of the published placebo-controlled antidepressant studies. But he knew that some of these studies never see the light of day. It’s easier to get a study published if it shows positive results than if it shows no difference between conditions. And perhaps the companies funding the studies would be less than enthusiastic about publishing data suggesting that their medications weren’t very effective.

The US Food and Drug Administration requires that all of the existing studies, published or not, be submitted to them before a drug can be approved. So Kirsch knew the FDA had them. He used a Freedom of Information request to obtain the complete data set and conducted another meta-analysis.

The results were even more discouraging than in his previous study. Response to the placebo condition was 82% as great as to the active medications. Only 18% of the response in medication conditions could be attributed to the chemical effect of the drug. And there was still the problem of unblinding of the study, because subjects could guess whether they were getting the placebo or the antidepressant.

The difference between placebo and antidepressant was still statistically significant. But Kirsch asked whether it was clinically significant. It amounted to an average difference of 1.8 points on the 51-point Hamilton Rating Scale for Depression.

I’ve treated depression for many years, and I can usually hazard a guess about where a client will score on the depression scales I use. But I wouldn’t be able to reliably guess within 1.8 points of their score – the difference is simply too slight. So even if there was a genuine chemical effect, it's questionable whether it was important from a patient's perspective.

Is there a publication bias favouring positive studies?

A subsequent study (Turner, Matthews, Linardatos, Tell, & Rosenthal, 2008) looked at whether there was a systematic difference between the published and unpublished drug trials. Of the 69% of studies that were published, 94% showed a positive result favouring the antidepressant being tested.

Of all the studies judged to exhibit a superiority of antidepressant over placebo, 37 were published and just one was not. Of those judged to have negative or equivocal results, 22 were not published, 3 were published with the negative result made explicit, and 11 were judged by Turner et al to have been interpreted in a misleadingly positive light.

A scrupulous reader evaluating the published literature would conclude that 94% of studies supported the effectiveness of antidepressants. One able to read all of the studies would find that only 51% were positive.

Whether or not a given trial supports a difference between drug and placebo is one thing; the size of that difference is another. Turner et al examined the difference in effect size between antidepressant and placebo for the total data set, and compared this to the difference found in the published studies. On average, the effect size was 32% higher in the published data than in the complete set of FDA-submitted studies.

This points to a serious problem. Clinicians are expected to follow the published literature and guide their practices accordingly. But a publication bias in favour of positive studies skews the picture.

Imagine a dutiful clinician asking each researcher whether antidepressant medications outperformed placebo in a given trial.  “Yes, no, no, yes, yes, no, yes, no, no…”

Then imagine the same clinician looking at the published literature.  “Yes, yes, yes, yes, yes, no, yes, yes, yes…” The resulting treatment decisions would likely differ markedly.

So do antidepressants work?

Let’s be clear. People who received antidepressants improved a great deal, on average. So yes, the medications work.

The question is why. Patients receiving placebos improved a great deal as well, though not quite as much as the patients receiving antidepressants. It is certain that much of the improvement we see in patients prescribed antidepressants is the result of expectancy rather than chemistry.

But is there a chemical effect too?

That remains unclear. It seems likely that there is, but we know that it is somewhat unreliable. We know that people who suddenly stop taking antidepressants will often experience a rebound depression, which suggests the medications must be doing something, even if we aren’t sure just what.

At this point I’m not willing to declare that antidepressants are placebos. I’ve seen too many remarkable effects in too many clients to dismiss the effectiveness of these medications out of hand.

My suspicion is that depression, like fever, is a symptom of many possible conditions, and that antidepressants may well help with some of these ailments but not others. I would guess that in 20 years we will look back and see that these weak effects were obtained by including a very diverse group of problems in the medication trials. (I've advanced this idea before on this blog, and I suspect that some of the more aggressive medication critics would snort at me for my timidity on this issue.)

Kirsch, who argues forcefully that there is no convincing evidence in favour of the antidepressants, would disagree with me. And his grasp of the literature is unquestionably better than mine. Others with expertise in this area have significant reservations about Kirsch’s work. At this point, a consensus has yet to emerge.

So: Is there a chemical antidepressant effect? At this point the answer remains unclear and unsettled in the research community.


Kirsch, I (2009) The Emperor's New Drugs: Exploding the antidepressant myth. London: Bodley Head.
Kirsch, I, Moore, TJ, Scoboria, A, & Nicholls, SS (2002).  The emperor’s new drugs: An analysis of antidepressant medication data submitted to the US Food and Drug Administration.  Prevention and Treatment, Vol 5, Article 23.
Kirsch, I, & Sapirstein, G (1998) Listening to Prozac but hearing placebo: A meta-analysis of antidepressant medication. Prevention and Treatment, Vol. 1, Article 2a.
Turner, EH, Matthews, AM, Linardatos, E., Tell, RA, & Rosenthal R. (2008). Selective publication of antidepressant trials and its influence on apparent efficacy. New England Journal of Medicine, 358, 252-260.

Tuesday 6 December 2011

A Christmas Tradition: The Survival Guide

Is it over yet?
Ahhh, December again. Time to dust the mall decorations that have been out since October. Time to check the credit limit twice. Time to practice the diaphragmatic breathing.

And for psychologists, time for the most hallowed tradition of them all. In newsrooms across the nation, reporters are drawing straws. The one who gets the shortest straw has to write the obligatory “how to cope with Christmas” article without make it sound like a retread from last year – and the year before, and…

'Twas the month before Christmas and all through the land, psychologists’ phones are ringing, interviews to be had.

The truth is, Christmas does not cause significant psychological problems. Anxiety, stress, disappointment, and sadness are not disorders, as therapists everywhere keep saying. They are part of being human. 

But for a holiday allegedly about joy, it’s surprising how much stress people can feel in the lead-up to it. So: here’s a dozen tips to help you make it to New Year’s.

1.  Remember: Christmas is voluntary.

People stare at me when I tell them this, but it’s true. December the 25th will come whether you like it or not. Christmas, however, is optional. If you don’t like it, you don’t have to do it. You can just announce that you won’t be celebrating it. And then don’t. Yes, this is possible. People everywhere are skipping the holiday altogether. Easter used to be mandatory as well; now only a minority actually observe the holiday. If you’re worried you will feel bereft, plan the day ahead of time. A pair of movies separated by a long walk, plus an hour of work on a pet project can fill the time.

2. Give up.

Disappointment is produced not by your experiences, but by your expectations. If you have no fantasy you cannot be disappointed. Popular media will attempt to ratchet your expectations up to a Victorian dinner with Tiny Tim and the late arrival of a reformed Scrooge – or at least a holiday with the Waltons. Recognize that this will not happen and has not happened in your recent past, so let it go.

3. Dice the holiday.

Christmas isn’t a monolithic structure. It’s a collection of bits. Chop it into pieces, preferably on paper: decorations, tree, family gift-giving, friend gift-giving, Christmas Eve get-together, Christmas dinner, whatever. Then ask yourself which bits you like and which bits you hate. Some (visiting Aunt Kate at the nursing home) may not be fun but you’ll decide to do them anyway. Some (risking your neck on the roof stringing lights) might be optional. Stop these ones.

4.  Compete with your worst, not your best.

If you must set a mark for yourself, don’t make it your ‘best-ever’ Christmas. Think back over your life, and try to remember what you did every holiday season. Sure, there was a great one here and there. But look for the very worst of the bunch – the one with the screaming fight, the trip to the Emergency Room, the deep depression, the house fire. And strive to make this year just a bit better than that one. Don’t try to push the brackets upward; just try not to set a new all-time low. It’s easier.

5.  Stop the arms race.

Arms races bankrupt the competitors. Much of the stress of Christmas comes from the “bigger and better” idea. Last year you gave gifts to X people and spent Y dollars. And some of those people outdid you. This year you feel you have to ramp it up a bit. But why? Take your foot off the gas a bit and start ramping it down. Pull back on the expense and let everyone breathe a little easier.

6. Fly.

The airport is a nightmare during the holidays, right? Yes, but there is an eye in the storm: Christmas Day. Almost no one flies, the airport is quiet, the flight crew is happy and relaxed, and you’re not at Aunt Mabel’s with your sister-in-law. An Air Canada bagged sandwich may be the best Christmas dinner you’ve ever had. (Yes, I’ve done this myself. It was blissful.)

7. Leave.

If it seems impossible to extract yourself from the trap of Christmas-as-usual if you stay home, then don’t stay home. Skip town. Go to a cheap cabin in the woods or get out of the country altogether. Spending the time with other Christmas refugees will make it even better.

'Tis the season to shoot your enemies, apparently.
8. Don’t buy gifts you don’t approve of.

I’ve noticed that one of the biggest stresses for people is doing things that are against their better judgment out of a misplaced sense of obligation. Maybe the only thing your nephew wants is a Call of Duty shoot-em-up video game (the top recommendation for holiday gift-giving in a recent article in Metro News) so he can practice slaughtering people with machine guns. Tough. Don’t buy it. If he doesn’t like what you give him, it ultimately doesn’t matter. If a package isn’t an expression of yourself to at least some extent, then it’s a bribe, not a gift.

9. Push experience.

Christmas memories are seldom of the gifts, the elaborateness of decorations, or the amount spent. They are about time spent with people. Make this the priority, not a slavish attempt to make your home mimic a magazine photo. Seven hours of labour may indeed produce a handmade wreath that Martha Stewart would declare a “good thing,” but seven hours spent with friends will be a better thing.

10. Cut an escape hatch.

Some families convene in large numbers for the holidays. Even if you generally get along, the close quarters can grate after a while. Plan breaks. Forget to pack enough underwear so you have an excuse to go shopping by yourself for a few hours. Plan to do things alone or with other friends after a few days with family. Remember that they probably don’t want to be around you 24 hours a day either.

11. Pick and choose.

When I was a child, Christmas streets were quiet. It almost seemed wrong to be driving in a car on that day. Somehow our culture morphed along the way, and now people spent half the day driving from place to place as though they are in a demented car rally, trying to hit all the checkpoints on their lists. The sense of futile pointlessness of this (“Is this any fun? Really?”) gets added to the stress of travel, and contributes to the sense of being trapped by the holiday. Instead, choose what you’re going to do and stick with it. My rule of thumb is that if you spend the day in more than two places you’ve made an error in planning.

12. Make someone else’s holiday.

“If you want others to be happy, practice compassion. If you want to be happy, practice compassion.” – The Dalai Lama. If you don’t have much to do, or if you don’t like the way you’ve spent the holiday the last few years, then make a change. Volunteer for a charity on Christmas Day. There are few guarantees associated with the holidays, but this one comes as close as you can get: It will almost certainly be one of the best Christmases you’ve had, and it will certainly be better than any alternative.

*    *    *

So, do I sound like Scrooge yet? I shouldn’t. I recognized years ago that my own dissatisfaction with the holidays was created in large part by a feeling that I was acting out a script written by someone else; a script I didn’t like, written by commercial authors I did not respect. Sometime in my 30’s I threw most of the script away, and I’ve been discarding pages ever since. I can heartily recommend this approach.

If you want a holiday script at all, then write it yourself. You’ll be happier, you’ll have more fun, and you’ll be more enjoyable to be around.

“Mm,” you say. “Nice try. But I still want to give gifts to a few people, and have no idea what to get them. They don’t actually need anything. That’s what stresses me out.”

Next week: Gift-giving for the needless.

Friday 2 December 2011

Medications: Is Placebo Response a Placebo Effect?

For the last month or so I've been posting about medications, the proposed mechanism of action of SSRI antidepressants, and the monoamine hypothesis.

Running through all of this has been a discussion of the placebo effect, which seems like a fairly straightforward idea, but like many such concepts it quickly morphs into something more complicated the more you look at it.

So: It seems obvious that the placebo effect is the amount of improvement that we see in people who are given a placebo (an inactive treatment). In fact, this seems so obvious that researchers themselves often report results as though this was true.

Well, it isn't.

In fact, the improvement due to expectancy (the true placebo effect) – is only one of several factors contributing to the apparent efficacy of placebos. Let’s look at a few others.

Regression toward the mean

How do you get into a drug trial?  You have to meet a number of criteria, one of which is to have a disorder of a minimum level of intensity.  So if the trial is on depression, you have to have a depression score of X or more.

Every measure has a degree of error. Imagine that right now your “true” level of depression could be quantified as a score of 20. If we give you a test to find this out, you might get a score of 16, or 21, or 24. You’d get a score of around 20, but seldom would the test peg you perfectly. This is just like your old math tests. Sometimes you’d luck out and look a bit smarter than you really were; sometimes the test would make you look worse than you really were.

Now imagine that we’ll only let people into the study if they get a test score of 21 or higher. People with a “true” score of 10 are unlikely to get a test score wrong enough to be over 21, so they’ll all be denied entry to the study. People with a true score of 35 probably won’t get a test score lower than 21, so they’ll all be admitted.

But think of what happens to people who score close to the cutoff of 21.  Some people with a “true” score of 18 will score 22, and they’ll get into the study group. Some people with a “true” score of 23 will score 19, and they’ll be tossed out. All the people with a true score of 21 and who score a bit too high will be included. Those who score a bit too low will be omitted.

In other words, we have a bias: People close to the cutoff who test a bit high will get into the study, and those who test a bit low won’t.

Imagine that neither the drug nor the placebo does anything at all. We test all of our study participants again. Our extremely depressed folks scored high the first time, and they score high again. The second test is a few points higher for some and lower for others due to the random error in the tests. They average out the same.

But think about our group who started out near the cutoff. We have dropped people who randomly tested low from the study, and included those who randomly tested high. When we retest them, about half will score higher than their “true” score, just like they did before; and about half will score too low. But this time we won’t dump the ones who score too low. It will look as though this group of people got a little bit better.

The result: If we use a cutoff score, and if there is any measurement error at all (and there always is), we will always get a little bit of improvement when we retest the subgroup of people we let into the study. We’ll get that improvement in the real drug condition, and in the placebo condition. And we’ll call it a placebo effect, but it isn’t.  It’s a statistical anomaly.

Passage of Time

Again, think of how people get into a medication study for a problem like depression. They’re depressed!

What is the natural history of depression? It gets a bit worse and it gets a bit better. Later on, it can get worse again.

Now: When are you going to seek treatment, or volunteer for an experimental drug trial? Probably not when you’re feeling better. You’d only seek help if you were feeling somewhat worse lately.

So if we conduct a drug trial for depression, we’re going to get a lot of volunteers who have a mood problem that spontaneously gets worse and gets better. And most of them will be at the “worse” phase. If we admit them to the study and give them a medication, or a sugar pill, or just have them wait around, what will happen?

A few of them, who felt fairly lousy, will get even worse. But many of them, who volunteered precisely because they felt unusually bad, will feel somewhat better. If we test everyone and average out the scores, we’ll discover that the average depression score is a bit lower than when the study started. It’ll look like being a part of our study was therapeutic, but it wasn’t. It was the simple passage of time, plus an anomaly caused by people seeking help at the worst part of their mood cycle.

The Hawthorne Effect

Just being part of a study can help you feel better. In the late 1920s and early 1930s a series of studies was carried out at an American electrical plant to see whether light levels would influence productivity. It turned out that productivity improved when changes were made, regardless of whether the light was increased or decreased.

Since 1950, when the Hawthorne effect (named for the factory) was first described, it has routinely been noticed that simply being a part of a study creates changes in the people being examined. People in a placebo-controlled drug trial are likely to improve regardless of what treatment they are given, simply because they are in a trial.

Care and Support

When you are in a drug trial you go through a long series of intake measures, you see clinicians regularly, and people monitor your condition. In some ways the care you receive is much more attentive than you would get in the average physician's office.

During depression people often feel isolated and insignificant, and they usually have difficulty getting out of the house. We know that if we can help people become more active, if we can have them interact with people more often, and if we can help them to feel (rightly) that they are deserving of care and support, this often works against the depression.

In effect, just having appointments and talking with a professional (or for that matter any warm human being) can be a genuine and effective treatment for depression - even if the medication taken as a part of that relationship does nothing.

For people who are away from work, I have often found that doing volunteer work is one of the most potent strategies to help people recover from depression. It provides structure during the day. It provides a reason to get out (and once out it is easier to stay out a bit longer and do some errands or buy groceries). It provides human contact. It gives the person a sense that they have something to contribute. And the person is genuinely participating in outside life. Participating in a drug trial does all of these things as well.

So in addition to whatever the capsules contain, being in a study is therapy itself.

*     *     *

These are just some of the effects that can contribute to improvement in a person who takes a placebo in a drug trial. And, of course, all of the same effects can likewise contribute to those who are given the active drug.

Some of these effects - regression to the mean and the passage of time - would also appear in a group given no treatment at all. Some (the Hawthorne effect; care and support) would be much weaker in a group that only came in for pretest and post-test screening.

So we might wonder whether a group of depressed clients given no treatment at all would improve, and by how much. This has been examined and yes, people given no treatment do tend to improve - but not a great deal. The effect size in studies of antidepressants have averaged just under 0.4 (Kirsch & Sapirstein, 1998), beneath a commonly-used cutoff of 0.5 to describe a moderate effect. Placebo groups average over 1.1, by contrast.

Who cares?

There are two main reasons to care about this issue.

First, if we carelessly combine a variety of influences into the placebo effect, we make placebos look much more effective than they really are. If we want to think carefully about the placebo effect, we need to separate it from the other effects that sometimes inflate it.

Second, all of the effects above, PLUS the placebo effect, also apply to people given active medications in these trials. It is arguably a little oversimplified to say this, but the actual drug effect is usually taken to be the magnitude of response for patients in the active drug condition, minus the response of those in the placebo condition.

Sometimes the difference between drug and placebo is so minimal that a genuine chemical effect of the drug cannot be found.

And some studies suggest that the effects we attribute to the medication may just be more powerful placebo effects, brought on by the presence of medication side effects: Study participants experience side effects and conclude that they are on the real drug, thus developing greater expectation than those in the placebo condition.

Well, fine.  But what's the actual difference between people given antidepressant medication and those given placebos?  Stay tuned.