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Tuesday 30 December 2014

The Medicalization of Mood: Worse Than Nothing, or Just Ineffective?

Not quite as good as advertised.
Sixty Years of Intervention

In the 1950s, Roland Kuhn identified an apparent antidepressant effect of the drug imipramine. Given what we know about depression in the 21st century, it's tempting to guess that the drug companies must have been over the moon with greedy excitement.

Not so. Clinical depression was regarded as a relatively small problem, unlikely to result in sufficient sales to recoup the costs of drug development and testing. Nevertheless, the pharmaceutical company Ciba went forward, and imipramine became the first of the tricyclic antidepressants on the market.

Since then, additional varieties of medication have been touted as antidepressant in action, and the antidepressants as a class have become some of the biggest moneymakers in pharmaceutical history. At the same time, numerous psychotherapies have been proposed and tested, and community mental health centres have sprung up across the developed world.

The aim of individual drugmakers may be to create profits, but the ultimate goal of the healthcare sector is the enhancement of human health and well-being and the minimization of illness, disability, and premature death. Tuberculosis, for example, was a major cause of disability, hospitalization, and death a hundred years ago. Today it remains a problem - but the sanataria have closed, hospitalizations are few, and deaths are a rarity. This is the mark of at least partial medical success.

After 60 years of intervention with depression, it’s reasonable to ask how we are doing.

To this end, we can look at a series of epidemiological markers that we might hope to improve with our efforts. We can classify each as successes, failures, or worse:

  • Success: Improvement on a marker.
  • Failure: Lack of movement on a marker that is clearly the target of intervention.
  • Worse: Movement in the wrong direction.

Let’s take a quick look at several of the most important markers. I won't go into full detail about any of these, but there is quite good data out there to address most of them.


Incidence refers to the rate of new cases of a disorder appearing within a given period of time (often a year). As noted above, in the 1950s depression was regarded as a rare disorder. Relatively few people were hospitalized with it. Estimates ran as low as 100 cases per million population. Today, 10% or more of the population is predicted to develop a major depressive episode in their lifetime. This represents a lifetime incidence of up to 100,000 cases per million. As psychiatrist David Healy has said, "Something must surely be going wrong if our treatments are so good yet the frequency of depression jumps a thousand-fold since the discovery of the antidepressants."

This represents an extreme example of case inflation, and almost certainly we do not have 1000 times as many depressed people as before we developed effective treatment. No one, however, disputes the increased incidence of depression since the 1950s. Verdict: Worse.


Prevalence refers to the number of cases of a disorder present within a population at a given point of time. Community surveys in the 1930s and 1940s reported less than one case per thousand (Silverman, 1968). In the 1950s, relatively few cases were identified in any given population. Today, an estimated 3-5% of men and 8-10% of women experience a major depressive episode in any given year. Again, estimates vary, and it may well be that many cases were missed in the 1950s. Despite this, no one has mounted a persuasive argument that the prevalence has declined or remained stable. Verdict: Worse.

Age at First Onset

Some illnesses are common results of aging. Occasionally, for example, one will hear that the rate of prostate cancer in males is likely to be 100% - if you're male and live long enough, you will get it. One of the goals of care is to put off the development of these common disorders until later in life. If we could put off the appearance of arthritis until age 90, for example, champagne corks would be popping at celebration parties - even if no fewer people eventually developed the problem.

For most of the 20th century, depression was described as a relatively rare disorder that tended to strike in mid-life and beyond. Since the 1980s, the average age of onset has been placed in the 20s - particularly the late 20s. In the 21st century, increasingly first episodes of depression are regarded as being most common in the early 20s. Verdict: Worse.


One obvious problem in the comparison of modern-day statistics from those in the 1950s is that case-finding has changed. People may have suffered in silence formerly, never seeing their physician nor being counted in surveys. Today we have public education campaigns, and screening questions about depression are common in standard medical examinations. This would mean that the average severity today should be lower than in earlier times, when one had to be utterly undone in order to seek treatment. Indeed, many people today are described as depressed despite working and carrying on reasonably productive lives.

The number of people experiencing severe depressive episodes, however, has unquestionably gone up rather than down. Hospitalization for depression today is more common than it was in the middle of the last century, and tens of thousands are forced to leave work due to the magnitude of their symptoms. Verdict: Worse.


In Anatomy of an Epidemic, Robert Whitaker reviews descriptions of the normal course of depression in the past. Between 39% and 60% of the severe cases that sought care at that time never had another attack, and a chronic course characterized by multiple episodes and poor inter-episode recovery was apparently rare. Robins & Guze (1972) reported that 50% of people hospitalized for depression did not have a second episode within ten years. Between episodes, recovery was expected to be virtually complete, with few or no lasting effects.

Today, recurrence is common and expected, and people with chronic mood difficulty are commonly seen. Depression, it is said, is best regarded as a chronic condition characterized by multiple episodes and relapses. Verdict: Worse.

Number in Treatment

At one point smallpox was a major strain on medical resources. Today no living doctor has seen a case in many years. This can be a goal for medicine: to so thoroughly defeat a disorder that it no longer shows up in a population. For many problems, however, eradication is not a reasonable goal. Once we develop effective treatments, we hope that all those who have been suffering at home will come to have their problem dealt with.

It would be nice to see depression eradicated, but this is perhaps unrealistic. If we have effective treatments, however, we can expect that symptoms will be well managed and people will not need intensive, ongoing care. We can provide the odd prescription renewal, for example, and not have to do much more.

This is not the situation in which we find ourselves. We have many more outpatient treatment resources than in the 1950s, but these are strained to the limit. Clinics everywhere have wait lists, and physicians report that the depressed make up a great deal of their clinic practice. Verdict: Certainly no better, and by most standards Worse.


As noted above, depression was formerly regarded as an episodic illness characterized by full inter-episode recovery. Although many people were disabled by other medical problems, once depression lifted most people returned to their regular life roles.

Since the 1980s, however, disability management organizations have noted that depression has leapt up the list of disability causes. Today, depression is regarded as the first or second most common cause of long term disability claims in Canada and elsewhere. Where it is not presently at the top of the list, most organizations expect it to take the lead within a few years based on current trends. Verdict: Worse.


If we treat a problem effectively, people should return to health and reasonably good life satisfaction, and they should live close to a normal lifespan. Recent studies of people with HIV, for example, suggest that with modern treatments the lifespan should approximate the population average.

Studies of lifespan for people with depression in the early 20th century either do not exist or I have not found them. Nevertheless, with the relatively good recovery between episodes reported at that time, it seems likely that average lifespan would not have been enormously impaired. It would not be surprising that with the more severe and disabling courses being described today, life expectancy had been reduced. And indeed, recent findings suggest that clinical depression can reduce life expectancy by 7 to 11 years (for a review, see here). Most of this is not due, as one might think, to suicide, which is not as common in major depressive disorder as commonly thought (see my previous blog post here for more on this issue). Something else is going on. Verdict: Difficult to evaluate with any certainty, but probably Worse.

What's Going On?

If the mark of successful medical intervention is that a disorder appears less often, is less prevalent in the population at large, appears later in life than previously, is less severe when it happens, if recurrence is less frequent and recovery is more complete, if the burden on the medical system is lower, if disability is minimized and mortality is reduced, then we consider the intervention a success. Sometimes we achieve gains on a few of these measures but not all of them.

In the case of depression, however, the problem has worsened on virtually all fronts. We are routinely told "The good news about depression is that we have safe, effective treatments. See your doctor!" But if this were true, surely we should see better results in the population.

The problem is clearly not that people go untreated. In British Columbia, a study in the early 2000s indicated that 19% of adult females had been prescribed an antidepressant in a single year. Over-diagnosis and over-treatment are increasingly being raised as significant problems (for an example, see here).

There is no doubt that many people have been helped by medication and other treatments for depression. But if this benefit is reliable and in any sense powerful, it should have an impact that can be seen in the population as a whole. To have no real sign of population-wide improvement and, instead, clear signs of population-wide worsening? This should sound warning bells that for the most part have remained silent.

Four Possibilities

We can sum up the possible problems in four main categories, while acknowledging that there may be more factors as well.

Cultural change. There have been vast changes in the way we live our lives since the 1950s. Our culture has devoted itself to the service of economic goals rather than life satisfaction and, perhaps not surprisingly, many of the changes have been in directions that likely contribute to the incidence of depression. These include reduced exercise, poor diet, less social contact, an increased emphasis on material success, and so on.

Border Creep. Over time, the range of mood and functioning that we consider to be normal has narrowed considerably, and the definitions of mental illnesses have correspondingly broadened. Each succeeding edition of the diagnostic manual (the DSM) has resulted in a larger proportion of the culture being diagnosable as ill. Depression is a much broader category than it was in the 1950s, so of course more people fit within it. This cannot explain the increases in severity, chronicity, or disability, however.

Profit Motive. One way to expand a problem is to make its treatment profitable. In the 1950s there were few products one could sell to the depressed; today there are many. Much of the drive to expand the number and scope of mental illness categories appears to have come from the pharmaceutical industry, which has grown enormously - in part by selling more products to the newly-labelled ill.

Iatrogenic Chronicity. A troubling possibility raised by recent research in the field suggests that the very medications we use to alleviate depression may, in the long run, cause a worsening of the problem in a subset of the individuals who take them. More on this in later posts.

Success, Failure, or Worse?

It would be difficult to declare the medicalization of mood a success, given the lack of improvement on any of the variables discussed. (Perhaps some glowing achievements have been missed, but these are not immediately apparent).

Failure would mean that the situation from the 1950s has remained unchanged. This doesn't seem true, given that things have become so markedly worse on so many fronts.

If, with all of our efforts, the burden of depression has not been even partially lifted, then we may need to face a difficult possibility. Maybe it's the healthcare system itself. Maybe we haven't just failed. Maybe something we are doing is making things worse.


Robins, E., & Guze, S. B. (1972). Classification of affective disorders: The primary-secondary, the endogenous-reactive, and the neurotic-psychotic concepts. In TA Williams, MM Katz, JA Shield (Eds) Recent Advances in Psychobiology of the Depressive Illness, 283-293.

Parker, G (2007). Is depression overdiagnosed? Yes. British Medical Journal, 335, 328. See also, however, Hickie, I (2007). Is depression over diagnosed? No. British Medical Journal, 335, 329.

Silverman, C (1968) The epidemiology of depression. Baltimore: Johns Hopkins Press.

University of Oxford. (2014, May 23). Many mental illnesses reduce life expectancy more than heavy smoking. ScienceDaily. Retrieved December 29, 2014 from

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Tuesday 23 December 2014

Screening for Childhood Mental Illness in BC: Good Idea or Pharma Marketing?

In recent years there have been many incidents of violence perpetrated by children and adolescents, many of them in the school system. Given the often-tragic results, there is an understandable lament that troubled youth could not be identified earlier and put into some form of treatment. Why not have an effective and comprehensive screening program in medical practices and in the schools to help identify problems before they become crises?

In British Columbia there is a proposal to do just that. The Practice Support Program for Child and Youth Mental Health (PSP-CYMH) trains physicians in the use of screening tools to help identify childhood mental illnesses. In its second phase, school personnel are to be included in some of the training.

This sounds like a good idea. When a tragedy happens, we often hear that the perpetrator turned out to be suffering from a mental illness. But we usually know this because the person was already in some form of mental health care: he or she had a therapist, a psychiatrist, was taking medication, and so on. Case-finding is irrelevant in such situations, as the case has already been found and action is being taken.

The implication seems to be that if we beef up the mental health service, fewer instances of violence will occur. But this begs a few questions:

  1. Given that most perpetrators are already in care and nevertheless offended, doesn't this call into the question the notion that treatment will prevent bad outcomes?
  2. If there was a better-funded service, would the perpetrators have been in two forms of therapy rather than one? Five, maybe? Ten? Is there any evidence that this would help?
  3. Is there any evidence that more elaborate mental health screening results in reduced levels of youth violence or better long-term mental health outcomes?

Mad in America ( is a website founded by Robert Whitaker, author of "Anatomy of an Epidemic," a remarkable book that examines the research literature on the long-term effectiveness of common mental health treatments. It hosts blogs and reporting from a wide variety of perspectives, most of which are skeptical of current mental health practices. Some of the posts are extreme and angry, most are not.

In July of this year, Rob Wipond, a Victoria-based freelance journalist, wrote about the PSP-CYMH that calls much of the program into question. See what you think:

One concern that is frequently raised about mental health screening initiatives is that they identify patients who can then be sold psychoactive medications. Authors of the initiatives almost always talk about the enhancement of social supports, the provision of psychotherapy, involvement with community, and so on. But in the real world of medical practice, screening usually translates into prescriptions written.

It is no wonder that so many of these initiatives have received generous financial support from the pharmaceutical companies whose products will be sold as a result. That said, I can find no evidence of direct pharmaceutical industry funding for the PSP-CYMH initiative.

It is possible, though, to look at the materials supplied to physicians as part of the program. Here they are:

You can even try them out for yourself. I was a sometimes anxious kid and have spent much of my life thanking the fates for not having my case found - believing as I do that things would have turned out much worse for me as a result. I was interested in the child form of the SCARED inventory of childhood anxiety, available here:

It's not a great measure, and hasn't been well thought through as published for BC Physicians. Look at the instructions, for example, which invite children to "fill in one circle that corresponds to the response that seems to describe you." There are no circles; the format has been changed to a table for checkmarks. This is an extremely minor problem, but one that suggests no one has even proofread the materials.

I thought back to one of the more anxious years of my own childhood and filled out the questionnaire as I believe I would have, had I been honest, back then. Sure enough, my score exceeded the screening cutoff. Try it yourself.

No problem, perhaps, if the help given as a result is useful, evidence-based, effective over both the short and long term, and aware of the context of the child's life. But if you are imagining legions of child and youth clinicians and support workers lolling about with nothing to do because not enough cases have been found, think again. Child and youth mental health services are already oversubscribed - not just in BC but in virtually every jurisdiction with which I am familiar.

It is very difficult to escape the notion that children identified through screening and subsequent assessment will be unable to access any resources other than medication, and that the result of the program will be even more children on psychoactive medication than there are now. Not such a bad outcome if the evidence supports the effectiveness of such an approach over the long term. But the evidence is fairly equivocal on this issue, to put it generously.

So what do you think? Should we be screening to find more cases of child and youth mental health problems? As I suggested at the outset, it doesn't sound like such a bad idea. But considering the state of the services available, the quality of the research on pharmacological interventions in children, and the criticisms levelled by Wipond and those he cites in the article, it's a bit hard to understand how violence might be reduced or the care of seriously ill children will be enhanced by the current initiative.

One of Wipond's sources is University of Victoria-affiliated drug policy researcher Alan Cassels, whose recent TEDx Victoria talk can be found here:

Tuesday 16 December 2014

Snapshot Versus Movie: Two Ways of Thinking

Too many passengers, too small a boat.
Missionaries, Cannibals, and Problem Solving

In the Missionaries and Cannibals problem, three missionaries and three cannibals must cross a river in a boat that can only hold two people - and the cannibals must never outnumber the missionaries.

It’s tempting to try to advance one's position with every move, never returning the boat with more than a single occupant. In most versions of the problem, however, this won’t yield a solution. At some point, two people have to move back across the river.

The puzzle is interesting from a psychological perspective because it requires a shift from move-by-move to longer-term planning - a process that the mind often rebels against. It appears that our default wiring causes us to look for linear solutions - a tendency that can blind us to
alternatives and to the negative consequences of our best intentions.

We might think of our default mode as "snapshot" thinking. We look at the current problem and try to find a solution that takes us a step in the right direction.

The alternative is "movie" thinking, in which we examine the consequences of our immediate actions and look a few steps down the road. In effect, we view the problem as an ecological system in which our own inputs alter the problem space and lead often to unexpected shifts.

Who really cares? 

The type of thinking we employ governs our responses to problems, and often determines whether our solutions work, prove ineffective, or make things worse. Many of our most pressing problems can only be solved with "movie" thinking, but our bias causes us to attempt to employ snapshot thinking.

Consider a few examples.

Invasive species.
Australia is well-known for the introduction of new species with unforeseen consequences. In the 1930s, hoping to battle the native cane beetle, cane toads from the Americas were released in Queensland. From a snapshot perspective, this made sense. Lacking natural predators, however, the toads spread uncontrollably across the state, causing greater problems than the one they were intended to solve. Similar eye-rolling foul-ups were caused by the introduction of foxes, rabbits, housecats, camels, goats, pigs, and deer.

Every school child learns about the ecological catastrophes visited upon Australia by naive snapshot-thinkers. We know and accept that it is generally a bad idea to introduce foreign species into an ecological system. This has not stopped us, however, from developing entirely new organisms and releasing them into the environment as though the lessons of Australia had never been taught.

Genetically modified corn is a good example of snapshot thinking. Developed to be resistant to widely-used herbicides or to express proteins that are poisonous to insect pests, these varieties produce healthier and more abundant crops. Switch to movie-style thinking, however, and the problem readily becomes apparent. A new selection environment has been introduced, and unexpected shifts in ecological systems will result. Already, some pests have evolved resistance to the supposedly insect-resistant strains, potentially resulting in greater insect problems than the strains were originally developed to address.

What about foreign policy initiatives? Imagine that you have intelligence indicating that there are 1000 terrorists operating in a given region. Using snapshot thinking the solution seems obvious. Invade, target the terrorists, and eliminate them one by one. Movie thinking would ask how those individuals became terrorists, and would wonder whether an invasion might inadvertently spawn more terrorists than it eliminates. Having armed and trained Osama bin Laden to fight Soviets in Afghanistan, for example, movie thinking might ask whether the creation of a band of Islamist fighters could cause more problems than it solves.

Snapshot thinking also bedevils our personal lives. We see the immediate problem that our spouse disagrees with our plans to renovate the garage, and press our point relentlessly. Although this might succeed in the short term, movie thinking might look a few steps down the road to see whether our browbeating style could have further-reaching consequences. Rushing to solve our children's problems, we might inadvertently undermine their ability to perceive and deal with the consequences of their own actions.

What about the field of mental health? Snapshot thinking would lead us to attempt the solution of an immediate problem using seemingly common-sense strategies. If depression is believed to be the result of insufficient neural transmission within serotonergic systems (an admittedly bad example, because this widely-believed notion has found little empirical support), then introducing medications to promote serotonergic action seems an obvious move. If some people with depression fail to seek medical assistance, then public education campaigns should surely help some of them to see their physician. If anxiety is a problem, then the administration of antianxiety medication is a no-brainer.

But all of these are the products of snapshot thinking. And like the environmental problems of Australia, the challenges of a GMO-infested world, the terrorist situation of a post-9/11 world, each of them suffers from the law of unintended consequences. Serotonin reuptake blockade may ultimately impair previously-functional serotonergic systems. Public education campaigns may cause epidemics of overdiagnosis and overmedication. And benzodiazepine dependence may ultimately be worse than the anxiety these drugs are intended to treat.

In coming weeks we will take a closer look at just a few of these issues within mental health - and examine whether a system designed to improve human welfare may have accidentally amplified the problem.

Friday 7 November 2014

The PHQ-9: A Tool for the Overdiagnosis of Depression

Physicians and other clinicians like to have quick and easy screening tools for common disorders. One of the most common mental disorders is Major Depression, so there is an understandable desire for a tool that can give the clinician a quick sense of whether there might be a problem.

The Patient Health Questionnaire, or PHQ-9, seems like a good option, and it is one of the most widely-used screening tools in clinical practice. The main section has nine items, corresponding to the nine diagnostic symptoms for Major Depressive Disorder in the DSM-5. Patients rate how they have been doing in each area using a 0 to 3 scale. “Over the last 2 weeks, how often have you been bothered by any of the following problems?” The ratings are accompanied by the following descriptors:

0: Not at all
1: Several days
2: More than half the days
3: Nearly every day

The “Over the last 2 weeks” specifier is relevant, because to count as a Major Depressive Episode (MDE) the symptoms have to have been present for at least two weeks. Importantly, eight of the nine DSM-5 criteria also specify that the symptom must be present "nearly every day" (NED, the suicidality item is excepted, and weight gain or loss over the course of a month without dieting can be substituted for appetite change).  

There’s a second item asking how difficult these problems have made it to work, take care of things at home, or get along with other people. This also seems relevant, because in order to count toward a diagnosis the symptoms must be disruptive in a person’s life.

On many versions of the form patients can score their own answers simply by adding up the numbers (0-3) for the nine symptoms. The questionnaire takes people only a minute or two to complete, and the clinician can score it in seconds. Perfect.

And let’s be clear: We use the PHQ-9 as a routine instrument in our own clinic. We like it. We print out the measure – and happily throw the accompanying interpretive guidelines in the trash. But what if you don’t?

So what's the problem?

The PHQ9 is useful as a quick self-report measure that can be used as a springboard for a more formal face-to-face assessment of depression symptoms. If a client/patient truthfully returns a form with a score less than 5, it is highly unlikely that further questioning will reveal the presence of a current major depressive episode.

There are two problems, however.

First, many practitioners appear to use the scale to make the diagnosis, without formal followup in interview. This is not an appropriate practice, because there is too much room for interpretation with many of the items. Clients might score 3 points on item e (poor appetite or overeating), for example, if they have had a lifelong pattern of overeating that is unrelated to current mood problems. Questioning would exclude these points.

More significantly, there is considerable vagueness in most of the interpretive guidelines accompanying the PHQ-9. A set distributed by a prominent pharmaceutical company, for example (at states “Scores of 5, 10, 15, and 20 represent cutpoints for mild, moderate, moderately severe, and severe depression, respectively.” This mimics the wording of the most common versions of the scoring guidelines - and is a paraphrase of wording in an oft-cited article by some of the developers of the measure (Kroenke et al, 2001).

Notice the wording:  "depression." Not "Major Depressive Disorder." Throughout the writing on the PHQ-9 there is vagueness about whether we are talking about depression-like symptoms or a diagnosable medical condition. And it makes a difference. 

Comparing PHQ-9 cutoffs to DSM-5 criteria

If, reader, you are a clinician who uses the PHQ-9, I encourage you to get out a copy and lay it alongside your DSM-5.

Major Depressive Episodes are, as the guidelines indicate, coded as Mild, Moderate, or Severe in intensity (along with other specifiers outside the scope of this post). 

Mild MDE is diagnosed if a person just barely meets the criteria on five of the nine symptoms. This is impossible to do with a PHQ-9 score of less than 12. This would involve a person scoring three symptoms at “3”, the poor appetite/overeating symptom at "2" (a bit dodgy, but this might make up for the lack of a weight gain specifier in the PHQ item), and the self-harm score at “1”, given that suicidality need not be present most days. All other symptoms would have to be scored "0."

I have seen hundreds of PHQ-9s, and have never seen a profile like this. If a person scores 3 symptoms “3”, other symptoms are always present to at least some degree. But it is conceivable.

What isn’t possible is being truthful on the measure, getting a total score of 5 – or anything less than 12 – and meeting diagnostic criteria for MDE of ANY level of severity.

To meet criteria for MDE-Moderate, a person has to meet criteria for more than 5 symptoms or the intensity of symptoms must be significantly greater than that required for the cutoff – very unlikely without a score of at least 15. To meet criteria for MDE-severe the score would need to be significantly higher still.

The widely-used PHQ-9 cutoffs, if misinterpreted as describing Major Depressive Episode, simply do not match up with DSM-5 criteria.

Who cares?

Some versions of the interpretive guidelines for the PHQ-9 acknowledge the distinction between symptoms and disorders. Others don't. One set that is widely distributed on the Internet suggest that a score from 0 to 4 suggests "the patient may not need depression treatment." On the other hand, perhaps they “may” anyway. Maybe we all do, the guidelines seem to imply.

The “may” is arguably defensible. It’s possible that the patient simply didn’t understand the questions, or flat-out lied to minimize their problems. One could as easily say that if the patient neglects to complete the measure altogether they “may not need depression treatment.”

Most sets of guidelines seem to suggest to physicians and others that if a patient scores 5 or more, the best guess is that the person has Major Depressive Disorder. This is far enough wrong that it comes across in some cases as the result of deliberate distortion. It is no surprise that the PHQ-9 is embraced with enthusiasm by pharmaceutical companies hoping to sell product.

If physicians take the suggested cutoffs seriously, the result would be (has been, perhaps?) a mammoth rate of overdiagnosis of Major Depression. 

The main function of diagnosis is to point the way to treatment. The dominant form of treatment for depression in today’s healthcare system is the prescription of antidepressant medication. The risk, then, is that vast numbers of people not suffering from Major Depressive Disorder will be prescribed medication for normal-range mood disturbance.

The effectiveness of antidepressant medication has never been properly evaluated with this group. Recent reviews examining their effectiveness with the largest group of MDE sufferers – those meeting full criteria for the Mild form – suggest that it is very difficult to discern a therapeutic effect over and above the placebo response (Fourneir et al, 2010; Kirsch et al, 2008). Given this, it’s hard to imagine that the results would be more impressive if we actually had data looking at antidepressant effectiveness in the subclinical population.

What should we do?

I like the use of brief screeners, but I sometimes shudder at the thought of what people do with the results. At our clinic we use both the PHQ-9 (as mentioned above) and the GAD-7, but we treat the cutoffs as pharmaceutical-promotion literature and throw them away. We never diagnose based on screener results, instead using them as jumping-off points for formal diagnostic interview. This seems to retain the usefulness of the measures but compensates for their shortcomings.

A BONUS: Does your practice will involve diagnosing clinical depression? Maybe my online course "Diagnosing Depression Using DSM-5" can help. Click here to access this $25 course for 80% off, or just $5.  


Fourneir, JC, DeRubeis, RJ, Hollon, SD, Dimidjian, S, Amsterdam, JD, Shelton, RC, & Fawcett, J. (2010) Antidepressant drug effects and depression severity: A patient-level meta-analysis. Journal of the American Medical Association, 303, 47-53.

Kirsch, I, Deacon, BJ, Huedo-Medina, TB, Scoboria, A, Moore, TJ, & Johnson, BT (2008) Initial severity and antidepressant benefits: A meta-analysis of data submitted to the Food and Drug Administration. PLoS Medicine 5(2):e45.

Kroenke, K, Spitzer, RL, & Williams, JB (2001) The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16, 606-613.

YouTube VLog

I have now launched a YouTube VLog on psychological topics called How to be Miserable, with new posts every Tuesday and occasional Thursdays! Come take a visit and see what you think. Consider subscribing (just press the big red SUBSCRIBE button on the page) to ensure that new videos appear in your YouTube feed.  Here's the intro video:

Tuesday 23 September 2014

Assertiveness Skills: Constructive Feedback Versus Criticism

Unrelated, from hiking in the Rockies.
Communication can be a wobbly bridge.

A while back I was asked a series of questions about assertiveness by a feature writer for a European fashion magazine. Here's the complete set of questions and replies:

How does constructive criticism differ from criticism?

Criticism can be of several forms. Without trying to be exhaustive, we can divide it into several main types.

Much criticism can be looked at as a way of establishing dominance over another person. “You’re not doing that right” implies that I know something you don’t and therefore, in at least this area, I am superior to you. The surface message is about your hair/homework/job performance. The underlying message is “You are inferior to me; I am the boss here.”

Aggressive criticism is more an expression of frustration. The person is feeling blocked from a goal they have (maybe getting a report out to the boss by this afternoon), frustration builds and gets expressed. “Damnit Joan, get a move on!”

Neither type is usually very constructive, because it tends not to focus on specific behavioural changes that are under the control of the person being addressed.

Constructive criticism, by contrast, is an attempt by the person giving it to provide guidance on how the receiver can improve their performance. “Joan, I think it would help the quality of the report if you reviewed the spelling more carefully.” The intent is to benefit the person getting it – though if they act on the information and change their behaviour this might also benefit the person giving the feedback.

Do most people find it difficult to differentiate between the two and if so, what are the signs people can look out for to know which is which?

Constructive feedback generally focuses on a person’s behaviour (“Your shirt is untucked”) rather than on their character (“You’re a slob”), and usually indicates not only what is wrong but also something that could be done to improve it.

That said, there is often much to be learned from criticism that is not given to us in a really constructive way. If, on a new job, we see that the boss is getting frustrated with us but isn’t communicating a clear path forward (“This report is nonsense!”) then we might try to extract something useful from her (“Can you show me which part and I’ll try to sharpen it up for you?”). If, on the other hand, it’s only cranky Uncle Bill goading you again (“You’re going out dressed like a prostitute!”) we might suspect there is little more to learn and move on (“Good night, Uncle; we’ll see you next week”).

How can constructive criticism benefit your career/relationships/financial situation? Should we all be more open to constructive criticism?

None of us can see ourselves very accurately. Witness the tendency to try on a new outfit and ask a friend “What do you think?” – despite the fact that we are standing in front of a mirror. Without feedback, almost no complex skill (writing, interviewing, having sex, throwing a party, kayaking) can be learned well. Imagine learning to type but never being able to see whether we have made errors – most likely we would never get any better.

The problem many people have is that they immediately become defensive, often because they assume they are simply being attacked (“Shut up! I know what I’m doing!”). By fending off valuable information, they prevent themselves from improving.

How is the best way to deal with constructive criticism?

Notice any internal temptation to counterattack or self-defend. Ask yourself whether this is really necessary. It usually isn’t. Then, often, the best thing is to behave counter to our instincts and thank the critic, inviting them to clarify their feedback to make it most useful to us. “Thank you for reading the draft of my play, John. Sounds like you didn’t like the character development – could you say more?” When in doubt, treat the criticism as a gift and respond accordingly.

Should we always act upon the information given to us or can we ever ignore it?

The observer is providing feedback about their reaction to or evaluation of our behaviour. We might agree or disagree with their assessment.

In some circumstances we might go along with their judgment. If we are preparing a report for our boss to give to a client, it is her judgment that counts – we are simply her assistant or advisor.

In most life circumstances, though, we should take the criticism and add it to our existing storehouse of information, rather than throwing out our own judgment and replacing it with theirs.  “You like the fuchsia bell-bottoms better? I can see your point, and thank you for saying so, but I think I’m still going to go with the business suit.”

What is the best way to give constructive criticism? 

First, ask yourself what your goal in giving the feedback might be. If you give it, what do you think will change and how might this be for the better? Constructive criticism is always designed with an outcome in mind. You might achieve that outcome, you might not. But it isn’t just spewed out.

Next, focus on what the person can actually do to change. Don’t tell anyone to be smarter, more considerate, sexier, or responsible. No one has control over their own character. We do, however, have at least some control over our behaviour. Focus there. “I’d like you to arrive at work by 9 am.”

Express the feedback clearly and briefly. Letting yourself wait until you are in a rage and then delivering a ten-minute sermon on the other person’s failings is never helpful.

In general, give constructive criticism privately. When others are present your receiver will have divided attention – partly they may be trying to listen to your message, but partly they will be conscious of the reaction of the others present and fearful of public humiliation.

Should the person giving the criticism include positive points to soften the blow? 

Yes, almost always it is useful to include the positive in the message along with the corrective feedback. If all you focus on is what’s wrong, the person may not know what to fix. They may also sense that you hate everything about them or what they have done. “The salad looked terrific and the service was just right. But the dressing tasted unpleasantly fishy to me.” This narrows and sharpens the message to the bits on which you most want the other person to focus.

Sometimes you might deliver the most important part of the message but omit parts that seem less essential. To your son heading out on his first date you might say “Your hair looks great” (a bit long for my taste but it’s too late now so I won’t mention it) “…but you know those pants are looking a bit short on you – what would you think of the black ones you got last week?” (I’ve always thought the slogan on that hoodie is stupid but it’s your favourite and I’ll never win that battle so I’m keeping my mouth shut about it.)

Tuesday 9 September 2014

Upcoming Presentations in Vancouver: September 2014

In September I will be presenting a pair of programs – one free and for the public; one a two-day training workshop for clinicians.  Here are the details:

Tuesday September 23 at 7 pm

Slippage: The Gap Between Perception and Reality
Alice MacKay Room, Vancouver Public Library

Has anyone ever told you that you don’t live in the real world? They were right: you don’t. But neither do they. We instinctively feel that our emotions and actions are based on the events around us, but our reactions are based on what we think is going on, not what is really happening. This talk examines the interface between the real world and our perception of it, pointing out some systematic ways that what we see differs from what is actually out there.

This free talk is part of the PsychologySalon series cosponsored by VPL and Changeways Clinic. The Alice MacKay Room is located beneath the concourse at the Central Branch, 350 West Georgia.

Wednesday-Thursday September 24-25

The Core Program: Evidence-Based Group Treatment for Depression

The Changeways Core Program is the most widely-used group depression treatment protocol in Canada, and has been implemented in Australia, China, the United States, and Great Britain. Arabic, Spanish, French, and Farsi editions are available at no extra charge.

Designed from a cognitive-behavioural and psychoeducational perspective, this evidence-based program is designed for adults coping with depression or adjusting to difficult life experiences. The two-day training workshop provides all the materials necessary for professional therapists to offer this program - in a group format, or as an adjunct to individual therapy.

This program is approved for 13 CE credits from the Canadian Psychological Association.
For further information, including online registration, click here. For a preview of the online course on the same subject, click here.

Tuesday 26 August 2014

Review: Mania - A Short History of Bipolar Disorder by David Healy

Johns Hopkins University Press, 2008, 296 pages
Mental Disorder: Cultural or Biological?

Are mental illnesses biological or cultural? Do they emerge from a malfunction of brain development or biochemistry, or are they a product of the society in which they appear?

The answer to that question has profound implications for a science of mental health. If mental illnesses are primarily biological in origin, then effective treatment must at some level have a biological impact – and an edge is given to strategies that focus directly on the body: pharmacology, surgical interventions, and the like. The edge is not an outright win: Type 2 Diabetes is unquestionably a biological ailment, but it is often managed behaviorally; ditto chronic pain, much heart disease, and many other documented physical conditions.

If mental illnesses are predominantly cultural/psychological in origin, then treatment must surely address life and lifestyle rather than relying exclusively on pharmacological assists. One of the battles in mental health currently has to do with the reliance on antidepressant medication for depression in cases where the decline in mood and motivation seem clearly tied to circumstance.

In a related vein, the answer might be important in guiding public education efforts. If a biologically-caused and easily-treated disease sits, undiagnosed, in a population, then it makes perfect sense to spread awareness and try to ferret out the hidden cases so that they can be resolved.

If a disorder is cultural, public education efforts might inadvertently “spread the culture,” resulting in more cases. The fashions we see in mental illness – hebephrenic schizophrenia, bulimia, glove anaesthesia – suggest that we may be dealing with memes rather than genes.

In Crazy Like Us (reviewed earlier here), Ethan Watters documents the apparent spread of previously-rare anorexia nervosa in Hong Kong society following a well-intended public education campaign. Some clinicians, myself among them, now regret having taken part in “Depression Screening Day,” an annual patient-finding exercise funded in part through the altruism of the pharmaceutical companies who would then profit from selling product to the (almost invariably subclinical) cases thus discovered.

The Biopsychosocial Model

The traditional dodge to the physical/cultural dichotomy is to speak of biopsychosocial origins of mental illness.  Although appropriately inclusive – most problems have elements of all three (bio, psycho, and social), it can also be a way of avoiding the question. “It’s caused by something or other and we’re not going to look much further.”

It seems clear that the answer varies by illness. No one doubts the biological component of Down Syndrome, nor the experiential element in post-traumatic stress disorder, for example.

One disorder that most clinicians believe to be predominantly biologically-“loaded” is bipolar disorder. One reason for this is the often-miraculous effects of an appropriate dose of lithium in resolving a manic episode. Another is the existence of accounts of what can sound like bipolar disorder in the historical record. Cases described by Hippocrates, are often repeated at conferences as clear evidence that bipolar disorder is a “real” – that is to say biological – disorder, one that has been with us for millennia but only properly understood recently.

Mania: A Short History of Bipolar Disorder

David Healy is widely known as a psychiatrist and historian of psychopharmacology – and as a harsh critic of the role of the pharmaceutical industry in the research and testing of its own products. As a part of the Johns Hopkins University Press series of “biographies” of diseases he has traced the appearance of mania, melancholia, and bipolar disorder from Hippocrates to the present in a fascinating act of medical detective work that reads – at least to mental health nerds – like a whodunit. Maybe a whohasit or a whatisit.

Healy takes a closer look at Hippocrates than is customary, and as usual this reveals that things are not as simple as they seem. Take the story of the woman at Thasos, often cited as proof of the ancient existence of bipolar disorder:

A sensitive woman became unwell, having been sad after a loss, and although she did not take to her bed, she suffered from insomnia, loss of appetite, thirst, and nausea…[Later] she leapt up and could not be restrained. She began raving…

Is this an early case of bipolar 1 disorder?

Healy fills in the ellipses from Hippocrates' account with the deleted details, including fever, spasm, severe pains, and black urine “with substances floating in it.” Suddenly the bipolar picture dissolves, and the details recounted in modern times seem almost to have been deliberately selected to tell a story, as though they were cobbled together by a team from Fox News.

Healy shows that most of the ancient cases held up as examples of bipolar disorder do not fit the description of the modern ailment. Presentations that sound a bit like mania were more likely delirium, and many of the cases – particularly the postpartum ones - seem to have involved severe infections.

Well, so what? The ancients didn’t know what they were looking at, so it’s no surprise that they confused things. But Healy points out that very clear descriptions of other diseases can be clearly identified in the writings of Hippocrates and others. He makes a case that the search for historical precedents for bipolar disorder has been subject to a profound case of confirmation bias – if not outright distortion. As he continues to trace its history, bipolar disorder shimmers at the edges and fades as a distinct ongoing entity.

From ancient times Healy jumps fairly quickly to the 1800s, where he picks up the thread, looking at writers attempting to delineate the boundaries of mental normalcy and illness. He covers the creation of the asylums and the types of difficulties that might land a person within their walls. He talks about early psychiatrists, the alienists, who seem to have described mania and manic depressive illness first. He goes into detail on the lives and contributions of early classifiers of the types of disorder, including Falret, Baillarger, Kahlbaum, and (eventually) Emil Kraepelin.

Some of the best passages in the book concern the files of the Denbigh Asylum in North Wales, opened in 1848 and serving an area that had a relatively stable population for over a hundred years. This multi-year time capsule offers the opportunity to review shifts in symptomatology and diagnosis over time – and raises questions about the incidence of bipolar disorder.

“Sifting through 3872 admissions from North West Wales between 1875 to 1924, it becomes clear that bipolar disorder patients are hard to find. Only 127 such patients were admitted for the first time during this period. This gives rise to 10 cases per million per year, a rate that remained constant across fifty years and continues to hold true to today.” (p. 86).

He further states “there were few if any patients in the Western world described as having manic-depressive disorder before the 1920s. In the United States, few patients had this disease before the 1960s.” (p. 20)

Later he traces the marked upswing in diagnosis: “The National Comorbidity Study reporting in 1994 estimated that 1.3 percent of the American population had bipolar 1 disorder alone. By 1998 Angst was reporting that 5 percent of the population had bipolar disorder of one or another sort.” (p 149)

Treatment Issues

The second half of the book focuses on the treatment of bipolar disorder, including the discovery of lithium’s effects and the subsequent adoption of a variety of other medication-based approaches. This area, the history of psychopharmacology, is Healy’s great forte and his grasp of both the published literature and the backroom politics seems formidable.

Healy reviews how marketing strategy dictated much of the professional education about bipolar disorder for decades, and how this shaped the field and the public consciousness (including the spread of the previously-unheard-of practice of diagnosing very young children with bipolar disorder, then commencing medication treatment using antipsychotics).

Healy’s sense of outrage is palpable regarding how profit motives have distorted the careful development of knowledge about mental illness and its treatment. In reserved though sometimes acid prose, he builds his case that although bipolar disorder is a genuine and treatable condition, it has been subject to such marketing pressures that it has become difficult to see the reality through the haze of disinformation.

The book is seemingly focused narrowly on mania, making it appear to be a marginal reading choice for most clinicians. But Healy has expanded the topic well beyond these boundaries, creating a sweeping and entertaining history of mental health as a whole. He does not shy away from controversy, and it is clear he has no great fondness for the present state of his field.

I sometimes wonder what I would say if someone asked me for a mental health syllabus – something that no one is ever really likely to do. This book would unquestionably be on that list. In fact, I would regard it as essential reading for any clinician treating the mood disorders.

Monday 4 August 2014

Resources: Welcome to the NHK and the Hikikomori Phenomenon

On Tuesday November 18 at 7 pm at the Vancouver Public Library I will be offering a talk entitled “Failure to Launch: The Lost Boys Phenomenon,” about the huge numbers of young, anxious, and unmotivated males who remain in their parents’ home, neither working nor attending school, all but housebound.

Although often bearing strong similarities to agoraphobia and social phobia, this phenomenon does not fit comfortably within any established formal diagnostic category. Nor should it, in my view. We have defined quite enough aspects of human experience as diseases, thank you very much.

The lack of a diagnostic label, however, has meant that different practitioners and researchers have observed and reported on the phenomenon almost independently of one another. Consequently, we have multiple accounts from different countries from different perspectives that are relatively untainted by preconceived notions imposed by the early investigators.

Shoshanna Campbell, helping out at Changeways Clinic for the past few months, has been looking through some of the research for this talk. She has unearthed papers on the topic from cultures all over the world. In Great Britain, for example, the term most often used is NEET – Not in Employment, Education, or Training.

The largest literature, however, comes from Japan, where these young men are known as hikikomori.  Nowhere on Earth has the problem penetrated popular culture like it has in Japan, where estimates have been made that there are an estimated 700,000 young people living these sharply restricted lifestyles. (Estimates for the incidence of issues related to mental health are almost always exaggerated, so it’s best to take these numbers with a grain of salt.)

Hikikomori regularly appear in the news and other media in Japan. In 2002, Tatsuhiko Takimoto published a novel with hikikomori characters, Welcome to the NHK, that was subsequently made first into a manga series and then into an anime television series.

Although I’m not generally an anime fan, I’ve spent part of the past week going through this series (available in a dubbed edition in North America). I have repeatedly been struck by the insights in the series and how closely the experiences of the characters mimic those of clients I have seen in therapy.

These individuals inevitably feel alone and unique. Because they know almost no one, they meet few who are similar to them. I’ve thought often while viewing Welcome to the NHK that I wish my clients could watch the series. Most would be astonished to find aspects of their own lives played out on screen, appearing within the setting of a Tokyo apartment block.


The series begins by introducing us to Tatsuhiro Sato, a 22-year-old who dropped out of college four years before the series begins after suffering what seems to have been a severe panic attack. He has lived ever since inside his tiny one-room Tokyo apartment, imagining that the NHK (Japan’s real-life public broadcaster, but within the context of the series a more wide-ranging organization) is behind a national conspiracy to create hikikomori by producing addictive programming – a delusion that persists and reappears when he is under stress. He rages against his next-door neighbor who blares theme music from an anime series apparently designed for young girls.

The neighbor turns out to be his old school friend Yamazaki, who would be hikikomori himself if he did not have to get out for classes at a school for game designers. A mysterious girl, Misaki, recruits Sato into her “project,” which is to cure a hikikomori with a mix of Freud, Jung, and exposure-like excursions into the outside world. Along the way we encounter suicide clubs, multi-level marketing schemes, polypharmacy, internet pornography addiction, and “girl games” designed to appeal to dateless young men.

The two young men become inspired to create the girl game to beat all girl games, using their ability to understand the longing and isolation of the players of such things as their trump card. I found myself concerned at this point, given the American imperative that any such quest must pay off with wild success in the end, thus countering any shred of realism in the plot up until that point. But Welcome to the NHK has bigger fish to fry, and chooses instead to side with a more sobering reality. The resolution they seek is a relinquishment of narcissistic self-aggrandizing fantasy and a coming to terms with the real world.

Episode 1, the link to which is below, gives something of the flavour of the series, though the conspiracy element quickly fades to the background in subsequent episodes only to recur in snippets. Watching the series should probably come with Continuing Education credits for professionals, given that it constitutes a virtual seminar on the inside world of the problem. At least some episodes are available on YouTube, and the full series is available on DVD (e.g., at Amazon).

Why might Welcome to the NHK be useful for western clinicians? 

Attend any North American seminar on an established phenomenon, and it will tend to resemble other local examinations of the same problem. Attend three seminars and you can sleep through the fourth: Nothing new will be said.

But view a phenomenon from the perspective of another culture, and the focus will be on elements that you have not seen highlighted in programs from your own culture. As a result, it is often possible to learn more from programs from another culture than those from your own – even if you’re not trying to cultivate your cross-cultural sensitivity.

Welcome to the NHK is a terrific introduction to NEETs, Hikikomori, Lost Boys, and the Failure to Launch phenomenon – both for professionals and for those currently stuck in such lives. The series includes difficult elements (including recurrent references to suicide), so it’s best not prescribed unless the prescriber has first watched it in its entirety. Luckily, that’s not hard to do.

Frankly, I’m surprised the English-language distributor, Funimation Entertainment, hasn’t targeted the clinical market, given that the product they are sitting on is so completely suited to it.

YouTube VLog

I have now launched a YouTube VLog on psychological topics called How to be Miserable, with new posts every Tuesday and occasional Thursdays! Come take a visit and see what you think. Consider subscribing (just press the big red SUBSCRIBE button on the page) to ensure that new videos appear in your YouTube feed.  One of the primary topics will be the Hikikomori phenomenon. Here's the intro video:

Online Course

What if one wants to overcome this tendency? One strategy is to seek the assistance of a qualified psychotherapist - preferably one trained in cognitive behavior therapy.

In addition, our clinic has developed a cognitive behavioral guide to self-care for depression. The strategies for working with depression and those for establishing one's adult life are extremely similar. 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 8 July 2014

Online Course Launch: Diagnosing Depression and Related Mood Disorders

Several months ago we launched the online course “What is Depression?” for the general public. It provides information on each of the major mood disorders and their symptoms, as well as an overview of depression epidemiology. This course has done very well, attracting over 800 students in a remarkably short period of time. We still have a 40% offer for that course, enabling people to take it for $12 instead of $20. Here’s the link:

Now we have launched a companion course, this time designed for healthcare professionals. The course is called “Diagnosing Depression and Related Mood Disorders” and is available for $15, which is 40% off the list price of $25. Here's the link for the discount:

Here’s the preview video:

About the Course

Diagnosing Depression provides over 2.5 hours of content spread over 17 brief lectures, plus 30 pages of course notes in downloadable pdf format.

The course is designed for healthcare professionals (and students in healthcare professions) wishing to learn more about the mood disorders and their diagnosis in clinical settings. The emphasis is on the symptoms and the experience of mood disorders, rather than on causes or treatment strategies. Much of the course is geared toward diagnosis, using the formal manual criteria to evaluate client behavior and reported symptoms in the clinical setting.

Course Goals

  • Identify the formal diagnostic criteria for each of the major mood disorders, including major depressive disorder, bipolar disorder (1 and 2), cyclothymia, persistent depressive disorder (dysthymia), and the related categories.
  • Learn strategy for assessing major depressive episode, manic episode, and hypomanic episode.
  • Learn how the various criteria translate into actual in-office client presentation, and how to make the "line calls" between clinical and subclinical presentations.
  • Learn the additional non-diagnostic symptoms associated with depressive episodes and major depression, to develop an understanding of the internal lived experience of these disorders.
  • Learn about the basics of mood disorder epidemiology.
  • Understand current controversies in the field of mood disorder diagnosis, including: Arguments about the utility of diagnosis in guiding treatment decisions; the controversy about the elimination of the bereavement exclusion for Major Depressive Disorder in the most recent revision of the diagnostic manual; and the problems associated with diagnosis of hypomanic episode, particularly in the young, and the apparent trend toward overdiagnosis of bipolar 2 disorder.

Sample Lecture Topics

The Floating Diamond Model - A strategy for parsing the depressive experience into physiological, cognitive, emotional, and behavioral aspects. This is useful conceptually for clinicians, patients/clients, and family/friends/supporters.

Major Depressive Episode - Separated into lectures on a) the critical mood-related criteria, and b) the remaining criteria.

Diagnosis of Major Depressive Disorder.

Nondiagnostic experiential aspects of the depression experience; and an examination of the manner in which symptoms self-perpetuate and magnify one another ("snowballs and reverberations").

Minor depression and dysthymia, or persistent depressive disorder - Including diagnostic criteria for the latter.

Bipolar disorders - Including strategies for diagnosis of manic and hypomanic episodes, bipolar 1 and 2 disorder, and cyclothymia.

Other mood disorders - Including premenstrual dysphoric disorder and the array of "miscellaneous" categories for individuals who do not meet criteria for the primary syndromes.

Epidemiology - A brief consideration of issues such as gender ratio, age of onset, cost of mood disorders to society, and the possibility that mood disorders are increasing in prevalence.

Group Rates

Group practices, employee assistance firms, HMOs, public agencies, professional organizations, and health regions may wish to purchase multiple spaces for their own employees. We are able to arrange discounts for groups of more than 5, with steadily greater discounts for groups of over 10, 50, 100, and 500 employees. To discuss the program or arrange a group discount, simply contact us.

Monday 16 June 2014

Why is stress such a big deal?

The life raft that sinks us.

The other day someone raised a question that I think lurks on the edges of a lot of people’s minds when they think about stress.

Why is it such a big deal?

We hear about it constantly, it’s implicated in any number of diseases, it supposedly contributes to premature mortality – and it’s designed to help us. How is it, exactly, that the lifeboat on this ill-designed ship we call a body causes us such trouble?

I think there are three main reasons for this.


The word “stress” has gradually crept away from the meaning normally assigned to it by researchers: a shorter form of the term “stress response” - by which we mean a specific set of bodily changes that tend to co-occur in response to a perception of threat (or the external circumstances capable of eliciting such a response.

Stress has come to mean anything we don’t like. Unpleasant people, disappointing workplaces, boredom, disillusionment, anything at all that we might place in the “minus” category of human experience. If it’s bad, it’s stress. The boundaries have blurred and grown over time.

As well, our culture seems to have shifted away from the acceptance of discomfort as a natural component of life. Everything we don’t like has become pathologized. If we can’t pin a diagnostic label on an experience (social phobia on shyness, ADHD on distractibility, depression on sadness) then we tend to use the catch-all term stress.

But even if we take a sharp knife and cut away all the extras, chronic elevation of the stress response remains a major problem for the human body. So there has to be more than just sloppy usage involved.


When we talk about stress, it is de rigueur to say that the stress response in not necessarily a bad thing. It’s a helper response that will almost certainly prove useful at some point in most people’s lives. We will need to run quickly from an assailant or fight hard if he catches us. The problem is that the response switches on in many situations where it is not needed – indeed, where it may actually degrade our ability to cope.

While undoubtedly true, this soundbite of therapyspeak tends to beg the question. If the stress response is going to be useful once every 30 years or so, the advantages seem likely to be outweighed by the risks of heart disease, diabetes, depression, and the array of other ailments and dissatisfactions that stress is thought to bring on.

We reply to those questions by pointing out that the response evolved in primitive environments that were more – well, exciting than the present day. This is usually enough so that people nod and allow us to move on to a litany of stress reduction techniques.

But we probably don’t go quite far enough. Life in the natural world is far from a Disney movie, where occasional bursts of violence are isolated by long stretches of interspecies harmony and inspiring Phil Collins songs. Nature really is red in tooth and claw. Survival is not a matter of once-a-generation tiger attacks. It is a daily struggle involving an oscillation between attack and withdraw (the ratio being determined in part by the species in question). In the natural world, the stress response is not the emergency lifeboat. It is the only boat.

The Human Brain

The stress response appears to have developed long before the appearance of humans, and it spread throughout the animal world. We inherited it along with the appendix, male nipples, and a spine questionably suited to bipedal locomotion. Doubtless in a primitive environment the advantages of the stress response still far outweighed the disadvantages. But the development of the brain brought with it an additional challenge, nicely laid out by Robert Sapolsky in his popular book Why Zebras Don’t Get Ulcers (1994).

Dogs, cats, and other familiar animals seem to have a fairly elaborate emotional system and clearly have a stress response. This response is readily activated in the presence of clear and present danger, just as it is in humans. But cats don’t seem preoccupied with memories of past humiliations, and dogs don’t seem concerned about tomorrow’s trip to the vet. They may have strong associations of threat with certain stimuli. For example, a dog that has been mistreated by a male human will show a stronger fear response around males than to females, but it does not appear to be brooding on the evils of men when none are present.

Humans, on the other hand, have a well-developed capacity to react emotionally not only to events in the present, but also to memories of the past and fantasies of the future. The armed robber in the bank lineup ahead of us will surely cause our heart to race, but so will memories of the robbery last week or fears of the same thing happening when we go to the bank tomorrow. Although there may be some adaptive advantage to the stress response in some immediately threatening situations, there is no point whatsoever in mounting a full stress response when we are away from all threats.

This feature of human emotional life means that we are capable of activating any and all of our emotions simply by calling to mind mental representations (images, memories, fantasies) of events that are not actually occurring at the moment. We don’t know to what extent this sets us apart from the animal world. It’s possible that our closest animal relatives have some capacity for forethought or episodic memory, but this likely diminishes substantially as we move down the brainpower scale.

The present emphasis by psychologists on mindfulness is largely a response to this capacity of the human brain. Much – almost certainly most, at least in the wealthy parts of the world – of our misery in life arises from our tendency to detach our attention from the present moment and focus instead on past and future. And not just any past and future, but the most exciting bits we can come up with.

In our mental film festival we ignore the pastoral scenes and family comedies and relentlessly play the horror movies over and over again. In so doing we inadvertently rehearse our unhappiness until we have honed it to a fine art, losing much of the capacity for reflection, appreciation, equanimity, and gratitude.

*  *  *

Are there other factors accounting for the frequency with which we dwell on the topic of stress? Probably. But those are some of the biggest.

Wednesday 21 May 2014

Online Course Launch: What Is Depression?

Announcing a new PsychologySalon online course: What is Depression?

Here’s a preview:

For the launch we are offering spaces in the course for just $5 for a limited time. This is a discount of 75% off the normal price of $20. The coupon code to use is "launch25" and can be reached via the following link:

This course is designed for the general public, though mental health professionals may also find it useful.

The emphasis is on the diagnosis and the experience of depression and related mood disorders. The causes of depression are not covered, nor are treatment strategies (though there are hints and recommendations throughout). Future courses will emphasize risk factors and treatment strategies more thoroughly.

Why talk so much about diagnosis? 

One of the central problems in mental health has been the shifting line dividing what we think of as normal-range distress from the territory labeled clinical disorder.

Life is difficult. We will all experience declines in mood and, yes, functioning at times in our lives. Mood has become medicalized, however, and it is difficult to experience these periods without wondering whether we are clinically depressed.

In fact, the majority of people referred to Changeways Clinic for mood disorders do not meet diagnostic criteria for any clinical disorder and, as far as we can tell by retrospective interview, never have. Perhaps by learning about the actual definitions of the various mood disorders, many people will be able to reassure themselves that they are distressed, but well.

If you are not clinically depressed, does treatment work? 

That depends on the treatment. Many of the lifestyle-based approaches that therapists advocate have been researched on both clinical and subclinical groups, and seem helpful for both. Exercise, watching your diet, managing your sleep, boosting social contact, and developing an awareness of distortions in thinking – all of these seem helpful whether one is clinically depressed or not.

Most medical treatments have only been researched with people who meet full diagnostic criteria – and there are indications that the milder the symptoms a person has, the less distinguishable medications are from the effects of placebo. Yet the majority of individuals prescribed antidepressant medication in Canada probably do not match the description even of mild major depressive disorder. They are part of a group on which such medications have never really been tested and appear likely to be ineffective.

So it can help to realize what depression really is – and to learn about some of the controversies in the field.

The course provides over 2 hours of content in 12 lectures: 

Lecture 1: Depression versus The Blues. Depression is both a diagnosable condition and a word in common usage. Where is the dividing line – and is depression qualitatively different from what most people experience?

Lecture 2: The Floating Diamond Model. Often called a “mood disorder,” implying that depression affects primarily the emotions, depression actually changes a person’s physical functioning, behaviour, and thought processes as well.

Lecture 3: Major Depressive Episode – Mood-Related Criteria. The diagnostic criteria for major depression are divided into two sets. This lecture considers the two primary mood criteria: sadness and anhedonia.

Lecture 4: Major Depressive Episode – Other Diagnostic Criteria. A consideration of the remaining seven symptoms used in diagnosing major depression.

Lecture 5: Major Depressive Disorder. The diagnosis of Major Depressive Disorder depends on the person having had at least one Major Depressive Episode – and meeting a few other rules besides. Plus, we talk about a controversy – can a person with recent bereavement be diagnosed as depressed?

Lecture 6: Additional Symptoms of Depression. The diagnostic list does not cover all aspects of the depressive experience. Here we go back to the Floating Diamond and cover more symptoms people often experience.

Lecture 7: Snowballs and Reverberations. Whether a person is experiencing full depression or only the blues, the symptoms can feed back and make the problem worse – often by making positive action seem less appealing and inactivity more tempting.

Lecture 8: So is there Minor Depression? If clinical depression is called Major Depression, what would Minor Depression be? Is it a real disorder? Here we consider the risks of pathologizing normality – even distressing normality.

Lecture 9: Dysthymia (Persistent Depressive Disorder) What if subclinical depression goes on and on and on? Eventually we might consider it a disorder. A major challenge with dysthymia is that it promotes a lifestyle and pattern of thinking that perpetuate the problem.

Lecture 10: Bipolar Disorder Mood can go problematically “high” as well as low. Here we consider the diagostic criteria for mania, hypomania, and the bipolar disorders.

Lecture 11: The Epidemiology of Depression. Who gets depression? How common is it? What does it cost the culture? Is it becoming more common with time?

Lecture 12: Course Wrapup. This isn’t a treatment or self-care course, but in this final lecture we provide some basic recommendations for self-care.

Coming Soon

We have more courses in the works and hope to launch them shortly. First up: A course for physicians and mental health professionals on the diagnosis of mood disorders. Stay tuned!

Tuesday 6 May 2014

Religion for Atheists, by Alain de Botton

Alain de Botton, founder of London’s School of Life (, is one of my favourite authors. His specialty is best summed up as “practical philosophy”, and his books could easily form a multi-year syllabus at the philosophical cafĂ© nights that are currently popular.

His books range from the usefulness of Proust (How Proust Can Change Your Life), to the effects of urban and dwelling design on emotion (The Architecture of Happiness), to the unintended effects of a culture based on equality (Status Anxiety). In each book, de Botton pushes beyond the obvious to examine issues of the everyday in a serious and insightful way.

Religion for Atheists (2012) asks whether the trappings of faith might offer significant psychological benefits - apart from the possibility of “getting the right answer” and securing an advantageous position in the afterlife (if any).

In this book he takes it as a given that the various deities are of human construction, and that if there are hidden influences beyond the natural world, they probably do not resemble our visions of them. This may be an annoyance to the religious, but I would advocate sticking with the book anyway.

De Botton dismisses virgin birth, resurrection, salvation, and all the rest with breathtaking speed not, it turns out, from scorn but simply because he is hurrying toward a series of observations that form his real topic. He has none of the impatient superiority that crop up so frequently in writings on atheism by Christopher Hitchens, Richard Dawkins, and others (I’ve read and enjoyed some of these books, but the sneering is always a barrier).

I suspect most of us have at one point or another considered or talked about whether religion has any usefulness if it turns out not to be based on an accurate understanding of the universe. It gives people a place to go, it provides an instant social network, it encourages thinking outside one’s own self-interest… and soon the conversation dries up, the topic apparently exhausted.

Well, it isn’t. There’s 312 pages to go. And in de Botton’s hands much of it is a fairly harsh critique of secular society, complete with expressions of sincere respect for the concerns of theology. Religion, he argues, accepts that earthbound life is often distressing, disappointing, and tragic, whereas much of secular thinking rejects this:

Despite occasional moments of panic, most often connected to market crises, wars, or pandemics, the secular age maintains an all but irrational devotion to a narrative of improvement, based on a messianic faith in the three great drivers of change: science, technology and commerce. Material improvements since the mid-eighteenth century have been so remarkable… as to deal an almost fatal blow to our capacity to remain pessimistic – and therefore, crucially, to our ability to stay sane and content… The secular are at this moment in history a great deal more optimistic than the religious – something of an irony, given the frequency with which the latter have been derided by the former for their apparent naivety and credulousness. (p. 182-3)

Why, it’s tempting to ask, might pessimism be so valuable? It sets the bar of expectations low, enabling real life to exceed it. By emphasizing unreachable ideals (we can all be president, we are all perfect just as we are, we can have inexhaustible happiness), we inevitably set ourselves up for disappointment. In an admittedly caustic example, de Botton considers marriage:

The benefits of a philosophy of neo-religious pessimism are nowhere more apparent than in relation to marriage, one of modern society’s most grief-stricken arrangements, which has been rendered unnecessarily hellish by the astonishing secular supposition that it should be entered into principally for the sake of happiness… In their effort to keep us from hurling our curdled dreams at one another, the faiths have the good sense to provide us with angels to worship and lovers to tolerate. (p. 185-8)

De Botton’s analysis is admirably wide-ranging. He talks about his passions of architecture and art, pointing out that religions have always appreciated the impact of buildings on psychological states, whereas the secular world has given us Stalinist tower blocks, faceless cities, and alienating housing. Stripped of the requirement to send a theological message, much modern construction is more a testament to the designer’s ego, the developer’s budget, or the desire to impress with ultimately unappealing stunt architecture.

Rust Belt Chic: Medium-Security Prison, or Inexplicably Hard-to-Sell Vancouver Condo Block?

He argues that religion has always had a deep appreciation of the use of multiple media in communicating its message. Theology finds its expression not just in dry books or sermons, but also in ritual, in the design of buildings, in music, and in art. By contrast, secular culture tries – and often fails – to get by with text alone.

In a surprising move, de Botton argues that one of the pinnacles of religious achievement has been in branding and international distribution:

It is a singularly regrettable feature of the modern world that while some of the most trivial of our requirements (for shampoo and moisturizers, for example, as well as pasta sauce and sunglasses) are met by superlatively managed brands, our essential needs are left in the disorganized and unpredictable care of lone actors. (p. 289)

And for emphasis, he draws aim on the field of psychotherapy, fires, and scores a direct hit.

For a telling illustration of the practical effects of branding and the quality control it is typically accompanied by, we need only compare the fragmented, highly variable field of psychotherapy with the elegantly discharged ritual of confession within the Catholic faith…. Psychotherapy as currently practiced lacks any consistency of setting or even any benchmarks for such apparently small yet critical details as the wording of the message on the therapist’s answering machine, his or her dress code and the appearance of the consulting room. Patients are left to endure a run of local quirks, from encounters with their therapists’ pets or children to gurgling pipework and bric-a-brac furnishings. (p. 289)

He goes on, but you get the idea. He is not an ardent anti-therapy activist, in case you wonder – the School of Life offers psychotherapy as one of its many activities. Psychotherapists have sometimes been described as the priests of the secular age. If so, de Botton argues, we aren’t doing a very good job at it. I’d have to agree.

De Botton’s book is an obvious choice for thoughtful atheists – at least those not consumed by rage or contemptuous superiority over the topic of religion. But as I was reading it struck me that his appreciation of the role of religion in psychological life is so thoughtful and ultimately respectful that believers might get even more out of reading it. A shame that the title will likely put them off.

Oh, and - too busy for this book? Here's his TED talk: