Why You Should Never Read Online Illness or Medication Forums, and Why You Should be Skeptical of Google Search Results as Well

The first thing many people seem to do when they get a diagnosis of a physical or a mental illness is to go to the internet and search on that illness. Patients who are prescribed medications do the same. Often the search results lead to internet forums. These forums consist of user-generated content that usually is not moderated or edited by any professional. Anyone can post on these forums. This seems reasonable, right? But in this article I’m going to tell you why, for the most part ,you should avoid reading these forums. And I will also tell you why you should be skeptical of Google search results regarding any illness.

When people read on forums about their illness or medication, they get scared. Many of the forum posts will say that your illness leads to awful and dire outcomes, and that the medications prescribed to you will make you depressed, addicted, or crazy.

For instance, I often treat tinnitus patients. Samplings of the forums that cover tinnitus suggest that most of the people who post on these forums are completely miserable and suffering terribly from their tinnitus.

So what’s the problem here? Isn’t this useful information? Can’t patients learn something interesting and helpful from these forums?

Unfortunately, Internet illness forums often present a distorted, grim, and negative impression of most illnesses and most medications. Why is this? The main reason is because of selection and sampling bias. The groups of people who post on illness forums are not a representative sample of people with a particular illness. Let’s use tinnitus as an example. If you read the tinnitus forums you would assume that everybody with tinnitus is anxious and depressed about it.

But actually, we know from research studies that roughly 20% to 40% of the population experience tinnitus symptoms from time to time. We also know that roughly 2% of people who have tinnitus symptoms suffer psychologically. So the data from research suggests that a small subset (2%) of people who have tinnitus symptoms suffer anxiety and depression as a result of their tinnitus. Most people (98%) with tinnitus symptoms do not suffer significantly or they have adapted over time and gotten over their suffering.

But the forums are full of posts from the people who suffer the most. People who don’t suffer don’t spend their time posting. And people who have overcome their suffering also don’t post. So reading the forums gives a tinnitus patient a distorted and scary view of the experience of tinnitus.

The other problem in reading internet information about illnesses is the way that Google Search ranks and orders search results. When you search on tinnitus, what you might not realize is that Google presents pages in order of popularity, not in order based on how accurate or scientific they are. Sites that are clicked on more frequently will rise up in the Google search results and sites that are clicked on less frequently will fall down. When you do a Google search people typically click on the most shocking and scary links. “Tinnitus caused by alien abduction” will get a lot of clicks even though it may represent a site run by a single person who claims to have been abducted by aliens. Thus the alien abduction tinnitus site will move up in the Google rankings.

Boring scientific sites fall down in the search rankings. That’s because they have scientific names that don’t encourage people to click on the links.

So how can patients get accurate information about their illness or about medication treatments?

One way is to search within scientific and medical sites. For instance, Medscape is an excellent website that offers medical articles about almost every illness. WebMD is another site more designed for lay people, which also offers good information. If you want to search scientific articles you can use the PubMed search engine which searches published research articles.

Let’s do a Google search on tinnitus. Overall, the 1st page of Google results is pretty representative of medical and scientific sites. But the 3rd listing titled “In the news”, is an article “Martin McGuinness tells of misery living with tinnitus,” from the Belfast Telegraph. Pretty grim, you think, misery!

But if you actually clicked through to the article you would get a very different impression because Martin McGuinness actually says that “it had a limited impact on day-to-day life and work and that family, friends and work colleagues were very supportive.… It does not limit me in a professional or personal capacity.” This is a much more positive view than suggested by the title and the Google link.

This is a great example of why the Internet is dangerous. The headline is what’s called click bait, a link that falsely represents the actual page, which is designed to attract people’s clicks.

Forums about medication are also problematic. Many psychiatric medications can have side effects. For most people these side effects are minimal or tolerable and are overbalanced by the benefits of the medications. For a minority of patients, the side effects are not minimal and these are the patients who are over-represented in most Internet medication forums. Also, on an Internet forum you never really know all of the medications the person is taking, the accurate dosages, as well as their underlying illness.

There is one more problem with reading about illnesses on the Internet. It’s one that particularly disturbs me. Many websites, even websites that purport to be objective, actually are selling something. They may be selling a supplement or vitamin, or an e-book or some other kind of program to treat an illness. Obviously, to increase sales, these commercial websites will paint a distorted negative picture of any illness or condition. They may also disparage other more traditional and scientifically validated treatments or drugs. In general, you should be skeptical of any information that comes from a website that sells products or services.

To review:

  1. Take Google search results with many grains of salt. Remember that Google orders search results by popularity not by accuracy.
  2. Beware of Internet illness and medication forums. By and large, they are populated with an unrepresentative sample of illness sufferers, the ones who suffer the most and cope the least well. Reading them will depress you and make you anxious.
  3. If you want to get information about your illness or potential treatments, utilize established and reputable medical and psychological information sites. An exhaustive list of best medical sites can be found at: the Consumer and Patient Health Information Site. Some of the good medical sites include MedscapeWebMD, and MayoClinic. Some of the best sites for mental health information include PsychCentral, NIMH , American Psychiatry Association, American Psychology Association .
  1. Finally, remember that a very large percentage of websites are actually selling something, and be skeptical of information from these sites.

In conclusion, suffering any illness or condition is unpleasant and sometimes scary. Don’t make it worse by consuming information on the Internet in a random way. Be skeptical and selective and remember that Google is not always your friend. Often a good physician or good psychologist can give you clear and balanced information.

 

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

The Treatment of Tinnitus using Cognitive Behavioral Therapy

Tinnitus is condition where the person hears a ringing in their ears or other sounds when none of these sounds are present. It is a very common problem, especially as people age. According to studies, up to 20% of people over the age of 55 report symptoms.

What causes tinnitus? There can be many causes. The most common cause is noise-induced hearing loss. Other causes include medication side effects, as well as withdrawal from benzodiazepines. In many cases no apparent cause can be found.

For many, tinnitus is a relatively minor problem that they tend to ignore. Almost everyone has momentary tinnitus symptoms. But for other people tinnitus creates a tremendous amount of psychological distress. This includes anxiety and depression. The person fears the loss of their hearing, and tends to focus intensely on their symptoms. They begin to avoid situations where their symptoms are more noticeable. This typically means avoiding quiet locations where there is no sound to mask the tinnitus sounds. Or it may involve avoiding situations where there are loud noises such as movie theaters due to the fear of further hearing loss.

Similar to some forms of obsessive compulsive disorder (OCD), the person may begin to engage in frequent checking behavior. This means that they consciously check the presence and volume of the ringing in their ears. They may also frequently check their hearing.

The person also suffers from constant thinking about causes of the tinnitus. They often blame themselves for exposure to loud noises in earlier life. They think about the music concerts they attended where they didn’t wear earplugs, or even recreational listening to music. They have strong feelings of regret that can blend into depressive symptoms.

Unfortunately there are no terribly effective physical treatments for tinnitus. This leaves psychological treatment as the primary modality for successful reduction of distress.

Cognitive behavioral therapy (CBT) conceptualizes tinnitus much like it conceptualizes the experience of chronic pain. Chronic pain consists of two components. The first component is the physical sensations. The second component is the bother or suffering caused by these physical sensations.

Tinnitus can be conceptualized in the same way. The subjective experience of sounds in the ears is the physical sensation. The interpretations of these sensations lead to the emotional reactions; suffering and bother.

Although CBT cannot directly change the physical sensations of tinnitus, it can change the reactions to these sensations. And changing the reactions can actually lead to a subjective experience of diminishing symptoms.

What are the components of the CBT treatment for tinnitus?

1. Psychoeducation. The first step is to educate the client about how tinnitus works. The model used is that the loss of certain frequencies in the hearing range leads the brain to fill in those frequencies with sounds. It is very much like phantom limb pain, where an amputee may experience pain in the removed extremity.

The nature of hearing loss is explained, and psychoeducation regarding tinnitus and the risk of further hearing loss is discussed. If needed, results of hearing tests can be discussed relative to the actual severity of hearing loss. Although in some cases of tinnitus hearing loss is quite significant and may actually impair functioning, in many cases the hearing loss is relatively minor and does not impair functioning in any way.

2. Cognitive therapy. Here the therapist helps the patient to identify the negative thoughts that are leading to anxiety and/or depression. Typical thoughts for anxiety are: “I can’t live my life anymore with this condition. I will lose my hearing entirely. The sounds will drive me crazy. I’m out of control. If I go into _____ situation I will be troubled by these sounds so I must avoid it. I need to constantly check my hearing to make sure it’s not diminishing. I need to constantly check the tinnitus sounds to make sure they are not getting worse. They are getting worse! They will get worse and worse until they drive me crazy.”

Typical thoughts for depression are: “Life has no meaning if I have these sounds in my ears. I can’t enjoy my life anymore. It’s hopeless. There’s nothing I can do about it. Doctors can’t help me. It will get worse and worse and slowly drive me crazy. I won’t be able to function.”

Once these thoughts are identified then the skills of challenging them and changing them are taught to the client. The client learns how to alter these thoughts to more healthy thoughts. This produces a large reduction in anxiety and depression.

3. Attentional strategies. Because much of the subjective perceived loudness of tinnitus is based on attention, with higher levels of attention leading to higher levels of perceived loudness, developing different attentional strategies will help very much. In this part of the treatment mindfulness training and attentional training is used to help the client learn how to shift their attention away from the tinnitus sounds onto other sounds or other sensations. Often a paradoxical strategy is first used, where the patient is asked to intensely focus only on their tinnitus sensations. This teaches them that attention to tinnitus symptoms increases the perceived severity, and helps motivate them to learn attentional strategies.

Another aspect of attentional retraining is to stop the constant checking of symptoms and hearing. Helpful techniques include thought stopping where the client may snap a rubber band against their wrist each time they notice themselves checking.

4. Behavioral strategies. Tinnitus sufferers typically develop an elaborate pattern of avoidance in their lives. They avoid situations where they perceive tinnitus sounds more loudly. This can include avoiding many quiet situations, including being in quiet natural places such as the woods, or even avoiding going to quiet classical music concerts. They also tend to avoid situations where they might be exposed to any loud noise. This includes movie theaters, concerts, and even noisy office situations.

The behavioral component of CBT encourages an exposure-based treatment whereby the client begins to deliberately go back into all of the avoided situations. In situations where there is actual loud noise exposure at a level potentially damaging to hearing, they are encouraged to use protective earplugs.

The purpose of the behavioral component is to help the person return to their normal life.

5. Emotional strategies. Sometimes it is necessary to help the client go through a short period of grieving for their normal hearing. This allows them to move forward and to accept the fact that they have hearing loss and tinnitus. Acceptance is a key factor in recovering psychologically. This often also includes forgiving themselves for any prior excessive loudness exposures.

Changing the thoughts about the tinnitus symptoms also produces emotional change and a reduction in anxiety and depression.

In summary, cognitive behavioral therapy of tinnitus seeks to reduce the psychological suffering caused by the sensations of tinnitus. Cognitive, emotional, behavioral, and attentional strategies are taught to the client to empower them to no longer suffer psychologically from their tinnitus symptoms. Successful treatment not only reduces the psychological suffering, but because it also changes the attentional focus and lowers the checking of symptoms, people who complete CBT for tinnitus often report that their perceived symptoms have reduced significantly.

Tips:

1. Traditional psychotherapy is typically NOT helpful for tinnitus.

2. Find a practitioner, typically a psychologist, with extensive training in Cognitive Behavioral Therapy. If they have experience treating tinnitus that is even better.

3. Give treatment a little time. You will have to work hard to learn new ways of thinking and reacting, and this won’t happen overnight. You should be doing therapy homework between sessions.

4. Medication treatment such as anti-anxiety or antidepressant medication is typically not very helpful, and in the case of anti-anxiety medications can actually worsen tinnitus especially during withdrawal. First line treatment should be CBT.

5. Get help. Although the actual symptoms of tinnitus have no easy fix, the suffering can be treated and alleviated. Especially if you are experiencing depression symptoms, is is important to seek therapy with a CBT expert.

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

How Reporters Screw up Health and Medical Reporting (and How You Can Catch Them Doing So)

I’ve written before about common mistakes in interpreting medical research in my blog post How to Read Media Coverage of Scientific Research: Sorting out the Stupid Science from Smart Science. I recently read a very interesting post by Gary Schwitzer about the most common mistakes that journalists make when reporting health and medical findings.

The three mistakes that he discusses:

 1.      Absolute versus relative risk/benefit data

“Many stories use relative risk reduction or benefit estimates without providing  the absolute data. So, in other words, a drug is said to reduce the risk of hip fracture by 50% (relative risk reduction), without ever explaining that it’s a reduction from 2 fractures in 100 untreated women down to 1 fracture in 100 treated women. Yes, that’s 50%, but in order to understand the true scope of the potential benefit, people need to know that it’s only a 1% absolute risk reduction (and that all the other 99 who didn’t benefit still had to pay and still ran the risk of side effects).

2.      Association does not equal causation

A second key observation is that journalists often fail to explain the inherent limitations in observational studies – especially that they cannot establish cause and effect. They can point to a strong statistical association but they can’t prove that A causes B, or that if you do A you’ll be protected from B. But over and over we see news stories suggesting causal links. They use active verbs in inaccurately suggesting established benefits.

3.      How we discuss screening tests

The third recurring problem I see in health news stories involves screening tests. … “Screening,” I believe, should only be used to refer to looking for problems in people who don’t have signs or symptoms or a family history. So it’s like going into Yankee Stadium filled with 50,000 people about whom you know very little and looking for disease in all of them. … I have heard women with breast cancer argue, for example, that mammograms saved their lives because they were found to have cancer just as their mothers did. I think that using “screening” in this context distorts the discussion because such a woman was obviously at higher risk because of her family history. She’s not just one of the 50,000 in the general population in the stadium. There were special reasons to look more closely in her. There may not be reasons to look more closely in the 49,999 others.”

Let’s discuss each of these in a little bit more depth. The first mistake is probably the most common one, where statistically significant findings are not put into clinical perspective. Let me explain. Suppose we are looking at a drug that prevents a rare illness. The base rate of this illness, which we will call Catachexia is 4 in 10,000 people. The drug reduces this illness to one in 10,000 people, a 75% decrease. Sounds good, right?

Not so fast. Let me add a few facts to this hypothetical case. Let’s imagine that the drug costs $10,000 a year, and also has some bad side effects. So in order to reduce the incidence from four people to one person in ten thousand, 9996 people who would never develop this rare but serious illness must be treated. The cost of doing so would be $99,960,000! Plus those 9996 people would be unnecessarily exposed to side effects.

So which headline sounds better to you?

New Drug Prevents 75% of Catachexia Cases!

Or

New Drug Lowers the Prevalence of Catachexia Cases by Three People per 10,000, at a Cost of Almost $100 Million Dollars

The first headline reflects a reporting of the relative risk reduction, without cost data, and the second headline reflects the absolute risk reduction, and the costs. The second headline is the only one that should be reported but unfortunately the first headline is much more typical in science and medical reporting.

The second error where association or correlation does not equal causation is terribly common as well. The best example of this is all of the studies looking at the health effects of coffee. Almost every week we get a different study that claims either a health benefit of coffee or a negative health impact of coffee. These findings are typically reported in the active tense such as, “drinking coffee makes you smarter.”

So which headline sounds better to you?

Drinking Coffee Makes You Smarter

Or

Smarter People Drink More Coffee

Or

Scientists Find a Relatively Weak Association between Intelligence Levels and Coffee Consumption

Of course the first headline is the one that will get reported, even though the second headline is equally inaccurate. Only the third headline accurately reports the findings.

The theoretical problem with any correlational study of two different variables is that we never know, nor can we ever know, what intervening variables might be correlated with each. Let me give you a classic example. There is a high correlation between the consumption of ice cream in Iowa and the death rate in Mumbai, India. This sounds pretty disturbing. Maybe those people in Iowa should stop eating ice cream. But of course the intervening variable here is summer heat. When the temperature goes up in Iowa people eat more ice cream. And when the temperature goes up in India, people are more likely to die.

The only way that one could actually verify a correlational finding would be to do a follow-up study where you randomly assign people to either consume or not consume the substance or food that you wish to test. The problem with this is that you would have to get coffee drinkers to agree not to drink coffee and non-coffee drinkers to agree to drink coffee, for example, which might be very difficult. But if you can do this with coffee, chocolate, broccoli, exercise, etc. then at least you could demonstrate a real causal effect. (I’ve oversimplified some of the complexity of controlled random assignment studies, but my point stands.)

The final distortion which involves confusion about screening tests is also very common, and unfortunately, incredibly complex. The main point that Schwitzer is trying to make here though is simple; screening tests are only those tests which are applied to a general population which is not at high risk for any illness. Evaluating the usefulness of screening tests must be done in the context of a low risk population, because that is how most screening tests are used. Most people don’t get colon cancer, breast cancer, or prostate cancer, even over 50. If you use a screening test only with high-risk individuals then it’s not really a screening test.

There is the whole other issue with reporting on screening tests that I’m only going to briefly mention because it’s so complicated and so controversial. It’s that many screening tests may do as much harm as good. Recently there has been a lot of discussion of screening for cancer, especially prostate and breast cancer. The dilemma with screening tests is that once you find cancer you almost always are obligated to treat it because of medical malpractice issues and psychological issues (“Get that cancer out of me!”) The problem with this automatic treatment is that current screening doesn’t distinguish between fast-growing dangerous tumors and very slow growing indolent tumors. Thus we may apply treatments which have considerable side effects or even mortality to tumors that would never harm the person.

Another problem is that screening often misses the onset of fast-growing dangerous tumors because they begin to grow between the screening tests. The bottom line is that screening for breast cancer and prostate cancer may have relatively little impact on the only statistic that counts – the cancer death rate. If we had screening tests that could distinguish between relatively harmless tumors and dangerous tumors then screening might be more helpful, but that is not where we are yet.

One more headline test. Which headline do you prefer?

Screening for Prostate Cancer Leads to Detection and Cure of Prostate Cancer

Or

Screening for Prostate Cancer Leads to Impotence and Incontinence in Many Men Who Would Never Die from Prostate Cancer

The first headline is the one that will get reported even though the second headline is scientifically more accurate.

I suggest that every time you see a health or medicine headline that you rewrite it in a more accurate way after you read the article. Remember to use absolute differences rather than relative differences, to report association instead of causation, and add in the side effects and costs of any suggested treatment or screening test. This will give you practice in reading health and medical research accurately.

Also remember the most important rule, one small study does not mean anything. It’s actually quite humorous how the media will seize upon a study, even though the study was based on 20 people and hasn’t been replicated or repeated by anybody. They also typically fail to put into context the results of one study versus other studies of the same thing. A great example is eggs and type II diabetes. The same researcher, Luc Djousse, published a study in 2008 (link) that showed a strong relationship between the consumption of eggs and the occurrence of type II diabetes, but then in 2010 published another study finding absolutely no correlation whatsoever. Always be very skeptical, and most often you will be right.

I’m off to go make a nice vegetarian omelette…

 

Copyright © 2011 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Money and Drugs

We hear a lot these days about the drug wars in Mexico and the US. There’s another drug war being waged, the war over drugs and money. That’s the war where drug companies pay influential psychiatrists to recommend the prescriptions of potent and dangerous drugs in children, adolescents and adults. Today the little guy won a small skirmish in that war.

National Public Radio (NPR) reported today that Harvard has punished three well-known psychiatrists over failing to reveal payments from drug companies. These three doctors are accused of accepting more than $4.2 million from drug companies between 2000 and 2007 without reporting the income to Harvard, Massachusetts General Hospital, or the federal government. $4.2 million!  That is $1.4 million per Doctor!

What did they do for this money?  Supposedly they did research, but if that were true then they probably would’ve revealed these payments. One can only guess, but it’s useful to look at their positions on prescribing. Dr. Joseph Biederman is well-known for being a proponent of the off-label use of antipsychotic drugs to treat supposed  “bipolar illness” in young children. Much of his work is seen as encouraging the growth in these kinds of prescriptions, and his funding came from drug companies that make these drugs. Biederman and the other two psychiatrists accused also have published extensively on the use of drugs to treat attention deficit hyperactivity disorder, also a huge growth industry in the Psycho-Pharma business.

All three doctors have been banned from taking any industry money for one year, and will be under probation for two more years after that. Good for Harvard and Massachusetts General Hospital! But it would be better if Harvard and Massachusetts General Hospital were more open themselves about disclosing what these doctors did, who they took money from, and whether they accepted federal grant money while not disclosing industry support which would be a violation of federal guidelines.

(I should add that most psychiatrists that I know and refer to don’t get any money from drug companies. In fact, when I ran some of the data regarding drug company’s payments to psychiatrists by a friend and colleague, he jokingly said, “Wow, I wish I had known, I could be driving a much nicer car!”  It appears that the biggest offenders are psychiatrists in academic settings or large hospital settings. Maybe we should all be asking our doctors to reveal their non-clinical funding so we know their biases.)

Copyright © 2010, 2011 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Want to Sleep Better? Get Brief CBT-I Therapy for Sleep Instead of Sleeping Pills

“To sleep–perchance to dream. Ay, there’s the rub”

The New York Times reported on a terrific study at the University of Pittsburgh, looking at ultra short treatment of insomnia in the elderly. According to the article roughly 1/4 of older adults suffer from insomnia. The researchers streamlined an approach called CBT-I, which stands for cognitive behavioral therapy of insomnia.

There were only two sessions of treatment, totaling about 90 minutes. There were also two brief follow-up phone calls, over the first month. They tested this brief treatment and 79 seniors with chronic insomnia.

So what were the results of this study? They couldn’t have been very powerful, right?

Wrong. Two thirds of the CBT-I group reported a clear improvement in sleep, compared with only 25% of the people in the control group. Even better, 55% were cured of their insomnia. And six months later the results were even better.

So what was this magic treatment and the magic rules for curing insomnia? There were only four rules.

  • Spend only seven or eight hours in bed.
  • Set your alarm and get up at the same time everyday.
  • Never go to bed until you actually feel sleepy.
  • If you are tossing and turning and can’t sleep, get out of bed and do something relaxing until you get sleepy again. Then go back to bed.

These are standard cognitive behavioral sleep hygiene rules. And they are very powerful. Although not mentioned in the study, a few other rules are also helpful.

  • Regular exercise performed no later than midday is also helpful.
  • Reducing caffeine, nicotine, and alcohol all are helpful.
  • Avoid all naps.
  • Only use your bedroom for sleep and sex. Don’t watch TV or read in bed.

So why isn’t this treatment widely available? Could it be because there isn’t a powerful drug lobby for sleeping pills pushing this very effective therapy?

What is really tragic is that most seniors end up being prescribed sleeping pills for insomnia. And this is in spite of very clear data from research that shows that modern sleeping pills such as Ambien, Lunesta, or Sonata, have very minimal effects. On average they reduced the average time to fall asleep by 12.8 minutes compared to placebo, and increased the total sleeping time by only 11.4 minutes.

Patients who took older sleeping medications like Halcion and Restoril fell asleep 10 minutes faster, and slept 32 minutes longer.

How can this be? Why is it that patients believe that sleeping pills are much more effective? The answer is very simple. All of these drugs produce a condition called anterograde amnesia. This means that you cannot form memories under the influence of these drugs. So you don’t remember tossing and turning.  If you can’t remember tossing and turning even though you may have, then you perceive your sleep has been better. The drugs also tend to reduce anxiety, so people worry less about having insomnia, and thus feel better.

The hazards of sleeping pills in older adults include cognitive impairment, poor balance, and an increased risk of falling. One study in the Journal of the American geriatrics Society found that even after being awake for two hours in the morning, elder adults who took Ambien the night before failed a simple balance test at the rate of 57% compared to 0% in the group who took placebo. This is pretty serious impairment. Interestingly enough, in the same study, even young adults who took Ambien showed impaired balance in the morning.

So what are the key messages here?

1. Even though sleeping pills give people a sense of perceived improvement in sleep, the actual improvement tends to be almost insignificant, especially with the newer and very expensive sleeping medications. The older medications increased sleep time a little better, but have more issues with addiction and tolerance. Side effects of these medications are potentially very worrisome, since they can cause cognitive impairment and increased falling which leads to injuries, especially in the elderly. Why risk these side effects for such small improvements in sleep quality?

2. Cognitive behavioral therapy for insomnia works better than sleeping pills, has no side effects, is cheaper in the long run, and has a lasting impact on sleep improvement.

3. Most people who suffer insomnia will see their physician, who will prescribe sleeping pills. This is partly because of the lack of availability of cognitive behavioral treatment for insomnia. There are relatively few cognitive behavioral practitioners, and even fewer who regularly do CBT-I. We need to improve the availability of these treatments, and should follow in the footsteps of the University of Pittsburgh researchers in learning how to streamline these treatments. Most people don’t have the patience to spend 6 to 8 weeks in cognitive behavioral therapy for insomnia. Instead we need treatments that can be administered in a single week or two with some brief follow-up.

4. CBT-I availability will always suffer from the fact that there is no powerful corporate interest backing it. There are no CBT-I sales reps going to doctors offices offering free samples of CBT-I for doctors to pass out to their patients. I don’t have a solution for this problem, but would be interested in hearing from my readers as to how we might more effectively promote effective and safe treatments such as CBT-I.

Okay, now that I’ve written this, it’s time to trundle off to bed. As Hamlet said, “To sleep — perchance to dream. Ay, there’s the rub!”

Copyright © 2010, 2011 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

How Ivan Pavlov Handled a Piece of Steak

Most psychology students recognize the name of Ivan Pavlov, one of the great minds of psychology, who developed the theory of classical conditioning (dogs salivating when he rang a bell). From the Yale Alumni magazine comes this wonderful tidbit of a story:

“In mid-August 1929, the Harvard Medical School hosted the Thirteenth International Physiological Congress, one of the largest gatherings of scientists ever convened in the United States. Pavlov, the doyen of experimental physiology at almost 80 and honored by a Nobel Prize a quarter-century earlier, was the lion of the gathering. His pioneering work on conditioned reflexes had been crucial to understanding brain function, and he was keen to see the Harvard neurosurgeon Harvey Cushing ’91 operate. The preeminent brain surgeon and father of modern neurosurgery as a field, Cushing, two decades younger than Pavlov, was at the top of his game. Performing for Pavlov in a theater at the Peter Bent Brigham Hospital, Cushing removed a large tumor of the left hemisphere from a cancer patient’s brain. The patient later recalled that Cushing introduced him to Pavlov, saying, “You are now shaking hands with the world’s greatest living physiologist.”

Pavlov was captivated by the new electrosurgical knife Cushing used in the operation, and at the end of the procedure, Cushing got a piece of beef so that the elder scientist could try his hand. After making a few incisions, Pavlov inscribed his name into the meat. “I asked him whether he wanted me to eat the meat in the hope of improving my conditional reflexes,” Cushing wrote in his journal, “or whether we could keep it in the museum, the latter we will proceed to do—’Pavlov’s beef-steak.'” A collector of old medical books and of brain tumors, when he died in 1939 Cushing bequeathed both to Yale, where his rare books would become the cornerstone for creating the Medical Historical Library.”

Anyway, I love this story, especially the concept of him eating the steak, to “improve his conditional reflexes!”

Next time I throw a barbecue party I’ll serve the Pavlov-Steak sandwich…

Copyright © 2010 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

How to Read Media Coverage of Scientific Research: Sorting Out the Stupid Science from Smart Science

Reading today’s headlines I saw an interesting title, “New Alzheimer’s Gene Identified.”

I was intrigued. Discovering a gene that caused late onset Alzheimer’s would be a major scientific breakthrough, perhaps leading to effective new treatments. So I read the article carefully.

To summarize the findings, a United States research team looked at the entire genome of 2269 people who had late onset Alzheimer’s and 3107 people who did not. They were looking for differences in the genome.

In the people who had late onset Alzheimer’s, 9% had a variation in the gene MTHFD1L, which lives on chromosome 6. Of those who did not have late-onset Alzheimer’s 5% had this variant.

So is this an important finding? The article suggested it was. But I think this is a prime example of bad science reporting. For instance, they went on to say that this particular gene is involved with the metabolism of folate, which influences levels of homocysteine. It’s a known fact that levels of homocysteine can affect heart disease and Alzheimer’s. So is it the gene, or is it the level of homocysteine?

The main reason why I consider this an example of stupid science reporting is that the difference is trivial. Let me give you an example of a better way to report this. The researchers could have instead reported that among people with late-onset Alzheimer’s, 91% of them had no gene changes, and then among people without late onset Alzheimer’s 95% of them had normal genes. But this doesn’t sound very impressive, and calls into question whether measurement errors would account for the differences.

So this very expensive genome test yields absolutely no predictive value in terms of who will develop Alzheimer’s and who will not. There is a known genetic variant, called APOE, which lives on chromosome 19. Forty percent of those who develop late-onset Alzheimer’s have this gene, while only 25 to 30% of the general population has it. So even this gene, which has a much stronger association with Alzheimer’s, isn’t a particularly useful clinical test.

The other reason this is an example of stupid science is that basically this is a negative finding. To scan the entire human genome looking for differences between normal elderly people and elderly people with Alzheimer’s, and discover only a subtle and tiny difference, must’ve been a huge disappointment for the researchers. If I had been the journal editor reviewing this study, I doubt I would’ve published it. Imagine a similar study of an antidepressant, which found that in the antidepressant group, 9% of people got better, and in the placebo group 5% got better. I doubt this would get published.

Interestingly enough, the study hasn’t been published yet, but is being presented as a paper at the April 14 session of the American Academy of Neurology conference in Toronto. This is another clue to reading scientific research. If it hasn’t been published in a peer-reviewed scientific journal, be very skeptical of the research. Good research usually gets published in top journals, and research that is more dubious often is presented at conferences but never published. It’s much easier to get a paper accepted for a conference than in a science journal.

It’s also important when reading media coverage of scientific research to read beyond the headlines, and to look at the actual numbers that are being reported. If they are very small numbers, or very small differences, be very skeptical of whether they mean anything at all.

As quoted in the article, “While lots of genetic variants have been singled out as possible contributors to Alzheimer’s, the findings often can’t be replicated or repeated, leaving researchers unsure if the results are a coincidence or actually important,” said Dr. Ron Petersen, director of the Mayo Alzheimer’s disease research Center in Rochester, Minnesota.

So to summarize, to be a savvy consumer of media coverage of scientific research:

1. Be skeptical of media reports of scientific research that hasn’t been published in top scientific journals. Good research gets published in peer-reviewed journals, which means that other scientists skeptically read the article before it’s published.

2. Read below the headlines and look for actual numbers that are reported, and apply common sense to these numbers. If the differences are very small in absolute numbers, it often means that the research has very little clinical usefulness. Even if the differences are large in terms of percentages, this doesn’t necessarily mean that they are useful findings.

An example would be a finding that drinking a particular type of bourbon increases a very rare type of brain tumor from one in 2,000,00 to three in 2 million. If this was reported in percentage terms the headline would say drinking this bourbon raises the risk of brain tumor by 300%, which would definitely put me and many other people off from drinking bourbon. (By the way, this is a completely fictitious example.) But if you compare the risk to something that people do every day such as driving, and revealed the driving is 1000 times more risky than drinking this type of bourbon, it paints the research in a very different light.

3. Be very skeptical of research that has not been reproduced or replicated by other scientists. There’s a long history in science of findings that cannot be reproduced or replicated by other scientists, and therefore don’t hold up as valid research findings.

4. On the web, be very skeptical of research that’s presented on sites that sell products. Unfortunately a common strategy for selling products, particularly vitamin supplements, is to present pseudoscientific research that supports the use of the supplement. In general, any site that sells a product cannot be relied on for objective information about that product. It’s much better to go to primarily information sites like Web M.D., or the Mayo Clinic site, or one can go directly to the original scientific articles (in some cases), by using PubMed.

So be a smart consumer of science, so that you can tell the difference between smart science and stupid science.

Copyright © 2010 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

New Study Finds the Best Pharmacological Stop Smoking Solution: (Hint, it’s not what you’d think)

A new study at the Center for Tobacco Research and Intervention, School of Medicine and Public Health, University of Wisconsin, Madison, compared all except one of the current drug treatments that help with quitting smoking. They looked at the following treatments and combined treatments:

  • “bupropion SR (sustained release; Zyban, GlaxoSmithKline), 150 mg twice daily for 1 week before a target quit date and 8 weeks after the quit date;
  • nicotine lozenge (2 or 4 mg) for 12 weeks after the quit date;
  • nicotine patch (24-hour, 21, 14, and 7 mg titrated down during 8 weeks after quitting;
  • nicotine patch plus nicotine lozenge;
  • bupropion SR plus nicotine lozenge; or
  • placebo (1 matched to each of the 5 treatments).”

Everyone received six 10- to 20-minute individual counseling sessions, with the first 2 sessions scheduled before quitting.

What were the results?

Three treatments worked better than placebo during the immediate quit period: the patch, bupropion plus lozenge, and patch plus lozenge.

At six months, only one treatment was effective; the nicotine patch plus nicotine lozenge. The exact numbers , as confirmed by carbon monoxide tests, were: “40.1% for the patch plus lozenge, 34.4% for the patch alone, 33.5% for the lozenge alone, 33.2% for bupropion plus lozenge, 31.8% for bupropion alone, and 22.2% for placebo.”

So we see that the combined nicotine substitution therapy worked best, followed closely by either nicotine substitute alone. Zyban or Welbutrin (bupropion) was a bust, no more effective than the simple nicotine lozenge. The only advantage to Zyban would be if one prefers not to use nicotine substitutes.

Now I mentioned that they omitted one drug treatment, which is the drug Chantix (varenicline). This is probably because the drug is a nicotine receptor blocker, so wouldn’t have made sense to combine with nicotine substitutes. Also, there have been some disturbing case reports of people having severe depressive reactions to Chantrix.

Of course, there was one glaring omission that any card-carrying psychologist would spot in a moment–the lack of a behavior therapy component. Giving 6 ten minute sessions is hardly therapy. I would have liked to see true smoking cessation behavior therapy combined with the drug treatments.

So, if you’re trying to quit smoking, combine nicotine patches with nicotine lozenges, sold in any pharmacy. If you do, you have a 40 percent chance of succeeding at 6 months.

Now I am off to have a cigarette….just kidding.

Study: http://cme.medscape.com/viewarticle/712074_print

Copyright © 2009/2010 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

So Much for the Germ Theory: Scientists Demonstrate That Sleep Matters More Than Germs

More in a continuing series about one of my favorite topics, something we all do every day, and spend roughly a third of our lives doing…sleep!

Since we are in the middle of the common cold season, this post will be particularly relevant.

It turns out, grandma was right. Getting good sleep really does prevent colds. This supports a favorite belief of mine—that I don’t believe in the germ theory of illness.  Read on and you will see why I liked the referenced article.

Researchers at a variety of universities collaborated and did a clever study looking at sleep and its effects on susceptibility to the common cold. First they had their 153 subjects, healthy men and women between 21 and 55, report their sleep duration and efficiency for 2 weeks. (Efficiency is what percent of the time you are actually sleeping while in bed.) Next, these diabolical researchers sprayed cold virus up the noses of all the subjects (in quarantine), and watched what happened over the next 5 days.

The results were very interesting. Those subjects who slept less than 7 hours were almost 3 times more likely to develop a cold than those who slept 8 hours or more. In addition, those whose sleep was less than 92% efficient were 5.5 times more likely to develop a cold than those with 98% or more sleep efficiency. Interestingly, how rested subjects reported feeling after sleep was not associated with colds.  The lead author of the study concluded, “The longer you sleep, the better off you are, the less susceptible you are to colds.”

Now I promised that I would report evidence that this study bolsters my theory that germs don’t really matter that much. Remember the researchers sprayed virus up everyone’s noses. After five days, the virus had infected 135 of 153 people, or 88% of the people, but only 54 people (35%) got sick. What this suggests is that even among the people who were infected with cold virus, 60% stayed healthy, while 40% got sick. And the ones who got sick were much more likely to have reported less and lower quality sleep in the two weeks before infection. 

This is very relevant for everyday life, since much of the time we can’t really avoid exposure to common germs like colds and flu. If good sleep protects us even when infected with such germs, then it may be the key to staying healthy.

What is truly fascinating about this study is the precise immune regulation showed by those who got infected, but stayed healthy. To understand this let me digress for a moment with a short primer on the common cold. Most people think cold symptoms are caused by cold virus. This is wrong. Actually, cold symptoms are caused by our bodies’ immune reaction to the cold virus. Our bodies produce germ fighting proteins called cytokines, and when our bodies make too much, we get the congestion and runny nose symptoms. If our bodies make just the right amounts of cytokines, we fight the virus without feeling sick.

So getting 8 or more hours of sleep a night may allow your body to fine tune an immune response, and make just the perfect amount of germ fighting proteins.

Another interesting finding is the relationship of sleep efficiency and illness. Sleep efficiency was an even more powerful predictor of getting sick than total sleep. (Of course, this might reflect an overall difference in sleep quality. Those who sleep deeply may tune up their immune systems better, and they are likely to spend most of their time in bed asleep.)

But assuming that increasing sleep efficiency is useful, then those people who take a long time to fall asleep, and who sleep fitfully may benefit from spending less time in bed, and working on sleeping more of the time they are in bed. On the other hand, those who fall asleep as soon as their head hits the pillow, and who are sleep like logs, would probably benefit from spending a little more time in bed, since they are not getting enough sleep.

So there you have it. Sleep 8 hours or more, try to sleep well, and you can lower your odds of getting a cold greatly. Even if you are exposed to the virus, if you have good sleep quality, you probably won’t get sick. So much for the simple germ theory! I suspect that this applies to all infectious diseases. So getting good quality and quantity in sleep may be one of the most important health behaviors for staying well.

It’s late, and I’m off to bed now…..zzzzzzzzzzzzzzz.

Copyright © 2009 The Psychology Lounge/TPL Productions/Andrew Gottlieb

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Followup on the Science of Sleep

 


It’s been a while since I wrote, and some of that is that I’ve been trying to get to bed earlier, and get a more consistent 8 hours of sleep. Since I last wrote, I saw an interesting factoid from an interview with Daniel Kripke, who is the co-director of the Scripps Clinic Sleep Center in La Jolla, California. In this interview, he talked about research he did on more than 1 million Americans that correlated sleep and mortality. There were some surprising findings, which have been corroborated by similar studies in other countries.

The results showed that those who slept between 6.5 and 7.5 hours a night lived the longest. And that those who slept more than 8 hours a night or less than 6.5 hours a night don’t live as long. This is interesting in that most previous writing I have seen suggests that sleeping more is good for you, but these data don’t support that.

Another good point he made was that when people try to get too much sleep, because they think the normal amount is 8 or 9 hours, they may unintentionally develop insomnia. Staying in bed longer than you can sleep will result in wakefulness, and anxiety about not being able to sleep. So for those of you who only can sleep 6.5 or 7 hours, just get up, it won’t hurt your health. In fact, restricting the time in bed is a more effective treatment for insomnia than sleeping pills, according to Kripke.

What we don’t know is which direction the causality runs in this association. Does the amount of sleep you get create your health status, or is it a reflection of underlying health? Do sicker people sleep too little or too much? Or does sleeping too little or too much make you sicker? No one knows for now, so I wouldn’t necessarily rush to change your sleep habits based on this study. But if you are sleeping in the 6.5 to 7.5 hour range, you can relax and not worry about it (especially late at night!)

Now I’ve got to stay up a little longer, so I don’t get too much sleep tonight…

Copyright © 2008 The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

The Mystery of the Obesity Epidemic: Solved? (Hint: It’s simpler than you think)

 

Was Grandma Right?

It’s been too long since I last wrote, but I’ve been catching up on my sleep. Why will become relevant after you read this article.

Sleep is something we mostly take for granted as part of our daily lives, much like eating and showering. But why do we sleep? What does sleep do for our minds and our bodies? What happens if we don’t sleep, or if we don’t sleep enough?

For those of you who are interested in these questions, I’d highly recommend that you read the transcript of The Science of Sleep, an excellent piece by 60 Minutes that aired on March 16, 2008. Not only did I learn many interesting facts about sleep, I learned about my own health and how sleep affects it. More on that later.

Why do we sleep? After all, from a survival point of view, sleep is not really a good thing, in the sense that we are unconscious and helpless during sleep. So for sleep to have evolved, then it must serve some vital functions. (I should point out though, that sleep might have survival advantages, since if early humans slept in caves and other sheltered places, sleep would have kept them out of the reaches of nocturnal predators. The folks who didn’t sleep much, and who wandered around all night, probably got eaten!)

One clue of how important sleep is in studies done in the 1980’s with rats. When rats were prevented from sleeping (did they use disco music to keep them awake?) they died after 5 days! Sleep seems to be as important to rats as food.

Let me present a quick primer on sleep. When we sleep, we actually go through multiple cycles of different stages of sleep. These stages are stages 1-4 of non REM (NREM) sleep, and stage 5 which is REM (rapid eye movement) sleep. The key stages are Stage 4, or Delta Sleep, and Stage 5, REM sleep. Stage 4 Delta sleep is the deep restorative sleep where our bodies get rebuilt and restored. Stage 5 REM sleep is when we dream, and it appears that our minds get restored during REM sleep. Typically the whole cycle takes about 100 minutes, and we have 3 or 4 of them each night.

Sleep may play an important role in enhancing memory. One study found that when people learned a new skill in the afternoon, and then were tested after a night of sleep, they did 20-30 percent better than those who were tested after twelve hours, but with no sleep in between the learning and testing. This is fascinating, and jibes with a trick I learned in graduate school. When I would study statistics, I’d always review my notes right before going to sleep. The next morning, the memories of those notes were imprinted magically in my mind.

Sleep also plays a critical role in stabilizing mood. One experiment tested people who were sleep deprived by showing them disturbing images within an fMRI scanner, to look at their brain activation. They found the sleep deprived subjects had a disconnect between the brain’s emotional center (the amygdala) and the part of the brain that controls rational thought (the frontal lobe). So they couldn’t control their emotional reactions. They looked more like psychiatric patients. Of course we all know that sleep deprivation makes us cranky and short-tempered, this explains why.

Another important function of sleep is physical rejuvenation. It appears that Stage 4 sleep is essential here. In the 60 Minutes piece they show an experiment where a young man named Jonathan is deprived of only Stage 4 sleep. Each time his brain waves show Stage 4 sleep, loud sounds are played to bring him out of deep sleep. He gets a normal amount of sleep, but a reduced amount of Stage 4 sleep. After 4 nights of this regimen, this 19 year old is starting to look physically like a 70 year old. His body becomes no longer able to metabolize sugar effectively, putting him temporarily at increased risk for Type 2 diabetes.

Other studies confirm this. After just a few nights of partial sleep deprivation, young healthy people show a metabolic change that is similar to what happens as people develop Type 2 diabetes. They no longer metabolize sugar effectively. They deposit more fat. The hormone leptin, which controls appetite, seems to drop, and they want to eat more.

This is truly astonishing. If relatively short term sleep deprivation can cause such a profound shift in the body’s sugar metabolism, then this may be the key to unlock one of the great medical mysteries of the 20th century: Why obesity has increased so rapidly since 1980? Could it be that the obesity epidemic is really a sleep deprivation epidemic? Could it be so simple? Not junk food, television, lack of exercise, and all of those things that people talk about? Could grandma have been right?

Here’s the clue.

In 1960 a survey of a million Americans showed an average of 8.0 hours of sleep per night. Today similar studies show we are only getting 6.7 hours a night. That’s a drop of 16.25% in less than a generation. And teenagers are the most sleep deprived of all, since they require 9-10 hours of sleep, and most get less than 7 hours of sleep, thanks to ridiculously early school start times. Teenagers may be lacking between 22 percent and 30 percent of their needed sleep.

So we have a plausible explanation for why everyone, even children and teenagers, is getting fatter. Sleep deprivation causes shifts in metabolism, creating a pre-diabetic state, and lowering level of the satiety hormone leptin, which causes us to eat more, and store more fat. Add sugary or high carbohydrate foods, and we get even fatter. Add inactivity, and we get even fatter. The damage begins early, perhaps in early teenage years.

So if we want to lose weight, then the old saw of a healthy diet and plenty of exercise may be wrong. The proper advice is probably lots of sleep, a reasonably healthy diet, and a little exercise. Or since exercise improves sleep quality, sleep, exercise, and diet. Without adequate sleep, diet and exercise are doomed to failure, since even young people may unintentionally be turning their bodies pre-diabetic, which makes it very hard not to gain fat.

So that’s why I haven’t written. After a lifetime of staying up late, and cheating sleep, I’m starting to try to get a solid 8 hours of sleep a night. Already I’ve lost a few pounds, even though I haven’t been exercising much. The other advantage of going to bed earlier is that when you are sleeping you are not eating.

So try it. Get 8 or 8 1/2 hours of sleep a night. And make sure your teenagers get 9 or 10 hours a night. No more websurfing or TV late at night. And write me and let me know if your weight drops as a result.

Now I’ve got to stop writing and go to sleep…

Copyright © 2008 The Psychology Lounge/TPL Productions

All Rights reserved (Any web links must credit this site, and must include a link back to this site.)

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Protecting Your Brain (and Your Heart) With Fish Oil

Protecting Your Brain (and Your Heart) With Fish Oil

A fascinating idea is how to protect your brain using simple nutrients. Can we protect our brains from depression, Alzheimer’s, even stroke using simple nutrients or over the counter supplements?

The Wall Street Journal just published an interesting article about using fish oil to treat or prevent a variety of illnesses. They even summarize the findings with recommended doses of fish oil. For instance, to prevent heart disease, they recommend one gram of EPA or more per day. For optimum brain health, take one half gram of DHA or more. Even Rheumatoid arthritis may respond to 2 grams or more of fish oil.

Fish oil contains omega-3 fatty acids, of which there are two main ones; EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid). Repeat after me if you want to really impress your physician: “eye-coh-sah-pent-ah-eh-no-ick  acid” and “doh-coh-sah-hex-ah-eh-no-ick acid”. Now you see why articles always say EPA and DHA!

There is a very interesting tie in with DHA and Alzheimer’s disease, as explained by an article on medicinenet.com.  It turns out that people with Alzheimer’s disease (AD) tend to have low levels of a brain protein called LR11, and about 15% of those with AD have a gene mutation that reduces LR11. LR11 works to clear the brain of amyloid proteins, which are implicated in the production of beta-amyloid plaque that clogs the neurons of those with AD.  Scientists tested DHA in rodents and in cultures of brain cells, and found that DHA causes higher production of LR11.

So should you be taking fish oil capsules, and how many, and which brand? I’d say if you eat oily fish like salmon 3 times a week or more, don’t worry about it. But for the rest of us (all of us?) it may make sense to add fish oil capsules to our vitamin regimen. A 1999 Italian study found that adding 3 capsules a day reduces the incidence of sudden cardiac death by 45%! The subjects in this study mostly also took baby aspirin, which may work to increase the effects of fish oil.

I’d certainly talk to your doctor about it. Be sure to print out the Wall Street Journal article, which demonstrates that there were few if any side effects. Some doctors think taking fish oil will make you bleed more easily, but studies of very high doses haven’t found this. In fact, the main side effect is belching fish smells, but I have found this is dependent on the brand and type of capsules you take.

Here’s a quick rundown on what to look for in fish oil capsules. First of all, they vary as to how much of the essential ingredients they contain. Most capsules contain 1 gram of oil, but much less Omega-3 fatty acids EPA and DHA. Some contain as little as 200mg. of the Omega-3’s, which means you have to eat  a LOT of capsules to get much EPA or DHA. Often the bottles will mislead you by citing the amount per serving, and when you look more carefully you will see that one serving is 3 or 4 capsules!

So you want as high a concentration of EPA and DHA as possible. You also want fish oil that has been molecularly distilled to remove any possible contaminants such as pesticides, dioxin, etc.

Although I rarely make product recommendations, I heartily recommend Trader Joe’s Fish Oil capsules. Priced at $7.99 for a bottle of 100 capsules, these capsules are molecularly distilled, and contain 300 mg. of EPA, and 200 mg. of DHA per capsule. That means that 2 capsules make up 1 gram of Omega-3’s.  So it is easy to take 1 or 2 grams of Omega-3’s per day, at an affordable cost. These compare favorably with much more expensive brands of omega-3 capsules.  Another trick is to store these in the refrigerator, so the oil doesn’t turn, and occasionally break open a capsule and smell it. Although it may have a slightly fishy smell, it should smell rancid or strong.

So there you have it, a simple way to reduce heart disease, autoimmune disease and inflammation, and improve brain health. Cost? About $0.16  per day for 2 capsules.

As always, as I am not a physician, and certainly not your physician, talk to your doctor and do your own research before consuming more than a capsule a day of fish oil.

Copyright 2008 The Psychology Lounge/ TPL Productions 

All Rights reserved (Any web links must credit this site, and must include a link back to this site)

 

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Scientists Try to Discover the Earliest Signs of Alzheimer’s disease (Is Alzheimer’s a Lifetime Genetic Disease?)


Today’s New York Times has a fascinating article about current research in Alzheimer’s called Finding Alzheimer’s Before a Mind Fails. It is simultaneously encouraging and deeply disturbing.

The encouraging part is that researchers are discovering ways to examine patients that can find evidence of Alzheimer’s many years before the disease manifests itself in symptoms. A radioactive dye call Pittsburgh Compound B (PIB) is injected into the patient. This dye attaches itself to amyloid plaques in the brain, and then these can be seen by using a Positron Emission Tomography (PET) scan.  Studies using PIB have found the astonishing fact that amyloid plaques are found in 20-25 percent of people over 65 who appear normal! If the amyloid hypothesis is accurate, then many of these people will go on to develop Alzheimer’s disease.  Using PIB testing we could predict more accurately who will develop the disease, and perhaps develop prevention methods much like we give statins to heart patients who have plaques in their arteries. This is encouraging.

Someday in the future hopefully we will be tested for early signs of Alzheimer’s disease in our 40’s, and those who at risk given medications that will prevent it, just like we do for heart disease now. This would make aging much less scary.

Current Facts About Alzheimer’s disease

But the current facts about Alzheimer’s are less encouraging. It is the sixth more common cause of death by disease in the U.S. Five million people over 65 have Alzheimer’s disease. Estimates suggest that perhaps as many as 16 millions will have the disease by 2050, which is a staggering number that would bankrupt the health care system. (Of course, this assumes that in 43 years we have made no progress in the treatment and prevention of Alzheimer’s disease, which is absurd.)

Costs are already staggering–$148 billion dollars per year, and are increasing every year. Why? Here’s the dark truth. Alzheimer’s disease is a disease of the elderly. Almost 40 percent of those who live past 85 will eventually develop Alzheimer’s disease. The problem is that medical improvements are curing the diseases that used to kill us well before 85. One of the reasons Social Security starts at age 65 is that until recently, most people didn’t live much past the age of 65. Now as we defeat cancer and heart disease, and people stop killing themselves with diet and smoking, we are living into our 80’s and 90’s.  And getting Alzheimer’s disease.

What is Alzheimer’s disease?

Let’s talk a little more about what Alzheimer’s disease really is. Everyone worries about Alzheimer’s disease as they age. But some forgetfulness is completely normal. (We hope.) There is a old joke about Alzheimer’s disease which actually is a useful rule of thumb, it’s not a big deal if you forget where you put the car keys, as long as you can remember what keys are for. It is significant changes in memory and problem solving that are more worrisome.

When does Alzheimer’s disease begin?

This is a mystery currently. Conventional wisdom says that Alzheimer’s disease may begin a few years before symptoms appear, but some scientists question this. Because the brain has a lot of spare capacity, it may take years of deterioration before we lose enough brain function to notice. This may explain one of the common findings that the more highly educated (and probably more intelligent) develop Alzheimer’s disease as  a lower rate. They may have more spare capacity. If you start off with an IQ of 150, and lose a third of your brain functioning, you end up with an IQ of 100, and can still function. Start at IQ 100, lose 1/3, and you now are functionally retarded with an IQ of 66, and you won’t be able to live independently.

One scientist, Dr. Richard Mayeux, who is a professor at Columbia University, says, “I think there’s a very long phase where people aren’t themselves.”

If Dr. Mayeux asks family members when a patient’s memory problem began, they almost always say it started a year and a half before. If he then asks when was the last time they thought the patient’s memory was perfectly normal, many reply that the patient never really had a great memory.” (New York Times)

This is interesting and disturbing stuff. Other research finds that people who later develop Alzheimer’s disease showed lower intelligence scores even early in life, suggesting that perhaps Alzheimer’s disease is a genetic disorder that affects the brain in subtle way even early in life. If this is true, then the data on highly educated people may have been interpreted in a backwards way—instead of higher education preventing Alzheimer’s disease, it may be that Alzheimer’s disease prevents higher education!

 

Treatment of Alzheimer’s disease

Currently there are drugs that address the symptoms of Alzheimer’s disease, but no drugs that address or slow the underlying disease progress. The good news is that there are numerous studies attempting to find drugs that will actually address the underlying disease process in Alzheimer’s disease. The bad news is that no one really knows exactly what that underlying disease process is.

There are two finding from examining the brains of those with Alzheimer’s disease. The first is that they show plaques of beta amyloid between the nerve cells of the brain. The second is that the brains show tangles inside nerve cells made of a protein called tau. This damaged tau kills the nerve cells because they no longer get nutrients.  Both these are well-established facts, but no one knows what is the relationship between beta amyloid and tau, and how much each contributes to Alzheimer’s disease.

 

What Society Should Do About Alzheimer’s disease?

So what can we as a society do about Alzheimer’s disease? My grandfather used to say, “Everyone dies, so it’s just a matter of how you die.” By choosing to treat or prevent heart disease and cancer, are we choosing to die from Alzheimer’s disease?   This is a scary thought.  It’s clearly worse to outlive your mind than to outlive your body. And Alzheimer’s disease puts huge burdens on society and caretakers. Maybe we should start a campaign to encourage cigarette smoking in the elderly! (Or motorcycle riding, but this might make the roads a bit dicey.) 

More seriously, we are in the unfortunate window of time where we have successfully improved longevity without really addressing this core disease of longer life, Alzheimer’s disease.  Society desperately needs to find an Alzheimer’s disease cure or preventative treatment. Without this we will as a society incur great costs and individual suffering. I believe that this should become a top priority of private and government research spending. First we need better basic research to find out what the disease process of Alzheimer’s disease looks like. Then we can develop effective drugs to block or reverse that disease process.

In the meantime, all we can do is not worry too much, since stress may damage the brain. Eat healthy, exercise, maybe take some anti-oxidant vitamins, and hope that science can solve this puzzle so we can get old without losing our brain function.   

As for me, I aspire to these not-so famous words of the comedian Will Shriner, “I want to die in my sleep like my grandfather… Not screaming and yelling like the passengers in his car.”

 

Copyright 2007 The Psychology Lounge/ TPL Productions, All Rights Reserved

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

The Physiological Mechanism for How Stress Affects the Brain


For those readers curious about the mechanisms by which emotional stress affects brain function, I found an interesting piece of research about the physical mechanisms for how chronic stress can induce brain changes that could lead to cognitive impairment.

Scientists at Salk Institute for Biological Studies subjected mice to mild chronic stress for two weeks. What they found was fascinating. First some background on the physiology of Alzheimer’s disease. As the article explains:

“Alzheimer’s disease is defined by the accumulation of amyloid plaques and neurofibrillary tangles. While plaques accumulate outside of brain cells, tangles litter the inside of neurons. They consist of a modified form of the tau protein, which–in its unmodified form–helps to stabilize the intracellular network of microtubules. In Alzheimer’s disease, as well as various other neurodegenerative conditions, phosphate groups are attached to tau. As a result, tau looses its grip on the microtubules, and starts to collapse into insoluble protein fibers, which ultimately cause cell death.”

So basically, when phosphate attaches the the tau molecules, it causes them to change from helpful molecules to damaging the neurons.

The mice research found that the brain-damaging effects of negative emotions are relayed through the two known corticotropin-releasing factor receptors, CRFR1 and CRFR2, which are part of the body’s central stress mediation system.

So what does this all mean? It suggests that we have to protect our brains from stress, particularly chronic stress. Occasional stress doesn’t cause problems, but daily chronic stress does. The mice only showed permanent brain changes after 2 weeks of daily stress.

So stress management through cognitive behavioral therapy (CBT) or other means is not just a nice comfort option, but may be essential if you want your brain to last. Emotional pain doesn’t just cause emotional damage, it also damages the brain.

Perhaps scientists will be able to develop drugs that change CRF1 and CRF2 levels, but in the meantime, better take up that yoga, meditation, relaxation exercise, or CBT stress management program!

Copyright 2007 The Psychology Lounge/TPL Productions

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Your Brain Wants You to Be Mellow: New Evidence Shows Chronic Emotional Stress Can Increase the Risk of Mild Cognitive Impairment in Later Life

So you’ve been putting off getting therapy, even though most of the time you feel anxious and upset? Well, a new study suggests that you may be putting your brain in danger.

Researchers at Rush University Medical Center in Chicago, Illinois, followed more than 1200 men and women who were 65 and older, average age of about 76. At the beginning of the study they made sure that none of them had mild cognitive impairment (MCI), and measured their emotional distress using a simple 6 item scale of neuroticism. Items such as 1) “Are you the type of person whose feelings are easily hurt?”; 2) “Are you the type of person who is rather nervous?”; and 3) “Are you the type of person who is a worrier?” make up this scale.

At the beginning of the study the average score was about 15 on this emotional distress scale. Patients were followed up for up to 12 years. About 38% developed MCI during the study. Those in the top 10% of emotional distress at the beginning of the study were about 40% more likely to develop MCI.

What is interesting is this relationship held even after researchers statistically removed the effects of depressive symptoms at the beginning of the study. So the results were from emotional distress, not from depression. The risk for MCI increased by 2% for every 1 point increase on the distress scale. This is a pretty strong correlation.

So what does this mean? I think what it means is that chronic emotional upset is hard on the brain. It makes sense, since emotional stress raises stress hormones such as cortisol, which we know can damage the brain, especially the hippocampus, which controls memory. What we don’t know is whether this study was picking up some early brain changes in the elderly, changes which correlate with both emotional distress AND a tendency to develop MCI. A better study would look at younger people, and see if emotional distress in those aged 40 or 50 leads to the development of MCI in later life.

Since about a third of those with MCI will develop Alzheimer’s Disease, any reductions in the prevalence of MCI would be tremendously beneficial to society. Perhaps psychotherapy should be mandatory for all those over 65!

What can you do to lower your brain risk? First of all, honestly evaluate whether you suffer chronic emotional stress. Ask yourself if most of the time you feel calm and happy, or upset and worried and stressed. Also ask your close friends and/or family what they think. If you are someone who suffers chronic stress, then get help. A cognitive behavioral psychologist can teach you good stress management skills, and may help break lifelong patterns of emotional stress. Another good option is to learn mindfulness meditation and yoga and practice them daily. These are known to reduce psychological distress.

Whatever you do, don’t take it lightly if you are in long term distress. Your brain wants you to be mellow!

Copyright 2007 The Psychology Lounge/TPL Productions

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Can Cognitive Behavioral Therapy Make a Baby? How Psychological and Behavioral Factors Can Reduce Infertility

An article in the May 7 edition of U.S. News and World Report titled “Success at Last: Couples Fighting Infertility Might Have More Control Than They Think” shows how health psychology can impact even something as basic as making a baby. This fascinating article shows that behavioral and psychological factors may play a big and controllable role in producing the infertility that 1 in 8 couples suffer. It turns out, that the body may be smarter than we gave it credit for. Woman’s bodies may recognize certain states as not ideal for childbearing, and therefore prevent or lower fertility. Two examples are being overweight or underweight. Overweight risks pregnancy complications such as diabetes, high blood pressure, so the extra estrogen produced by body fat interferes with ovulation. Underweight women may not have enough body fat to sustain a baby, so the pituitary gland releases less of key ovulation hormones. Other behaviors strongly influence fertility. Take smoking for example. Multiple studies show that smoking can delay getting pregnant by a year or more. And one study at

Columbia University found smokers entered menopause 3 years earlier on average. Or diet. Trans fats, a key component in such unhealthy foods as donuts, cakes, etc. may raise testosterone, which suppresses the ovaries. Research shows that as little as 4.5 grams, which is the amount found in one donut, can have this effect. Even positive behaviors can negatively affect fertility. One study found woman who exercised four or more hours a week were 40 percent less likely to conceive after their first IVF (In vitro Fertility) treatment than women who didn’t exercise. Once again, it may be that the body interprets hard exercise as danger and stress, and shuts down the fertility system.

Even pure psychological stress can affect fertility. Here’s the biological mechanism. A few hours before ovulation, the pituitary gland sends out luteinizing hormone (LH), which tells the ovaries to release an egg. But if you are experiencing psychological stress such as a fight with your husband, or a dressing down from your boss, or a kid having a tantrum, then your LH will be suppressed, disrupting ovulation.

Even mild stress may have a big effect. One study of monkeys found that moving monkeys to a new cage, combined with a little less food and 1 hour on treadmill caused 70 percent of the monkeys to have irregular menstruation! So don’t skip that meal and take a long run when stressed, or you’ll greatly lower you odds of getting pregnant.

What’s worse is that IVF treatment itself may lead to large amounts of psychological stress. One fertility expert found that 40 percent of women in infertility treatment had all of the symptoms of an anxiety disorder or depression: sleep disturbances, difficulty concentrating, and irritability. So if stress lowers fertility, and fertility treatment increases stress, then fertility treatment may actually harm fertility!

But cognitive behavioral therapy may improve the situation. Alice Domar and colleagues at Harvard found that a 10 week cognitive behavioral group therapy program improved the success of fertility treatment from 20 percent to 55 percent in the women who participated in the group therapy. So what can we learn from this research?

  1. A woman’s body is wise. It will respond to behavioral and psychological stressors by lowering fertility. Anything that resembles stress, even hard exercise, will trigger physical responses that lower fertility.
  2. At critical points such as several hours before ovulation, even normal stressors can disrupt the ovulation process. And in stress-prone or perfectionist or angry women, the likelihood of experiencing stress during these critical hours is very high. Thus for women who are experiencing difficulty getting pregnant and who by personality are “stressy” (you know who you are!) cognitive behavioral therapy (CBT) will be helpful in learning to manage and lower stress.
  3. Infertility treatment is by its nature stressful, and this leads to a paradox; infertility treatment may lower fertility if it increases stress. It may be helpful to evaluate stress levels in women undergoing IVF and if stress is high, intervene with CBT group or individual therapy.
  4. The ultimate in infertility treatment may be what I recommended to my friend Jill, who had tried many cycles of IVF to no avail. I told her, “You’re young, why don’t you and your husband stop trying to get pregnant, and just have sex for fun, and enjoy life for a few years. If nothing happens then you can adopt.” She was pregnant within the year, and now has two lovely children. A good long relaxing vacation with no schedule, no hard exercise, healthy food, and no stress may be the best fertility treatment available, and even if it doesn’t work, at least you’ve gotten a great vacation!
  5. Finally, what this research shows us is how linked our minds and bodies are. Changing thoughts and feelings and behaviors changes our bodies, and fertility is just one example of this.

Copyright 2007 The Psychology Lounge/TPL Productions

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Is Your Shrink Being Paid to Give You Drugs? The Secret Link Between Psychiatrists and the Drug Industry

Regular readers of this blog will remember my earlier article on Rebecca Riley, the young girl whose overtreatment with powerful psychiatric drugs may have led to her death.

Now it turns out that some psychiatrists may actually be getting paid by the drug industry to give kids powerful drugs! And this is in spite of an almost complete lack of evidence that these drugs work or are safe for children.

The New York Times has an article called Psychiatrists, Children, and Drug Industry’s Role, and this scary article documents the secretive practice of paying psychiatrists to prescribe certain drugs.

The article documents that more than half a million children are now receiving atypical antipsychotics such as Risperdal, Seroquel, Zyprexa, Abilify, and Geodon. These drugs have never been tested on or approved for use in children!

In Minnesota alone, the only state that requires such reporting, from 2000 to 2005 payments from pharmaceutical companies to psychiatrists soared by six times, to $1.6 million, and the rates of prescribing antipsychotics to children went up by nine times.

And the Times found that the money worked. Those psychiatrists who received more than $5000 from the drug companies wrote 3 times as many prescriptions for atypical antipsychotics than those doctors who got less or no money. Other interesting figures are that the average payment to psychiatrists was $1750, with a maximum of $689,000. (Nice work if you can get it!)

I should point out that atypical antipsychotics are not benign drugs. Side effects can include rapid weight gain that leads to diabetes, and movement disorders such as tics and dystonia, which can lead to a lifelong muscle disorder.

The Times describes one unfortunate girl, Anya Bailey, who was given Risperdal for an eating disorder by her psychiatrist George Realmuto, who had received more than $7000 from Johnson and Johnson, the maker of Risperdal.

Although the drug helped her gain weight, she also developed a painful and permanent dystonia in her neck that now causes her chronic pain and a movement disorder, even after stopping the drug.

And she was never given any counseling for her problems, only drugs!

So what can we learn from this article? First of all, the practice of paying psychiatrists to prescribe certain medications is widespread, but only Minnesota requires full disclosure. We should pressure our legislatures to mandate full disclosure in every state. Write to your state and federal congress and senate and ask them to either ban this practice or to require full disclosure, on the web, by name of doctors, of how much money is given by each drug company.

Secondly, when you take your child to a psychiatrist, you should ask them for a full written disclosure of any money they received in the last few years from drug companies for speaking, or for research. Payments to psychiatrists (and other M.D.’s) are disguised as speaking honorariums or research payments, but when a doctor receives $5000 for giving one or two talks, it is safe to say that they are being paid for something else. If the psychiatrist admits to receiving money, then you should probably find another psychiatrist, as this creates a bias to prescribe that I do not think can be overcome.

Third, you should be dubious about any suggestion to give your child an antipsychotic medication for any diagnosis other than true psychosis. This means that unless your child is actively hallucinating, and delusional, i.e. “crazy” there is no evidence that antipsychotics will help them. For instance, there was only one well controlled study of the use of atypical antipsychotics in bipolar illness in children, and it found little or no difference between using the antipsychotic and not using it. And most of the children in the group receiving the antipsychotic dropped out of the study due to side effects. A second study by the same researchers found no advantage to using antipsychotics.

Fourth, consider taking your child to a psychologist or counselor rather than a psychiatrist. Psychologists don’t receive money to influence their treatment decisions, and use behavioral approaches that don’t have side effects. And there is much more research evidence that supports the use of these behavioral approaches in childhood disorders. Dangerous medications should be reserved as second or third line treatments only. Remember the old saying that to a young boy with a hammer everything becomes a nail, similarly to a doctor whose specialty is giving drugs, all problems become biochemical.

Finally, let’s put pressure on our legislators to outlaw this thinly disguised bribery, which threatens the health of children and adults. Shame on the pharmaceutical industry! And even more shame on psychiatrists, who of all people should be trustworthy and not willing to accept such bribes. I make the perhaps radical suggestion that patients boycott psychiatrists who accept money from drug manufacturers. If doctors can’t earn a decent living without taking payments from drug companies that often have the appearance of bribes, then perhaps they need a new profession. I realize that there are decent, honest psychiatrists who either don’t take drug company money or don’t let it influence them, but I suggest that it may be hard to tell the difference, unless psychiatrists employ full disclosure.


Copyright 2007 The Psychology Lounge/TPL Productions

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

The Mind-Body Connection: Depression and Its Effects On Physical Health

I will return to the theme of happiness in a few more days, but today we will continue with our series about depression, based on Peter Cramer’s book Against Depression, which I heartily recommend to anyone who wants to learn more about depression.

Depression is not just a psychological disease. It impacts the whole body, and especially impacts the cardiovascular system. Depression is one of the strongest predictors of cardiac disease. Even minor depression increase the risk of cardiac disease by 50 percent. Major depression increases risk by 3 to 4 times. For those with pre-existing coronary artery disease, risk is increased 5 times!

You might be thinking that this is no surprise. Perhaps depressed people smoke more, exercise less, eat more bacon, etc. What is surprising is that the numbers in the preceding paragraph are after adjusting for lifestyle and behavior! The raw numbers are even higher!

Why is this? What is the mechanism by which depression reeks havoc with the cardiovascular system?

There are several possible mechanisms. One is through the impact on blood clotting.

Blood clotting is controlled by cells in the blood called platelets. The stickier the platelets are, the more likely you are to develop blood clots, which can lead to stroke or heart attack. Depressed patients have stickier platelets.

Another mechanism is stress. Depressed patients are under constant physiological stress, with excess stress chemicals circulating in their blood. This may raise blood pressure and cause other changes that affect the cardiovascular system.

So what happens if you treat depression? Does this reduce risk of cardiovascular disease?

Studies of antidepressants given after heart attack show a 30 to 40 percent reduction in subsequent heart attacks and deaths.

Antidepressants improve the outcomes after stroke as well. When stroke patients were given either antidepressants or placebo, 66 percent of the antidepressant group survived 2 years, but only 35 percent of placebo group.

Other physical triggers like treatment with interferon for hepatic C and melanoma can also cause depression. In fact, 50 percent of patients who receive interferon will get seriously depressed. Depression in these cases is serious because it can cause the person to stop taking a potentially life-saving treatment.

Antidepressants help even in these cases of drug induced depression. One study found that treatment with Paxil, an antidepressant, reduced depression from 45 percent to 11 percent.

What are the implications of these finding?

  1. All patients who have had a heart attack or a stroke should probably take an antidepressant.
  2. All patients taking long-term interferon treatment should begin taking an antidepressant several weeks before starting the interferon.
  3. Probably most seriously ill cancer patients should take an antidepressant as well.
  4. Counseling that focuses on evaluating and treating depression should be part of any seriously ill medical patient’s treatment regimen.

Copyright 2007 The Psychology Lounge/TPL Productions

All Rights Reserved


——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Forbes Magazine Endorses Cognitive Behavioral Therapy! In a Faceoff between Cognitive Behavioral Therapy and Antidepressant drugs, Therapy Wins!


As regular readers know, your editor is a big fan of a type of psychotherapy called Cognitive Behavioral Therapy (CBT). Cognitive therapy is a modern non-drug therapy that teaches clients new ways of thinking and feeling. The basic concept is that it is our distorted thinking that creates psychological problems of anxiety, depression, panic, etc. The cognitive therapist combines teaching cognitive skills with behavioral techniques that allow the client to overcome their difficulties.

And much to his surprise, this week Forbes Magazine put CBT on their cover! The Forbes article about Cognitive Behavioral Therapy was very positive. They summarize 30 years of research, including studies that show that CBT works well for insomnia, hypochondria, anxiety, depression, bulimia, obsessive compulsive disorder, preventing suicide, and even matches surgery for low back pain. Here is a video demonstration of exposure treatment for an elevator phobia.

They also compare the effectiveness of CBT to antidepressant medication. Although both work, in the long run CBT is more cost effective, and leads to less relapse. In one study comparing Paxil to CBT, only 31% of the CBT group relapsed within one year of completing treatment, compared to 76% of the Paxil group! This is a very big difference. The skills that clients learn seem to have a lasting impact on preventing future depressions.

Even in terms of cost, CBT beats antidepressant medications, at least with the assumptions the Forbes editors made. After three months of treatment, they estimate the costs of cognitive therapy at $1200 and the costs of medication treatment with Effexor at $502, which includes one psychiatrist visit at $200, and $302 in drug costs. At one year, they estimate the costs of cognitive therapy at $2000, and drug treatment at $2009, which includes $800 for four psychiatrist visits at $200 each, and $1209 for the Effexor.

As much as I like the comparison, it is based on faulty assumptions. First of all, it’s not clear how many sessions of cognitive therapy they are estimating. The $2000 would pay for 20 sessions at $100, but only 13 at $150. It’s probably optimistic to believe that a good outcome would come out of only 13 sessions. And because the primary group of professionals who perform cognitive therapy are psychologists, who typically charge more than masters level therapists, $100 is probably too low.

So let’s fix the numbers. Let’s assume 25 sessions of cognitive therapy, at $150 per session, which comes out to $3750. That’s probably a fairer assumption.

Now let’s look at the other assumptions. Effexor is an expensive, non-generic anti-depressant, which costs $100 a month, or even more. But the generic version of Prozac, called fluoxetine, can cost as little as $10 a month. And four psychiatrist visits in a year is also too optimistic. In my experience, patients need every two week visits initially to get the medication adjusted, and after 6 or 8 weeks, can graduate to once a month, and after another 3 visits, can be seen every three months. Also, psychiatrists typically charge at least $300 for the initial evaluation, and less than $200 for the follow-up visits which tend to be shorter visits.

So by these assumptions, the psychiatrist visits would cost $1380 at least. This brings the total cost of one year of treatment with Effexor to $2589. Of course, if fluoxetine was substituted then the total costs would only come to $1500!

So drug treatment costs less than cognitive therapy, right? It either costs a lot less ($1500 compared to $3750) or somewhat less ($2589 compared to $3750).

But there is still a glitch in the assumptions. We are only looking at the first year costs. Remember the statistics mentioned above, that up to 76% of patients who stop taking antidepressants relapse back into depression. Those are pretty bad odds. If a patient stayed on Effexor for 5 more years, their total cost of treatment would skyrocket to $6756, assuming psychiatrist visits 4 times a year. Compared to this cognitive therapy looks good!

There is another, unmentioned advantage to cognitive therapy, which is incredibly important, and which too often is left out of this debate. Here’s the dirty little secret the drug companies don’t want you to know—most antidepressants ruin your sex life! With really just a few exceptions (Wellbutrin, and Emsam) almost all of the major antidepressants make it much harder to have an orgasm for both men and women, and for men may make it difficult or impossible to get or maintain an erection. Antidepressants should really be called anti-sex drugs! (Caveat: not everyone will have the sexual side effects, but most will.) Here is a good article about the sexual side effects of antidepressants.

And this leaves out all of the other side effects of antidepressants. Here’s a link to common side effects of antidepressant medication Dry mouth, dry eyes, blurred vision, nausea, insomnia, headaches, the list goes on and on. How do you place a value on the costs of side effects?

Cognitive therapy obviously has no sexual side effects, or any other side effects. So for this reason, and for the advantage in preventing relapse, I believe cognitive therapy should be the first choice therapy for those patients suffering depression, providing they can afford therapy or have good insurance coverage for therapy. If not, then having your regular doctor prescribe and monitor a generic antidepressant such as fluoxetine (Prozac), sertraline (Zoloft), or bupropion (Wellbutrin) is the best option, with the downside being that you will most likely need to take the medications long-term to avoid relapse, and that you will most likely have physical side effects. Thus it may be worth taking a loan from your credit card in the form of a cash advance, or simply using a credit card to pay for cognitive therapy. After all, that’s how most people pay for their next car, or flat screen television set.

So here’s the executive summary. Cognitive therapy works for a large variety of common psychological problems, and even a few physical problems. Although initially it costs a little more, the effects are longer lasting than medication treatment. And in the long run, it can end up saving money. Best of all, other than working a little bit on therapy homework, there are no side effects of therapy! Conclusion: If you are depressed, anxious, having insomnia, obsessive compulsive disorder, hypochondriasis, phobias, or relationship problems, your first move should be to find a psychologist who specializes in cognitive therapy. Borrow the money if you don’t have it, or put it onto your credit card, but don’t miss out on this effective treatment out of some false sense of economizing.

Copyright 2007 The Psychology Lounge/TPL Productions

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

No Articles This Week: The Lounge Wizard Gets the Flu

The Lounge Wizard is down with the flu this week, so until I’m up to full strength, there will be no posts. Sorry about that.

I’m trying out Tamiflu, which I started to take the night I started to have a high fever and aches. We will see if I can sidestep most of the flu with this magical medication. So far it has brought my fever down from about 102 to almost normal, at 99.6.

But I still feel pretty punk, with an achy body and low energy. We’ll see how tomorrow goes….more later.

Copyright 2007 The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Let’s Not Kill Any More Rebecca Riley’s! Debate Over the Use of Psychiatric Drugs for Young Children

 

The New York Times reported that Rebecca Riley, a four year old girl from near Boston, was found dead on the morning of December 13, a victim of an apparent overdose of the psychiatric drugs Seroquel, an antipsychotic drug; Depakote, a powerful anti-seizure medicine used for mood control, and Clonidine, a blood pressure drug often prescribed to calm children. Rebecca had been diagnosed at having bipolar disorder at the age of two! So some overzealous psychiatrist had diagnosed her as been manic depressive at age 2.

Now this is pretty crazy. A child at two is a work in progress, and if is virtually impossible to diagnose anything at that age. The only exceptions are the developmental disorders, such as autism. Probably Rebecca was a difficult child, prone to moodiness and maybe even tantrums. So her parents, with a willing psychiatrist, gave her mind-numbing drugs to calm her, rather than learning better parenting skills. From the article: “A relative of her mother, Carolyn Riley, 32, told the police that Rebecca seemed “sleepy and drugged” most days, according to the charging documents. One preschool teacher said that at about 2 p.m. every day the girl came to life, “as if the medication Rebecca was on was wearing off,” according to the documents.”

This is more than sad, it is pitiful. How many other, nondrug interventions were tried before using medication? Was there parenting training? Was there a home visit, to see how Rebecca and her parents were interacting? The article does not say, but I’m guessing that none of these things were done. There’s an old saying, “Give a young boy a hammer, and everything becomes a nail.” In much the same way, bringing a child to a psychiatrist means that they are likely to get drugs. That’s why the first stop for children, especially young children, should be to a child psychologist, a psychologist who specializes in treating children and their families.

It should also be noted that most psychiatric medications are not and have never been approved for use in young children. There are no studies of using these drugs on toddlers. Although it might be occasionally reasonable to use drugs meant for adults on older teenagers, who are at least biologically similar to adults, it is irresponsible at best to use these drugs with young children.

The problem is that giving kids drugs is too easy. From the New York Times article, “Paraphrasing H. L. Mencken, Dr. Carlson added, ‘Every serious problem has an easy solution that is usually wrong.’” Behavioral problems in children can be very serious, and the behavioral interventions take time and commitment. Learning good parenting techniques, such as the proper use of time-outs and other interventions, takes dedication and a competent psychologist’s help.

As with adults, medications should always be reserved for after all other interventions have failed. And with children, only medications that have been tested on children, and used for years should be tried. If psychiatrists want to prescribe these medications for children, let them first run the research trials required by the FDA to test safety and effectiveness. Let’s not kill anymore Rebecca Riley’s!

PermaLink to article

Copyright 2007 The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Mild Depression, A Mild Problem?

 

More from Peter Cramer’s book Against Depression, which I heartily recommend to anyone who wants to learn more about depression.

We talked about the full blown diagnosis of depression. For a diagnosis of major depression you need 5 or more symptoms for at least 2 weeks. What if a patient has only 2 or 3 symptoms for 2 weeks? Is that a problem?

First of all these mild depressions can be the precursor or follow-up to major depression. So they are important for that reason.

But even if there is no major depression, mild depression looks like major depression. Mild depression runs in families where major depression is prevalent. Low level depression causes disability, absenteeism, more medical visits.

Another type of mild depression is dysthymia. Dysthymia means being sad at least 50% of the time, for 2 years or more. And dysthymia is not the same as unhappiness. Dysthymics suffer the same relentless internal stress, the hopelessness, sadness, and low self-esteem of the depressed. The fact that they may function well, or eat and sleep well, is of small comfort to them.

The problem with dysthymia and mild depression is that medications may be less effective with these conditions, and some types of psychotherapy, more effective. Although no one exactly knows, the general consensus is that dysthymia is less responsive to antidepressants than is major depression. But it may be more responsive to cognitive behavioral therapy.

In summary, even mild depression has serious impacts on people. Mild depression can be effectively treated with cognitive behavioral therapy, and responds well to it.


Copyright 2006 The Psychology Lounge/TPL Productions

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

The Natural History of Depression

I’m still reading Peter Cramer’s book Against Depression, which is his follow-up to Listening to Prozac, his groundbreaking book about depression and Prozac. This is a fascinating book, as good as Listening to Prozac. I continue to be impressed by his scholarship and ability to pull interesting research together. If you have any interest at all in learning more about depression, I would strongly recommend this book, which is a philosophical and scientific exploration of depression.

What is the natural history of depression? That is, what happens later in life if you get depressed now? Do you recover, or do you have more depressions?

We have good data on this issue from some studies funded by the National Institute of Mental Health. These studies followed depressed patients over many years. The findings are astounding, at least to me.

They show that if you are diagnosed as being depressed today, there is a 20 percent chance you will still be depressed 2 years later, and a 7 percent chance you will still be depressed ten years later, and a 6 percent chance you will be depressed 15 years later!

Even if you recovered, your probability of relapse is high. In these studies, most patients had subsequent depressions: 40 percent at two years, 60 percent at five years, 75 percent at ten years, and 87 percent at 15 years.

And with each episode of depression the prognosis worsens. After the second episode of depression, the 2 year recurrence rate soars to 75 percent!

One likely explanation for this effect is called kindling. The kindling model was first developed to explain how epilepsy works. In epilepsy, each seizure you have makes you more likely to have more seizures. This is because the seizure damages the brain.

We now think that each major depression may alter the brain as well. Particularly it may cause a shrinking of cells in several important areas of the brain. One of these is the hippocampus, which governs the formation of short term memory. Another is the prefrontal cortex, which has many functions in reasoning.

And how many patients got treatment? Only 3 percent of the patients who were diagnosed with depression had ever received even a single one month trial of anti-depressant medication! This is shameful in a country that claims to have good health care.

So what do we learn from these studies?

  1. Depression is a chronic disease, and relapse is very high.
  2. Each relapse makes you more susceptible to future depressions. Each depression erodes the resilience of the brain.
  3. A small but substantial percentage of depressed patients remain depressed for years on end.
  4. Prevention of initial depressions, early treatment of major depression, and prevention of future depressions can change the natural history of depression, and prevent a lifetime of depression.


The other important thing to realize about these studies is that they only looked at major depression. That is, at depression with many serious symptoms. Later studies that have looked at milder versions of depression have found that even mild depressions predict future major depressions. A future post will talk about minor depression, or dysthymia.

Copyright 2006 The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Depression: No Big Problem? Right? Wrong!

Here is some more good stuff from Peter Cramer’s book Against Depression, which is his follow-up to Listening to Prozac, his groundbreaking book about depression and Prozac. This is a fascinating book, as good as Listening to Prozac. If you have any interest at all in learning more about depression, I would strongly recommend this book, which is a philosophical and scientific exploration of depression. Much of what follows is inspired by this book.

How big a problem is depression compared to other illnesses? Other health problems such as AIDS, arthritis, heart disease, diabetes, and cancer are much bigger problems, right?

Wrong. If you look at the impact of depression on disability, very interesting facts emerge. Let me explain how these figures are calculated. Imagine a 20 year old woman develops chronic depression that causes her to be 1/3 disabled for the next 60 years. That means she loses the equivalent of 20 years of life, which is the same as if a healthy woman died at age 60 instead of the normal lifespan of 80.

When disability from depression is calculated this way, the figures are astounding. The World Health Organization looked at this data from around the world. They found that by the year 2020 depression will be the largest cause of disability with the sole exception of heart disease. Even in 1990, depression was already the number one cause of disability within the major chronic diseases of midlife. Major depression accounted for almost 20 percent of disability-adjusted life years lost for women in the developed countries. This was more than three times the amount caused by the next illness.

Other studies looked at the impact of depression in the workplace. In the United States this cost is estimated at over 40 billion dollars, which is almost 3% of the total economy. Being depressed on the job is estimated as the equivalent of calling in sick half a day per week.

Just how common is depression? There are many studies and they often disagree, but the best studies suggest that about 16 percent of Americans will suffer a major depression over their lifetime. That is almost 1 in 6 Americans. Look around at your friends and family and co-workers, 1 in 6 of them will suffer a major depression. In any given year, between 6-7 percent suffer major depression.

And depression has major health implications. Studies that look at elderly people find that depression increases the risk of death very significantly, independent of suicide. One study found that elderly people who were depressed were 40 percent more likely to die than those who were undepressed. When they analyzed the data to see what the cause was, they found that even when you controlled for all other health behaviors and other factors, depression still accounted for 24 percent increase in deaths. This was the equivalent of high blood pressure, smoking, stroke, or congestive heart failure.

So depression is no big deal? Not unless you consider major disability, huge workplace effects, and shortened life a big deal. In reality, depression is one of the most devastating diseases that human beings suffer.

Copyright 2006 The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Depression in Middle Age and Beyond

Here is some more fascinating stuff from Peter Cramer’s book Against Depression, which is his follow-up to Listening to Prozac, his groundbreaking book about depression and Prozac. This is a fascinating book, as good or better than Listening to Prozac. I continue to be impressed by his scholarship and ability to pull interesting research together. If you have any interest at all in learning more about depression, I would strongly recommend this book, which is a philosophical and scientific exploration of depression.

What about those people who have their first depression later in life? Are they similar or different to those who get depressed earlier in life?

What is interesting is that there may be a type of depression in older adults that is physically triggered. Let me tell you a story about how this was discovered.

Much of this research was conducted by K. Ranga Ram Krishnan and his group at Duke University. In the 1980’s they got their first MRI machines. These machines let you take detailed pictures of the brain without using radiation (they use magnetic resonance imagery instead.)

His group didn’t really know what to do with these new machines. So they decided to take a look at the brains of elderly depressed patients. What they found was fascinating. In 70% of the patients who had suffered late in life depressions, they found small white patches in various areas of the brain. When they autopsied some of the these patients who later died, they found that these were lesions in the brain that ranged from tiny pinpoint lesions up to rather large (2 inches in diameter) lesions. These were where silent strokes had occurred, killing the brain tissue.

Silent strokes are those strokes that happen in a part of the brain that does not control sensation or motion, so you often are unaware you even had the stroke.

This led to the realization that these people were suffering from vascular depression, that is, depression caused by damage to the brain from a silent stroke.

The main area of the brain where Krishnan found these lesions was the prefrontal cortex, or more specifically the orbitofrontal cortex, right behind the eyes.

These depressions were very similar to regular depression, with the main difference being that this group generally hadn’t suffered depression earlier in life.

The good news is that these depressions respond well to antidepressant medications, and the patients tend to get well just like regular depressions.

In summary, if you or a relative suffers a sudden depression later in life, suspect a vascular depression. And get treatment. (Also, if your elderly relative suffers a vascular depression, they may also show pseudo-dementia, which is a type of cognitive impairment which is caused by serious depression. It can look like they have suddenly developed Alzheimer’s or some other dementing disorder, but it actually is a side effect of the depression. Treating the depression will often resolve the pseudo-dementia. )

Most important, if a doctor or psychologist tells you that your older relative is depressed because they are old and sick, don’t accept this. There is no reason for the elderly to be more depressed, in spite of age or infirmity.

Copyright 2006 The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

New Research into the Causes of Depression

 

Lately I’ve been reading Peter Cramer’s book Against Depression, which is his follow-up to Listening to Prozac, his groundbreaking book about depression and Prozac. This is a fascinating book, as good as Listening to Prozac. If you have any interest at all in learning more about depression, I would strongly recommend this book, which is a philosophical and scientific exploration of depression. Much of what follows is inspired by this book.

Today I want to talk about the new and exciting research on depression done by Kenneth Kendler at the Virginia Commonwealth University.

Dr. Kendler has looked at the causes of major depression. His research finds that there are three pathways to depression. That means there are a number of different triggers that cause people to become depressed.

The first is what he calls the internal pathway. This includes two variables that predict depression–childhood onset anxiety disorders (before age 18) and neuroticism (a general trait of psychological disorder). This means that if you have an anxiety disorder as a child, or if you are generally neurotic, you are more likely to become depressed later in life.

The second is the external pathway. This path includes two variables: conduct disorder and substance abuse. (Conduct disorder means getting into trouble with the law.) So if you abused alcohol as a teenager, and got arrested, you are more likely to get depressed later in life.

The third path is not surprisingly, through adversity in life. And this pathway is the most complex. It starts in childhood with a disturbed family environment, childhood sexual abuse, and the loss of a parent. It continues with low educational achievement, lifetime trauma, low social support, and the likelihood of divorce. Finally, it ends with current stressors such as marital problems, life difficulties, and stressful events in the last year before depression starts. Kendler believes that much of the adversity that people experience are actually interpersonal difficulties.

What is worse is that the factors are related to one another. If you have adversity in childhood, you are more likely to develop conduct disorder and substance abuse, and these disorders make it more likely you will get into a bad marriage, lose your job, etc.

This complex model was able to account for 52 percent of the likelihood of depression in a one year period.

So far none of this is really that surprising or interesting. After all, most people would predict that a lousy childhood, getting into trouble, and being anxious might lead to depression.

The really interesting part of his research is how these factors influence one another, and how the genetic component influences all of them. Genetic factors influence all three of the major factors. If you are genetically prone to depression, you are more likely to have a lousy childhood, get into trouble and abuse substances, and be anxious and neurotic! How does this work?

Kendler isn’t sure, but suspects that if you are prone to depression, your parents might have been also, and this impaired their ability to parent well. Or perhaps, it is harder to parent an anxious, depressed, neurotic child. Or perhaps both are true; depressed parents have a harder time parenting, and their children tend to be moodier and harder to deal with. The genetic propensity to depression may also be connected to substance abuse directly or as an attempt to self-medicate the depression.

Other findings from his research. He found that if you have an anxiety disorder before age 18, this is a strong and independent predictor of depression.

So what can we learn from this research?

There appears to be a tragic path to depression. The depressed person is born with a genetic tendency to depression which in turn is correlated with the likelihood of a bad childhood. Then they do worse in school, get in trouble more, turn to substance abuse, and then aas adults pick bad relationships, have more conflict in jobs and family, and are more likely to be traumatized. Basically their whole life goes poorly. Chaos and conflict and loss and low social support leads to depression. A single depression leads to future depressions.

It is all pretty depressing! But what it shows is also the pathway to healing. For instance, therapy in childhood may help prevent some of this. Treating early anxiety disorders or substance abuse may prevent some of the later chaos.

It also shows why therapy is so important in the treatment of adult depression. Although anti-depressant medications may help with the biological problems in depression, therapy is necessary to help clients learn new ways to relate to people and how to make better interpersonal decisions. A supportive therapist may also help buffer the effects of adversity and loss and make depression a less likely outcome.

This research also suggests that depression is not just a mood state, but is an illness that affects many aspects of a person’s life (and in a negative direction.) We need to be aggressive in treating this serious and debilitating illness.

Copyright 2006 The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

What is Depression? Is It the Same as Being Sad?

What is depression, anyway? Is it the same as feeling sad? No. Depression is not just feeling down for a day or two. The diagnosis of depression is based on having certain symptoms.

Two key symptoms are depressed mood, which is feeling sad or blue, and difficulty experiencing pleasure or joy, which is sometimes called anhedonia.

Other symptoms of depression are problems sleeping, changes in appetite (more or less), feelings of worthlessness or guilt, problems concentrating, fatigue or low energy, mental/physical agitation or chronic worry or slowing, and having thoughts about suicide.

To have major depression, you need to have at least five of these symptoms, including one of the first two, depressed mood and anhedonia. And the symptoms have to last at least two weeks, and cause you some discomfort and impairment in your functioning.

The exception is mourning or bereavement, which can cause the same symptoms, but doesn’t count as depression. So if your mother has died and you have these symptoms, don’t worry.

Depression Screening Checklist

Instructions: Check any symptoms that you have been troubled by and that has lasted for the past two weeks.

Category A

___ I have felt sad or blue or depressed

___ I have had a hard time feeling joy or pleasure, even while doing activities that typically bring me joy or pleasure. I feel “flat”.

Category B

___I have had a hard time concentrating.

___I have felt tired or low energy.

___I have had difficulty sleeping (sleeping too little or too much)

___I have had changes in my appetite (eating too little, or too much).

___I have felt mental/physical agitation or slowing down.

___ I have felt worthless or guilty or lowered self-esteem.

___I have had thoughts about death or suicide or hurting myself.

Scoring:

Count the number of checks in Category A. Write that here:____

Count the number of checks in Category B. Write that here: ____.

Add up the number of checks in Category A and Category B, and write that here: _____.

If A is 1 or 2, and the sum of A and B is 5 or more, you have major depression, and should seek help from your doctor or from a psychologist. If A is 1 or 2, and the sum of A and B is 3 or 4, you may have mild depression, and should probably seek help as well.

IMPORTANT: If you are having any thoughts about hurting yourself or killing yourself, you should seek help immediately, calling your local suicide prevention line (listed in the front of your phonebook), or calling 911, or seeing your doctor or a psychologist right away.

Copyright 2006 The Psychology Lounge/TPL Productions

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.