Does our attitude towards aging increase Alzheimer Dementia?

Posted on December 11, 2015 by cedwardpitt

“I think I’m forgetting something …”
Does our attitude towards aging increase Alzheimer Dementia?

For the last few years, I’ve worked as a doctor for a number of my local nursing homes. On my morning rounds, I would literally reintroduce myself to every second patient, because even though I’d seen them every week for the previous few months, they still couldn’t remember who I was.

And it’s not just because I have a less than memorable face. Most of my nursing home residents had dementia.

While there are many different causes for dementia, the one first described by Mr Alzheimer in the (early 1900’s) is the best known and most feared. It is also the most common, and is a significant drain on the nation’s economy as well as the quality of life in the twilight of years.

Recently, an article was published by a group of researchers from Yale University in the US which claimed to show that the attitude a person had towards aging contributes to their chances of Alzheimer Disease. I first saw it yesterday on the social media feed of Dr Caroline Leaf, communication pathologist and self-titled cognitive neuroscientist. Dr Leaf is known for her scientifically dubious assumptions that the mind changes the brain, not the other way around, and has previously publically stated that dementia was caused by toxic thinking. This article seems to vindicate her assumptions.

However, this article also made it onto Facebook’s trending list ands was picked up by news site all over the world (such as this article in the Australian http://goo.gl/RavbMl), so the interest wasn’t just from Dr Leaf, but also from the broader public. And I can understand why. No one wants to ‘grow old and senile’, or to ‘lose our marbles’. Any potential cure or prevention for Alzheimer Dementia is worth paying attention to.

I admit, the headline intrigued me too, both personally and professionally. I wasn’t aware that one’s attitude towards aging would contribute to Alzheimers, since Alzheimers is predominantly genetic, and the other associated risk factors have more to do with physical health (like diabetes, high blood pressure etc). Psychological stress is a risk factor for Alzheimers in mice, but good evidence in humans has been lacking [1].

So, does negative attitudes to aging really cause stress which then leads to Alzheimers as the report suggested, or is there a much better explanation?

The scientific article that the news reports were based on is A Culture-Brain Link: Negative Age Stereotypes Predict Alzheimer’s Disease Biomarkers [2]. This study was done in two stages. Volunteers were recruited from a larger study called the Baltimore Longitudinal Study of Aging. At entry point, the participants answered a questionnaire about their attitudes towards aging. This was about 25 years before the participants were actively studied.

The first study examined the change in volume of a part of the brain called the hippocampus (which plays an essential part in our memory system). The second part of the study examined the volunteers’ brains at autopsy for markers of Alzheimer Dementia, namely ‘plaques’ and ‘tangles’. The number of plaques tangles were combined to form a single composite score, which was then compared to the baseline attitude towards aging score.

In the first study, the researchers reported that those people who held negative views of aging were more likely to have a smaller hippocampus which more rapidly decreased in size over time.

In the second study, the researchers reported that those people who held negative views of aging were more likely to have more plaques and tangles in their brain.

On the surface, this seems to suggest that people who hold negative views on aging contribute to the development of Alzheimer Dementia, and certainly this is how the different news agencies seemed to interpret the outcomes of the study. Though on deeper palpation, a number of questions arise about how the researchers did the study and chose to interpret the results.

For example, the aging attitude survey was only done once, which means there’s a 25 year gap or longer between the questionnaire and the active studies. That’s a long time, and the attitudes of the volunteers may have improved or worsened in that time, but that doesn’t seem to have been considered

Levy and her researchers also report that the average size of the hippocampus changed significantly when they averaged the size of the left and the right hippocampus. But when they analyzed the two sides separately, there was no significant change over time. So this makes me wonder about the validity of their analysis too – if the volume of each side separately doesn’t change much at all, then how can the average volume of the two sides change so much?

I’m not much of a statistician, but I wonder if the secret’s in their modeling. They used a linear regression model to compare their data to their hypothesis, a legitimate statistical method, but which involves adjustment for other variables. If you do enough adjusting, you can get a significant result statistically, but according to their numbers, their Cohen’s d was 0.29, which is considered a weak effect overall.

Then there’s the question of clinical significance. Even if the hippocampus did shrink in those who thought aging was negative two decades ago, was the shrinkage enough to contribute to the cognitive impairment seen in Alzheimer Dementia? When compared to other studies, probably not. Looking at Levy’s graph, the “negative” attitudes group changed about 150mm³ over the 10 year follow up period, or about 5%. A recent study also showed that the the hippocampal size of subjects with mild memory loss is about 12% less than a healthy age matched control [3].

The same problems are seen in study 2 – Levy and her researchers reported an increase in the number of plaques and tangles in the “aging is bad” group. But her numbers are small, and not statistically strong. And again, the question of clinical significance arises. Plaques and tangles represent biomarkers of Alzheimer Dementia, not necessarily a diagnosis. Normal aging brains without dementia also have plaques and tangles, and it’s the number of tangles that seem more significant for developing cognitive impairment [4, 5], not the combined score that they used in this study.

And when all is said and done, all Levy and colleagues have shown is a correlation between attitude to aging and changes in the brain. But correlation does not equal causation. Just because two things are associated does not mean that one causes the other. There maybe another variable or factor that causes both observations to co-occur.

In Levy’s case, the common connecting cause could easily be neuroticism, which they discussed as a co-variant but did not say if or how they corrected for it. The other thing they did not examine in this study is the ApoE gene subtypes, which contribute significantly to the onset of Alzheimer Dementia [6]. The action of ApoE subtypes in the brain may contribute to both negative attitudes and Alzheimers changes?

The bottom line is that Levy’s study shows a weak correlation between a single historical sample of attitude towards aging, and some changes in the brain that are known to be markers for Alzheimer Dementia some three decades later.

They’ve certainly NOT shown that stress, or a person’s attitude to aging, in anyway causes Alzheimer Dementia. They did not correct for genetics in this study which is the major contributor to the risk of developing Alzheimers. So the results mean very little as it stands, and further research is required to delineate the cause and effect relationship here.

So don’t stress. It’s not definitely proven that how you view the aging process determines your risk of dementia. There will be those like Dr Leaf who will trot out this cherry-picked little titbit of information in the future to try and justify their pretense that thought can change our brain and impact our mental health, but what the press release says and what the study shows appear to be two different things altogether.

References

[1]       Reitz C, Brayne C, Mayeux R. Epidemiology of Alzheimer disease. Nat Rev Neurol 2011 Mar;7(3):137-52.
[2]       Levy BR, Slade MD, Ferrucci L, Zonderman AB, Troncoso J, Resnick SM. A Culture-Brain Link: Negative Age Stereotypes Predict Alzheimer’s Disease Biomarkers. Psychology and Aging 2015;30(4).
[3]       Apostolova LG, Green AE, Babakchanian S, et al. Hippocampal atrophy and ventricular enlargement in normal aging, mild cognitive impairment (MCI), and Alzheimer Disease. Alzheimer Dis Assoc Disord 2012 Jan-Mar;26(1):17-27.
[4]       Nelson PT, Alafuzoff I, Bigio EH, et al. Correlation of Alzheimer disease neuropathologic changes with cognitive status: a review of the literature. J Neuropathol Exp Neurol 2012 May;71(5):362-81.
[5]       Jansen WJ, Ossenkoppele R, Knol DL, et al. Prevalence of cerebral amyloid pathology in persons without dementia: a meta-analysis. JAMA : the journal of the American Medical Association 2015 May 19;313(19):1924-38.
[6]       Liu CC, Kanekiyo T, Xu H, Bu G. Apolipoprotein E and Alzheimer disease: risk, mechanisms and therapy. Nat Rev Neurol 2013 Feb;9(2):106-18.

Dr Caroline Leaf – The mystery of he said/she said is no longer a mystery

Posted on December 4, 2015 by cedwardpitt

This weeks edition of New Scientist magazine carried an article entitled “Scans prove there’s no such thing as a ‘male’ or ‘female’ brain” [1]. The article was inspired by a journal article published in the PNAS last month [2], which reviewed the scans of 1400 different people to see if there were specific differences in the neuroanatomy of the brains of men and women (i.e., are there ‘male’ and ‘female’ brains, or are the commonly accepted male/female differences just a myth, or a cultural, not biological phenomenon?)

According to the article, there is an “extensive overlap between the distributions of females and males for all gray matter, white matter, and connections assessed. Moreover, analyses of internal consistency reveal that brains with features that are consistently at one end of the ‘maleness-femaleness’ continuum are rare. Rather, most brains are comprised of unique ‘mosaics’ of features.” [2]

So essentially, there’s no strong biological basis for gender differences after all. “This means that, averaged across many people, sex differences in brain structure do exist, but an individual brain is likely to be just that: individual, with a mix of features. ‘There are not two types of brain,’ says Joel.” [1]

This news is a blow to one of Dr Leaf’s less renowned books, “Who switched off your brain? Solving the mystery of he said/she said” [3].

Dr Caroline Leaf is a communication pathologist and a self-titled cognitive neuroscientist. Her ‘he said/she said’ book is based on the idea that there are definitive characteristics of the male and female brain which define each gender. From her conclusion on page 211,

“Men and women are different. Both the physical anatomy and functional strategy of our brains are different. We can’t attribute this to social engineering, cultural norms or our up-bringing. We’ve been created different – it’s in our fundamental design. Our parents, our communities, and the cultural context of our childhood and adolescence certainly have a prominent developmental role in each of our lives. But your brain has been fashioned in a specific way that shapes your ‘true you’ long before any of these other factors have had the opportunity to exercise their influence on you.”

As a quick aside, this quote shows the confusion in Dr Leaf’s teaching. As I’ve discussed before in other blogs, Dr Leaf contradicts herself by claiming that our brain determines our gifts and our behaviours in some books (like ‘He said/she said’ and ‘The gift in you’) but then claims that our thought life controls our brains and our physical reality in the rest of her teaching. So which is it?

But this quote also sounds the death knell for her book, in light of the recent scientific evidence to the contrary. Which is a shame, since out of all of her books, this one initially seemed the most scientifically robust.

Even though the book is based on a now defunct theory, I wonder if the thrust of her book still holds true to a point. We’ve all been created to be different, and we should celebrate those differences and how they complement other people around us. It just so happens that those differences aren’t inherent to our gender, but to us as individuals, uniquely designed by God “for good works, which God prepared in advance for us to do” (Ephesians 2:10).

So, yes, the mystery of he said/she said has been solved, but not quite as Dr Leaf envisaged.

References

[1]        Hamzelou J. Scans prove there’s no such thing as a ‘male’ or ‘female’ brain. New Scientist. 2015 Dec 5.
[2]        Joel D, Berman Z, Tavor I, et al. Sex beyond the genitalia: The human brain mosaic. Proceedings of the National Academy of Sciences of the United States of America 2015 Nov 30.
[3]        Leaf CM. Who swithced off your brain: Solving the mystery of he said/she said. Texas, USA: Inprov, Ltd, 2011.

Ritalin may not help children with ADHD?

Posted on November 29, 2015 by cedwardpitt

A few days ago, the media had a frenzy over a new study about the use of Ritalin (methylphenidate – a stimulant medication) for Attention Deficit Hyperactivity Disorder (ADHD) (http://goo.gl/Ht9GKF).

ADHD is always good for a headline grab because it is so polarizing. It’s like the new HIV – everyone’s got an opinion on ADHD, and most of them are facile or just plain ignorant. That doesn’t stop the armchair experts from sharing their opinions, and this new Cochrane review into the studies of Ritalin for ADHD just gives them another chance to vent their fatuous spleens.

Like a couple of the comments posted at the end of The Australian article. One suggested that ADHD was a disease invented so they could find another drug to treat it, and suggested that mobile phone games were the problem. Another thought he was rather humorous when he trotted out the tired old chestnut that it’s all the parents fault: “ADHD has been nicnamed {sic} ‘Absent Dad At Home’ syndrome!” Sorry, but no one’s laughing.

We need to take a step back from the uneducated and unwarranted opinion of the self-titled experts, and look at what the study actually said. To do that, lets have a look at what the study was, what it looked at, and what the results were. We’ll then compare the results with some of the other options available for treating ADHD, so we can make an informed decision about how to best manage ADHD.

First, what study are we talking about? The study in question is a Cochrane Review lead by Storebo, titled “Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)” [1]. (You can read the official press release here: http://www.cochrane.org/news/researchers-urge-caution-prescribing-commonly-used-drug-treat-adhd or the abstract here: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009885.pub2/abstract)

Cochrane reviews are scientific works that pool the best research on a particular topic and combine it into a mega-study, to get the best results available for a particular topic. First, all the papers written about the topic in question are found. The poorest quality studies are discarded, leaving studies that are suitable quality and are fairly uniform in how they did their research, so that the results from each study can be combined into one uniform result.

This process of meta-analysis increases the statistical power of the results enormously. The Cochrane Collaboration has been at the forefront of meta-analysis and has developed specific rules about the quality of evidence it accepts for its reviews, making a Cochrane review as trustworthy as medical research can be.

So what did the meta-analysis of methylphenidate for children with ADHD actually show? In short,

A strong improvement in the Teacher-Rated Symptoms score,
A strong improvement in the Teacher-Rated Behaviour score,
Small-to-moderate improvement in the ADHD rating scale,
Small increase in minor side effects such as poorer sleep and appetite, and
No increase in serious harm from methylphenidate.

So … that sounds pretty positive overall. Why the big hullabaloo? Why are these experts supposedly urging caution?

The concerns the researchers had was with the quality of the studies. Overall, the research that’s been done thus far has been deemed low quality by Cochrane’s standards. So they were cautious about suggesting that the results were reliable given the quality of the studies they had to work with. And that’s fair enough. Better quality studies are required to confirm the findings of the current Cochrane review, and this should be done as a matter of priority.

Unfortunately, the reviewer’s cautious approach to the research has been misinterpreted as a concern about the drug itself.

There are two important points here: 1. Accepting the limitations of the quality of the research it’s based on, the review still found a moderate effect of methylphenidate, and 2. Other “treatments” for ADHD have been proven in separate meta-analyses to be wholly ineffective.

There’s a little bit of statistical interpretation required here, but the Standardised Mean Difference (SMD, or sometimes called Cohens d) for the Teacher-Rated Symptoms score and Teacher-Rated Behaviour score was -0.77 and -0.87 respectively. The negative value here doesn’t mean that it’s bad; it’s just the arbitrary direction the reviewers chose to show improvement favouring Ritalin. Then there’s the SMD itself. The SMD takes into account the variability of the results overall, using a specific formula to take that into account.

The SMD used here doesn’t equate to the other value the reviewers used for the side effect statistics, which they expressed as a relative risk. So you can’t look at the numbers given and directly equate the power of the improvements with the chance of side effects of the medication.

However, it’s been said that an SMD of 0.2 is a small effect size, 0.5 is moderate, and 0.8 is large [2], so the effect of Ritalin given by the study was actually a strong effect. In comparison, the relative risk of minor adverse effects given by the review was 1.29, or a 29% increased risk, which is relatively small.

Then there’s the important consideration of the effects of other treatments for ADHD. The effect of Ritalin maybe backed by low quality evidence, but there’s no evidence of any effect for the other so-called ‘treatments’ for ADHD. As per the review by Sonuga-Barke (2013), there is a tiny amount of evidence for supplementation with omega-3 and 6 fatty acids, but none for:

Elimination diets (including those for ‘antigenic’ foods, specific provoking foods, general elimination diets and ‘oligoantigenic’ diets)
Food colouring (including certified food colours, Fein-gold diets and tartarazine)
Cognitive training (including working memory specific, and attention specific training)
Neurofeedback, and
Behavioural intervention [3]

So no matter how inane or facile the arm-chair experts may be, there is no evidence that Ritalin for ADHD is harmful. There is a small risk of minor effects such as reduced appetite and sleep, but there is evidence (albeit low quality evidence) that it has a strong positive effect. In comparison, there’s no evidence of improvement from any other treatment that’s been adequately studied.

No drug is perfect, and that includes Ritalin. But it’s certainly not the devil in pill form either. It’s time to stop demonizing it, and ignorantly criticizing those children and their families who need it.

References

[1]       Storebo OJ, Ramstad E, Krogh HB, et al. Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD). The Cochrane database of systematic reviews 2015 Nov 25;11:CD009885.
[2]       Faraone SV. Interpreting estimates of treatment effects: implications for managed care. P & T : a peer-reviewed journal for formulary management 2008 Dec;33(12):700-11.
[3]       Sonuga-Barke EJ, Brandeis D, Cortese S, et al. Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. The American journal of psychiatry 2013 Mar 1;170(3):275-89.

Dr Caroline Leaf and the Me-Too approach to mental health

Posted on November 13, 2015 by cedwardpitt

Since her recent less-than-successful attempt at portraying herself as a mental health expert, Dr Leaf has been laying low on social media, sticking to bland, innocuous quotes or passages of scripture.

Today, she thought it was safe enough to pop her head up from the trenches to fire off another opinionated volley on mental well-being, with a quote from one of her favourite authors, Peter Kinderman:

“It’s our framework of understanding the world, not our brains and not even the events that happen to us – not nature and not nurture – that determines our thoughts, emotions, behaviours and, therefore, our mental health.”

Dr Leaf is a communication pathologist and self-titled cognitive neuroscientist. Without any training or professional experience in mental illness, she has also taken it upon herself to act as an expert on mental health within the Christian church.

Unfortunately, posting quotes like today’s offering only further destroys her flagging credibility among those with professional psychiatric experience, and adds to the confusion of the rest of the Christian church when it comes to understanding mental illness.

There are two main problems with Dr Leaf’s meme: the quote itself and it’s source.

The quote itself is wafer-thin, unable to stand up to even the most basic interrogation. For example, we know through basic common sense that the brain changes how we think, our moods, our emotions and our behaviours. We change our mood, our emotions and our alertness every time we have a cup of coffee, or a glass of wine. Hallucinogenic medications like LSD definitely change our framework of understanding the world. Coffee, alcohol, and illicit substances like LSD all change the mood or experience of the person using them because they all temporarily alter the function of the users brain.

Though it’s not just external substances that change how we experience our external and internal worlds, but our own internal hormonal ecosystem changes our emotions, our moods, our thoughts and our behaviours. This isn’t so obvious for most men as our hormones are fairly constant, though testicular failure is known to result in reduced energy, vitality, or stamina; depressed mood or diminished sense of well-being; increased irritability; and difficulty concentrating and other cognitive problems. For the female gender, monthly hormonal changes can sometimes result in sudden, marked changes in emotions, moods, thoughts and behaviours.

There are a lot of other reasons why the brain controls the mind, and our mental health, which I’ve also discussed numerous times in other blogs (here, here and here)

If you aren’t satisfied with a common sense approach, then consider the scientific evidence that personality, the name that we give to our inbuilt ‘framework of understanding the world’ is largely genetic, and dependent on the function of various neurotransmitter systems [1-4].

So to suggest that the brain is not responsible for our moods, our emotions, our thoughts and our behaviours isn’t supported by the weight of scientific evidence.

The quote by Kinderman doesn’t stop there, but suggests that “not even the events that happen to us … determines our thoughts, emotions, behaviours”, something that also flies in the face of current scientific evidence. For example, the other forty percent of personality is determined by our environment (specifically the ‘non-shared’ environment, the environment outside of our parental influence) [5, 6]. And common psychiatric illnesses are associated with early childhood adversity, such as schizophrenia [7] and ADHD [8]. So again, the quote is unscientific.

Who then is this Kinderman guy, and why does he disagree with the scientific literature?

Peter Kinderman is a Professor of Psychology at University of Liverpool, and the President-elect of the British Psychological Society. He’s a highly outspoken critic of modern psychiatry and what he perceives to be the medicalisation of normal moods and emotions and overuse of medications to treat these non-existent diagnoses. Kinderman believes that it’s our learning history that shapes the paths that our lives take, and so if we simply understand our personal models of the world and how they were shaped by the events and experiences to which we’ve been exposed, we can simply think our way out of any disease process [9].

Kinderman has come out in favour of talking treatments for psychosis in schizophrenia instead of medication, when there’s no scientific proof of benefit for psychosocial therapies in schizophrenia [10, 11] (and here).

This, and his staunch opposition of the DSM5 as invalid, makes me concerned about his bias against modern psychiatry, despite it’s many advances, scientifically and clinically.

However, I’m surprised that Kinderman would make such a statement because it’s such an asinine argument, I find it hard to believe that it came from a professor of psychology. Kinderman would surely recognise the role of biology in our mental health and wellbeing, even if he doesn’t agree with how it’s managed. Perhaps there’s an alternative explanation. Perhaps Kinderman didn’t say what Dr Leaf has claimed?

The answer is, he does, and he doesn’t.

Dr Leaf has quoted Kinderman correctly. Today’s quote is taken directly out of Kindermans 2014 book, “The New Laws of Psychology” [9], on the penultimate page of his introduction. So he does say that our brains and our experiences aren’t relevant for our mental health. But then again, in a blog on the militant anti-psychiatry blog ‘Mad in America’, Kinderman wrote this:

“I’ve spent much of my professional life studying psychological aspects of mental health problems. Inevitably, this has also meant discussing the role of biology. I hope I’ve made some progress in understanding these issues, in working out how the two relate to each other, and the implications for services. That’s my academic day-job. But it’s not just academic for me. I’m probably not untypical of most people reading this; I can see clear examples of how my experiences may have affected my own mental health, but I can also see reasons to suspect biological, heritable, traits. As in all aspects of human behaviour, both nature and nurture are involved and they have been intimately entwined in a complex interactive dance throughout my childhood and adult life.” http://www.madinamerica.com/2015/03/brain-baked-beans/

So he seems confused, both recognising that biological traits influence psychiatric illness, then denying it.

Personally, I disagree with the quote from his book, although I’m just a suburban GP from Australia, so what would I know, right? Though I think the evidence I’ve cited is on my side, and Kinderman is not without his critics who are more than his academic equal.

It also concerns me because the logical conclusion of this line of thinking is that psychiatric illnesses have no biological basis, and therefore psychiatric medications have no place in treatment of them. But as I outlined previously, there is good evidence for the beneficial effects of medications for schizophrenia and ADHD amongst other mental health disorders.

Dr Leaf continues to ignore the scientific evidence for the biological basis for mental ill-health, medications for their treatment, and even the most basic of all that our mind is a product of our brain. Instead, she’s nailed her colours to her mast and aligned herself with outspoken authors on the fringe of modern neuroscience. Rather than addressing the science behind her opposition to modern psychiatry and neuroscience, she has resorted to hiding behind their quotes, a ‘me-too’ commentator, rather than an actual expert.

Of more importance is the confusion that this brings to the vulnerable Christians who follow her social media “fan sites”. The more Dr Leaf criticises psychiatric medications and condemns their prescription and usage, the more likely it is that someone will come to serious harm when they inappropriately cease their medications. And if Dr Leaf won’t come to her senses, our church leaders are going to have to take action, before it’s too late.

References

[1]        Vinkhuyzen AA, Pedersen NL, Yang J, et al. Common SNPs explain some of the variation in the personality dimensions of neuroticism and extraversion. Translational psychiatry 2012;2:e102.
[2]        Chen C, Chen C, Moyzis R, et al. Contributions of dopamine-related genes and environmental factors to highly sensitive personality: a multi-step neuronal system-level approach. PloS one 2011;6(7):e21636.
[3]        Caspi A, Hariri AR, Holmes A, Uher R, Moffitt TE. Genetic sensitivity to the environment: the case of the serotonin transporter gene and its implications for studying complex diseases and traits. The American journal of psychiatry 2010 May;167(5):509-27.
[4]        Felten A, Montag C, Markett S, Walter NT, Reuter M. Genetically determined dopamine availability predicts disposition for depression. Brain and behavior 2011 Nov;1(2):109-18.
[5]        Krueger RF, South S, Johnson W, Iacono W. The heritability of personality is not always 50%: gene-environment interactions and correlations between personality and parenting. Journal of personality 2008 Dec;76(6):1485-522.
[6]        Johnson W, Turkheimer E, Gottesman, II, Bouchard TJ, Jr. Beyond Heritability: Twin Studies in Behavioral Research. Current directions in psychological science 2010 Aug 1;18(4):217-20.
[7]        Howes OD, Murray RM. Schizophrenia: an integrated sociodevelopmental-cognitive model. Lancet 2014 May 10;383(9929):1677-87.
[8]        Thapar A, Cooper M, Eyre O, Langley K. What have we learnt about the causes of ADHD? Journal of child psychology and psychiatry, and allied disciplines 2013 Jan;54(1):3-16.
[9]        Kinderman P. The New Laws of Psychology: Why Nature and Nurture Alone Can’t Explain Human Behaviour: Robinson, 2014.
[10]      Buckley LA, Maayan N, Soares-Weiser K, Adams CE. Supportive therapy for schizophrenia. The Cochrane database of systematic reviews 2015;4:CD004716.
[11]      Jones C, Hacker D, Cormac I, Meaden A, Irving CB. Cognitive behaviour therapy versus other psychosocial treatments for schizophrenia. The Cochrane database of systematic reviews 2012;4:CD008712.

The Prospering Soul – Christians and Anxiety

Posted on October 31, 2015 by cedwardpitt

When you say the word “anxiety”, it can mean different things to different people. To a lot of people, anxiety is the same as being a little frightened. To others, it’s being really scared, but with good reason (like if you have to give a speech and you’re afraid of public speaking).

Medically speaking, anxiety isn’t just being frightened or stressed. After all, it’s normal to be frightened or stressed. God made us so that we could experience fear, because a little bit of fear is actually protective. There are dangers all around us, and if we had no fear at all, we’d end up becoming lunch for a wild animal, or road-kill. So there’s nothing wrong with a little bit of anxiety – in the right amount, for the right reason.

But anxiety in the wrong amount or for the wrong reason, can disrupt our day-to-day tasks and make it hard to live a rich and fulfilling life. That’s the anxiety that we’ll be talking about today.

The official description of anxiety reflects this idea of the wrong amount of anxiety about the wrong things: “… marked symptoms of anxiety accompanied by either general apprehension (i.e. ‘free-floating anxiety’) or worry focused on multiple everyday events, most often concerning family, health, finances, and school or work, together with additional symptoms such as muscular tension or motor restlessness, sympathetic autonomic over-activity, subjective experience of nervousness, difficulty maintaining concentration, irritability, or sleep disturbance. The symptoms are present more days than not for at least several months and result in significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning.” (This is taken from the beta-version of the latest WHO diagnostic guidelines, the ICD-11, but has yet to be formally ratified).

There are six main disorders that come under the “anxiety disorders” umbrella, reflecting either an abnormal focus of anxiety or an abnormal intensity:
1. Panic Disorder (abnormally intense anxiety episodes)
2. Social Anxiety Disorder (abnormal anxiety of social interactions)
3. Post-traumatic Stress Disorder (abnormally intense episodes of anxiety following trauma)
4. Obsessive-Compulsive Disorder (abnormally intense and abnormally focussed anxiety resulting in compulsive behaviours)
5. Specific phobias (abnormally focussed anxiety on one particular trigger), and
6. Generalised Anxiety Disorder (abnormal anxiety of everything)

The common underlying theme of anxiety is uncertainty. Grupe and Nitschke wrote, “Anxiety is a future-orientated emotion, and anticipating or ‘pre-viewing’ the future induces anxiety largely because the future is intrinsically uncertain.” [1]

The dysfunctional approach to uncertainty that underlies anxiety is in turn related to genetic changes which affect the structure and function of the brain, primarily in the regions of the amygdala and the pre-frontal cortex, which then alters the processing of our brain in five different areas:
> Inflated estimates of threat cost and probability
> Hypervigilance
> Deficient safety learning
> Behavioural and cognitive avoidance
> Heightened reactivity to threat uncertainty

In simpler language:
> the brain thinks that threats are more likely and will be worse than they are
> the brain spends more time looking for possible threats
> the brain fails to learn what conditions are safe, which is aggravated by
> the brain over-using avoidance as a coping mechanism, and
> the brain assumes that unavoidable uncertainty is more likely to be bad.

It’s important to understand at this point that anxiety disorders aren’t the result of poor personal choices. They are the result of a genetic predisposition to increased vulnerability to early life stress, and to chronic stress [2].

The other way of looking at it is that some people are blessed with amazing tools for resilience [3, 4].

It’s not to say that our choices have no impact at all, but we need to be realistic about this. Everyone will experience stressful situations at some point in their lives, and everyone will also make dumb choices in their lives. Some people are naturally better equipped to handle this, whereas some people have genes that make them more vulnerable. It’s wrong to blame yourself, or allow other people to blame you, for experiencing anxiety, just as it’s wrong for other people to assume that if one person can cope with the same level of stress, then everyone else should too.

It’s not to say that you shouldn’t fight back though. Just because your facing a mountain doesn’t mean to say you can’t climb it. It will be hard work, and you’ll need good training and support, but you can still climb that mountain.

Managing anxiety is very similar to managing depression like we discussed in a previous post. Following the tap model, there’s overflow when there is too much going into the system, the system is too small to handle it, and the processing of the input is too slow. So managing anxiety involves reducing the amount of stress going into the system, increasing the systems capacity through learning resilience and coping skills, and sometimes by improving the systems processing power with medications.

Reducing the input – stress management

Sometimes the best way of coping with anxiety is to reduce the stress that’s fanning the flames. It mightn’t seem to come naturally, but as we discussed in the last chapter, there are a few basic skills that are common to all stress management techniques that can form the platform of ongoing better skills in this area.

Engaging the “vagal brake” as proposed by the “Polyvagal Theory” [5] is as important in anxiety as it is in depression. By performing these techniques, the activity of the vagus nerve on the heart via the parasympathetic “rest-and-digest” nervous system is increased, which not only slows down the heart, but enhances the activity of other automatic parts of our metabolism. Some of the techniques allow a relaxed body to have a relaxed brain which can cope better with whatever is confronting it. The full list will be a blog for another time, but the simplest technique is to breathe!

It’s really simple. Sit in a comfortable position. Take slow, deep breaths, right to the bottom of your lungs and expanding your chest forward through the central “heart” area. Count to five as you breathe in (five seconds, not one to five as quickly as possible) and then count to five as you breathe out. Keep doing this, slowly, deeply and rhythmically, in and out. Pretty simple! This will help to improve the efficiency of your heart and lungs, and reduce your stress levels.

Remember, B.R.E.A.T.H.E. = Breathe Rhythmically Evenly And Through the Heart Everyday.

Increasing capacity – coping and resilience

Like with depression, anxiety responds well to psychological therapies which help to increase coping skills and enhance our innate capacity for resilience. And like depression, anxiety improves with CBT and ACT [6, 7], which enhance the activity of the pre-frontal regions of the brain [8]. For anxiety, CBT teaches new skills to handle uncertain situations, and to re-evaluate the chances of bad things happening and what would happen if they do. ACT puts the train of anxious thoughts and feelings in their place, and teaches engagement with the present moment, and a future focusing on values, and accepting the discomfort of uncertainty by removing the distress associated with it.

Practicing each of these skill sets is like practicing any other skill. Eventually, with enough practice, they start to become more like a reflex, and we start to cope with stress and anxiety better automatically.

Increased processing – Medications

Sometimes, to achieve long-term successful management of anxiety, a little extras help is needed in the form of medication. Like depression, the main group of medications used are the Selective Serotonin Reuptake Inhibitors (or SSRI’s for short). Medications appear to reduce the over-activity of a number of brain regions collectively called the limbic system [8], which are involved with many innate and automatic functions, but in its simplest form, the limbic system controls many of our emotions and motivations, including fear, anger and certain aspects of pleasure-seeking [9]. So essentially, SSRI’s help the anxious brain to make better sense of the incoming signals.

There are other medications commonly used for anxiety treatment, collectively called benzodiazepines. Most people wouldn’t have heard that term before, but would have heard of the most famous member of the benzo family, Valium. Benzos are like having a bit too much alcohol – they slow down the activity of the brain, and induce a feeling of relaxation. When used appropriately (i.e.: in low doses and in the short term), they can be helpful in taking the edge off quite distressing feelings of anxiety or panic. But benzos are not a cure, and after a while, the body builds a tolerance to them, where a higher dose is required to achieve the same effect. Continued long term use eventually creates dependence where a person finds it difficult to cope without them.

The final way to help manage anxiety is prayer. Like for depression, there is limited scientific information on the effects of prayer on, although a small randomised controlled trial did show that prayer with a prayer counsellor over a period of a number of weeks was more effective than no treatment [10].

Though given that anxiety is a future orientated emotion, excessively anticipating possible unwelcome scenarios and consequences, it’s easy to see why prayer should work well for anxiety. Trusting that God has the future in hand and knowing “that in all things God works for the good of those who love him, who have been called according to his purpose” (Romans 8:28) means that the future is less uncertain. The Bible also encourages us, “Do not be anxious about anything, but in every situation, by prayer and petition, with thanksgiving, present your requests to God. And the peace of God, which transcends all understanding, will guard your hearts and your minds in Christ Jesus.” (Philippians 4:6-7) When we give the future to God, he will give us peace in return.

Again, like in the case of depression, it’s sometimes hard for Christians to understand how strong Christians can suffer from anxiety in the first place. After all, we’ve just read how God gives us peace. And the Bible says that the fruit of the Spirit is peace (Galatians 5:22).

So when you’re filled with the opposite, when all you feel is overwhelming fear, it makes you feel like a faithless failure. Christians without anxiety assume that Christians with anxiety aren’t living in the Spirit. And it’s the logical conclusion to draw after all – if the fruit of the Spirit is peace, and you’re not filled with peace, then you mustn’t be full of the Spirit.

But like depression, when you look through the greatest heroes in the Bible, you see a pattern where at one point or another in their lives, they went through physical and emotional destitution, including mind-numbing fear … Moses argued with God about how weak and timid he was (Exodus 3 and 4), Elijah ran for his life in panic and asked God to kill him, twice, over the period of a couple of months after Queen Jezebel threatened him (1 Kings 18 and 19). Peter had spent three years with Jesus, the Messiah himself, hearing him speak and watching him perform miracle after miracle after miracle. But Peter denied his Messiah three times when he was confronted with possible arrest (John 18).

For the same pattern is also seen in King David, Gideon, and a number of other great leaders through the Bible. The take home message is this: it’s human nature to suffer from disease and dysfunction. Sometimes it’s physical dysfunction. Sometimes it’s emotional dysfunction. It’s not a personal or spiritual failure to have a physical illness. Why should mental illness be treated any different?

As the stories of Moses, Elijah and Peter testify, being a strong Christian doesn’t make you impervious to fear and anxiety. Hey, we’re all broken in some way, otherwise why would we need God’s strength and salvation? Having anxiety simply changes your capacity to experience God’s peace. As I said in the last chapter, closing your eyes doesn’t stop the light, it just stops you experiencing the light. Being anxious doesn’t stop God’s peace, it just makes it harder to experience God’s peace.

In summary some anxiety, at the right time and at the right intensity, is normal. It’s not unhealthy or sinful to experience some anxiety. Anxiety at the wrong time or at the wrong intensity, can disrupt our day-to-day tasks and make it hard to live a rich and fulfilling life. Anxiety related to a dysfunctional approach to uncertainty, and is a future-orientated emotion because anticipating or ‘pre-viewing’ the future induces anxiety largely because the future is intrinsically uncertain. Anxiety disorders can be debilitating.

Like depression, anxiety disorders can be managed in four main ways, by reducing the amount of stress coming in with stress management techniques, by increasing capacity to cope with psychological therapies like CBT and ACT, and sometimes by using medications, which help the brain to process the uncertainty of each situation more effectively. Prayer is can also useful to helping to manage anxiety.

Christians are not immune from anxiety disorders, and it’s important for the church to understand that Christians who suffer from anxiety are not weak, backsliding or faith-deficient. Having anxiety is not because of making poor choices. Though if you have anxiety, trust in the promises of the Bible, that God has the future under control.

References

[1]        Grupe DW, Nitschke JB. Uncertainty and anticipation in anxiety: an integrated neurobiological and psychological perspective. Nature reviews Neuroscience 2013 Jul;14(7):488-501.
[2]        Duman EA, Canli T. Influence of life stress, 5-HTTLPR genotype, and SLC6A4 methylation on gene expression and stress response in healthy Caucasian males. Biol Mood Anxiety Disord 2015;5:2.
[3]        Wu G, Feder A, Cohen H, et al. Understanding resilience. Frontiers in behavioral neuroscience 2013;7:10.
[4]        Russo SJ, Murrough JW, Han M-H, Charney DS, Nestler EJ. Neurobiology of resilience. Nature neuroscience 2012 November;15(11):1475-84.
[5]        Porges SW. The polyvagal perspective. Biological psychology 2007 Feb;74(2):116-43.
[6]        James AC, James G, Cowdrey FA, Soler A, Choke A. Cognitive behavioural therapy for anxiety disorders in children and adolescents. The Cochrane database of systematic reviews 2013;6:CD004690.
[7]        Swain J, Hancock K, Hainsworth C, Bowman J. Acceptance and commitment therapy in the treatment of anxiety: a systematic review. Clinical psychology review 2013 Dec;33(8):965-78.
[8]        Quide Y, Witteveen AB, El-Hage W, Veltman DJ, Olff M. Differences between effects of psychological versus pharmacological treatments on functional and morphological brain alterations in anxiety disorders and major depressive disorder: a systematic review. Neuroscience and biobehavioral reviews 2012 Jan;36(1):626-44.
[9]        Sokolowski K, Corbin JG. Wired for behaviors: from development to function of innate limbic system circuitry. Frontiers in molecular neuroscience 2012;5:55.
[10]      Boelens PA, Reeves RR, Replogle WH, Koenig HG. A randomized trial of the effect of prayer on depression and anxiety. Int J Psychiatry Med 2009;39(4):377-92.

If you’re suffering from anxiety or any other mental health difficulties and if you want help, see your GP or a psychologist, or if you’re in Australia, 24 hour telephone counselling is available through:

Lifeline = 13 11 14 – or – Beyond Blue = 1300 22 4636

Dr Caroline Leaf and the Myth of the Chemical Imbalance Myth

Posted on October 26, 2015 by cedwardpitt

There are lots of medical myths that people believe.

“I have acne because I eat too much chocolate, or my face isn’t clean enough”

“Stomach ulcers are because of stress”

“I coughed up some yellow phlegm, so I must need antibiotics right?”

“My baby’s fevers are because of teething.”

Is the “chemical imbalance” theory one of them?

Dr Leaf is a communication pathologist and self-titled cognitive neuroscientist. A couple of weeks ago she opened a proverbial can of worms by quoting the out-spoken Peter Gøtzsche, claiming that psychiatric drugs are the third leading cause of death after heart disease and cancer. This did not go down well, and Dr Leaf had to issue three separate statements on social media to try and justify herself and attempt to rescue her rapidly deteriorating credibility.

Not that she issued an apology, mind you, or retracted her statement.

Today, Dr Leaf published a blog on psychiatric medications … but again, not to apologise but to further justify why she’s right, and nearly every other doctor and scientist in the world is not. Worse than that, she went so far as to accuse doctors of deliberately prescribing “clearly dangerous” drugs, which she claims have no therapeutic effects, just because of some overcooked drug-company sponsored dinner and a few pens. More on that later.

Her post is a defiant deflection, a logically flawed and factually inaccurate criticism of modern psychiatry and psychopharmacology – not fueled by research, but largely based on the books of disgruntled fringe psychiatrists and researchers with an axe to grind.

Dr Leaf doesn’t discuss the actual science of the medications that she’s so against, but simply tries to create a smokescreen of distrust.

A good example of all that is wrong with this post is contained in the opening paragraph.

Today, it has become commonplace to say that people have chemical imbalances in their brain, most notably a disruption in the proper production of dopamine (for “diseases” like ADHD) and serotonin (for “diseases” like depression). These people, it is supposed, need drugs to “cure” these chemical imbalances, hence the terms “antipsychotics” or “antidepressants”.

The first thing to note is how Dr Leaf uses the term “cure”. No doctor ever uses the word “cure”, especially when talking about complex diseases. This is a pejorative term implying that modern medicine is only interested in permanently fixing things. But it’s a straw man fallacy, a false premise that Dr Leaf then uses to cast the medical model as impotent and futile. Nice try, but no one in medicine ever promises cure, and no doctor in their right mind would ever be so narrow-minded as to suggest that drugs are the only treatment for every condition. That doesn’t mean that drugs aren’t useful, nor that the medical model is broken. As we’ll discuss soon, medications are extremely helpful for certain conditions, when used carefully, as are non-drug treatments like CBT.

Dr Leaf also puts inverted commas around the word “diseases” as if to suggest that ADHD and depression aren’t diseases, an act which smacks of petulance and willful ignorance, and is insulting to those who have or who have ever suffered from ADHD and depression. Last week, Dr Leaf was happy to share that her eldest daughter suffered from bulimia and depression, but now she’s suggesting that depression isn’t really a disease. So what is it then? Malingering? Personal weakness? Bad parenting?

It’s really surprising that someone claiming to be a cognitive neuroscientist would ignore strong scientific evidence. For example, ADHD is associated with dopamine dysfunction as well as the dysfunction a number of other neurotransmitters [1-3]. And depression is associated with a decrease in the growth factor BDNF, (known as the neurotrophic hypothesis of depression) [4-6]. Schizophrenia, which Dr Leaf conveniently failed to mention, is clearly related to dopamine dysfunction in nerve cells of the pre-frontal cortex and the striatum, two parts of the brain that are incredibly important for how your brain processes incoming and outgoing signals [7-9].

There’s nothing to suppose here .. there’s ample evidence that psychiatric diseases are related to dysfunction within the brain, commonly with the function of neurotransmitters among other things. Call it whatever you like, the truth doesn’t change. “Chemical imbalance” is just an easy phrase for the general public to remember.

Dr Leaf then tries to suggest that psychiatric drugs don’t fix chemical imbalances but create them, citing the 1950’s observations of French researchers Deniker and Delay who noted that the first anti-psychotic, chlorpromazine, caused symptoms of Parkinson’s Disease. And indeed it did, but this wasn’t a new disease, just evidence that it worked.

Psychosis, a pathological state involving hallucinations and delusions, is because of an excess of the neurotransmitter called dopamine. Dopamine is the neurotransmitter that’s used by the nerve cells deep in the brain in a part called the basal ganglia, which acts like a central mail delivery centre for incoming and outgoing signals from other parts of the brain. The function of the nerves in one part of the basal ganglia are responsible for sending sensory signals to the frontal lobes of the brain. In another part, the signals are important for smooth movements of our muscles. Proper function depends on just the right amount of dopamine – too much and you get psychosis. Not enough and you get Parkinson’s disease symptoms.

The French researchers were simply noting the side-effects of too much medication blocking the action of dopamine in the basal ganglia – the psychosis had improved, but the blockade of dopamine was just too much in some patients, who had the opposite symptoms.

Again, Dr Leaf’s position is diametrically opposed to the published science [10, 11], and if anything, her claim contradicts her fundamental argument. After all, if chemical imbalances are myths, then how can chlorpromazine create a “new neurological syndrome” because of a chemical imbalance?

Dr Leaf then launches into a discussion on the history of the DSM and psychiatric medications. This is just the first in her ad hominem attacks on the medical profession – playing the man, not the ball if you will. If she can discredit the doctors that prescribe the medication, then she indirectly discredits the medications. This appears desperate and ultimately serves to weaken her case.

“It was just assumed that since these drugs affected brain chemistry in a certain way, the opposite reaction must be the result of the disease, notwithstanding the fact that this has never been adequately proven.”

The history of medicine is littered with cures being found without the disease being fully understood. Take Edward Jenner, for example, who is the founder of the modern technique of vaccination. He didn’t know why his smallpox vaccine worked, only that it did. Electron microscopes and a modern understanding of the immune system were centuries away, but Jenner saved billions of lives through his observation that prior vaccination with a small sample of cowpox virus would protect against smallpox [12].

When amphetamines, known to increase dopamine concentrations in the brain, caused psychotic symptoms and reserpine, a dopamine blocker, improved psychosis, it stood to reason that dopamine was a good candidate as a cause of psychosis and schizophrenia. Decades of research have gone on to further confirm and delineate the link [7]. Again, this is not “an overly simplistic explanation of chemical imbalances”. It is well proven, and rather complex.

Dr Leaf also makes the astounding accusation that psychiatrists inflicted suffering and caused “a public health disaster” by creating the DSM. The DSM, the ‘Diagnostic and Statistical Manual’ is an agreed-upon standard classification for psychiatric diagnoses. It is nothing more than a system of classification. It allows psychiatrists and researchers to speak a common language and attempt some coherence among their diagnoses.

Dr Leaf wrote, “… institutions like the American Psychiatric Association and the DSM would define what is normal, in turn telling us what it means to suffer and, essentially, what it means to be human. They medicalized misery, and today millions are suffering because of their actions, creating a public health disaster.”

That’s like saying that classifying the different types of cancer causes cancer. And that millions of people are suffering from cancer because doctors know to call it ‘cancer’. People have been suffering long before the DSM came along. The DSM doesn’t tell people they’re suffering, and it certainly doesn’t define what it is to be human. Such statements are disingenuous and melodramatic.

But wait, there’s more. “Today a psychiatrist can be praised for drugging a depressed person with mind-altering substances and, if these do not work, institutionalizing them and shocking their brain with ECT (electroconvulsive therapy). It is even an acceptable and commonplace practice to imprison mentally ill persons, drug them and lock them in solitary confinement, compelling them to live their days marinating in their own excrement.”

Dr Leaf is again playing to the fears of the public who have watched too many movies and only think of ‘One Flew Over the Cuckoo’s Nest’, ‘Shutter Island’ or scenes from ’12 Monkeys’. There are more oversight boards and lawyers than there are psychiatric patients, and the only people who are institutionalised are those who are clearly a danger to themselves or others. And while institutionalised, they are not subjected to random bouts of electrical shock as if some doctor is wandering around with a medical grade cattle prod, zapping people and laughing maniacally. Nor is anyone locked in solitary confinement and forced “to live their days marinating in their own excrement”.

The paranoid accusations continue some more. Dr Leaf accuses all psychiatrists of ignorance, and then accuses primary care physicians of negligence, by claiming that we prescribe medications that we do not understand because of the bribes and a pretty smile from a pharmaceutical rep.

Again, Dr Leaf contradicts her own argument:

Despite the recognition amongst many psychiatrists and medical health professionals that the chemical imbalance theory is not valid, drug companies like Eli Lilly still claim that ‘antipsychotic medicines are believed to work by balancing the chemical found naturally in the brain’.

Except that antipsychotic medications DO balance the naturally occurring chemical in the brain (dopamine) as we discussed earlier. What the … a drug company telling doctors how their drug works! How dare they tell the truth!

I find it disturbing that Dr Leaf would stoop so low as to insult the entire medical profession, especially every GP and family physician the world over.

Hey, I’m not above criticism. It’s important to have a good long look at ourselves from time to time, to review our practice, and make sure we’re treating our patients in the best possible way. The RACGP, the peak body of Australian GP’s, invited Prof Gøtzsche to present his opinions on anti-depressant medications so that GP’s could decide for themselves if they should adjust their prescribing.

But to suggest that primary care physicians are stupid, ignorant, incompetent and money hungry … that we would sell our soul for a drug company branded pen … is insulting. Though the irony of her statement, “we do not ask ourselves if these doctors really understand all the implications of using these substances. Not even the psychiatrists understand these drugs” is clearly lost on Dr Leaf. It’s certainly clear from the rest of her essay that Dr Leaf has no idea how these medications work or what benefits they have for those who suffer from mental ill-health.

There’s a lot more to discuss in response to Dr Leaf’s diatribe, but for the sake of brevity, I’ll try and discuss just a couple of other important themes.

Dr Leaf continues to try to make the medications sound useless and poisonous. She has several paragraphs on the placebo effect, making the false argument that the effect of the medications is just because someone tells you it will work. Of course, the placebo effect is part of the therapeutic effect, but that’s the same for all treatments, even Dr Leaf’s programs … “So, if the pastor or cell-group leader says that these programs are safe and will fix your toxic thinking, even though they get most of their information from the author, we believe wholeheartedly in what he or she may say and are more inclined to believe the program will work for us. These beliefs, which ignore actual scientific results, are buttressed by a flood of distorted and biased news reports, press releases and scientific journal articles on supposed toxic thoughts, and have transformed the theory into church dogma. So, obviously, if we experience negative side effects and do not feel the program is working, it must be something wrong with us, not the program.” Is that a fair statement?

Dr Leaf then plays the fear card again by listing all of the potential side effects from psychiatric medications. Dr Leaf is right in saying that psychiatric medications have serious proven long term side effects, and we should be careful.

For instance, if you knew that thrombocytopenia, anaphylaxis, cutaneous hypersensitivity reactions including skin rashes, angioedema and Stevens Johnson syndrome, bronchospasm and hepatic dysfunction were the potential side effects for a medication, would you take it? Most people wouldn’t. Reading the list makes that drug sound really dangerous. We should be up in arms about such a potentially harmful drug being put up for sale … except that this list of side effects isn’t a psychiatric drug at all, but’s actually the side effect profile of paracetamol (acetaminophen in the US). People take paracetamol all the time without even thinking about it.

Saying that we shouldn’t take medications because of potential side effects is a scarecrow argument, a scary sounding straw man fallacy. All drugs have serious proven long term side effects. Licencing and prescribing a medication depends on the overall balance of the good and the harm that a medication does. And no one has ever hidden these side effects from the public as if there is a giant conspiracy from the doctors and the pharmaceutical companies. They’re right there in the product information (here is the product information for fluoxetine. See for yourself).

Whilst it’s true that these side effects do happen, we know that they happen infrequently, just like we know that people win lotteries infrequently. Even so, the medications are not just doled out like sweets at a candy store. You require a minimum of ten years of university level education to be able to prescribe them.

Patients ALWAYS have a right to ask questions about possible benefits and side effects, and in my practice, I tell my patients the pros and the cons before prescribing, and I give them the choice of whether they want them or not. No one is ever forced into taking them.

Finally, Dr Leaf makes a number of irrational statements and flawed arguments in her final page of ranting. Let me quickly go through some of the honourable mentions:

* “Most people recover from depression without antidepressants” – true, because most cases of depression are mild. That doesn’t mean to say that antidepressants shouldn’t be used for severe depression, just like most people recover from upper respiratory infections without antibiotics, but that doesn’t mean that we shouldn’t use antibiotics for severe tonsillitis or pneumonia.
* “Antidepressants are no better than placebos” – It’s a controversial topic right now. There are many pushing the barrow that SSRI medications are no better than a sugar pill. But Dr Leaf has conveniently ignored several Cochrane reviews (the best of medical evidence) that shows anti-depressants work for a variety of disorders [13-15], but that psychological therapy might not [16].
* Equating antidepressants and antipsychotics with illicit drugs, and claiming that “more people die from overdoses of psychiatric drugs than illicit drugs” – This is Reductio ad absurdum – the logical conclusion from this argument is that illicit drugs are safer than psychiatric drugs. And therefore we should not give people psychiatric drugs since we don’t give people the ‘safer’ illicit drugs. But that conclusion is absurd, and when you think about it, the whole thing is based on hidden false premises – people rarely die of illicit drug overdoses because they’re illegal and are hard to come by. And also, people who use illicit drugs are not usually suicidal, whereas those given psychiatric medications sometimes are suicidal, and sometimes use them to try and commit suicide. But modern psychiatric drugs are much less dangerous in overdose than their old counterparts. It should also be noted here that more overdose suicide attempts are with paracetamol or ibuprofen than with psychiatric medications [19], but I don’t see paracetamol or ibuprofen being demonised.
* Psychiatric medications are part of a neo-liberal capitalist plot to keep the rich, richer and the poor, poorer – To me, this looks like Dr Leaf clutching at straws. Her statement, “By emphasizing that the problem lies within an individual’s biology, we are less inclined to look at their experiences and the social context of why they are feeling the way they feel. We look at the mythical chemical imbalance instead of economic exploitation, violence and inept political structures” is false. Schizophrenia is often seriously discussed in terms of neurodevelopment and not just ‘chemical imbalances’ [17, 18]. So it’s just plain wrong to suggest that researchers don’t look at the “economic exploitation, violence and inept political structures”. Oh, and Dr Leaf suggests that foster children are abused because they’re all forced to take psychiatric medication, and implies that ADHD children are abused by being force-fed Ritalin because they “move a lot in class”. Again, these are emotional over-generalisations that have no basis in reality.

Dr Leaf seems lost. She’s ignored solid published medical and scientific evidence in coming to an opinion based on the discontented rumblings of a few vocal but outspoken critics. In order to make her arguments, she has had to resort to borderline-slanderous ad hominem attacks on scientists and the medical profession, and purely emotional arguments based on fear and mistrust.

And this was only part one. If Dr Leaf’s promised second part is anything like the first, we’re in for a real treat.

Though as if that wasn’t enough, by suggesting that psychiatric drugs cause changes in your brain, cause chemical imbalances, and cause that slew of negative side effects, Dr Leaf is admitting that it’s your brain that changes your thought life, which directly contradicts her most recent teachings. After all, if thought was the dominant force in your neurology and your mind controlled your brain, then the medications would have no effect since they’re physical and aren’t connected to our mind.

So which is it? Because if the brain controls our mind, then her best-seller needs to be pulped and refunds offered to the hundred of thousands of people who bought it. But on the other hand, if the mind really does control the brain, then her entire argument against psychiatric medications implodes.

Dr Leaf has painted herself into a corner and there’s still part two to come.

References

[1]        Prince J. Catecholamine dysfunction in attention-deficit/hyperactivity disorder: an update. J Clin Psychopharmacol 2008 Jun;28(3 Suppl 2):S39-45.
[2]        Del Campo N, Chamberlain SR, Sahakian BJ, Robbins TW. The roles of dopamine and noradrenaline in the pathophysiology and treatment of attention-deficit/hyperactivity disorder. Biological psychiatry 2011 Jun 15;69(12):e145-57.
[3]        Cortese S. The neurobiology and genetics of Attention-Deficit/Hyperactivity Disorder (ADHD): what every clinician should know. European journal of paediatric neurology : EJPN : official journal of the European Paediatric Neurology Society 2012 Sep;16(5):422-33.
[4]        Haase J, Brown E. Integrating the monoamine, neurotrophin and cytokine hypotheses of depression–a central role for the serotonin transporter? Pharmacol Ther 2015 Mar;147:1-11.
[5]        Bus BA, Molendijk ML, Tendolkar I, et al. Chronic depression is associated with a pronounced decrease in serum brain-derived neurotrophic factor over time. Molecular psychiatry 2015 May;20(5):602-8.
[6]        Sousa CN, Meneses LN, Vasconcelos GS, et al. Reversal of corticosterone-induced BDNF alterations by the natural antioxidant alpha-lipoic acid alone and combined with desvenlafaxine: Emphasis on the neurotrophic hypothesis of depression. Psychiatry research 2015 Sep 1.
[7]        Howes OD, Fusar-Poli P, Bloomfield M, Selvaraj S, McGuire P. From the prodrome to chronic schizophrenia: the neurobiology underlying psychotic symptoms and cognitive impairments. Curr Pharm Des 2012;18(4):459-65.
[8]        Williams GV, Castner SA. Under the curve: critical issues for elucidating D1 receptor function in working memory. Neuroscience 2006 Apr 28;139(1):263-76.
[9]        Der-Avakian A, Markou A. The neurobiology of anhedonia and other reward-related deficits. Trends Neurosci 2012 Jan;35(1):68-77.
[10]      Leucht S, Tardy M, Komossa K, et al. Antipsychotic drugs versus placebo for relapse prevention in schizophrenia: a systematic review and meta-analysis. Lancet 2012 Jun 2;379(9831):2063-71.
[11]      Torniainen M, Mittendorfer-Rutz E, Tanskanen A, et al. Antipsychotic treatment and mortality in schizophrenia. Schizophrenia bulletin 2015 May;41(3):656-63.
[12]      Riedel S. Edward Jenner and the history of smallpox and vaccination. Proc (Bayl Univ Med Cent) 2005 Jan;18(1):21-5.
[13]      Arroll B, Elley CR, Fishman T, et al. Antidepressants versus placebo for depression in primary care. The Cochrane database of systematic reviews 2009(3):CD007954.
[14]      Soomro GM, Altman D, Rajagopal S, Oakley-Browne M. Selective serotonin re-uptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder (OCD). The Cochrane database of systematic reviews 2008(1):CD001765.
[15]      Kapczinski F, Lima MS, Souza JS, Schmitt R. Antidepressants for generalized anxiety disorder. The Cochrane database of systematic reviews 2003(2):CD003592.
[16]      Jakobsen JC, Lindschou Hansen J, Storebo OJ, Simonsen E, Gluud C. The effects of cognitive therapy versus ‘treatment as usual’ in patients with major depressive disorder. PloS one 2011;6(8):e22890.
[17]      van Os J, Linscott RJ, Myin-Germeys I, Delespaul P, Krabbendam L. A systematic review and meta-analysis of the psychosis continuum: evidence for a psychosis proneness-persistence-impairment model of psychotic disorder. Psychological medicine 2009 Feb;39(2):179-95.
[18]      Howes OD, Murray RM. Schizophrenia: an integrated sociodevelopmental-cognitive model. Lancet 2014 May 10;383(9929):1677-87.
[19]   Prescott K, Stratton R, Freyer A, Hall I, Le Jeune I. Detailed analyses of self-poisoning episodes presenting to a large regional teaching hospital in the UK. Br J Clin Pharmacol 2009 Aug;68(2):260-8.

Disclaimer

Do not abruptly stop any medications that you are taking. Talk to your licenced physician first. They’re not all money-hungry, imbecilic drug-company bitches. Most of them actually know what they’re talking about.
For the record, I declare that I have no connection with any pharmaceutical company. I do not accept gratuities of any form from any sales representative. I don’t eat their food, I don’t take their pens, and I don’t listen to their sales pitches

Update – 8 August 2016.

Dr Leaf has since taken the offending post from her blog page, and re-gifted it as an answer on her “Scientific” FAQ page (“Chemical Imbalances and Mental Health” http://drleaf.com/about/scientific-faqs/). It remains as unbalanced and inaccurate as it’s former iteration. It’s unfortunate that Dr Leaf continues to make such preposterous claims in the face of overwhelming scientific evidence to the contrary.

Dr Caroline Leaf and the can of worms – UPDATE

Posted on October 19, 2015 by cedwardpitt

Yesterday, Dr Leaf opened a proverbial can of worms with her quote from Gøtzsche, that “Psychiatric Drugs are the third leading cause of death, after heart disease and cancer.”

Dr Caroline Leaf is a communication pathologist and a cognitive neuroscientist. Clearly scrambling, she attempted to placate her growing number of detractors with an unprecedented explanatory statement. But rather than distancing herself from her comments, she still chose to portray psychiatric medications as harmful and ungodly.

Instead of quelling the fire, this seems to have thrown fuel on it. Dr Leaf has continued to try and justify her comments with a further two statements today. Neither of them contain a retraction or an apology.

Earlier today, she wrote:

Dear all, regarding the recent two posts I put up on mental health and medications and the flood of positive and negative responses that followed, I would love you to hear my heart: all my posts are lovingly crafted, designed to help, based on my years of extensive research and experience in the field of mind, learning and mental health, including within my immediate and extended family..and {sic} most importantly, they are Holy Spirit led. I work with a team of professionals, that include medical doctors, neurosurgeons, neurologists, neuroscientists, theologians, pastors and historians in order to provide excellent information. I am a messenger: I teach and provide information and encourage you, in turn, not to be reactive, but to read, do your own research and think. To this end, I provide as much help as I can on my web page and TV shows and resources with information and research links and citations. I DO believe in using general medications and surgeries when managed correctly and not abused, I myself have been helped by surgery and used medications when necessary, as have my family. I DO NOT judge anyone. I believe in your right to choose; I DO NOT tell anyone to go off their meds, I recommend supported and supervised withdrawal if this is what you choose; I DO encourage you to make Holy Spirit led educated choices about your choices, I DO encourage you to use your love, power and sound mind – your intellect, will and emotions, the way God designed these to be used – led by Him continuously. Please watch this incredible and touching video by Laura Delano on You Tube, which highlights why I do what I do. https://m.youtube.com/watch?list=PLK_W1lA1BNLk2vbBH2XetI80LDpmaGTUG&params=OAFIAVgF&v=b6ZljUs4Xos&mode=NORMAL Many blessings to you all and my prayer for you is: “Beloved, I pray that you may prosper in every way and [that your body) may keep well, even as [I know) your soul keeps well and prospers.” 3 John 1:2 AMP see http://www.drleaf.com scientific FAQ’s for more information, citations and links

then later in the day:

Dear all, some of you have questioned whether or not I have ever dealt with people experiencing severe mental health issues. As someone who has specialized in the mind over the past 30 years, I have been given the opportunity to work, first hand, with people experiencing mental and physical pain in the most terrible life situations, from severe traumatic brain injuries to rape, murder and abysmal poverty. I have seen these individuals choose with their minds not to allow their life circumstances to take control over their identity… through the power of God, love and community they overcame what life threw their way. But, on a more personal level, my eldest daughter (@therascalcook) was severely bulimic, suicidal and depressed for most of her early years due to a chronic illness and traumatic bullying. I have been in hospitals, crying beside her bed when she nearly died. I have experienced her pain…I am crying as I write this. But as a family we supported her and loved her through it, as did her friends and many of our loved ones, (it was not easy but it was worth it!). She never took a single medication nor was she institutionalized, even though doctors were telling me she would never recover if she didn’t. Yet today, after rejecting God and life for many years, she is a graduate student in historical theology, whose life goal is to bring a piece of heaven to earth through sustainable farming communities in disadvantaged areas. There is hope, God is greater than anything, and magic bullets are never the answer. You are not a label or a faulty biological machine. You are a child of God, as we all are. Unless all of us realize what it truly means to be the church, to bring heaven to earth as we love our God and people, to be the community of love that this world is so desperately crying out for, people will continue to have mental health issues, be labeled {sic}, face stigma and suffer. We all have this responsibility, and none of us can do it alone. We were created by God to help each other. Jessica used to call me her Sam. We all need a Sam, because we all know what it is like to be Frodo.

Kudos to Dr Leaf for the bravery and vulnerability that sharing such a personal story took. I’m genuinely happy that Jessica found her way through those dark and distressing days and has once again found peace and success. I have been through the same dank and destructive times of depression, and I know what it feels like. I wouldn’t wish it on anyone. When I hear stories of people who have overcome, I truly appreciate their joy.

I also recovered from my depression without ever using medications. What helped me enormously was a psychologist who listened to me without judgement as I unloaded years of emotional turmoil and distress. To this day, I don’t remember what we actually talked about in my first session with him. All I remember is getting ten minutes in and then crying almost uncontrollably for the next forty. Thankfully, I did more talking and less crying over the few months as my mood lifted and I grew to accept my brokenness, just like God does.

Clearly, the story of Jessica Leaf is heart-warming and uplifting. Dr Leaf clearly understands the pain and distress that severe mental illness brings to those who suffer with it, and their families. But all emotions aside, Dr Leaf has still left important issues unresolved. Indeed, those who are more cynical might see such an emotional recollection as a play for sympathy and a distraction from the lingering questions surrounding Dr Leaf’s handling of this issue, and of her expertise in mental health.

Dr Leaf’s expertise, revisited.

Dr Leaf’s experience during those darkest of times may give her a legitimate platform to discuss what worked for her daughter and her family, but however moving, it does not qualify her as an expert in mental health more broadly. Science isn’t about generalising from your personal experience. It’s about looking at the evidence from a number of rigorously designed trials with a minimum of bias, conducted across a broad range of participants.

When women come to see me in the few weeks after giving birth, they’re usually confused. Nearly every woman that’s ever given birth sometime in the last century believes their experience automatically qualifies them as experts in breast feeding and infant health. But their ‘helpful’ advice, given with the best of intentions, often conflicts with the opinion of every other self-proclaimed motherhood expert. By the time the poor new mother comes to see me, they’ve been given so many pieces of conflicting advice that they’re completely lost.

Just living through an experience doesn’t qualify you as an expert. So I don’t claim to be an expert in mental health just because I’ve lived through prolonged periods of anxiety and depression. Nor should Dr Leaf.

Dr Leaf can’t use the fact that she has worked with people who have mental health problems as a claim to expertise either. She may been given the opportunity to work, first hand, with “people experiencing mental and physical pain in the most terrible life situations, from severe traumatic brain injuries to rape, murder and abysmal poverty.” That doesn’t make her an expert in mental health any more than seeing female patients makes me a gynaecologist.

That’s because expertise in medical fields requires specific training. You can read surgical textbooks for thirty years but that doesn’t quality you as a surgeon. You can learn a bit of anatomy and physiology in the same lab as some medical students, but that doesn’t make you equivalent to a medical doctor. You might do some research involving some neurobiology, but that doesn’t make you a neuroscientist.

Dr Leaf is a communication pathologist who completed a PhD which included some educational psychology. She is not a counsellor, she is not a psychologist, she is not a medical doctor and she isn’t even a cognitive neuroscientist. Dr Leaf is not qualified to provide an expert opinion on the risks and harms of psychiatric medication.

Dr Leaf’s heart

Coming back to Dr Leaf’s first statement today, Dr Leaf said that she wanted to share her heart:

all my posts are lovingly crafted, designed to help, based on my years of extensive research and experience in the field of mind, learning and mental health, including within my immediate and extended family..and {sic} most importantly, they are Holy Spirit led

If I were Dr Leaf, I’d be careful about blaming the Holy Spirit for her posts. I have rebutted and debunked scores of Dr Leaf’s memes over the last couple of years. The Holy Spirit is the ‘Spirit of all truth’, not of half-baked facts and misquotes.

Dr Leaf goes on to say

I teach and provide information and encourage you, in turn, not to be reactive, but to read, do your own research and think. To this end, I provide as much help as I can on my web page and TV shows and resources with information and research links and citations.

I respectfully disagree. Dr Leaf rarely references her social media memes, and until recently, her website was bereft of citations. I have never seen her encourage critical thinking before. And if Dr Leaf really wanted to encourage thinking amongst her followers, then why does her team actively block people on social media who dare to disagree with her? That’s not encouraging free thinking, that’s presenting an illusion of conformity.

Dr Leaf’s Do’s and Don’ts

To clarify her position on several issues, Dr Leaf stated:

I DO believe in using general medications and surgeries when managed correctly and not abused, I myself have been helped by surgery and used medications when necessary, as have my family. I DO NOT judge anyone. I believe in your right to choose; I DO NOT tell anyone to go off their meds, I recommend supported and supervised withdrawal if this is what you choose; I DO encourage you to make Holy Spirit led educated choices about your choices, I DO encourage you to use your love, power and sound mind – your intellect, will and emotions, the way God designed these to be used – led by Him continuously.

Dr Leaf may say that she doesn’t tell anyone to go off their meds, but I think that’s a little disingenuous.

Sure, Dr Leaf never directly said to stop taking their medications. She just said that psychiatric medications were unscientific and unbiblical [1: p31-32], that psychiatric medications are the third most common cause of death after heart disease and cancer, and admonished her followers to “Take all thoughts into captivity, not drug all thoughts into captivity.” And just yesterday, she also linked psychiatric medications with evolutionary theory and said that they strip 15-25 years off your lifespan.

So it’s more like, “I DO NOT tell anyone to go off their meds, I just scare them by telling them the drugs are unholy poison”.

That’s not encouraging “Holy Spirit led educated choices”, it’s encouraging fear-driven poor choices.

Dr Leaf’s support team

One last point. Dr Leaf stated,

I work with a team of professionals, that include medical doctors, neurosurgeons, neurologists, neuroscientists, theologians, pastors and historians in order to provide excellent information.

Really? Dr Leaf’s work consistently conflicts with basic medical and psychological science, and she regularly misquotes scripture. Would they be willing to be named? Because either they’re providing Dr Leaf with terrible oversight or Dr Leaf is ignoring everything they say.

Dr Leaf still hasn’t apologised for, or retracted her statements

It’s no secret that I disagree with Dr Leaf’s teaching, and I have outlined why I think some of her statements today are disingenuous. You may agree with me, or not. I don’t mind. Hey, I could be wrong.

Though when you get down to brass tacks, the most important issue is that Dr Leaf remains legally vulnerable.

Since she opened up the can of worms with her Gøtzsche quote, she has made three separate statements, none of which apologise for potentially misleading nearly 150,000 people about the true risks and benefits of psychiatric medications. Nor has she issued any retraction or taken the posts down.

When Dr Leaf says that psychiatric medications are unbiblical and poisonous, people on psychiatric medications will want to come off them. She may not have said the words “Stop your medications”, but people will still want to come off them because they’re afraid, or because of the stigma, or because of their desire to live true to God. And as I discussed yesterday, there is a very real chance that some of those people who were stable on their medications but who unnecessarily cease them because Dr Leaf told them to, may harm themselves or take their own life, since that’s what the studies tell us [2, 3]. At the very least, they are likely to have a shorter life expectancy because of it [4, 5]. This may open Dr Leaf to law suits, as well as the possibility of having someone’s death on her conscience.

No one wants that scenario. But the only way to avoid it is to:

Take the offending posts down
Issue an apology
Specifically direct those of her followers on psychiatric medications to stay on them until they have spoken to their doctors,
In future, provide a balanced view of the benefits of psychiatric medications as well as their harms.
Better yet, unless Dr Leaf gets a medical degree, it may be better not to publically discuss psychiatric medication at all.

Again, I implore Dr Leaf, for her sake and for the sake of her ministry and those who follow her, please unequivocally apologise, retract your statement, and encourage people to see their doctors if they have concerns about their medication, or their mental health.

This is not a game: people’s lives are at stake. I hope that Dr Leaf sees this before it’s too late.

References
[1]        Leaf CM. Switch On Your Brain : The Key to Peak Happiness, Thinking, and Health. Grand Rapids, Michigan: Baker Books, 2013.
[2]        Correll CU, Detraux J, De Lepeleire J, De Hert M. Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder. World psychiatry : official journal of the World Psychiatric Association 2015 Jun;14(2):119-36.
[3]        Tiihonen J, Suokas JT, Suvisaari JM, Haukka J, Korhonen P. Polypharmacy with antipsychotics, antidepressants, or benzodiazepines and mortality in schizophrenia. Archives of general psychiatry 2012 May;69(5):476-83.
[4]        Tiihonen J, Lonnqvist J, Wahlbeck K, et al. 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). Lancet 2009 Aug 22;374(9690):620-7.
[5]        Torniainen M, Mittendorfer-Rutz E, Tanskanen A, et al. Antipsychotic treatment and mortality in schizophrenia. Schizophrenia bulletin 2015 May;41(3):656-63.

Remember: This article is a rebuttal of Dr Leaf’s opinion regarding psychiatric medication. This blog doesn’t constitute individual medical advice. If you do not like your medication or think you should come off it, please talk to your own GP or psychiatrist. Do not stop it abruptly or without adequate medical advice.

Dr Caroline Leaf and her can of worms

Posted on October 18, 2015 by cedwardpitt

Dr Caroline Leaf is a communication pathologist and a self-titled cognitive neuroscientist. She also likes to think that she’s an expert on mental health. So this morning, she felt like she was quite justified in publishing a meme about the evils of psychiatric medications.

She quoted Professor Peter Gøtzsche, stating that “Psychiatric Drugs are the third leading cause of death, after heart disease and cancer.” Then followed it with “Take all thoughts into captivity, not drug all thoughts into captivity. You have the mind of Christ! (1 Cor 2:16) **DRUG WITHDRAWAL should ALWAYS be done under the supervision of a qualified professional. These drugs alter your brain chemistry, and withdrawal can be a difficult process.”

The subsequent comments were primarily made up of the usual sycophantic responses that Dr Leaf has cultivated by blocking anyone that disagrees with her. But there were more than the usual responses confused by her meme, and quite a few that we’re asking for help in weaning off the medications that they were on.

Then there were those who weren’t happy at all. One respondent, a certified Nurse Practitioner, wrote, “I am appalled that you are posting this inaccurate information and causing vulnerable people to possibly stop taking medication that may be allowing them to function and live.” The same person followed up with another comment soon after, quoting the CDC figures for the top ten causes of death in the US, in which the third on the list wasn’t psychiatric drugs at all, but chronic lower respiratory diseases.

The overall response must have taken her aback, because Dr Leaf posted a follow-up comment to explain herself, an unusual step for her.

In it, she said, “I do not speak out against psychiatric medication because I want to condemn people, or make them feel guilty. I want to help people. If, for example, I knew that eating some food could kill you or seriously injure you, and kept this to myself, you would justifiably be angry at me. These drugs have serious, proven long term side affects that are hidden from the public, and the logic behind them is not God’s desire for you to be healthy in your spirit, soul and body. Psychiatric drugs are based off of a theoretical view of evolution as a mindless, unguided process that created you as mechanistic individual with a biological brain that has chemicals that need to be “balanced”. You are more than your biology; you are the temple of the Lord, created in his image. This is not a game: these drugs can decrease your lifespan by 15-25 years. I want you to have those 15-25 years, and I want them to be characterized by God’s perfect, good plan for your life. I ask you to not to just take my word for this, but to do your own research. You can find a multitude of references on my site http://www.drleaf.com under Scientific FAQs. It is my earnest desire that people do not perish for lack of knowledge (Hosea 4:6). **DRUG WITHDRAWAL should ALWAYS be done under the supervision of a qualified professional. These drugs alter your brain chemistry, and withdrawal can be a difficult process.”

But it was too late. Dr Leaf had opened a can of worms, and once out, those wriggly little critters are impossible to put back in.

Both her initial offering and her reply shows just how poor Dr Leaf’s understanding of mental health truly is. She is fixated on the notion that the mind controls the brain, and she is unwilling to consider any other notion, instead preferring to accept any opinion that conforms to her world view, no matter how poorly conceived it might be. This includes the work of Gøtzsche, accepting it as gospel even though he has critics of his own.

It’s important to examine Dr Leaf’s reply in more detail as her statement has the potential to cause a great deal of harm to those who are the most vulnerable. Lets break down Dr Leaf’s statement and review each piece, and then I will outline some other important and contradictory considerations of Dr Leaf’s stance.

The safety of psychiatric medications

Dr Leaf claims that “These drugs have serious, proven long term side affects {sic} that are hidden from the public” and “This is not a game: these drugs can decrease your lifespan by 15-25 years.”

Dr Leaf is right in saying that psychiatric medications have serious proven long term side effects. And we should be careful. I mean, if you knew that thrombocytopenia, anaphylaxis, cutaneous hypersensitivity reactions including skin rashes, angioedema and Stevens Johnson syndrome, bronchospasm and hepatic dysfunction were the potential side effects for a medication, would you take it?

Most people wouldn’t. Reading the list makes that drug sound really dangerous. We should be up in arms about such a dangerous drug … except that this list of side effects isn’t for a psychiatric drug at all, but is actually the side effect profile of paracetamol (Panadol if you’re in Australia, Tylenol if you’re in the US). People take paracetamol all the time without even thinking about it. Saying that we shouldn’t take medications because of potential side effects is a scarecrow argument, a scary sounding straw man fallacy. All drugs have serious proven long term side effects, and most of the time, those serious long term side effects don’t occur. Licensing and prescribing a medication depends on the overall balance of the good and the risk of harm that a medication does.

Oh, and no one has ever hidden these side effects from the public as if there’s some giant conspiracy from the doctors and the pharmaceutical companies. The side effects are listed right there in the product information (here is the product information for fluoxetine. See for yourself).

As for Dr Leaf’s assertion that psychiatric medications decrease your lifespan by 10-25 years, I think that’s a red herring. I read through Dr Leaf’s ‘Scientific FAQ’ and I couldn’t find any references that back up these statements, so who knows where she got this figure of ’15-25 years’ from.

On the contrary, what is known is that severe mental illness is associated with a 2 to 3-fold increase in mortality, which translates to an approximately 10-25 year shortening of the lifespan of those afflicted with severe depression, schizophrenia or bipolar disorder [1]. So Dr Leaf has it backwards. It isn’t the medications that cause people who take them to die 25 years earlier than they would have without the illness, but it’s the illness itself.

The benefits of long term psychiatric medications

So psychiatric medications have their side effects, true, but they also have protective benefits which Dr Leaf consistently fails to acknowledge.

Correll and colleagues note in the conclusion to their article that “Although antipsychotics have the greatest potential to adversely affect physical health, it is important to note that several large, nationwide studies providing generalizable data have suggested that all-cause mortality is higher in patients with schizophrenia not receiving antipsychotics.” [1]

More specifically, in one recent study, the use of any anti-psychotic medication for a patient with schizophrenia decreased their mortality by nearly 20% [2]. In another study, the mortality of those with schizophrenia who did not take anti-psychotics was nearly ten times that of the healthy population, but taking anti-psychotic medication cut that back to only four times the risk [3].

These findings are mirrored by other studies on other psychiatric medications. For example, as noted by Correll and colleagues, “clozapine, antidepressants, and lithium, as well as antiepileptics, are associated with reduced mortality from suicide. Thus, the potential risks of antipsychotics, antidepressants and mood stabilizers need to be weighed against the risk of the psychiatric disorders for which they are used and the lasting potential benefits that these medications can produce.” [1]

So psychiatric medications are not useless. Let me be clear, I’m not saying that taking psychiatric medications always makes life a cake-walk – there are still side effects from the medications, and the disease isn’t always fully controlled. But on average, well treated patients with psychiatric conditions clearly do better than patients who are not treated.

Therefore Dr Leaf’s assertion that psychiatric medications are harmful are inaccurate. And given that there are genuine benefits to these medications, particularly in the prevention of suicide, Dr Leaf’s discouragement of these medications has the real potential to result in real harm to those of her followers who take her at her word.

The ‘logic’ behind psychiatric medications

Dr Leaf says in her statement, “the logic behind them (psychiatric medications) is not God’s desire for you to be healthy in your spirit, soul and body. Psychiatric drugs are based off of a theoretical view of evolution as a mindless, unguided process that created you as mechanistic individual with a biological brain that has chemicals that need to be ‘balanced’. You are more than your biology; you are the temple of the Lord, created in his image.”

Dr Leaf’s argument here is that based on a false premise and some straw man fallacies which inevitably leads to a false conclusion.

Evolution is a mindless unguided process
Evolution says that you are just a machine
Psychiatric illness is because of a chemical imbalance in that machine (a false premise)

therefore taking psychiatric medication is accepting evolution (a straw man fallacy)

and

You are more than your biology,
you are the temple of the Lord, created in his image,

therefore evolution is wrong (another straw man fallacy)

therefore psychiatric medications are not God’s desire (false conclusion)

The problem with this logic is that it could be applied to all medications, since modern medicine has predominantly been devised by agnostic scientists within an evolutionary framework, and nearly all disease is defined by an imbalance of one thing or another.

For example, simply rewording Dr Leaf’s statement shows up the distorted logic that it entails:

“Insulin can have serious, proven long term side affects that are hidden from the public, and the logic behind it is not God’s desire for you to be healthy in your spirit, soul and body. Diabetes is based off of a theoretical view of evolution as a mindless, unguided process that created you as mechanistic individual with a biological pancreas that has chemicals that need to be ‘balanced’.”

You can’t have this both ways. If psychiatric medications are against God’s plan, then all medications are against God’s plan. But if we accept medications for physical ailments, then we also have to accept medications for psychological ailments.

The Mind-Brain link

Dr Leaf tried to protect herself with a glib disclaimer at the end of both posts in question today, “**DRUG WITHDRAWAL should ALWAYS be done under the supervision of a qualified professional. These drugs alter your brain chemistry, and withdrawal can be a difficult process.”

Which is interesting, because in her Scientific FAQ, Dr Leaf has this to say about the mind,

“The Brain is part of the Physical Body and therefore is controlled by the Mind. The Mind does not emerge from an accumulation of Brain activity. Brain activity, rather, reflects Mind activity. Even though the Mind controls the Brain, the Brain feeds back to, and influences, the Mind. The Brain seats the Mind, and therefore the Mind influences the Physical world through the Brain.”

So if that’s true, then why is withdrawal from psychiatric medication so difficult? If the mind is outside the physical realm and controls the brain as Dr Leaf proposes, then the medications effect on brain chemistry should make little or no difference to the mind, and withdrawal should be simple.

The fact that withdrawal from these medications is not simple is testament to the fact that the mind is a function of the brain, and does not control the brain as Dr Leaf proposes here and through her books and other written materials.

Issuing the warning is responsible, but shows again just how far Dr Leaf’s teaching is from scientific reality.

Dr Leaf’s motivations

Finally, I want to talk about Dr Leaf’s motivation. In her statement, Dr Leaf said, “I do not speak out against psychiatric medication because I want to condemn people, or make them feel guilty. I want to help people.” And, “I want you to have those 15-25 years, and I want them to be characterized by God’s perfect, good plan for your life … It is my earnest desire that people do not perish for lack of knowledge (Hosea 4:6).”

I want to state, for the record, that I believe Dr Leaf when she says this. I don’t doubt her motives are to try and help people. But good intentions are not enough. What she says has real life consequences.

Dr Leaf is idolised by her followers and portrayed as a mental health expert by the churches she preaches at. People don’t question experts recommended to them by their pastors or their friends. So when she says that psychiatric medications kill people, people on psychiatric medications will want to come off them, because of fear, because of stigma, because of their desire to live true to God and his good and perfect plan. Without wanting to sound melodramatic, there is a very real chance that some of those people who were stable on their medications but who unnecessarily cease them because Dr Leaf told them to, may harm themselves or take their own life, since that’s what the studies tell us [1, 4]. At the very least, they are likely to have a shorter life expectancy because of it [2, 3]. So telling people that psychiatric medications are dangerous is morally and ethically dubious.

There are also potential legal implications too. God forbid, but if a person committed suicide because they went off their medication because of what Dr Leaf wrote, law suits could easily follow. No one wants that situation. Dr Leaf also runs the risk of being accused of practicing medicine without a licence, since some of her followers have asked personal medical questions in the comments, and the reply from Dr Leaf’s Facebook team is to direct them to their programs like the 21-day detox, which depending on the legal interpretation and the mood of a judge, could be seen as giving medical advice, which Dr Leaf is not legally qualified to give.

To summarise, I certainly hope that neither of these hypothetical scenarios becomes reality, but Dr Leaf and her social media team are skating on thin ice, and a glib disclaimer at the end of a post won’t necessarily cut it.

I would hope that Dr Leaf and her social media team would reconsider their approach. In fact, I would suggest that Dr Leaf unequivocally apologises for what she’s written, retracts her statement, and encourages people to see their doctors if they have concerns about their medication, or their mental health.

Indeed, I would implore Dr Leaf to step back and re-evaluate the entire breadth of her teaching, and the advice that she is giving. Dr Leaf is obviously a very smart woman and a very engaging speaker. With great power comes great responsibility. If she were to reconsider her teaching and start from a basis of scientific fact, then she could be a major force for the good of the church and its physical and mental health. At the moment, I fear that she is doing the opposite.

This is not a game: people’s lives are at stake. I hope that Dr Leaf sees this before it’s too late.

References

[1]        Correll CU, Detraux J, De Lepeleire J, De Hert M. Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder. World psychiatry : official journal of the World Psychiatric Association 2015 Jun;14(2):119-36.
[2]        Tiihonen J, Lonnqvist J, Wahlbeck K, et al. 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). Lancet 2009 Aug 22;374(9690):620-7.
[3]        Torniainen M, Mittendorfer-Rutz E, Tanskanen A, et al. Antipsychotic treatment and mortality in schizophrenia. Schizophrenia bulletin 2015 May;41(3):656-63.
[4]        Tiihonen J, Suokas JT, Suvisaari JM, Haukka J, Korhonen P. Polypharmacy with antipsychotics, antidepressants, or benzodiazepines and mortality in schizophrenia. Archives of general psychiatry 2012 May;69(5):476-83.

Here’s my glib disclaimer: This article is a rebuttal of Dr Leaf’s opinion regarding psychiatric medication. This blog doesn’t constitute individual medical advice. If you do not like your medication or think you should come off it, please talk to your own GP or psychiatrist. Do not stop it abruptly or without adequate medical advice.

The significance of thoughts

Posted on October 13, 2015 by cedwardpitt

A few days ago, I posted a rebuttal to one of Dr Leaf’s favourite memes, “Thoughts are real and occupy mental real estate.”

In short, I wrote that thoughts are real, but the issue hasn’t ever been whether thoughts are real, but what thoughts really are. The conclusion was that thoughts are just a projection, a function of the brain. They are not independent of the brain and they do not control the brain.

Dr Caroline Leaf is a communication pathologist and a self-titled cognitive neuroscientist. Dr Leaf tried to refine her meme today, saying:

“Your thoughts produce proteins, which form real structures that change the landscape of your brain.”

So, is that true? Do thoughts produce proteins which change the structure of the brain? To answer that, we need to have a look at some basic neurobiology.

The brain is made of nerve cells. Nerve cells have three unique structures that help them do their job. First are dendrites, which are spiny branches that protrude from the main cell body, which receive the signals from other nerve cells. Leading away from the cell body is a long thin tube called an axon which helps carry electrical signal from the dendrites, down to the some tentacle-like processes that end in little pods. These pods, called the terminal buttons of the axon, and then convey the electrical signal to another nerve cell by directing a burst of chemicals towards the dendrites of the next nerve cell in the chain.

In order for the signal to be successfully passed from the first nerve cell to the second, it must successfully traverse a small space called the synapse.

Despite being very close to each other, no nerve cell touches another. Instead, the spray of chemicals that’s released from the terminal button of the axon floats across a space of about 20-40nM (a nanometre is one billionth of a metre).

http://study.com/academy/lesson/synaptic-cleft-definition-function.html

Combining nerve cells and synapses together creates a nerve pathway, where the input signal is received by specialised nerve endings and is transmitted down the nerve cell across a synapse to the next nerve cell, across the next synapse to the next nerve cell, and on and on until the signal has reached the destination for the output of that signal.

And that’s it. The entire nervous system is just a combination of nerve cells and the synapses between them.

What gives the nervous system and brain the near-infinite flexibility, and air of mystery, is that there are eighty-six billion nerve cells in the average adult (male) brain. Each nerve cell has hundreds to thousands of synapses. It’s estimated that there are about 0.15 quadrillion (that’s 150,000,000,000,000) synapses throughout the average brain [1]. Each of these cells and synapses connect in multiple directions and levels, and transmit signals through the sum of the exciting or inhibiting influences they receive from, and pass on to, other nerve cells.

The brain is a highly plastic organ. When biologists talk about plasticity, they aren’t talking about the chemical plastic that we make everything out of, like plastic cups or bottles, but the ability for the cells, tissues or organs to change or adapt. And the brain does this all of the time. Every stimulus changes one or more of the billions of branches and synapses that the brain has. Branches can be pruned back, or new ones grown. Existing branches can be strengthened or weakened. Each change to the branches of the nerve cells helps the brain to adapt to the ever-changing internal and external stream of signals that the brain is required to process.

So returning to Dr Leaf’s statement: The key part of the meme is, “Your thoughts produce proteins”. This is where Dr Leaf’s statement is wrong. The error is deceptively subtle, but it’s still wrong. When changes are required, new branches are formed, which do indeed require new proteins. But most brain function, including our thoughts, is simply electrical current running along the pathways already formed by the branches of our nerve cells.

Even then, our stream of conscious thought is only a tiny fragment of the billions of nerve impulses our brains produce each and every second of our lives. As I described in my previous post, thought is not dominant. Our thoughts do not control our brains, it’s our brains that control our thoughts. Thoughts are real, but they’re real like an image on a screen is real, but isn’t the real thing.

Thoughts are only significant when they are considered for what they truly are. Our stream of consciousness is simply a selective place of refinement for highly salient parts of our non-conscious information that need further processing before further action is taken with that information. They are like the dials on your dashboard, which give selective important information about the car but they don’t control the car. Thoughts do not control our brains growth, or alter our brains architecture.

Dr Leaf should have said something along the lines of, “The landscape of the brain is created by real structures called neurons and synapses, which have many functions including our thoughts.”

As it is, Dr Leaf’s meme creates a false impression that our thoughts are the critical factor in determining our brains structure and function, when the reality is the exact opposite.

References

[1] Sukel K. The Synapse – A Primer. 2013 [cited 2013 28/06/2013]; Available from: http://www.dana.org/media/detail.aspx?id=31294

The Prospering Soul – Christians and Depression Part 2

Posted on October 11, 2015 by cedwardpitt

For most church-goers, putting the terms “Christian” and “depression” in the same sentence just doesn’t seem natural. In part 1, we looked at what depression is and why depression affects a lot more of the church than the church is aware of.

In this instalment, we’ll look at some general ways to handle depression, and what the Bible says about being depressed.

In the first blog, I explained how I understood depression as the end result of the brains capacity to deal with the demands of life. Too many demands or not enough resources overwhelms the brain and low mood is the end result.

So how do you manage depression? Well, if the system is failing because of increased demand or decreased capacity to cope, then it’s logical to manage depression by decreasing demand and increasing capacity to cope.

We can increase our capacity to cope by increasing our brains capacity to grow new nerve branches, and to make the cells more efficient at doing their job.

Increasing the growth of new nerve cell branches (in science speak – ‘synaptogenesis’) involves increasing the growth factors. BDNF has been proven to be increased by anti-depressant medications [1, 2] and by exercise [3, 4]. There may be some evidence that diet might improve depression in a similar way although the evidence is weak [5], so we should take that with a grain of salt.

The next way of managing depression is to increase the capacity to cope. The way we do that is through psychological therapies. There are several styles of psychological therapies, too many for me to discuss them all here. In the real world, most psychologists use a mix of a number of techniques that they tailor to the needs of their patient. I’m going to quickly outline the two most commonly used therapies.

Cognitive Behavioural Therapy, or CBT for short, is “based on the theory that emotional problems result from distorted attitudes and ways of thinking that can be corrected. The aim is to treat difficulties by problem solving, finding better strategies for coping, and overcoming irrational fears.” [6] Essentially it’s the combination of two different therapies, Cognitive therapy, and Behavioural therapy. Cognitive therapy, as the name suggests, assumes that people have mental health problems because of patterns of irrational thinking. Behavioural therapy is quite broad, but looks to challenge the thinking patterns with action (for example: gradual exposure to something a person is afraid of).

CBT is the most well researched form of psychotherapy, and has a lot of evidence for it’s effectiveness [7]. Though there is good evidence that it’s the behavioural arm that gives it any clout [8, 9]. Trying to change your mental health just by trying to change your thoughts is generally ineffective.

In the last couple of decades, a new wave of psychological therapies has emerged from this idea that Cognitive Behavioural Therapy is just Behavioural Therapy with bling. The most notable is Acceptance and Commitment Therapy, or ACT for short. ACT is different to CBT in that ACT doesn’t rely on the idea of changing thoughts, but on simply accepting them. ACT “is a psychological therapy that teaches mindfulness (‘paying attention in a particular way: on purpose, in the present moment, non-judgementally’) and acceptance (openness, willingness to sustain contact) skills for responding to uncontrollable experiences and thereby increased enactment of personal values.” [10]

According to ACT, you don’t have to change your thoughts, because thoughts aren’t that powerful to begin with – they’re just words. Sometimes they’re true, and sometimes they’re helpful, but if we spent all of our time trying to fight them, we miss out on experiencing the joy in the present moment, and we can lose sight of the values that guide us into our future fulfilment.

The common link between good psychotherapy is that their therapeutic effect comes from improving skills in different areas that the patient lacks. That is, psychological therapies increase the capacity of the patient to cope with things that would have otherwise wouldn’t have handled well and would have caused distress.

The last way to manage depression is to limit the excessive demands that have been placed on the system in the first place, or in other words, reduce the unnecessary stressors. People who are depressed tend to be bad at this, but there are a few basic skills that are common to all stress management techniques that can form the platform of ongoing better skills in this area. The full list will be a blog for another time, but the simplest technique is to breathe!

Remember, B.R.E.A.T.H.E. = Breathe Rhythmically Evenly And Through the Heart Everyday.

To recap, there are three main ways to manage depression – increase the brains ability to process the incoming information, increase the capacity to cope, and decrease the amount of stress that our brains have to process.

The fourth way to help manage depression is prayer. There is limited scientific information on the effects of prayer on depression, although a small randomised controlled trial did show that prayer with a prayer counsellor over a period of a number of weeks was more effective than no treatment [11]. But the Bible encourages us, “Do not be anxious about anything, but in every situation, by prayer and petition, with thanksgiving, present your requests to God. And the peace of God, which transcends all understanding, will guard your hearts and your minds in Christ Jesus.” (Philippians 4:6-7)

And Jesus himself called to those heavy in heart, “Come to me, all you who are weary and burdened, and I will give you rest. Take my yoke upon you and learn from me, for I am gentle and humble in heart, and you will find rest for your souls. For my yoke is easy and my burden is light.” (Matthew 11:28-30)

One final thought. It’s sometimes hard to understand how strong Christians can become depressed in the first place. After all, the Bible says that the fruit of the Spirit is joy (Galatians 5:22). 1 Peter 1:8 seems to suggest that every Christian should be “filled with an inexpressible and glorious joy.”

So when you’re filled with the opposite, it makes you feel like a faithless failure, and Christians without depression assume a similar thing for Christians they know who are suffering from depression. It’s the logical conclusion to draw after all – if the fruit of the Spirit is joy, and you are not filled with joy, then you mustn’t be full of the Spirit.

But when you look through the greatest heroes in the Bible, you see a pattern where at one point or another in their lives, they went through physical and emotional destitution. Sure, their lives had some pretty amazing highs, but they often experienced some amazing lows as well. Moses spent forty years in the wilderness, and when God appeared to him in the burning bush, he argued with God about how weak and timid he was (Exodus 3 and 4).

In 1 Kings 18, Elijah had just seen God rain down fire to supernaturally consume his sacrifice, capture and kill four hundred and fifty prophets of Baal, and watched God break the drought over Israel. At the height of this run of amazing connection to God, Jezebel the evil queen threatened him, and he ran for his life in a panic and asked God to kill him, twice, over the period of a couple of months (1 Kings 19).

Peter had spent three years with Jesus, the Messiah himself, hearing him speak and watching him perform miracle after miracle after miracle. Peter even saw the empty tomb first hand on the very first Easter Sunday, but still, he gave up on life with God and went back to his former occupation, which turned out to be lots of hard work for very little reward (John 21:1-3).

The same pattern is also seen in King David, Gideon, and a number of other great leaders through the Bible. The take home message is this: it’s human nature to suffer from disease and dysfunction. Sometimes it’s physical dysfunction. Sometimes it’s emotional dysfunction. It’s not a personal or spiritual failure to have a physical illness. Why should mental illness be treated any different?

As the stories of Moses, Elijah and Peter testify, being a strong Christian doesn’t make you impervious to low mood or emotional fatigue. Hey, we’re all broken in some way, otherwise why would we need God’s strength and salvation! Having depression simply changes your capacity to experience the joy and love of God. Closing your eyes doesn’t stop the light, it just stops you experiencing the light. Being depressed makes it hard to experience God’s love, but it doesn’t stop God’s love.

In the 80’s and 90’s, a popular Christian musician was a man named Carmen. One of his best known songs had these words,

“When problems try to bury you and make it hard to pray, it may seem like Friday night, but Sunday’s on the way!”

It’s really hard when you’re afflicted by the dank darkness of depression. But nothing will separate us from the love of God (Romans 8:35-39), including depression. You may not feel it, but God’s love is there, and Sunday’s on the way.

Remember:

Depression is a common mental health condition that can have prolonged and devastating consequences. Depression is characterised by either a sadness or a lack of joy which are abnormal in their intensity and their duration, but also affects sleep, appetite and motivation. It’s caused by abnormalities in genes which affect the brains ability to grow new nerve cell branches, and which also affect in-built coping mechanisms, so stress is both more likely to occur in people who are more prone to depression, and the stress is then handled poorly, overloading their emotional capacity.

The management of depression is three-pronged: to improve the brains ability to grow new nerve cells through exercise and/or medication, to learn new ways to cope with distress, and to decrease the amount of stress in the first place.

Christians are not immune from depression, and it’s important for Christians to understand that Christians suffering from depression are not weak, or failing in their spiritual walk, or are unloved by God. The love of God is always present, even if they are unable to process it properly. As dark and dismal as depression can become, there is hope. It may seem like Friday night, but Sunday’s on the way.

References

[1]        Duman RS, Li N. A neurotrophic hypothesis of depression: role of synaptogenesis in the actions of NMDA receptor antagonists. Philosophical transactions of the Royal Society of London Series B, Biological sciences 2012 Sep 5;367(1601):2475-84.
[2]        Anderson I. Depression. The Treatment and Management of Depression in Adults (Update). NICE clinical guideline 90.2009. London: The British Psychological Society and The Royal College of Psychiatrists, 2010.
[3]        Karatsoreos IN, McEwen BS. Resilience and vulnerability: a neurobiological perspective. F1000prime reports 2013;5:13.
[4]        Rimer J, Dwan K, Lawlor DA, et al. Exercise for depression. The Cochrane database of systematic reviews 2012;7:CD004366.
[5]        Lai JS, Hiles S, Bisquera A, Hure AJ, McEvoy M, Attia J. A systematic review and meta-analysis of dietary patterns and depression in community-dwelling adults. The American journal of clinical nutrition 2014 Jan;99(1):181-97.
[6]        NowOK. Cognitive Behavioural Therapy. Dictionary of Psychotherapy 2015 [cited; Available from: http://www.dictionary.nowok.co.uk/cognitive-behavioural-therapy-cbt.php
[7]        Ruiz FJ. Acceptance and Commitment Therapy versus Traditional Cognitive Behavioral Therapy: A Systematic Review and Meta-analysis of Current Empirical Evidence. International journal of psychology and psychological therapy 2012;12(3):333-58.
[8]        Longmore RJ, Worrell M. Do we need to challenge thoughts in cognitive behavior therapy? Clinical psychology review 2007 Mar;27(2):173-87.
[9]        Dobson KS, Hollon SD, Dimidjian S, et al. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression. Journal of consulting and clinical psychology 2008 Jun;76(3):468-77.
[10]      Smout M. Acceptance and commitment therapy – pathways for general practitioners. Aust Fam Physician 2012 Sep;41(9):672-6.
[11]      Boelens PA, Reeves RR, Replogle WH, Koenig HG. A randomized trial of the effect of prayer on depression and anxiety. Int J Psychiatry Med 2009;39(4):377-92.

If you’re suffering from depression or any other mental health difficulties and need help, see your GP or a psychologist, or if you’re in Australia, 24 hour telephone counselling is available through:

Lifeline = 13 11 14 – or – Beyond Blue = 1300 22 4636

Dr C. Edward Pitt

Faith, Hope, Love, Science.

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