Public Health Minute: My interview with Dr. William Latimer

Public Health Minute

Public Health Minute (PHM) is a one-minute segment in which Dr. William Latimer, interviews researchers, medical and other professionals about a wide variety of public health topics. The Institute of Medicine estimates it takes 20+ years for health researchers to get scientifically proven findings that inform best practices into communities. Public Health Minute gets practical health advice informed by cutting edge research to the public today. I was interviewed last year on PHM. I spoke with Dr. Latimer about the importance of context and environment in depression and other mental disorders.

https://soundcloud.com/publichealthminute/social-and-environmental-causes-of-depression-dr-karasz

Science vs Scientism: Why Does it Matter? (Copy) (Copy)

To a lot of people, even to a lot of scientists, science is a subject matter. “Science” is numbers. Science is molecules. Science is ‘scientific experts,’ white coats, stethoscopes, medicine bottles, brain images. When we think about science in this way, it’s easy to get sucked into a phenomenon I called scientism. Scientism is a cultural phenomenon unique to modern culture. “Scientism” is like the child’s joke about washing a diaper. As a seven-year-old, I rolled on the ground with laughter at this one.

(pretending to scrub a diaper in the sink): “Wishy washy wishy washy wishy washy!

(Holds up the diaper to inspect) “Looks clean, feels clean. . .

(Smells the diaper) “Smells. . .  (pause).

(Scrubs vigorously) “Wishy washy wishy washy wishy washy!”

The fact is that scientism isn’t a subject matter, like a class at school. When I teach research methods at my medical school, I define science as “systematic inquiry.” The question of how to treat mental disorders requires systematic scientific inquiry to painstakingly uncover the truth.

When you understand science as a subject and not a method, you start to confuse something that looks like science…sounds like science…smells like science?

But isn’t science.

I did a post-doctoral fellowship at a prestigious mental health services institute. In the 1990s, the big question for mental health researchers was the question of why so many depressed patients, especially low income patients, were not getting effective medications for depression. And the goal of a lot of the research at the institute focused on how to get more medication into these patients. At the same time, there was a lot of emerging data regarding the effectiveness of these medications that suggested that getting more poor people on antidepressants might not solve the public health crisis of depression. When it comes to treatment, both for medication and psychotherapy, evidence suggests that a lot of the healing comes from the relationship between the healer and the patient. Something like caring, empathy, support, guidance…

One of my colleagues had designed a program that used a complicated algorithm to identify depressed patients and offer them antidepressants. When I asked her about the issue of therapeutic relationship, she scoffed: “Sounds like you think that the way to treat depressed people is to be nice. But being nice is not science!”

That’s scientism in a nutshell. The fact is, if being ‘nice’ helps patients, we need a science of ‘niceness.’ What is it about empathy, warmth, and support that makes people better? How do individuals differ in terms of what they need? How do we develop effective therapeutic relationships?  How do we design institutions like schools, hospitals, workplaces, so that individuals are supported and cared for? The jury is still out…

Research in Psychotherapy: Are we getting better?

After 75 years of psychotherapy research, many questions remain. . .

How and why does psychotherapy work? 75 years of scientific study show that psychotherapy works much better than no treatment at all. Yet, to date, we have very little understanding of why. If some therapies worked better than others, it would help move the science along—because then we would understand how active ingredients associated with particular therapies may differ from one another. Unfortunately, well designed large studies have shown repeatedly that psychotherapies are all equally effective.

It is sometimes suggested that highly structured therapies, like Cognitive Behavioral Therapy, work better than other therapies. But in fact, a close look at these studies suggests that this widely believed fact may be a mirage—a kind of large-scale misperception that is surprisingly common in the scientific literature! An important point to understand is that when it comes to mental health treatment, the dominant and prestigious therapies of the moment always seem to do better than older, or less ‘popular’ treatments. This is due in part to a phenomenon called the ‘Champion Effect’—if the project leader and champion is associated with a particular type of treatment in a clinical trial, that treatment always does better than the comparison condition!

Weird, huh?

In fact, what the science really tells us is that it is probably the non-specific factors in therapy—the relationship that grows during treatment and the support and understanding offered by the therapist—that really works. Studies show that while treatment type makes no difference in outcome, the therapist makes a huge difference! Surprisingly, therapists differ drastically in quality. Therapists who offer support, are non-critical, who are able to apologize when they make mistakes, tend to have better outcomes with their patients. Yet to date, the science of psychotherapy has not really focused on these issues. If it did, training programs would look a lot different.

I really like Scott Miller. In this blog piece, he talks about why the science of psychotherapy is moving forward so slowly. Research keeps focusing on specific techniques that really have almost no real relationship to outcomes. Scott suggests some solutions.

https://www.scottdmiller.com/time-for-a-new-paradigm-psychotherapy-outcomes-stagnant-for-40-years/

Do Anti-Depressants Work?

 Anti-depressants are the most prescribed medications in the history of mankind. Doctors have issued hundreds of millions of prescriptions over the last two decades. But how effective are they? It appears that much of the benefit that some people perceive is a kind of generalized treatment effect that has nothing to do with molecules in the brain. Instead, it seems that people often feel better from just being in treatment. In clinical trials, antidepressants don’t work much better than a placebo pill. 

The File Drawer Phenomenon

If that’s the case, why does the ‘science’ seem to suggest that antidepressants are highly effective? One major reason is that pharmaceutical companies conduct the research—and this really matters. If a drug is equally as effective as a placebo, then about half of trials will show that the drug outperformed the placebo, while the other half will show that the placebo outperformed the drug. If a drug company puts their ‘failed trials’ into a file drawer and sends their ‘successful,’ trials out for publication, the published literature will seem to suggest that the drugs work. Research over the past ten years has shown that pharmaceutical companies are indeed building up huge file drawer repositories of failed trials—research they hope will never see the light of day. 

Comparing Cognitive Behavioral Therapy with other therapies: What the science really says. . .

The scientific literature is full of clinical trials showing that cognitive behavioral therapy is superior to other forms of therapy. CBT is also regarded as more efficient and more grounded in ‘science.” As Dr. Drew Weston writes in his important paper on empirically supported therapies https://pubmed.ncbi.nlm.nih.gov/15250817, what the science really tells us is not so simple. When comparing different psychotherapies, it all depends on who is leading the study.

Most university clinical psychology departments are dominated by cognitive behavioral therapists. Accordingly, cognitive behavioral psychologists get most of the grant money and run most of the trials comparing different therapies. And this is a problem! A phenomenon called the Champion Effect means that the therapy preferred by the Principal Investigator in any trial tends to outperform the other treatments in the trial. Because there are so many cognitive behavioral psychologists out there running trials, the literature reflects these results, seeming to suggest that CBT works better than other treatments. To know whether or not CBT works better than other forms of treatment, we need large scale clinical trials that are run by Principal Investigators who are unaffiliated with any particular school of therapy. But these trials are very expensive and hard to do.

The NIMH Treatment of Depression Collaborative Research Program was carried out in the 1980s by a team of psychologists and psychiatrists. Its goal was to compare two forms of brief psychotherapy—CBT and “Interpersonal Psychotherapy.” The DCRP enrolled hundreds of patients and followed them over a long period of time. They found no differences between CBT and IPT. *

CBT techniques can be incredibly helpful for some clients—and when it comes to CBT “bibliotherapy,” I love David Burns’ Feeling Good (https://www.thriftbooks.com).  But what the science really shows is that no one therapeutic approach is more ‘scientific,’ or more effective, than others. To the contrary, it seems pretty clear that non specific and relational factors, like warmth, intimacy, and respect, are the most important predictors of effective treatment.

*Elkin I, Parloff MB, Hadley SW, Autry JH. NIMH Treatment of Depression Collaborative Research Program: Background and Research Plan. Arch Gen Psychiatry. 1985;42(3):305–316. doi:10.1001/archpsyc.1985.01790260103013

Antidepressants over the long term

Over a quarter of people currently on these medications have been taking them for a decade or longer. Some people feel a significant benefit and would not dream of cutting back or stopping. Increasingly, though, many people are wondering about the road ahead. How long should a person stay on antidepressants?

The problem is that we don’t know very much about the effectiveness, or the impact, of these drugs over the long term. Since most studies track patients for only a year or two, we just don’t know enough about their long term effects. A recent ‘meta-analysis’—which combines data from many different studies and analyzes these data using a uniform method—shows that in the general population, anti-depressant use significantly increases the risk of mortality. See a link to the paper here: https://pubmed.ncbi.nlm.nih.gov/28903117/

Yet, for many patients, going off an antidepressant is a scary prospect. Relapses can occur. On the other hand, over 30% of people on antidepressants report that they experience occasional relapses even while taking the medications. Furthermore, the ‘discontinuation’ effects of anti-depressants—the symptoms some people get when they go off the drugs—can mimic an attack of depression and anxiety.

If you are considering going off anti-depressants, have a serious talk with your doctor. Many general practitioners and psychiatrists will be supportive if it seems an appropriate step. The process should be slow and gentle. It should only be undertaken under the care of a physician.

One of the most ‘famous’ advocates of anti-depressants, Lauren Slater, is a psychologist and an amazing, gifted writer. She was an influential in the creation of the 1980s cultural movement sometimes called the Prozac Generation—in which we became the biggest consumers of mood altering drugs in the history of the world. Now 30 years later, she is wondering about her legacy:

https://www.theguardian.com/books/2018/apr/01/the-drugs-that-changed-our-minds-lauren-slater-review

Science vs Scientism: Why Does it Matter?

To a lot of people, even to a lot of scientists, science is a subject matter. “Science” is numbers. Science is molecules. Science is ‘scientific experts,’ white coats, stethoscopes, medicine bottles, brain images. When we think about science in this way, it’s easy to get sucked into a phenomenon I called scientism. Scientism is a cultural phenomenon unique to modern culture. “Scientism” is like the child’s joke about washing a diaper. As a seven-year-old, I rolled on the ground with laughter at this one.

(pretending to scrub a diaper in the sink): “Wishy washy wishy washy wishy washy!

(Holds up the diaper to inspect) “Looks clean, feels clean. . .

(Smells the diaper) “Smells. . .  (pause).

(Scrubs vigorously) “Wishy washy wishy washy wishy washy!”

The fact is that scientism isn’t a subject matter, like a class at school. When I teach research methods at my medical school, I define science as “systematic inquiry.” The question of how to treat mental disorders requires systematic scientific inquiry to painstakingly uncover the truth.

When you understand science as a subject and not a method, you start to confuse something that looks like science…sounds like science…smells like science?

But isn’t science.

I did a post-doctoral fellowship at a prestigious mental health services institute. In the 1990s, the big question for mental health researchers was the question of why so many depressed patients, especially low income patients, were not getting effective medications for depression. And the goal of a lot of the research at the institute focused on how to get more medication into these patients. At the same time, there was a lot of emerging data regarding the effectiveness of these medications that suggested that getting more poor people on antidepressants might not solve the public health crisis of depression. When it comes to treatment, both for medication and psychotherapy, evidence suggests that a lot of the healing comes from the relationship between the healer and the patient. Something like caring, empathy, support, guidance…

One of my colleagues had designed a program that used a complicated algorithm to identify depressed patients and offer them antidepressants. When I asked her about the issue of therapeutic relationship, she scoffed: “Sounds like you think that the way to treat depressed people is to be nice. But being nice is not science!”

That’s scientism in a nutshell. The fact is, if being ‘nice’ helps patients, we need a science of ‘niceness.’ What is it about empathy, warmth, and support that makes people better? How do individuals differ in terms of what they need? How do we develop effective therapeutic relationships?  How do we design institutions like schools, hospitals, workplaces, so that individuals are supported and cared for? The jury is still out…

Why Exercise? The Role of Pleasure (Copy)

People who exercise live longer, healthier lives, and are less vulnerable to a host of poor health conditions, including Alzheimer’s disease. If you can find a way to work exercise into your daily routine, it’s a good idea to start. Unfortunately, even though most people believe they should exercise more, more than 50% of those starting exercise programs drop out in the first year. https://pubmed.ncbi.nlm.nih.gov/8153498/

One of the ways to increase the amount you exercise in your life is to make sure that the exercise you do is pleasurable. Research shows that if you actually enjoy exercise while you are doing it (as opposed to feeling satisfied after you are finished) you are going to be much more likely to stick to an exercise routine. https://pubmed.ncbi.nlm.nih.gov/25921307/

Not to mention the fact that pleasurable activities, in themselves, make you feel better!

So, find some kind of exercise that really is pleasurable for you. For many people, outdoor activities may be a lot more pleasurable than going to the gym. Do you like to bike? Hike? Ski? Kayak? Walk? These are highly pleasurable activities for some people, and may be good activities to incorporate into your life if you can. Do you like group activities, like dancing? Join a dance group or take a class.

 On the other hand, if you don’t really enjoy exercise, think of ways to trick yourself into enjoying your exercise routine. Find a fantastic podcast or a book on tape—and listen to it ONLY when you are exercising. Make sure it’s really good—so you can’t wait to get to it!

Finally, try to reduce the un-pleasurable aspects of exercise. For example, research shows that in the long run, very vigorous exercise may provide more benefit. However, vigorous exercise is often much more unpleasant! And it is very hard to stick to a habit that involves a behavior that is no fun. So, keep your exercise to a level that feels pleasurable. Don’t bike so fast you can’t take in the scenery. Don’t run so hard it hurts. As you exercise more, you’ll build strength, and will be able exercise harder while still enjoying it.

Depression and productivity

One of the most common reasons that clients in my Fort Greene practice seek therapy is work and productivity issues. Many of my clients have problems with procrastination. They feel like they can’t ‘get going.’ Blocks to action—whether work, socializing, exercising, planning—are a common consequences of strong negative emotion. Sometimes, procrastination and the anguish that it generates becomes its own problem, and may be easier to experience than the original emotions themselves. Procrastination is an especially severe problem among people in the creative professions—artists, entrepreneurs, etc—but it can affect anyone. Treatment of procrastination and its variants, such as writers’ block, is two pronged. First, I work with my client to understand and experience the strong emotions—sadness, feelings of failure, anxiety—that are preventing you from doing what you really want to do. Next, we work to understand how procrastination creates a vicious circle of shame and depression—as you blame yourself and your lack of productivity. As we try to normalize and forgive doing ‘nothing,’ it becomes easier to take small action steps, and can lead you to return to your normal state.

Some of my strategies for treating procrastination come from my cross cultural research. I’ve come to realize the very cultural component that contributes to these problems in my own practice. Our society values productivity above almost anything else. Paradoxically, this has led to an epidemic of depressive procrastination. People, naturally, are highly creative. We want to work, to act, and to make things. But when the stakes become too high, we can get paralyzed.

 My paper (link below) examines how culture affects the ways that European American women and a comparison group of South Asian immigrants, understood their health and daily symptoms. A key finding from this paper is that European Americans conceptualize health in terms of productivity, energy, creativity, and output. Maybe that is why American Depression takes its peculiar form—as sluggish, slow, and unproductive. I think the research can help us think more creatively about depression and anxiety. To what degree is our suffering caused by cultural values insisting on endless innovation, creativity and get up and go—all part of the culture of late capitalism.

 https://journals.sagepub.com/doi/pdf/10.1177/1363461508094674

American Motherhood

I’m interested in mothering—as a cultural phenomenon, as an influence on child health, and as a risk factor for depression and anxiety. I’m carrying out a randomized controlled trial on child feeding among South Asian immigrant mothers in the New York area. As we move forward with this study, larger issues of motherhood, and how we define it, are becoming more and more salient. Our team is realizing that problems in child feeding have a lot to do with how motherhood is defined and the obligations that are imposed on South Asian moms.

More on the clinical trial some other time. In the meantime, I have been looking into what other people are writing about mothering in the US. In the 1940s and 50s—mothers were often blamed for society’s problems. Smothering, hostile, envious, indulgent…mothers were even blamed for schizophrenia and other severe mental disorders. Despite the advances in women’s equality over the past forty years, some things never change. The twenty first century is is a difficult time to be a Mom. Standards for childrearing are incredibly high. Today’s mothers are not only expected to provide top quality physical care for their children, to love and nurture them, but also to make a huge investment in children’s cognitive, emotional, and play lives.

Read this super review by Judith Warner to get a sense of the major ant-feminist themes in a lot of our modern assumption about parenting.

https://www.nytimes.com/2012/05/13/books/review/the-conflict-and-the-new-feminist-agenda.html?pagewanted=all

Understanding post partum depression

Over the past three years, I’ve been carrying out an intervention for South Asian immigrant mothers (from Bangladesh, Pakistani and India). We’re trying to address feeding problems in South Asian families that may increase children’s risks of obesity and diabetes. One factor that really affects the quality of children’s feeding is the mother’s mood. When mothers are depressed, children’s nutrition suffers. In societies where food is scarce and expensive, children of depressed mothers tend to be malnourished. In societies like ours, where food is overly plentiful and not very nutritious, depressed moms have overweight kids. See a link to my study here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5984363/.

We’ve been learning a lot about distress and depression in the post-partum period while conducting this study. One thing we’ve noticed: A lot of our immigrant Moms feel distressed. They may not call it depression. In fact, they may feel a lot of different symptoms, especially irritability and exhaustion. But one symptom that that all most all distressed Moms report is loneliness.

When the media talks about postpartum depression, there’s always a lot of focus on hormones. But actually, there is no consistent evidence that fluctuations in hormones cause post-partum distress and depression. To the contrary, there is plenty of evidence that a lack of support, lack of companionship, and simple loneliness are a major cause of this problem.

Our immigrant moms miss their own mothers very much, along with the extended family network of siblings, cousins, and aunts and uncles. Mothers who are caring for their second child, alone in a small apartment, often talk about what it was like to have their first baby back home, surrounded by caring relatives, and never having to lift a finger.

For immigrants and non-immigrant mothers alike, companionship and support may be the very best treatment for postpartum depression. That may be one reasons why more and more women are working with doulas, or birth attendants, in the post-partum period. https://www.wbur.org/commonhealth/2014/06/20/best-kept-secret-for-postpartum-depression-help-at-home.

If you are feeling post-partum distress—sadness, anxiety, or excessive guilt—you may also want to consider psychotherapy. Working with a skilled therapist can help you navigate this challenging period. Reach out to me at 718-858-7968 to schedule a consultation.

Psychotherapy and the sense of flow

Personally I am fascinated by ideas about flow—that state of mind in which you lose self-awareness and become completely immersed in something. This seems like it is easier for children than for adults. It’s kind of the opposite of being distracted. And it’s definitely the opposite of burnout. Flow can help explain the calming, therapeutic effects of certain repetitive experiences. Even knitting can produce flow…

When I am with a patient in the consultation room, sometimes we both become aware that flow is happening. Researchers and clinicians have started writing about the experience of ‘flow’ in psychotherapy. It includes a feeling of intense connectedness, engagement, and sometimes joy—even if the emotions that are emerging in the moment are not all positive. When I experience this with a patient, I often find that both of us seem to be able to read the other person’s thoughts much more easily than usual. Freud’s disciple Sandor Ferenczi believed that he had telepathic experiences in the consultation room. I don’t personally believe in telepathy. None the less, the ‘peak’ experiences of flow lead to a heightened empathy that help connect the therapist and patient.

http://positivepsychology.org.uk/living-in-flow/

Could boredom be good for you?

It’s obvious that in a society like ours, obsessed with productivity, doing nothing at all feels like it can’t be good. But interesting new research suggests that boredom can sometimes be good for you. Paradoxically, it may even help you be more productive.

https://www.theatlantic.com/magazine/archive/2017/06/make-time-for-boredom/524514/

Sleep problems in teenagers

Sleep problems in kids

As a psychologist, one of the most common concerns that I hear about from parents of young children is sleep problems. I’ll write more about this in another blog, but this week I want to talk about sleep problems in teenagers. By the time kids reach adolescence, their parents often give up trying to influence their sleep patterns. But poor sleep is a huge health issue for adolescents. Poor sleep affects kids’ mental health, their school work, relationships, and emotional lives. Here is an article about it, with some helpful tips for parents:

https://www.psychologytoday.com/us/blog/healthier-minds-happier-world/201806/what-poor-sleep-could-be-doing-your-child-or-teen