tag:theconversation.com,2011:/au/topics/psychiatry-408/articlesPsychiatry – The Conversation2024-01-23T16:34:21Ztag:theconversation.com,2011:article/2213762024-01-23T16:34:21Z2024-01-23T16:34:21ZPeople with OCD are more likely to die earlier, of any cause<figure><img src="https://images.theconversation.com/files/570860/original/file-20240123-21-eh39uf.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C7578%2C4263&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/obsessive-compulsive-disorder-arranging-paperclips-row-2025295895">Microgen/Shutterstock</a></span></figcaption></figure><p>People with <a href="https://www.nhs.uk/mental-health/conditions/obsessive-compulsive-disorder-ocd/overview/">obsessive-compulsive disorder</a>, or OCD for short, are 82% more likely to die earlier – from natural or unnatural causes – than people without the condition, a <a href="https://www.bmj.com/content/384/bmj-2023-077564.full">new study</a> reveals.</p>
<p>Previous studies have found <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2484488">excess deaths</a> in people with OCD, but the specific causes of death had been poorly researched – maybe with the exception of suicide. Notably, people with OCD have <a href="https://www.nature.com/articles/mp2016115">similar suicide rates</a> to people with other mental health disorders.</p>
<p>OCD affects about <a href="https://www.psychiatry.org/patients-families/obsessive-compulsive-disorder/what-is-obsessive-compulsive-disorder">2% of the population</a>. People with the condition have distressing intrusive and repetitive thoughts (such as a fear of being contaminated or becoming aggressive towards others) and feel compelled to perform time-consuming rituals to reduce the discomfort caused by the thoughts, such as cleaning, repeating or checking. </p>
<p>The disorder significantly impairs daily life, affecting relationships, social activities and the general ability to function. </p>
<p>My colleagues and I at the Karolinska Institutet in Sweden <a href="https://www.bmj.com/content/384/bmj-2023-077564.full">aimed to understand</a> the specific natural and unnatural causes of death contributing to the reported elevated mortality rates in OCD. We used Swedish population registers, which include administrative and healthcare data from the whole population, to compare a group of 61,378 people who had received a diagnosis of OCD with 613,780 people without OCD. </p>
<p>We followed both groups for more than four decades (from 1973 to 2020) and found that people with OCD died at an earlier average (mean) age than those without OCD (69 v 78 years). </p>
<p>The risk of death during the study period was 82% higher in the group with OCD, compared to the group without OCD. The increased risk of death was attributable to both natural (31% increased risk) and unnatural causes (230% increased risk).</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/1MJVG8kWBbc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">OCD explained.</span></figcaption>
</figure>
<h2>Specific causes</h2>
<p>For the first time, we were able to identify specific causes of death due to natural causes. People with OCD had increased risks due to lung diseases (73%), mental and behavioural disorders (58%), diseases of the urinary and reproductive organs (55%), endocrine, nutritional and metabolic diseases (47%), diseases of the blood vessels (33%), nervous system (21%) and digestive system (20%). </p>
<p>Intriguingly, the risk of death due to cancer was 13% lower in those with OCD. The reason this risk goes in the opposite direction is not known. </p>
<p>Among the unnatural causes of death, suicide was the main contributor to the increased mortality. Those with OCD, compared to those without, had a nearly fivefold increased risk of dying by suicide. Also, people with OCD had a 92% increased risk of dying due to accidents, including traffic accidents or falls. </p>
<p>The results held even after we took mental health disorders other than OCD – for example, anxiety, depression and substance use disorders – into account. </p>
<p>Also, when we compared the OCD group with their siblings without OCD, the results remained largely unchanged. This confirms that our results cannot only be attributed to any accompanying mental health disorders or genetic or environmental factors shared between families, but that are likely to be related to OCD itself. </p>
<h2>Mostly preventable</h2>
<p>Although these are not positive findings for people with OCD, it’s important to note that the proportion of people dying of each cause was relatively small, even if compared with the group without OCD it translated to a higher risk. </p>
<p>For example, during the study period, 2.5% of people with OCD died due to circulatory system diseases (such as heart attacks and strokes), which is a low percentage. Nonetheless, this percentage is higher than the 1.8% of deaths by this cause in the group without OCD. </p>
<p>Even so, it is not acceptable that people with OCD have to face these extra risks. I hope that these results spur healthcare professionals into action and contribute to people with OCD receiving better care. </p>
<p>Importantly, most of the causes of death that showed an increased risk are related to non-communicable diseases (for example, cardiovascular diseases, diabetes, chronic lung diseases, mental disorders, neurological disorders) and to external causes (for example, suicide, accidents), which can be classified as preventable. </p>
<p>People with OCD need to be aware of these risks. This may motivate behavioural changes – such as getting more exercise and having a healthy diet – that can play a role in preventing ill health and early death.</p><img src="https://counter.theconversation.com/content/221376/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span><a href="mailto:lorena.fernandez.de.la.cruz@ki.se">lorena.fernandez.de.la.cruz@ki.se</a> has received funding from the Swedish Research Council for Health, Working Life and Welfare (FORTE), Region Stockholm (ALF funding), the Swedish Society of Medicine (Svenska Läkaresällskapets), and Karolinska Institutet. She also receives royalties for contributing articles to UpToDate and Wolters Kluwer Health and for editorial work from Elsevier, outside the submitted work.</span></em></p>People with OCD have a 31% increased risk of death from natural causes and a 230% increased risk of death from unnatural causes compared to those without the disorder.Lorena Fernández de la Cruz, Clinical Researcher, Psychiatric Epidemiology, Karolinska InstitutetLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2169802023-12-21T21:37:49Z2023-12-21T21:37:49ZThe Douglas-Bell Canada Brain Bank: a goldmine for research on brain diseases<figure><img src="https://images.theconversation.com/files/557356/original/file-20231005-26-rmh9lm.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4000%2C1508&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The experimental methods available today allow us to break the brain down into its elementary components in order to understand its functions and dysfunctions.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Human beings have always been fascinated by the brain. </p>
<p>Although scientific knowledge about this 1.3 kg of fragile substance embedded in our cranium has long been incomplete, dazzling technical breakthroughs made in recent years are now ushering in a Golden Age of molecular neuroscience. </p>
<p>These breakthroughs have been made possible partly thanks to brain banks, which preserve human brains in the best possible conditions for scientific research. Here in Montréal, we have one of the world’s largest such banks, the Douglas-Bell Canada Brain Bank (DBCBB), <a href="https://douglasbrainbank.ca">founded in 1980 at the Douglas Hospital</a>. </p>
<p>The DBCBB, which receives several brains each month, has collected over 3,600 specimens to date. Every year, its team processes dozens of tissue requests from scientists in Québec, Canada and abroad, preparing some 2,000 samples for research. </p>
<p>Over the past 40 years, these efforts have led to a considerable number of discoveries about different neurological and psychiatric diseases. </p>
<p>As a full professor in the department of psychiatry at McGill University, researcher at the Douglas Research Centre and director of the DBCBB since 2007, I work in close collaboration with <a href="https://www.mcgill.ca/psychiatry/gustavo-turecki">Dr. Gustavo Turecki</a>, co-director of the DBCBB and responsible for the component devoted to psychiatric illnesses and suicide.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&rect=14%2C2%2C1535%2C1231&q=45&auto=format&w=1000&fit=clip"><img alt="cerebral hemisphere" src="https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&rect=14%2C2%2C1535%2C1231&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=475&fit=crop&dpr=1 600w, https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=475&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=475&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=596&fit=crop&dpr=1 754w, https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=596&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=596&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Douglas-Bell Canada Brain Bank, which receives several brains each month, has collected over 3,600 specimens to date.</span>
<span class="attribution"><span class="source">(Naguib Mechawar)</span>, <span class="license">Fourni par l'auteur</span></span>
</figcaption>
</figure>
<h2>A brief history of research on the human brain</h2>
<p>Scientists only began to identify the microscopic elements that make up the human brain in the second half of the 19th century. </p>
<p>That was when brains were preserved for the first time in formalin, a solution that preserves biological tissue so that it can be handled more easily and stored over a longer term.</p>
<p>At the same time, precision instruments and protocols were being developed that made it possible to examine the microscopic characteristics of nervous tissue.</p>
<p>Until the middle of the 20th century, researchers were mainly satisfied with preserving the brains of patients, taken during autopsies, so they could use them to identify possible macroscopic or microscopic changes linked to either neurological or psychiatric symptoms.</p>
<p>This is in fact what the German neurologist Alois Alzheimer did when he analyzed the brain of one of his patients suffering from dementia. In 1906, he described, for the first time, the microscopic lesions which characterize the disease that now bears his name.</p>
<p>Until the end of the 1970s, numerous collections of brain specimens preserved in formalin were built in hospital environments, a bit like the cabinets of curiosities of olden days.</p>
<p>Towards the end of the 20th century, new experimental approaches were developed allowing the high-resolution analysis of cells and molecules within biological tissues.</p>
<p>It then became necessary to collect and preserve human brains, obtained with the consent of the individual or his or her family, in conditions compatible with modern scientific techniques.</p>
<p>Researchers began freezing one of the cerebral hemispheres in order to measure its various molecular components. The other hemisphere was preserved in formalin to be used for macroscopic and microscopic anatomical studies.</p>
<p>This was the context in which the Douglas-Bell Canada Brain Bank was created.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="The DBCBB premises" src="https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Montréal is home to one of the world’s largest brain banks, the Douglas-Bell Canada Brain Bank, which was founded in 1980 at the Douglas Hospital.</span>
<span class="attribution"><span class="source">(Naguib Mechawar)</span>, <span class="license">Fourni par l'auteur</span></span>
</figcaption>
</figure>
<h2>New experimental approaches are yielding results</h2>
<p>Leading researchers from many universities around the world now use DBCBB samples to advance their research. This, of course, includes a number of teams in Québec.</p>
<p>For example, with his team from the Douglas Research Centre, which is affiliated with McGill University, <a href="https://douglas.research.mcgill.ca/judes-poirier/">Judes Poirier</a> discovered that the APOE4 gene is a <a href="https://doi.org/10.1016/0140-6736(93)91705-Q">risk factor for Alzheimer’s disease</a>. More recently, the team of <a href="https://crhmr.ciusss-estmtl.gouv.qc.ca/en/researcher/gilbert-bernier">Gilbert Bernier</a>, professor in the department of neuroscience at Université de Montréal, discovered that the lesions characteristic of this disease are associated with <a href="https://doi.org/10.1038/s41598-018-37444-3">abnormal expression of the BMI1 gene</a>.</p>
<p>With regard to psychiatric illnesses, and more specifically depression, major progress has been made recently by the <a href="https://douglas.research.mcgill.ca/mcgill-group-suicide-studies-mgss/">McGill Group for Suicide Studies</a>. </p>
<p>Using cutting-edge methods to isolate and analyze human brain cells, Turecki’s team has succeeded in precisely identifying the cell types whose function is affected in men <a href="https://doi.org/10.1038/s41593-020-0621-y">who have suffered from major depression</a>, and then discovering that the cell types involved in this illness differ <a href="https://doi.org/10.1038/s41467-023-38530-5">between men and women</a>. </p>
<p>These experimental approaches generate huge data sets that can be examined in subsequent studies. This is the case, for example, of work carried out in my laboratory, which identified signs of persistent changes in neuroplasticity within the prefrontal cortex of people with a history of <a href="https://doi.org/10.1038/s41380-021-01372-y">child abuse</a>. In fact, the studies mentioned above enabled us to discover at least one of the cell types involved in this phenomenon. </p>
<p>In short, the experimental methods we have today allow us to break the brain down into its elementary components in order to understand its functions and dysfunctions.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Cerebral hemispheres preserved in formalin" src="https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Leading researchers from many universities around the world benefit from Douglas-Bell Canada Brain Bank samples to advance their research.</span>
<span class="attribution"><span class="source">(Naguib Mechawar)</span>, <span class="license">Fourni par l'auteur</span></span>
</figcaption>
</figure>
<h2>Identify, prevent, screen and treat</h2>
<p>Thanks to the hard work and dedication of the entire DBCBB team, as well as the unfailing support of all its partners, patrons (often anonymous) and funding bodies — particularly the FRQS research fund and Québec’s suicide research network, the <a href="https://reseausuicide.qc.ca">Réseau québécois sur le suicide, les troubles de l'humeur et les troubles associés</a> — this invaluable resource has not only managed to survive, but to grow and become one of the largest brain banks in the world. </p>
<p>There is every reason to believe that, in the years to come, the DBCBB will play an important role in the increasingly precise identification of the biological causes of brain diseases, and, as a result, will contribute to the identification of new targets for better approaches to prevention, screening and treatment.</p><img src="https://counter.theconversation.com/content/216980/count.gif" alt="La Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Naguib Mechawar has received funding from CIHR, NSERC, HBHL (CFREF) and FQRS (NEURON ERA-NET and RQSHA).</span></em></p>Montréal is home to one of the world’s largest brain banks, the Douglas-Bell Canada Brain Bank, where discoveries about different neurological and psychiatric diseases are made.Naguib Mechawar, Neurobiologiste, Institut Douglas; Professeur titulaire, Département de psychiatrie, McGill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2136472023-09-20T15:04:57Z2023-09-20T15:04:57ZDepression recovery can be hard to measure − new research on deep brain stimulation shows how objective biomarkers could help make treatment more precise<figure><img src="https://images.theconversation.com/files/548890/original/file-20230918-23-pisigx.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2190%2C1369&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Deep brain stimulation can alleviate treatment-resistant depression for some patients.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/brain-connection-royalty-free-image/1272275035">PM Images/Digital Vision via Getty Images</a></span></figcaption></figure><p>It can be challenging to create a treatment plan for depression. This is especially true for patients who <a href="https://doi.org/10.2147%2FNDT.S198774">aren’t responding to conventional treatments</a> and are undergoing experimental therapies such as deep brain stimulation. For most medical conditions, doctors can directly measure the part of the body that is being treated, such as blood pressure for cardiovascular disease. These measurable changes serve as an objective biomarker of recovery that provides valuable information about how to care for these patients. </p>
<p>On the other hand, for depression and other psychiatric disorders, clinicians rely on <a href="https://doi.org/10.1371/journal.pone.0203574">subjective and nonspecific surveys</a> that ask patients about their symptoms. When a patient tells their doctor they are experiencing negative emotions, is that because they are relapsing in their depression or because they had a bad day like everyone does sometimes? Are they anxious because their depression symptoms have lessened enough that they are experiencing new feelings, or do they have some other medical problem independent of their depression? Each reason may indicate a different course of action, such as altering a medication, addressing an issue in psychotherapy or increasing the intensity of <a href="https://theconversation.com/brain-stimulation-can-rewire-and-heal-damaged-neural-connections-but-it-isnt-clear-how-research-suggests-personalization-may-be-key-to-more-effective-therapies-182491">brain stimulation</a> treatment.</p>
<p><a href="https://scholar.google.com/citations?user=JHuo2D0AAAAJ&hl=en">We are</a> <a href="https://scholar.google.com/citations?user=K0dED3QAAAAJ&hl=en">neuroengineers</a>. In our study, newly published in Nature, we identified <a href="https://www.nature.com/articles/s41586-023-06541-3">potential biomarkers</a> for deep brain stimulation that could one day help guide clinicians and patients when making treatment decisions for those using this approach to alleviate treatment-resistant depression.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/hki3lR_Ysvo?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Deep brain stimulation involves surgically implanting electrodes in the brain.</span></figcaption>
</figure>
<h2>Biomarker for depression</h2>
<p>Clinical depression does not respond to available therapies in a significant number of patients. Researchers have been working to find alternative options for those with <a href="https://doi.org/10.2147%2FNDT.S198774">treatment-resistant depression</a>, and many decades of experiments have identified specific brain networks with abnormal electrical activity in those with depression.</p>
<p>This notion of depression as abnormal brain activity rather than a chemical imbalance led to the development of <a href="https://doi.org/10.1016/j.neuron.2005.02.014">deep brain stimulation</a> as a depression treatment: a surgically implanted, pacemaker-like device that delivers electrical impulses to certain areas of the brain. Studies testing this technique have found that it can <a href="https://doi.org/10.1016/s2215-0366(17)30371-1">decrease depression severity</a> over time in most patients.</p>
<p>Our research team wanted to find specific changes in brain activity that could serve as a biomarker that objectively measures how well deep brain stimulation is helping patients with depression. So we <a href="https://www.nature.com/articles/s41586-023-06541-3">monitored the brain activity</a> of 10 patients receiving deep brain stimulation for severe treatment-resistant depression over six months.</p>
<p>At the end of six months, 90% of the patients responded to the therapy – defined by a reduction of symptoms by at least a half – and 70% were in remission, meaning they no longer met the criteria for clinical depression.</p>
<p>To identify a potential biomarker, we developed an algorithm that looked for patterns in brain activity changes as patients recovered. The algorithm was based on data from six out of the original 10 patients who had usable data from the experiment. We found that there are <a href="https://www.nature.com/articles/s41586-023-06541-3">coordinated changes in different frequencies</a> present in the electrical activity within the area of the brain being stimulated. Using these patterns, the algorithm was able to predict whether someone was in a stable recovery with 90% accuracy each week.</p>
<p>Interestingly, we observed some parts of this pattern <a href="https://doi.org/10.1038/s41398-021-01669-0">moved in the</a> <a href="https://doi.org/10.3389/fncom.2018.00043">opposite direction</a> later in stimulation therapy compared with the patterns at the start of therapy. This finding provides evidence that the long-term recovery is due to the brain adapting to the stimulation in a process <a href="https://theconversation.com/medication-can-help-you-make-the-most-of-therapy-a-psychologist-and-neuroscientist-explains-how-209200">called plasticity</a> rather than as a direct effect of the stimulation itself.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/548887/original/file-20230918-23-pyx5bp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person lying in bed, light speckled over their face." src="https://images.theconversation.com/files/548887/original/file-20230918-23-pyx5bp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/548887/original/file-20230918-23-pyx5bp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/548887/original/file-20230918-23-pyx5bp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/548887/original/file-20230918-23-pyx5bp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/548887/original/file-20230918-23-pyx5bp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/548887/original/file-20230918-23-pyx5bp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/548887/original/file-20230918-23-pyx5bp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Depression is a debilitating disease.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/depressed-woman-lying-on-the-bed-at-home-royalty-free-image/1433295949?adppopup=true">Guido Mieth/Moment via Getty Images</a></span>
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<p>We also saw other potential biomarkers worth investigating further. </p>
<p>For example, abnormalities in brain imaging taken before implanting the electrodes in specific parts of the brain correlated with how sick each patient was. This could provide clues about what’s causing depression in some people, or help develop imaging methods to determine who might be a good candidate for deep brain stimulation. </p>
<p>For another example, we found that the facial expressions of patients changed as their brains changed over the course of their treatment. While physicians often report this anecdotally, quantifying these changes may provide a way to develop objective markers of recovery that incorporate a patient’s behavior with their brain signals. </p>
<p>Because the results of our study are based on a small sample of patients, it’s important to further investigate how broadly they can be applied to other patients and newer deep brain stimulation devices.</p>
<h2>Improving decision-making for depression</h2>
<p>Clinical depression is a debilitating condition that causes significant personal and <a href="https://doi.org/10.1007/s40273-021-01019-4">societal suffering</a>. It is one of the largest contributors to the <a href="https://apps.who.int/iris/handle/10665/254610">overall disease burden</a> of many countries. Despite the many approved treatments available, <a href="https://doi.org/10.4088/jcp.20m13699">nearly 30% of the 8.9 million U.S. adults</a> taking medications for clinical depression continue to have symptoms.</p>
<p>Deep brain stimulation is one of the alternative therapies for treatment-resistant depression that researchers are investigating. Studies have shown that deep brain stimulation can offer effective and <a href="https://doi.org/10.1176/appi.ajp.2019.18121427">long-term relief</a> for some patients. </p>
<p>Although deep brain stimulation is an approved treatment for other conditions like <a href="https://www.ninds.nih.gov/about-ninds/impact/ninds-contributions-approved-therapies/deep-brain-stimulation-dbs-treatment-parkinsons-disease-and-other-movement-disorders">Parkinson’s disease</a>, it remains an experimental therapy for treatment-resistant depression. While the results from small experimental studies have been positive, they have not been successfully replicated in <a href="https://doi.org/10.4088/jcp.21m13973">large-scale, randomized clinical trials</a> necessary for approval from the U.S. Food and Drug Administration.</p>
<p>Finding an objective biomarker that measures recovery in depression has the potential to improve treatment decisions. For example, one patient in our study had a relapse after several months of remission. Were a biomarker available at the time, the clinical team would have had warning that the patient was relapsing weeks before standard symptom surveys showed that anything was wrong. Such a tool could help clinicians intervene before a relapse becomes an emergency.</p><img src="https://counter.theconversation.com/content/213647/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher Rozell serves on the scientific advisory board and owns shares in Motif Neurotech, Inc. and is a listed inventor on intellectual property related to this work. He receives funding from NIH, NSF and the James. S. McDonnell Foundation. Hs is affiliated with the Georgia Institute of Technology, serves on the board of directors at Neuromatch, Inc., and serves on the advisory council of the Institute of Neuroethics. </span></em></p><p class="fine-print"><em><span>Sankaraleengam Alagapan receives funding from the National Institute of Health. He is affiliated with the Georgia Institute of Technology. He is a listed inventor on intellectual property related to this work.</span></em></p>Deep brain stimulation can help some people with treatment-resistant depression feel better, but it can be unclear whether a bout of low mood is a relapse or a bad day.Christopher Rozell, Professor of Electrical and Computer Engineering, Georgia Institute of TechnologySankaraleengam Alagapan, Research Scientist in Electrical and Computer Engineering, Georgia Institute of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2110172023-09-15T12:31:04Z2023-09-15T12:31:04ZAnxiety can often be a drag on creativity, upending the trope of the tortured artist<figure><img src="https://images.theconversation.com/files/546477/original/file-20230905-19-xuho6l.jpg?ixlib=rb-1.1.0&rect=0%2C487%2C5145%2C3245&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Creative journeys often entail entering the unknown -- and doing it on your own.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/man-on-a-mission-royalty-free-image/1369468881?phrase=minimalism+minimal+surreal+journey">DNY59/iStock via Getty Images</a></span></figcaption></figure><p>In the U.S., anxiety disorders affect about <a href="https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder">one-third of the population</a>. So it’s no surprise that a good number of artists and writers also suffer from anxiety and depression.</p>
<p>But whereas some critics see Vincent Van Gogh’s striking paintings and Sylvia Plath’s confessional poetry <a href="https://www.thecollector.com/sylvia-plath-famous-poet/">as the direct result of their psychosis and depression</a>, I tend to be less romantic about this subject. I see their brilliant output as having happened in spite of – rather than because of – their mental anguish.</p>
<p>In my new book, “<a href="https://rowman.com/ISBN/9781538170380/Afraid-Understanding-the-Purpose-of-Fear-and-Harnessing-the-Power-of-Anxiety">Afraid</a>,” I explore the interaction between fear, anxiety and creative work. </p>
<p>They’re more intertwined than you might think: Depending on the situation, fear and anxiety can either inspire or impede. But when anxiety becomes overwhelming, creative work often stalls.</p>
<h2>Anxiety as a roadblock</h2>
<p>The most basic way anxiety can hinder creative work is by shifting attention away from that work and toward fears and worries. </p>
<p>If a writer is worried about losing her day job, it’s harder for her to focus on her writing. Excessive anxiety bypasses all nonthreat-related tasks, and people regress <a href="https://www.verywellmind.com/learning-brain-vs-survival-brain-6749311">to basic survival mode</a>. Most attention, thinking and emotions will be focused on dealing with the source of the danger, whether it’s real or imagined. And creative minds are especially adept at the latter.</p>
<p>Because fears center on survival, <a href="https://www.psychologytoday.com/us/blog/fixing-families/202212/are-you-too-routinized-too-rigid-maybe-youre-anxious">people become less flexible and more wary</a> when they’re scared and anxious. At that point, going down a known path is far more appealing than taking risks and venturing into the unknown. Suffice to say, an aversion to the unknown won’t often lead to creative breakthroughs.</p>
<p>Another way fear can hinder creativity has to do with fear of rejection.</p>
<p>Friends, family, colleagues and critics <a href="https://www.theatlantic.com/business/archive/2014/10/why-new-ideas-fail/381275/">often resist</a> unusual ideas or those that stray from established artistic norms. Aside from arising out of envy and competition, these reflexive reactions also make sense from <a href="https://doi.org/10.1098/rstb.2009.0134">an evolutionary perspective</a>: Norms and agreed-upon ways of thinking cultivate group harmony. History is filled with the rejection, mockery and oppression of novel ideas and styles deemed too “out there” – painters <a href="https://www.famsf.org/stories/memorable-rejections-monet-and-the-artists-struggle-part-one#">Claude Monet</a> and <a href="https://truthout.org/articles/honoring-radical-women-worldwide-who-have-positively-changed-history/">Frida Kahlo</a> and author <a href="https://www.pbs.org/wgbh/americanexperience/features/whaling-biography-herman-melville/">Herman Melville</a> were all harshly criticized, dismissed or persecuted by their contemporaries.</p>
<p>To create something truly original, an artist must often break from the status quo. </p>
<p>So it’s only natural that any creative endeavor will lead to fear of criticism, rejection or failure. The road less traveled might be more dangerous. It might even be fruitless. And sometimes the cost is one’s life: <a href="http://www.pbs.org/empires/thegreeks/keyevents/399.html">Socrates was executed</a> on charges that his probing questions were corrupting young people, while Italian philosopher Giordano Bruno <a href="https://blogs.scientificamerican.com/observations/was-giordano-bruno-burned-at-the-stake-for-believing-in-exoplanets/">was burned to death, in part, for his heretical claims</a> that the Earth was not the center of the universe.</p>
<h2>When anxiety inspires</h2>
<p>This is not to say that being cool as a cucumber is a requisite for great art. Some level of anxiety can serve a purpose. </p>
<p>While being truly terrified can paralyze you, being bored and feeling languid <a href="https://link.springer.com/referenceworkentry/10.1007/978-3-319-01384-8_288#:%7E:text=Optimal%20arousal%20is%20a%20psychological,and%20the%20intensity%20of%20readiness.">can grind your motivation to a halt</a>.</p>
<p>There’s a sweet spot of anxiety that actually harnesses motivation and cognition and directs all attention to the task at hand.</p>
<p>With the deadline for “Afraid” fast approaching, I felt a pang of anxiety that propelled me to the finish line: I decided to tuck myself away in a resort next to the mountains in Tucson for two weeks and work 12-hour days to wrap up the book. The anxiety of not meeting the deadline was enough to inspire me to buckle down and get the job done. </p>
<p>Then there’s the specter of death. </p>
<p>No one is spared. Yet, even as geniuses like Michelangelo and Charles Dickens met the same fate as their peers, their brushstrokes and words became eternal.</p>
<p>Creative work is a way to achieve a certain level of immortality – art and books and articles that live on past your expiration date. </p>
<p>American anthropologist Ernest Becker argued that fear of death <a href="https://doi.org/10.1177/0146167213490804">motivated humans to compose</a> stories, myth and legends about the afterlife and immortality, and it inspired great works of architecture like the Egyptian pyramids.</p>
<p>This existential dread <a href="https://theconversation.com/i-want-to-stare-death-in-the-eye-why-dying-inspires-so-many-writers-and-artists-128061">has also motivated authors and artists</a> to seek a form of immortality through their work. I find it somewhat comforting that after I am dead, some of my scientific discoveries and writings might continue to live through others. </p>
<p>In fact, you might be reading this piece long after I am gone.</p>
<h2>What you can and can’t control</h2>
<p>Creative work entails traversing a mental landscape that can be treacherous, whether you’re mining your imagination, plotting your next steps or plumbing your memories. Failure always looms. </p>
<p>This uncertainty can elicit fear and doubt. </p>
<p>Interestingly, fear is solely focused on survival, while creativity operates at its best <a href="https://www.simplypsychology.org/maslow.html">when basic survival needs are met</a>. Furthermore, fear is a primitive emotion, whereas art, science and culture are among humankind’s most evolved abilities. </p>
<p>But fear and creativity are also similar in that both possess automatic and intuitive processes. The best works of art are not the sole result of logical thinking. Like a fetus, art grows inside the artist autonomously while the artist keeps feeding it; when the time comes, delivery happens. Fear is also mostly autonomous: When you notice a car barreling toward you, you leap out of the road before thinking about the driver’s intentions. </p>
<p>In that sense, people don’t fully control their fear and creativity. For both to work productively, a balanced harmony needs to exist between the unconscious and the conscious mind.</p>
<h2>Cultivating your creativity</h2>
<p>Still, there are elements of your consciousness that you can influence.</p>
<p>If you want to create something but feel inhibited by <a href="https://theconversation.com/the-5-000-year-history-of-writers-block-190037">writer’s block</a>, hesitancy or insecurity, think about which kind of fear might be holding you back.</p>
<p>Is it fear of failure or judgment? Fear of your own inner critic? Or is there a different day-to-day challenge or responsibility that’s soaking up most of your attention?</p>
<p>Once you’ve identified the source of the anxiety, see if you can reframe the fear in an objective way that liberates you from its shackles. Maybe you can recognize failure as a possibility but ultimately something that won’t kill you: You can always just try again.</p>
<p>Another option is to engage your brain’s <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8992377/#:%7E:text=The%20mesolimbic%20system%2C%20also%20known,and%20cognitive%20processing%20of%20reward.">reward circuitry</a> – say, thinking of the possible positive outcomes of your work, including immortality. Or you could use the fear network to your advantage, remembering a deadline, a promotion that might hinge on the work or the crummy feeling of not completing a task. Breaking the work into pieces will also make it seem more doable and less scary. </p>
<p>Sometimes, shaking things up with a change of scenery can help. When I went away to finish “Afraid,” I chose the desert not only because I find the landscape inspiring. There’s also something about the starkly different and empty geography that clears my head from all of the clutter of daily life back in Michigan.</p>
<p>Just as there are many paths to take as you pursue a creative endeavor, there are a range of strategies to combat or use all of the little fears that crop up along the way.</p><img src="https://counter.theconversation.com/content/211017/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Arash Javanbakht does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A psychiatrist explains the many ways anxiety can hinder, color or compel creativity.Arash Javanbakht, Associate Professor of Psychiatry, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2108712023-09-05T12:32:35Z2023-09-05T12:32:35ZIf anxiety is in my brain, why is my heart pounding? A psychiatrist explains the neuroscience and physiology of fear<figure><img src="https://images.theconversation.com/files/545631/original/file-20230830-27-pr5ir8.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4429%2C1900&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In the face of a perceived threat, your body often activates a fight-or-flight response.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/woman-with-shocked-facial-expression-royalty-free-illustration/1444323335">George Peters/DigitalVision Vectors via Getty Images</a></span></figcaption></figure><p><a href="https://theconversation.com/si-la-ansiedad-esta-en-mi-cerebro-por-que-me-late-el-corazon-un-psiquiatra-explica-la-neurociencia-y-la-fisiologia-del-miedo-213461">Leer en español</a>. </p>
<p>Heart in your throat. Butterflies in your stomach. Bad gut feeling. These are all phrases many people use to describe fear and anxiety. You have likely felt anxiety inside your chest or stomach, and your brain usually doesn’t hurt when you’re scared. Many cultures tie cowardice and bravery more <a href="https://afosa.org/the-meaning-of-heart-qalb-in-quran/">to the heart</a> <a href="https://byustudies.byu.edu/article/bowels-of-mercy/">or the guts</a> than to the brain.</p>
<p>But science has traditionally seen the brain as the birthplace and processing site of fear and anxiety. Then why and how do you feel these emotions in other parts of your body?</p>
<p>I am a <a href="https://scholar.google.com/citations?user=UDytFmIAAAAJ&hl=en">psychiatrist and neuroscientist</a> who researches and treats fear and anxiety. In my book “<a href="https://rowman.com/ISBN/9781538170380/Afraid-Understanding-the-Purpose-of-Fear-and-Harnessing-the-Power-of-Anxiety">Afraid,</a>” I explain how fear works in the brain and the body and what too much anxiety does to the body. Research confirms that while emotions do originate in your brain, it’s your body that carries out the orders.</p>
<h2>Fear and the brain</h2>
<p>While your brain evolved to save you from a falling rock or speeding predator, the anxieties of modern life are often a lot more abstract. Fifty-thousand years ago, being rejected by your tribe could mean death, but not doing a great job on a public speech at school or at work doesn’t have the same consequences. Your brain, however, <a href="https://doi.org/10.1006/nimg.2002.1179">might not know the difference</a>.</p>
<p>There are a few key areas of the brain that are heavily involved in processing fear.</p>
<p>When you perceive something as dangerous, whether it’s a gun pointed at you or a group of people looking unhappily at you, these sensory inputs are first relayed to <a href="https://doi.org/10.1038%2Fnpp.2009.121">the amygdala</a>. This small, almond-shaped area of the brain located near your ears detects salience, or the emotional relevance of a situation and how to react to it. When you see something, it determines whether you should eat it, attack it, run away from it or have sex with it.</p>
<p><a href="https://theconversation.com/the-science-of-fright-why-we-love-to-be-scared-85885">Threat detection</a> is a vital part of this process, and it has to be fast. Early humans did not have much time to think when a lion was lunging toward them. They had to act quickly. For this reason, the amygdala evolved to bypass brain areas involved in logical thinking and can directly engage physical responses. For example, seeing an angry face on a computer screen can immediately trigger a <a href="https://doi.org/10.1006/nimg.2002.1179">detectable response from the amygdala</a> without the viewer even being aware of this reaction.</p>
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<figcaption><span class="caption">In response to a looming threat, mammals often fight, flee or freeze.</span></figcaption>
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<p><a href="https://doi.org/10.1038/npp.2009.83">The hippocampus</a> is near and tightly connected to the amygdala. It’s involved in memorizing what is safe and what is dangerous, especially in relation to the environment – it puts fear in context. For example, seeing an angry lion in the zoo and in the Sahara both trigger a fear response in the amygdala. But the hippocampus steps in and blocks this response when you’re at the zoo because you aren’t in danger. </p>
<p>The <a href="https://doi.org/10.1176/appi.ajp.2016.16030353">prefrontal cortex</a>, located above your eyes, is mostly involved in the cognitive and social aspects of fear processing. For example, you might be scared of a snake until you read a sign that the snake is nonpoisonous or the owner tells you it’s their friendly pet. </p>
<p>Although the prefrontal cortex is usually seen as the part of the brain that regulates emotions, it can also teach you fear based on your social environment. For example, you might feel neutral about a meeting with your boss but immediately feel nervous when a colleague tells you about rumors of layoffs. Many <a href="https://theconversation.com/trump-the-politics-of-fear-and-racism-how-our-brains-can-be-manipulated-to-tribalism-139811">prejudices like racism</a> are rooted in learning fear through tribalism.</p>
<h2>Fear and the rest of the body</h2>
<p>If your brain decides that a fear response is justified in a particular situation, it activates a <a href="https://doi.org/10.1093/med/9780190259440.003.0019">cascade of neuronal and hormonal pathways</a> to prepare you for immediate action. Some of the fight-or-flight response – like heightened attention and threat detection – takes place in the brain. But the body is where most of the action happens.</p>
<p>Several pathways prepare different body systems for intense physical action. The <a href="https://doi.org/10.3389/fnins.2014.00043">motor cortex</a> of the brain sends rapid signals to your muscles to prepare them for quick and forceful movements. These include muscles in the chest and stomach that help protect vital organs in those areas. That might contribute to a feeling of tightness in your chest and stomach in stressful conditions.</p>
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<figcaption><span class="caption">Your sympathetic nervous system is involved in regulating stress.</span></figcaption>
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<p>The <a href="https://www.ncbi.nlm.nih.gov/books/NBK542195/">sympathetic nervous system</a> is the gas pedal that speeds up the systems involved in fight or flight. Sympathetic neurons are spread throughout the body and are especially dense in places like the heart, lungs and intestines. These neurons trigger the adrenal gland to release hormones like adrenaline that travel through the blood to reach those organs and increase the rate at which they undergo the fear response.</p>
<p>To assure sufficient blood supply to your muscles when they’re in high demand, signals from the sympathetic nervous system increase the rate your heart beats and the force with which it contracts. You feel both increased heart rate and contraction force in your chest, which is why you may connect the feeling of intense emotions to your heart.</p>
<p>In your lungs, signals from the sympathetic nervous system dilate airways and often increase your breathing rate and depth. Sometimes this results in a feeling of <a href="https://theconversation.com/pain-and-anxiety-are-linked-to-breathing-in-mouse-brains-suggesting-a-potential-target-to-prevent-opioid-overdose-deaths-174187">shortness of breath</a>.</p>
<p>As digestion is the last priority during a fight-or-flight situation, sympathetic activation slows down your gut and reduces blood flow to your stomach to save oxygen and nutrients for more vital organs like the heart and the brain. These changes to your gastrointestinal system can be perceived as the discomfort linked to fear and anxiety.</p>
<h2>It all goes back to the brain</h2>
<p>All bodily sensations, including those visceral feelings from your chest and stomach, are relayed back to the brain through the pathways <a href="https://www.ncbi.nlm.nih.gov/books/NBK555915/">via the spinal cord</a>. Your already anxious and highly alert brain then processes these signals at both conscious and unconscious levels.</p>
<p><a href="https://doi.org/10.1176/appi.ajp.2016.16030353">The insula</a> is a part of the brain specifically involved in conscious awareness of your emotions, pain and bodily sensations. The <a href="https://doi.org/10.1038%2Fs41598-019-52776-4">prefrontal cortex</a> also engages in self-awareness, especially by labeling and naming these physical sensations, like feeling tightness or pain in your stomach, and attributing cognitive value to them, like “this is fine and will go away” or “this is terrible and I am dying.” These physical sensations can sometimes create a loop of increasing anxiety as they make the brain feel more scared of the situation because of the turmoil it senses in the body.</p>
<p>Although the feelings of fear and anxiety start in your brain, you also feel them in your body because your brain alters your bodily functions. Emotions take place in both your body and your brain, but you become aware of their existence with your brain. As the rapper Eminem recounted in his song “Lose Yourself,” the reason his palms were sweaty, his knees weak and his arms heavy was because his brain was nervous.</p><img src="https://counter.theconversation.com/content/210871/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Arash Javanbakht does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Although emotions like fear and anxiety originate in your brain, they ultimately travel through your body and make your heart race and your stomach twist.Arash Javanbakht, Associate Professor of Psychiatry, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2111242023-08-31T02:57:53Z2023-08-31T02:57:53ZBipolar disorder isn’t the same for everyone. So people should have more say in how they’re treated<p>Imagine you, or someone you know, is diagnosed with bipolar disorder. One drug is prescribed, but you have heard another drug is better. What are your next steps? Do you seek evidence? And if so, what type of evidence would you consider? </p>
<p><a href="https://doi.org/10.1001/archpsyc.64.5.543">Around 2%</a> of the adult population have a bipolar disorder. It can create <a href="https://doi.org/10.1111/bdi.12423">high levels of suffering, carry suicide risks</a>, and <a href="https://doi.org/10.1016/j.eurpsy.2009.11.012">persist for decades</a>. Management options vary, and if you search for information online, it’s easy to become overwhelmed by the many different views and interpretations of “the evidence” obtained from clinical trials. </p>
<p>Some medications can be extremely helpful for stabilising mood, but they can often have <a href="https://doi.org/10.1097/YIC.0b013e32836435e2">side effects</a>. Certain medications may be more <a href="https://doi.org/10.1177/1039856214568219">beneficial for certain types of bipolar disorder</a>, but how do you know which “type” you or a loved one has?</p>
<p>Clinical specialists, including psychiatrists, often rely on guidelines authored by professional organisations to evaluate the evidence for treatments. However, there is minimal agreement between many of the current guidelines. A new approach is needed that places emphasis on “real-world” effectiveness and respects the observations of people with bipolar disorder.</p>
<h2>Two types of bipolar disorder</h2>
<p>As far back as Hippocrates, <a href="https://www.nimh.nih.gov/health/topics/bipolar-disorder#:%7E:text=Bipolar%20I%20disorder%20is%20defined,lasting%20at%20least%202%20weeks.">bipolar disorder</a> has been known to the medical community. Originally called “manic-depressive psychosis”, it is now known as bipolar I disorder. In the mid-1990s, bipolar II disorder was defined. Although this second “sibling” has always existed, it was previously viewed as more of a personality style, and frequently given the label of “cyclothymia”.</p>
<p>Both bipolar I and bipolar II are marked by pronounced mood swings. During “highs”, individuals feel energised and “wired”. They talk more, spend more, and require less sleep but don’t feel tired. They might experience a heightened sex drive, feel more creative, or so “bulletproof” they take more risks. Anxiety seems to melt away.</p>
<p>During “lows”, depression rolls in like a fog. Sufferers may lie in bed for days, lacking any energy. They can’t derive any pleasure in life. Cheerless and battling impaired cognitive capacity, they can be at greater risk of suicide. </p>
<p>The key distinguishing feature between the two bipolar conditions is the presence of psychotic features (delusions and/or hallucinations) in those with bipolar I.</p>
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Read more:
<a href="https://theconversation.com/better-bipolar-diagnosis-may-reduce-suicide-rates-in-boys-new-research-206256">Better bipolar diagnosis may reduce suicide rates in boys – new research</a>
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<h2>Current treatments</h2>
<p>Medication is the main way bipolar disorders are managed. </p>
<p>Melbourne psychiatrist John Cade discovered the effectiveness of lithium as a treatment for manic depression <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2560740/pdf/10885180.pdf">in 1949</a>. This landmark research ushered in the era of condition-specific psychopharmacology. </p>
<p>Psychiatry can proudly claim its status as an evidence-based discipline. Practitioners refer to research-based guidelines to determine the best medications to help stabilise a bipolar disorder. <a href="https://www.canmat.org/wp-content/uploads/2019/07/Yatham-LN-2018-CANMAT-ISBD-guidelines-for-bipolar-disorder-Bipol-Disord.pdf">Options</a> now include lithium, three anti-epileptic drugs, multiple antipsychotic drugs and antidepressants. While most guidelines rate lithium highly for both bipolar types, we personally favour lithium as the first choice medication only for bipolar I, and the anti-seizure drug lamotrigine for bipolar II.</p>
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Read more:
<a href="https://theconversation.com/what-causes-depression-what-we-know-dont-know-and-suspect-81483">What causes depression? What we know, don’t know and suspect</a>
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<h2>But evidence isn’t everything</h2>
<p>In 2017, our research group <a href="https://doi.org/10.1111/acps.12717">examined 11 guidelines</a> published by professional organisations. All were “evidence-based”, but we found minimal agreement between them, thus raising questions about their validity. New guidelines have been published since then but the trend for minimal agreement continues.</p>
<p>Assessing a psychiatric evidence base is difficult. For medical trials, the treatment being tested is compared against a treatment in common use, and/or against a placebo. Results from multiple trials are aggregated to compare their overall impact. </p>
<p>But the way study participants are selected to participate in trials presents a problem. <a href="https://doi.org/10.1001/jama.297.11.1233">Recruitment is generally limited</a> to those with milder conditions, those without co-existing disorders, or those taking limited medications. Participants might also sign up to obtain medication at no cost, which may affect their motivation and reporting. Finally, the observations made by managing doctors commonly differ from those made by the patients about the benefits and side effect impact of the drugs given.</p>
<p>So there is a strong argument for the need for “real-world” studies prioritising the views of patients with a bipolar disorder, instead of judging drugs via clinical trials and external raters.</p>
<h2>Accounting for side effects</h2>
<p>In addition to evaluating the effectiveness of any drug, we need to assess the side-effects. For instance, lithium can be the right medication for some with a bipolar disorder and, as noted, it is the <a href="https://doi.org/10.1111/acps.12717">most frequently recommended</a> medication across clinical guidelines. However, it has <a href="https://doi.org/10.1186/s40345-016-0068-y">multiple side effects</a>. </p>
<p>Our 2021 <a href="https://doi.org/10.1097/JCP.0000000000001424">efficacy study</a> compared lithium and lamotrigine in a small sample of patients with bipolar II. For the 28 patients who completed the study, the benefits were similar for the two medications. But 50% of the completers receiving lithium experienced distinctive cognitive impairment – side effects that affected their thinking and reasoning. </p>
<p>This is of particular concern because bipolar disorders are known to be <a href="https://www.simonandschuster.com/books/Touched-With-Fire/Kay-Redfield-Jamison/9780684831831">over-represented in creative people</a> and high achievers. We suspect, from clinical observation, that lithium is not the best option for bipolar II, and the first author has long observed it is <a href="https://doi.org/10.1097/JCP.0000000000001424">more cognitively “toxic”</a> for those individuals with a bipolar II condition.</p>
<p>Many of the antipsychotic drugs nominated in guidelines also have major side effects, including <a href="https://doi.org/10.1371/journal.pone.0094112">weight gain</a> and <a href="https://doi.org/10.1192/bjp.bp.109.076935">diabetes</a>. People who are stable while taking these medications without major side effects should not be alarmed. But these risks support a push for more tailored treatments based on real-life costs and benefits, informed by people’s experiences.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/a-poo-dose-a-day-may-keep-bipolar-away-when-it-comes-to-mental-health-what-else-could-poo-do-177748">A poo dose a day may keep bipolar away. When it comes to mental health, what else could poo do?</a>
</strong>
</em>
</p>
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<h2>We want to hear from people with bipolar disorders</h2>
<p>All these concerns highlight the need for research focused on “real-world” samples to determine the best treatments that consider each person’s responses to any medication. We are conducting such a study now, in collaboration with the Black Dog Institute. If you are interested, you can access the study <a href="https://www.blackdoginstitute.org.au/research-studies/optimising-treatments-for-bipolar-disorder/">here</a>.</p><img src="https://counter.theconversation.com/content/211124/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gordon Parker receives funding from the Australian National Health and Medical Research Council. </span></em></p><p class="fine-print"><em><span>Michael Spoelma does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Psychiatrists rely on guidelines to prescribe medication for bipolar disorders. But beyond side-effects and clinical trials, ‘real-world’ effectiveness should be considered thoughtfully.Gordon Parker, Scientia Professor, UNSW SydneyMichael Spoelma, PhD Student, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2092002023-08-28T12:01:17Z2023-08-28T12:01:17ZMedication can help you make the most of therapy − a psychologist and neuroscientist explains how<figure><img src="https://images.theconversation.com/files/544648/original/file-20230824-2975-7ib62y.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1917%2C1564&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medications can open a biological window of opportunity for psychotherapy to take advantage of.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/metaphor-bipolar-disorder-mind-mental-double-royalty-free-illustration/1294477039">melitas/iStock via Getty Images Plus</a></span></figcaption></figure><p>There is mounting recognition in the scientific community that combining different treatment approaches for mental health conditions can <a href="https://doi.org/10.1016/j.biopsych.2018.09.004">create a benefit</a> greater than the sum of its parts.</p>
<p>As a <a href="http://www.canlab.pitt.edu/home/people/">clinical psychologist</a> and <a href="https://scholar.google.com/citations?user=7wB91zsAAAAJ&hl=en">neuroscience researcher</a>, I have been working to integrate insights from both fields to expand treatment options for those suffering from depression, anxiety and related conditions. Designing a treatment plan that pays careful attention to the sequence and dose of both biological and behavioral therapies might benefit people in new ways that neither approach can achieve on its own.</p>
<p><a href="https://doi.org/10.1093/ije/dyu038">Anxiety and depression</a> are the most prevalent mental health conditions around the world. Globally, <a href="https://www.who.int/news-room/fact-sheets/detail/depression">about 280 million people</a> experience depression, and <a href="https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder">as many as 1 in 3</a> will meet the diagnostic criteria for an anxiety disorder at some point in their lives. There are <a href="https://www.nhs.uk/mental-health/conditions/depression-in-adults/treatment/">numerous effective</a> <a href="https://www.nhs.uk/mental-health/conditions/anxiety/types-of-anxiety/">treatment options</a> for both conditions, including medications, psychotherapy, lifestyle changes and neurostimulation. </p>
<p>Doctors and therapists recommend many patients seeking mental health care try <a href="https://evidence.nihr.ac.uk/alert/combined-drug-and-psychological-therapies-may-be-most-effective-for-depression/">more than one approach simultaneously</a>, such as medication and therapy. This is based on the idea that if they were to respond well to any of the prescribed treatments, they would experience a net benefit more quickly or more strongly than if they were to try each sequentially. However, researchers have historically studied each approach in isolation. Most research has focused on comparing individual treatments <a href="https://doi.org/10.1002/wps.20701">one at a time</a> to a control, such as a pill placebo or a psychotherapy waitlist.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/z-IR48Mb3W0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Depression is a leading cause of disability around the world.</span></figcaption>
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<h2>Neuroplasticity and treatment</h2>
<p>Recent advances in scientific understanding of <a href="https://doi.org/10.1016/j.biopsych.2021.05.008">depression</a>, <a href="https://doi.org/10.2147/IJGM.S413176">anxiety</a> and <a href="https://doi.org/10.1016/j.mehy.2005.05.007">other stress-related conditions</a> suggest that changes and impairments in neuroplasticity are critical contributors.</p>
<p>Neuroplasticity refers to the brain’s capacity to flexibly adjust in response to an ever-changing environment – it’s a <a href="https://theconversation.com/cognitive-flexibility-is-essential-to-navigating-a-changing-world-new-research-in-mice-shows-how-your-brain-learns-new-rules-204259">critical component of learning</a>. In animal studies, deficits in neuroplasticity are seen as changes to molecular and neural pathways, such as a decreased number of synapses, or points of contact between neurons, following chronic stress. These changes might be related to <a href="https://doi.org/10.1038/s41380-019-0615-x">mental patterns and symptoms</a> of depression and anxiety in people, such as when patients report a reduced capacity to think, feel and act flexibly. They may also be linked to thinking about, remembering and interpreting information in a way that tends to be biased toward the negative.</p>
<p>Research has shown that many effective biological treatments, including medications and neurostimulation, can <a href="https://doi.org/10.1038/tp.2013.30">enhance or</a> <a href="https://doi.org/10.1016/j.biopsych.2021.05.008">alter neuroplasticity</a>. Certain lifestyle changes such as regular exercise can have similar effects. Scientists consider this key to how they reduce symptoms. Unfortunately, symptoms often return when these treatments are discontinued. Relapse is particularly apparent for medications. For both <a href="https://doi.org/10.1038/s41380-022-01824-z">older</a> and <a href="https://doi.org/10.1001/jamapsychiatry.2019.1189">newer</a> antidepressant and anti-anxiety medications, relapse rates begin climbing shortly after patients stop treatment.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/544652/original/file-20230824-27-homnj8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Close-up of hand holding pill beside a glass of water on a table" src="https://images.theconversation.com/files/544652/original/file-20230824-27-homnj8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/544652/original/file-20230824-27-homnj8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/544652/original/file-20230824-27-homnj8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/544652/original/file-20230824-27-homnj8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/544652/original/file-20230824-27-homnj8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/544652/original/file-20230824-27-homnj8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/544652/original/file-20230824-27-homnj8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Patients can experience a relapse of symptoms after they stop taking antidepressants or anti-anxiety medications.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/unrecognizable-man-holding-a-pill-in-front-of-a-royalty-free-image/1297835134">Vasil Dimitrov/E+ via Getty Images</a></span>
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<p>In contrast, behavioral treatments such as psychotherapy introduce new skills and and habits that <a href="https://doi.org/10.1146/annurev.psych.57.102904.190044">may be more long-lasting</a>. Benefits continue even after the most intense phase of treatment ends. Regular meetings <a href="https://theconversation.com/cbt-dbt-psychodynamic-what-type-of-therapy-is-right-for-me-171101">with a therapist</a> over the course of several months can help many patients learn to cope with negative symptoms and life circumstances in new ways. But such learning depends on neuroplasticity to forge and retain these new, helpful pathways in the brain.</p>
<p>Researchers hypothesize that enhancing or modulating plasticity with a biological intervention like medication may not only reduce symptoms but may also provide a <a href="https://doi.org/10.1016/j.biopsych.2018.09.004">window of opportunity</a> for behavioral interventions like psychotherapy to be more effective. Learning-based interventions like cognitive-behavioral or exposure therapy, if properly timed, could harness the enhanced neuroplasticity that biological interventions induce and improve long-term outcomes.</p>
<p>Think of pathways in the brain as roads. Biological treatments transform a sparsely connected set of roads – consisting only of a few well-trodden pathways that represent unhelpful thoughts, fears and habits – into a denser network of interconnected, freshly paved roadways. Behavioral treatments can be likened to repeatedly driving over a specific subset of new roads that lead to more balanced perspectives on yourself and the world around you, learning them until you can drive down them effortlessly, no GPS required. This ensures that those now familiar roadways will be readily available to you in the future and protect you against the return of anxiety and depression.</p>
<h2>Synergies in combined treatment</h2>
<p>Designing combined treatments to explicitly promote synergy is relatively new, and there is increasing evidence supporting it. A few specific examples are noteworthy.</p>
<p>First, some studies have shown that <a href="https://doi.org/10.1097%2FHRP.0000000000000183">D-cycloserine</a>, an antibiotic used to treat tuberculosis, may make <a href="https://doi.org/10.1001/jamapsychiatry.2016.3955">exposure therapy for anxiety conditions</a> more effective by helping patients learn to quell their fears. D-cycloserine may also enhance the antidepressant effects of a type of neurostimulation called <a href="https://doi.org/10.1001/jamapsychiatry.2022.3255">transcranial magnetic stimulation</a>, which stimulates nerve cells using magnetic fields.</p>
<p>Several studies suggest that pairing neurostimulation with cognitive-behavioral approaches like cognitive-behavioral therapy or cognitive control training may yield <a href="https://doi.org/10.1016/j.biopsych.2018.09.004">longer-term reductions in depression and anxiety</a>.</p>
<p>Similarly, low doses of ketamine, a drug used in general anesthesia, with rapid antidepressant effects, can be used to “<a href="https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.20220216">prime the pump</a>” <a href="https://theconversation.com/ketamine-paired-with-looking-at-smiling-faces-to-build-positive-associations-holds-promise-for-helping-people-with-treatment-resistant-depression-190950">for new, helpful learning</a>. A study my team and I conducted found that daily computer-based exercises of 30 to 40 minutes over four days following a single ketamine dose led to a ninefold increase in the duration of antidepressant effects – <a href="https://doi.org/10.1001/jamanetworkopen.2023.12434">90 days of reduced symptoms</a> – compared with ketamine alone, which led to 10 days of reduced symptoms.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/dYN64GJzGfc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Researchers are exploring the potential of psychedelics to treat many mental health conditions.</span></figcaption>
</figure>
<p>Finally, there is increasing interest in using other medications with psychedelic properties to assist in psychotherapy. The therapeutic benefits of taking these <a href="https://doi.org/10.1007/s11920-022-01363-y">psychedelic-assisted therapies</a> under medical supervision are attributed to the rapid <a href="https://doi.org/10.1523/JNEUROSCI.1121-22.2022">neuroplasticity-enhancing</a> and consciousness-altering effects of drugs like psilocybin and MDMA. Researchers think these short-term effects foster new insights and perspectives that psychotherapists can help patients integrate into their permanent worldview.</p>
<p>There is great potential in neuroscience-guided ways to combine treatments. However, it’s important to note that different treatment approaches can occasionally work against each other, <a href="https://doi.org/10.1016/S0272-7358(97)00084-6">lessening the long-term benefits of psychotherapy alone</a>. For example, one study on panic disorder found that patients who learned psychotherapy techniques while taking anti-anxiety medication had a <a href="https://jamanetwork.com/journals/jama/fullarticle/192707">greater chance of relapse</a> after discontinuing their use compared with those given psychotherapy alone.</p>
<p>Carefully designed clinical trials and long-term follow-ups are needed to fully understand how to combine the biological and the behavioral to develop treatments that are efficient, accessible, safe and enduring.</p><img src="https://counter.theconversation.com/content/209200/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rebecca Price receives funding from the National Institute of Mental Health and the Laurel E. Zaks Memorial Research Fund and is named as the inventor on a University of Pittsburgh-owned patent filing relevant to synergistic bio-behavioral treatments for anxiety and depression.</span></em></p>Combining psychotherapy with medication can lead to more immediate and enduring results by boosting the brain’s neuroplasticity.Rebecca Price, Associate Professor of Psychiatry and Psychology, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2096362023-07-17T16:05:23Z2023-07-17T16:05:23ZHow childhood trauma can lead to obesity in people with serious mental illness<figure><img src="https://images.theconversation.com/files/537128/original/file-20230712-24-tjrwvy.jpg?ixlib=rb-1.1.0&rect=0%2C6%2C4031%2C2257&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Research suggests childhood trauma has a big part to play in obesity.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/silhouette-woman-sitting-on-bed-beside-1439614217">Ken stocker/Shutterstock</a></span></figcaption></figure><p>People with a serious mental illness (SMI), like schizophrenia, often experience obesity. And in the UK, such people are almost <a href="https://www.gov.uk/government/publications/severe-mental-illness-smi-physical-health-inequalities/severe-mental-illness-and-physical-health-inequalities-briefing#:%7E:text=This%20analysis%20shows%20that%20compared,the%20difference%20is%20not%20significant">twice as likely</a> to be obese compared to those without a diagnosis. </p>
<p>People with SMI also have a greater risk of having other obesity related illnesses such as type 2 diabetes, respiratory disease, cardiovascular disease and heart failure. The result is a life expectancy that is <a href="https://pubmed.ncbi.nlm.nih.gov/28237639/">15 years less than</a> the general population. </p>
<p>Many experts believe the greater risk of obesity is due to the medications used to treat mental illness. Antipsychotics, for example, have <a href="https://pubmed.ncbi.nlm.nih.gov/37159349/">frequently been shown</a> to impact body weight. </p>
<p>But that explanation does not consider the role that deeper psychological factors play in obesity. There is a body of research that suggests childhood trauma <a href="https://pubmed.ncbi.nlm.nih.gov/33506595/">has a big part to play</a> too.</p>
<h2>Psychological trauma and obesity</h2>
<p>Psychologists often refer to the trauma experienced in childhood as “adverse childhood experiences” (ACEs). Such experiences include abuse and neglect (both physical and emotional), mental illness and substance abuse in the home, witnessing domestic abuse and having an incarcerated relative. </p>
<p>This type of trauma is <a href="https://link.springer.com/article/10.1007/s00787-021-01938-9">strongly associated</a> with the development of mental illnesses in later life. This may explain why many people who are treated in psychiatric hospitals have had such experiences. For example, <a href="https://nccu.nhs.wales/qais/national-reviews/making-days-count/mdc-documents/making-days-count1/">70% of people</a> in forensic psychiatric hospitals have at least one ACE, compared to 47% of the population of Wales. </p>
<p>Research also shows trauma can effect the way people behave. A <a href="https://academic.oup.com/eurpub/article/26/suppl_1/ckw167.009/2448496">recent study</a> found someone who has experienced four or more adverse childhood experiences is twice as likely to have an unhealthy diet. This may explain why there is a <a href="https://www.sciencedirect.com/science/article/pii/S003193842030278X?ref=pdf_download&fr=RR-2&rr=7e5964419ba4730c">46% increase</a> in the odds of adult obesity following exposure to multiple ACEs. </p>
<p>Despite this knowledge, however, little attention is paid by policymakers to the impact childhood trauma can have on obesity in people with serious mental illness. </p>
<p>Why is it that people who experience trauma in childhood have a greater risk of being obese? It is well known that people who have experienced traumatic childhoods engage in behaviour that isn’t particularly healthy, such as self-harming, abusing drugs and binge eating. These people do this as a form of avoidance, to distract themselves from the difficult thoughts and feelings they experience. </p>
<p>The term used to describe this behaviour is <a href="https://www.verywellmind.com/experiential-avoidance-2797358#:%7E:text=Experiential%20avoidance%20is%20an%20attempt,in%20contact%20with%20internal%20experiences.">“experiential avoidance”</a>.</p>
<h2>Eating our emotions</h2>
<p>Experiential avoidance can take many forms, but a common method is emotional eating, which is the tendency to eat in response to negative emotions. It is associated with the consumption of tasty food that is high in calories. </p>
<p>When someone emotionally eats, they can experience the numbing of intense negative emotion, can be distracted and <a href="https://link.springer.com/article/10.1007/s40519-016-0301-9">feel a sense of comfort</a>. This is because when we eat food with lots of fat and sugar, it activates the reward and pleasure areas centres of the brain. Eating foods high in fats and sugar is fine in moderation, of course. But the positive effects of eating tasty, high calorie foods are often short lived. </p>
<figure class="align-center ">
<img alt="A selection of food, including chips, doughnuts, ice cream and cakes are laid out on a blue table." src="https://images.theconversation.com/files/537485/original/file-20230714-25-kx7uff.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/537485/original/file-20230714-25-kx7uff.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/537485/original/file-20230714-25-kx7uff.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/537485/original/file-20230714-25-kx7uff.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/537485/original/file-20230714-25-kx7uff.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/537485/original/file-20230714-25-kx7uff.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/537485/original/file-20230714-25-kx7uff.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Eating food high in sugar and fat activates the reward and pleasure areas centres of our brain.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/unhealthy-products-food-bad-figure-skin-1062629861">beats1/Shutterstock</a></span>
</figcaption>
</figure>
<p>So, people who engage in experiential avoidance may rely on these foods and consume them to excess. This, <a href="https://www.sciencedirect.com/science/article/pii/S0195666315001397?casa_token=-bqvrnAs3uIAAAAA:KJr48KBwRoU3lPcRkV-OOURVvgJ78F8gUnEkMxsNrcEVRqt3j0-esBpn5kBS_uoTjbvazswR3PQ">according to research</a>, is what can lead to weight gain and obesity. </p>
<p>Currently, the <a href="https://www.nice.org.uk/sharedlearning/improving-physical-health-for-people-with-serious-mental-illness-smi">treatment guidelines</a> for people with SMI do not consider the impact that ACEs can have on obesity in this group of people. This is probably due to the emphasis placed on antipsychotic drugs as the main contributor to excessive weight gain. </p>
<p>And despite the negative impact that obesity can have on people with a serious mental illness, psychiatric services often <a href="https://onlinelibrary.wiley.com/doi/10.1111/j.1600-0447.2008.01211.x">overlook physical health issues</a> because some psychiatric staff feel they are <a href="https://onlinelibrary.wiley.com/doi/10.1111/j.1747-0080.2011.01568.x">not adequately trained</a> to deal with the physical health of their patients.</p>
<p>To improve physical health in people with a serious mental illness, it is important that mental health professionals and policymakers consider the impact that psychological trauma has on obesity in this group of people. </p>
<p>Promoting a trauma-informed approach to both psychiatric and physical health care is vital. In essence, this would involve care teams having a <a href="https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/">complete picture</a> of their patient, mentally and physically, and providing adequate training around the impact that psychological trauma can have on a person’s behaviour.</p><img src="https://counter.theconversation.com/content/209636/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joseph Lloyd Davies does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Deep psychological factors play a part in obesity, including childhood trauma.Joseph Lloyd Davies, Lecturer in Applied Psychology, Cardiff Metropolitan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2095912023-07-14T02:06:30Z2023-07-14T02:06:30ZKetamine injections for depression? A new study shows promise, but it’s one of many options<figure><img src="https://images.theconversation.com/files/537183/original/file-20230712-29-dtpug1.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C666&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Psychedelics like ketamine affect chemical messengers in the brain.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/abstract-brain-fractal-background-digital-illustration-2212346843">Shutterstock</a></span></figcaption></figure><p>Ketamine might be better known as a recreational drug or anaesthetic. But there’s growing evidence for its use for people with hard-to-treat depression.</p>
<p>An Australasian study <a href="https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/efficacy-and-safety-of-a-4week-course-of-repeated-subcutaneous-ketamine-injections-for-treatmentresistant-depression-kads-study-randomised-doubleblind-activecontrolled-trial/FDBAEC51F0891B57F5B04C572D13DA17">out today</a> showed some positive results for people with treatment-resistant depression when they had ketamine injections.</p>
<p>But we don’t know if these effects are sustained in the long term, and there are other ways of delivering ketamine. There are also other treatment options for this type of depression.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-anaesthetic-and-recreational-drug-ketamine-could-be-used-to-treat-depression-81468">Weekly Dose: anaesthetic and recreational drug ketamine could be used to treat depression</a>
</strong>
</em>
</p>
<hr>
<h2>What is ketamine?</h2>
<p>Ketamine has been used as a powerful <a href="https://www.nature.com/articles/s41593-022-01203-5">general anaesthetic</a> for more than 50 years.</p>
<p>It’s also an <a href="https://www.ncbi.nlm.nih.gov/books/NBK470357/">illicit drug</a> of abuse and is considered a psychedelic. Psychedelics dramatically alter some neurotransmitters (chemical messengers) in the brain <a href="https://pubmed.ncbi.nlm.nih.gov/36280799/">to create</a> a profound change in perception, mood and anxiety.</p>
<p>In early animal studies, ketamine led to increase in levels of certain brain chemicals, such as dopamine, by <a href="https://www.nature.com/articles/mp2017190">up to 400%</a>. This led researchers to trial ketamine in humans to see what would happen in our brains.</p>
<p>Now, doses of ketamine (at those lower than used as an anaesthetic) are being used to help treatment-resistant depression. That’s when someone has tried at least two antidepressants and shows no improvement.</p>
<p>It is usually prescribed under strict conditions and observation that mitigate some <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6322816/">serious risks</a>, such as increased feelings about suicide in some people. So people need to be assessed and monitored not only during treatment, but afterwards.</p>
<p>But some clinicians have resisted using ketamine due to its potential to become a <a href="https://www.ranzcp.org/getmedia/75baa529-2b71-419f-993a-2ff64ede50fe/cm-use-of-ketamine-in-psychiatric-practice.pdf">drug of abuse</a>.</p>
<p>Ketamine is also used to treat other mental health disorders such as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8959757/">PTSD</a> (post-traumatic stress disorder).</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/hallucinations-in-the-movies-tend-to-be-about-chaos-violence-and-mental-distress-but-they-can-be-positive-too-204547">Hallucinations in the movies tend to be about chaos, violence and mental distress. But they can be positive too</a>
</strong>
</em>
</p>
<hr>
<h2>How about this new study?</h2>
<p>The research involved <a href="https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12616001096448">multiple centres</a> across Australia and New Zealand and compared how well ketamine injected <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8193034/">under the skin</a> compared with taking another drug in treating people with treatment-resistant depression.</p>
<p>The trial randomised the 184 study participants into different groups – some receiving ketamine, the rest the drug <a href="https://pubmed.ncbi.nlm.nih.gov/9258787/">midazolam</a>, twice a week over four weeks. Neither the study participants nor those assessing the results knew who had ketamine and who didn’t.</p>
<p>At the start of the study, all participants had a clinical depression score of at least 20 (moderate depression) using a particular scale known as the Montgomery-Asberg Depression Rating Scale.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/537220/original/file-20230713-25-gs9tri.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Doctor in white coat putting hand on shoulder of patient" src="https://images.theconversation.com/files/537220/original/file-20230713-25-gs9tri.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/537220/original/file-20230713-25-gs9tri.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/537220/original/file-20230713-25-gs9tri.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/537220/original/file-20230713-25-gs9tri.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/537220/original/file-20230713-25-gs9tri.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/537220/original/file-20230713-25-gs9tri.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/537220/original/file-20230713-25-gs9tri.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The study participants had moderate depression.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-psychiatrist-shakes-hands-encouragement-patient-2188082723">Shutterstock</a></span>
</figcaption>
</figure>
<p>The researchers then looked for a score of less than 11, indicating a shift from a depression to remission.</p>
<p>After four weeks, there was a big difference between people treated with ketamine (19.6% in remission) compared with midazolam (2%). Another, less-strict way of measuring outcomes is to look for a halving of the depression score. This had an even bigger difference (29% compared with 4%). </p>
<p>However, four weeks after the treatment had ended, there was only limited sustained improvement in symptoms in the ketamine group. This suggests treatment may be needed over a longer period.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/do-psychedelics-really-work-to-treat-depression-and-ptsd-heres-what-the-evidence-says-208857">Do psychedelics really work to treat depression and PTSD? Here's what the evidence says</a>
</strong>
</em>
</p>
<hr>
<h2>There are other options</h2>
<p>In the trial, ketamine was given via an injection under the skin, which is a low-cost and efficient option. But ketamine can also be delivered directly into the bloodstream via an intravenous drip. Neither of these two options are routinely available in Australia and New Zealand outside clinical trials.</p>
<p>A third option uses a <a href="https://www.nps.org.au/australian-prescriber/articles/esketamine-hydrochloride-for-treatment-resistant-depression">different form</a> of ketamine and comes in a <a href="https://www.spravato.com/">nasal spray</a> (approved for use in <a href="https://www.tga.gov.au/resources/auspmd/spravato">Australia</a> and New Zealand). </p>
<p>Each option delivers ketamine in different amounts, and research into how these work in practice, and how they compare, is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8193034/">ongoing</a>.</p>
<p>There are also other drug and non-drug options for treatment-resistant depression. These include:</p>
<ul>
<li><p><a href="https://pubmed.ncbi.nlm.nih.gov/33834408/">transcranial magnetic stimulation</a>, which stimulates parts of the brain to improve mood</p></li>
<li><p><a href="https://www.ranzcp.org/events-learning/psychedelic-assisted-therapy">psilocybin</a>, another psychedelic drug that has just been given the go-ahead for use in Australia under strict conditions as part of <a href="https://theconversation.com/psychedelic-medicine-is-on-its-way-but-its-not-doing-shrooms-with-your-shrink-heres-what-you-need-to-know-208568">psychedelic-assisted therapy</a></p></li>
<li><p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8429332/">psychotherapy</a> (talking therapy) such as cognitive behavioural therapy, <a href="https://www.psychologytoday.com/au/therapy-types/acceptance-and-commitment-therapy">acceptance and commitment therapy</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/29761488/">dialectical behaviour therapy</a></p></li>
<li><p>changing some lifestyle factors, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7164235/">such as diet</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/28110494/">exercise</a>, or <a href="https://pubmed.ncbi.nlm.nih.gov/32985916/">practising mindfulness</a> meditation.</p></li>
</ul>
<h2>In a nutshell</h2>
<p>Serious consequences of depression include <a href="https://theconversation.com/suicide-rates-are-rising-with-or-without-13-reasons-why-lets-use-it-as-a-chance-to-talk-116434">suicide</a> or a lifetime of anguish. This latest research shows promising outcomes for people whose symptoms are harder to treat. But this option is not yet widely available outside a clinical trial. Only the ketamine nasal spray has been approved for use in Australia and New Zealand.</p>
<p>There are also other treatments. So if your existing treatment is not working for you, discuss this with your doctor who will explain what else is available.</p>
<hr>
<p><em>If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14. Beyond Blue provides the free resource <a href="https://www.beyondblue.org.au/docs/default-source/resources/bl0556-what-works-for-depression-booklet_acc.pdf?sfvrsn=fe1646eb_2">A guide to what works for depression</a>.</em></p><img src="https://counter.theconversation.com/content/209591/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Musker does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>This latest research provides hope for people whose symptoms are harder to treat.Michael Musker, Enterprise Fellow (Senior Research Fellow/Senior Lecturer), University of South AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2088572023-07-05T04:08:40Z2023-07-05T04:08:40ZDo psychedelics really work to treat depression and PTSD? Here’s what the evidence says<figure><img src="https://images.theconversation.com/files/535446/original/file-20230704-19-n5mgl2.jpg?ixlib=rb-1.1.0&rect=33%2C22%2C7315%2C4880&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/relaxed-young-caucasian-patient-lying-on-1925319578">Shutterstock</a></span></figcaption></figure><p>As of July 1, authorised psychiatrists have been allowed to prescribe MDMA (the chemical found in “ecstasy”) to treat post-traumatic stress disorder (PTSD), and psilocybin (found in “magic mushrooms”) to treat depression that hasn’t responded to other treatment. </p>
<p>Psychedelic therapies have researchers excited because evidence suggests they might have lasting beneficial effects on factors that cause psychological distress beyond the treatment period. These include <a href="https://link.springer.com/article/10.1007/s00213-017-4701-y">feeling disconnected from other people</a>, <a href="https://link.springer.com/article/10.1007/s00213-019-05391-0">fear of death</a>, and <a href="https://www.sciencedirect.com/science/article/pii/S2212144719301140?casa_token=OP6tKGxjPHAAAAAA:NTQ4khgsOY5wmsQ5HzCMcZ4eZ43wQV-sdhUbf5LXFiIeKWNwdonhfCxo77k7QbNk4G69EfX-">rigid ways of thinking</a>. </p>
<p>This stands in contrast to most medications for psychological issues, which only directly help while people keep taking them regularly. </p>
<p>But how strong is the evidence for psychedelic therapy? </p>
<h2>Early promise</h2>
<p>Early results from studies around the world have found psychedelic therapy <a href="https://www.ranzcp.org/getmedia/0cf57ea2-0bd7-4883-9155-d2ba1958df86/cm-therapeutic-use-of-mdma-for-ptsd-and-psilocybin-for-treatment-resistant-depression.pdf">might be effective</a> for treating a range of psychological issues. </p>
<p>For instance, most studies (<a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2032994">but not all</a>) have found patients tend to report <a href="https://pubmed.ncbi.nlm.nih.gov/37357767/">fewer depression symptoms</a> for periods ranging from several weeks to several months after psilocybin therapy. </p>
<p>Similarly, studies have found <a href="https://journals.sagepub.com/doi/10.1177/0269881120965915">reductions in PTSD symptoms</a> three weeks after MDMA therapy. </p>
<h2>Not so fast</h2>
<p>However, as psychedelic research has grown, <a href="https://pubmed.ncbi.nlm.nih.gov/35243919/">limitations</a> of the research have been identified by researchers both <a href="https://psyarxiv.com/ak6gx/">within</a> and <a href="https://www.sciencefictions.org/p/psychedelics">outside</a> the psychedelic field. </p>
<p>One issue is that we aren’t sure whether findings might be due to a <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/placebo-effect">placebo effect</a>, which occurs when a treatment works because people expect it to work. </p>
<p>In clinical trials, participants are often given either a medication or a placebo (inactive) drug – and it’s important they don’t know which they have been given. However, due to the strong effects, it is difficult to prevent participants from knowing whether they have been given a psychedelic drug. </p>
<p>Researchers have tried to use a range of different drugs (such as Ritalin) as a placebo in order to “trick” those participants not given a psychedelic into thinking they have received one. But this can be difficult to achieve.</p>
<p>In 2021, researchers <a href="https://www.tandfonline.com/doi/full/10.1080/17512433.2021.1933434?casa_token=Dovn7x_rkdUAAAAA%3AsPzBTYNTPnNwqj9NvwN0m9ptrP4x4-c83gp3tGcshs30dWHNnmB_Vx-X5H5Y3pZJdG02IWW6X2E">reviewed</a> clinical trials involving psychedelics such as LSD, psilocybin, and dimethyltryptamine (found in animals and plants) for mood and anxiety disorders. They found trials either had not assessed whether participants guessed correctly which drug they had been given, or that this had been tested and participants tended to guess correctly. </p>
<p>More recent trials <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2032994">either don’t measure this</a> or find participants have a <a href="https://journals.sagepub.com/doi/full/10.1177/02698811231154852?casa_token=VsPt344fVGwAAAAA%3AA-i1VPBE1EWyFITWNncZEt876lWMiC7rtTOLJBQnb2pHI2775imUJhrzeSZW6r9doaBeDaj61D0">pretty good idea</a> of whether they’ve had a placebo or a psychedelic drug.</p>
<p>Given the publicity and excitement around psychedelic research in recent years, it is likely most participants have <a href="https://culanth.org/fieldsights/the-pollan-effect-psychedelic-research-between-world-and-word">strong beliefs</a> such therapies work. This could lead to a significant placebo effect for participants given a psychedelic dose. Additionally, participants who realise they have received a placebo could experience <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10184717/">disappointment and frustration</a>, resulting in worse symptoms. The benefits of a psychedelic may seem even greater when they are compared to the experiences of disappointed participants. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-tga-has-approved-certain-psychedelic-treatments-the-response-from-experts-is-mixed-199290">The TGA has approved certain psychedelic treatments: the response from experts is mixed</a>
</strong>
</em>
</p>
<hr>
<h2>Translating trials to practice</h2>
<p>Anecdotally, patients might be motivated to report they have gotten better, even when they haven’t. </p>
<p>On a 2021 podcast, one clinical trial participant <a href="https://www.psymposia.com/powertrip/">described</a> how, in hindsight, the information they provided to the trial did not accurately capture the worsening of their symptoms. Trial participants are likely aware their results might affect whether treatments are legalised. They may not want to “ruin” the research by admitting the treatment didn’t work for them. </p>
<p>There is also uncertainty about whether the findings from clinical trials mean treatments will work in private practice. There may be a lack of clarity around <a href="https://psyarxiv.com/ak6gx/">how trial participants</a> are recruited and selected. Therefore participants may not represent the typical person with PTSD or treatment-resistant depression. </p>
<p>And while <a href="https://journals.sagepub.com/doi/full/10.1177/02698811211069100">the safety of psychedelics</a> within controlled contexts is often emphasised by advocates, less is known about safety of psychedelic therapy <a href="https://www.frontiersin.org/articles/10.3389/fpsyt.2021.737738/full">outside</a> clinical trials. </p>
<h2>Resolving issues</h2>
<p>These issues do not mean the promising psychedelic research conducted over the past several decades is worthless. Nevertheless, a <a href="https://pubmed.ncbi.nlm.nih.gov/35285280/#full-view-affiliation-1">recent review</a> of the effects of MDMA and psilocybin on mental, behavioural or developmental disorders by Australian researchers concluded the “overall certainty of evidence was low or very low”.</p>
<p>Dutch researchers recently drafted a <a href="https://psyarxiv.com/ak6gx/">roadmap for psychedelic science</a> with a checklist for future research to help avoid these pitfalls. When more research is done, it might turn out psychedelic treatments help patients and don’t come with unacceptable harms – we simply don’t know that yet.</p><img src="https://counter.theconversation.com/content/208857/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sam Moreton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In addition to placebo effects, patients might be motivated to report they have gotten better, even when they haven’t.Sam Moreton, Associate Lecturer, School of Psychology, University of WollongongLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2085682023-06-29T06:54:42Z2023-06-29T06:54:42ZPsychedelic medicine is on its way. But it’s not ‘doing shrooms with your shrink’. Here’s what you need to know<figure><img src="https://images.theconversation.com/files/534483/original/file-20230628-7269-u63go1.jpg?ixlib=rb-1.1.0&rect=1%2C0%2C997%2C666&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/focus-on-female-psychiatrist-writing-information-2160876067">Shutterstock</a></span></figcaption></figure><p>Many people in Australia, including psychiatrists, were <a href="https://theconversation.com/the-tga-has-approved-certain-psychedelic-treatments-the-response-from-experts-is-mixed-199290">surprised</a> when earlier this year the medicines regulator <a href="https://www.tga.gov.au/news/blog/understanding-changes-mdma-and-psilocybin-access">down-scheduled</a> MDMA, known colloquially as ecstasy, and psilocybin, from magic mushrooms.</p>
<p>This means that under certain circumstances from July 1, <a href="https://www.tga.gov.au/sites/default/files/2023-03/change-classification-mdma-psilocybin-enable-prescribing-authorised-psychiatrists_.pdf">authorised psychiatrists</a> will be able to prescribe MDMA to treat post-traumatic stress disorder and psilocybin to treat depression that has not responded to other treatments. Patients must also undergo psychotherapy (talking therapy). </p>
<p>It all sounds very certain but it’s not really.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-post-traumatic-stress-disorder-11135">Explainer: what is post-traumatic stress disorder?</a>
</strong>
</em>
</p>
<hr>
<h2>Beware the hype</h2>
<p>The Therapeutic Goods Administration decision has left a lot of <a href="https://theconversation.com/the-tga-has-approved-certain-psychedelic-treatments-the-response-from-experts-is-mixed-199290">questions unanswered</a> about how the new scheme will be implemented and operated, both effectively and safely.</p>
<p>There are a small number of countries where psychedelic-assisted therapies are used outside clinical trials – in a very limited manner. However, this is the first time a national government has altered the way these substances are formally classified.</p>
<p>So the world is watching closely how “psychedelic-assisted therapy”, as it’s officially called, is rolled out in Australia.</p>
<p>It’s a hot topic, with much <a href="https://www.abc.net.au/radio/programs/pm/australia-to-allow-psychiatric-treatment-with-psychedelics/102526508">public interest</a>. But for researchers, there are concerns the hype is getting way ahead of the research.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-tga-has-approved-certain-psychedelic-treatments-the-response-from-experts-is-mixed-199290">The TGA has approved certain psychedelic treatments: the response from experts is mixed</a>
</strong>
</em>
</p>
<hr>
<h2>The first steps</h2>
<p>The Royal Australian and New Zealand College of Psychiatrists this week <a href="https://www.ranzcp.org/clinical-guidelines-publications/clinical-guidelines-publications-library/therapeutic-use-of-mdma-for-ptsd-and-psilocybin-for-treatment-resistant-depression">released guidance</a> to their members about how this would work in practice.</p>
<p>As researchers in this field, we helped develop these guidelines. They cover topics such as patients’ suitability for this therapy, and how to administer and monitor it.</p>
<p>The guidelines also stress the importance of patient safety and appropriate training for prescribers, and advocates for continued research.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1673359318408650753"}"></div></p>
<h2>What does this mean for patients?</h2>
<p>This has several implications for potential patients: </p>
<ul>
<li><p>their existing psychiatrist may not be authorised to prescribe these psychedelics. So patients will have to ask their psychiatrist or GP for a referral to one who is</p></li>
<li><p>the psychiatrist authorised to prescribe these psychedelics will need to assess whether the therapy is suitable for each individual patient. This involves a detailed and comprehensive assessment. If the treatment is suitable, several sessions of further assessment and therapy are required before the actual dosing session</p></li>
<li><p>patients will be informed of what to expect before, during and after treatment, and need to give consent to proceed. We also recommend psychiatrists tell patients this therapy is not guaranteed to work, and provide patients with a clear account of the risks and possible negative side effects of psychedelic medications.</p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/psychedelics-how-they-act-on-the-brain-to-relieve-depression-183320">Psychedelics: how they act on the brain to relieve depression</a>
</strong>
</em>
</p>
<hr>
<h2>Expectations are high, but clear evidence is lacking</h2>
<p>Despite a growing <a href="https://www.ranzcp.org/getmedia/0cf57ea2-0bd7-4883-9155-d2ba1958df86/cm-therapeutic-use-of-mdma-for-ptsd-and-psilocybin-for-treatment-resistant-depression.pdf">body of evidence</a>, psychedelic-assisted therapies are in their infancy.</p>
<p>In a time when demand for mental health services <a href="https://theconversation.com/a-bigger-budget-for-mental-health-services-wont-necessarily-improve-australias-mental-health-160767">far outstrips supply</a>, exaggerated promises about the effectiveness of these drugs, before the research results are in, has many researchers worried. Patient expectations remain high but good clear evidence is still lacking.</p>
<p>Australian research is just getting under way and so far most psychedelic research has been done overseas. Yes, early findings have been <a href="https://www.ranzcp.org/getmedia/0cf57ea2-0bd7-4883-9155-d2ba1958df86/cm-therapeutic-use-of-mdma-for-ptsd-and-psilocybin-for-treatment-resistant-depression.pdf">quite promising</a>, but numbers are small, long-term follow-ups sparse, and potential risks and dangers still need to be explored.</p>
<p>Destigmatising these drugs has allowed us to begin our research, but sensationalising their effectiveness has the potential to disappoint and even harm patients because we really don’t know enough about how they work and who is suitable for this treatment.</p>
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<a href="https://images.theconversation.com/files/534487/original/file-20230628-19-xd13tl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Older man, sitting on sofa, palms together, with therapist taking notes" src="https://images.theconversation.com/files/534487/original/file-20230628-19-xd13tl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/534487/original/file-20230628-19-xd13tl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/534487/original/file-20230628-19-xd13tl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/534487/original/file-20230628-19-xd13tl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/534487/original/file-20230628-19-xd13tl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/534487/original/file-20230628-19-xd13tl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/534487/original/file-20230628-19-xd13tl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">We still don’t know who is suitable for this treatment.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/psychology-depression-elderly-asian-adult-man-2100727735">Shutterstock</a></span>
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<p>Psychedelic-assisted therapy is no miracle cure. Espousing the benefits without a thorough examination of the risks and limitations is not only a misrepresentation of the science, it is arguably unethical.</p>
<p>Very few psychiatrists have had much experience in this fascinating but challenging field. We still have a lot to learn about the use of psychedelic medicines to treat psychiatric illness.</p>
<p>Undue haste in translating psychedelic-assisted therapy conducted in clinical trials to community clinics could affect how well these treatments work and their safety. Outside clinical trials, patients will also need to shoulder the <a href="https://theconversation.com/the-tricky-economics-of-subsidising-psychedelics-for-mental-health-therapy-201462">cost</a> of this therapy, raising equity issues.</p>
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Read more:
<a href="https://theconversation.com/the-tricky-economics-of-subsidising-psychedelics-for-mental-health-therapy-201462">The tricky economics of subsidising psychedelics for mental health therapy</a>
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<h2>There’s potential for harm</h2>
<p>Psychedelic-assisted therapy is not simply “doing shrooms with your shrink”.</p>
<p>There is potential for psychedelic substances to cause fear, panic or cause psychological damage if given to susceptible and vulnerable people who have been inadequately screened or assessed.</p>
<p>Paranoia, traumatisation, worsening depression, and even suicidal behaviour, among other <a href="https://pubmed.ncbi.nlm.nih.gov/36988924/">serious</a> <a href="https://pubmed.ncbi.nlm.nih.gov/36453037/">side-effects</a>, <a href="https://journals.sagepub.com/doi/full/10.1177/02698811211069100">have been observed</a> in some cases.</p>
<p>So we need ongoing monitoring of outcomes, including adverse events.</p>
<p>We also know psychedelic substances render patients particularly vulnerable. Boundary issues and safeguards are vital considerations for patient safety, particularly when patients are under the influence of the psychedelic drug. For instance, it is important to discuss and agree with patients beforehand about the nature and timing of any touch during treatment sessions, so any touch is appropriate and done with full informed consent.</p>
<h2>An exciting prospect</h2>
<p>Despite the potential harms, we remain excited at the prospect of psychedelic-assisted therapy becoming an established treatment to help a select group of patients.</p>
<p>But we want to do this in a safe, controlled and sustainable manner.</p>
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<p><em>If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.</em></p><img src="https://counter.theconversation.com/content/208568/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nigel Strauss is a psychiatrist and senior consultant with St Vincent’s Hospital Melbourne, an investigator on several psychedelic clinical trials, is on the scientific advisory board of the European Mind Foundation, and is the medical director of the Millswyn Clinic in Melbourne, a private psychiatric clinic. He has made his own philanthropic donation to Monash University for a trial of MDMA assisted psychotherapy for PTSD. The trials he's involved in have not personally received any funding.</span></em></p><p class="fine-print"><em><span>Colleen Loo receives research grant funding from the Australian NHMRC and MRFF. </span></em></p><p class="fine-print"><em><span>David Jonathan Castle has received grant monies for research from Servier, Boehringer Ingelheim; travel support and honoraria for talks and consultancy from Servier, Seqirus, Lundbeck, Mindcafe, Psychscene, Inside Practice. He is a founder of the Optimal Health Program (OHP) and holds 50% of the IP for OHP; and is part owner (5%) of Clarity Healthcare. He is an unpaid Chair of an Advisory Board of Psychae, an Australian not-for-profit institute specialising in psychedelic medicines research. He is a member of the Royal Australian and New Zealand College of Psychiatrists Psychedelic Assisted Therapy Working Group. He does not knowingly have stocks or shares in any pharmaceutical company.</span></em></p><p class="fine-print"><em><span>Steve Kisely was the first author of the report commissioned by the Therapeutic Goods Administration on the possible clinical benefits of MDMA and psilocybin. </span></em></p>From July 1, authorised psychiatrists will be able to prescribe MDMA and psilocybin in some circumstances. Here’s what we’re excited and concerned about.Nigel Strauss, Psychiatrist and Clinical Associate at The Centre of Mental Health, Swinburne University of TechnologyColleen Loo, Professor of Psychiatry, UNSW & Black Dog Institute, UNSW SydneyDavid Jonathan Castle, Chair of Psychiatry, The University of MelbourneSteve Kisely, Professor, School of Medicine, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2081492023-06-21T15:11:48Z2023-06-21T15:11:48ZHearing voices? You’re not alone<figure><img src="https://images.theconversation.com/files/533167/original/file-20230621-29-qk8487.jpeg?ixlib=rb-1.1.0&rect=0%2C2%2C1920%2C1327&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It estimated one out of ten of us will hear voices at some point in our lives.</span> <span class="attribution"><a class="source" href="https://www.pexels.com/fr-fr/photo/mains-femme-visage-preoccupe-4584457/">Keyut Subiyanto/Pexels</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span></figcaption></figure><p>From the little voice telling us we’re no good to the one offering advice, the experience of hearing voices <a href="https://theconversation.com/sports-extremes-epuisement-nous-pouvons-tous-halluciner-litteralement-206146">is more common</a> than you might think. It is estimated that <a href="https://pubmed.ncbi.nlm.nih.gov/21574793/">13.2% of the adult general population are subject to it</a>, yet this experience still carries much stigma. Whom can you turn to <a href="https://theconversation.com/entendre-des-voix-plus-frequent-quon-ne-le-croit-71378">when you’re no longer alone in your head</a>?</p>
<p>For several decades now, the international <a href="https://pubmed.ncbi.nlm.nih.gov/24936088/">Hearing Voices Movement</a> (HVM) has been campaigning to improve the way this condition is perceived. <a href="https://hal.univ-lorraine.fr/hal-04108011">Two recent studies</a> conducted at the University of Lorraine in eastern France have assessed how its support groups have impacted the French health care system.</p>
<h2>Changing textbooks</h2>
<p>You’re hearing voices and in one fell swoop, the gavel falls: you’re mad. How could it be otherwise? You don’t need a shrink to say so. Our entire culture teaches us that the ego must remain master of its own house.</p>
<p>In psychiatry, hearing voices in the absence of external inputs is equated with hallucination, a <a href="https://www.cairn.info/load_pdf.php?download=1&ID_ARTICLE=PSN_102_0045">clear expression of psychosis</a>. Until recently, the mere symptom of voices conversing with each other was enough to warrant a <a href="https://www.cairn.info/revue-psn-2021-3-page-55.htm">diagnosis of schizophrenia</a>. But even psychiatric textbooks are changing.</p>
<p>In addition to psychosis, which is sometimes diagnosed, such experiences occur spontaneously in unusual states of consciousness – for example, bereavement or trauma. The voices are often accompanied by <a href="https://www.dunod.com/sciences-humaines-et-sociales/clinique-experiences-exceptionnelles">paranormal experiences</a> such as visions or messages. What would happen to Joan of Arc if she consulted a psychiatrist in 2023?</p>
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À lire aussi :
<a href="https://theconversation.com/sports-extremes-epuisement-nous-pouvons-tous-halluciner-litteralement-206146">Sports extrêmes, épuisement… Nous pouvons tous halluciner (littéralement) !</a>
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<h2>Less lonely together</h2>
<p>Researchers now differentiate the experience of hearing voices from <a href="https://www.em-consulte.com/article/1308514/entendre-des-voix-sans-etre-schizophrene%C2%A0-impact-d">our distressed interpretations of them</a>. Since <a href="https://hearingthevoice.org/2011/10/20/reflections-on-marius-romme-and-sandra-escher-accepting-and-making-sense-of-hearing-voices">the 1980s</a>, a growing number of people have confessed to <a href="https://www.sciencedirect.com/science/article/abs/pii/S0003448713002680">“hearing voices”</a>.</p>
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<figcaption><span class="caption">“The voices in my head”, Eleanor Longden, 2014.</span></figcaption>
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<p>All have managed to tap into a range of resources to deal with their experiences, without necessarily turning to psychiatry. By coming together, first in the Netherlands and then as an international movement, they realised that they possessed “experiential knowledge” that could help others like them find help and reverse the stigma they were suffering.</p>
<p>Some clinicians and researchers have backed this shift, whose watchword is <a href="https://www.sciencedirect.com/science/article/abs/pii/S0003448722001433">“nothing about us without us”</a>. Out with the <a href="https://theconversation.com/sports-extremes-epuisement-nous-pouvons-tous-halluciner-litteralement-206146">accoustico-verbal hallucinations</a>, in with the <em>voices</em>. The change in vocabulary is just one indication of the overall change in perspective, against the backdrop of a <a href="https://www.editions-eres.com/ouvrage/4495/pour-des-usagers-de-la-psychiatrie-acteurs-de-leur-propre-vie-ne">growing demand for health democracy</a>.</p>
<h2>Inclusive change</h2>
<p>The movement “campaigns to drop models that pathologise these experiences,” <a href="https://www.cairn.info/revue-topique-2018-3-page-109.htm">says Magali Molinié</a>, a psychologist and academic at the universities of Paris 8 and Cornell, who in 2011 cofounded the <a href="https://revfrance.org/">French Network on Voice Understanding</a>. Its members prefer to consider that voices are real, carry meaning and links to trauma – even if opinions differ as to their explanations.</p>
<p>Among the alternatives promoted by the movement are <a href="https://hal-univ-paris8.archives-ouvertes.fr/hal-03226291">Hearing Voices Groups</a> (HVG). There are <a href="https://research.manchester.ac.uk/en/publications/hearing-voices-groups">180 in the United Kingdom</a> alone, and they can now be found <a href="https://pubmed.ncbi.nlm.nih.gov/24936088/">in 30 countries</a>.</p>
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<figcaption><span class="caption">Testimonies from voice-hearing groups (Ma Santé Ré).</span></figcaption>
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<p>These self-help groups have no stated therapeutic aim. Instead, they act as a microsociety, where members can safely open up on their experiences and the events to which they are linked. It’s all part of the trend toward health care patient and provider empowerment, which has been <a href="https://www.recherche-sante-mentale.fr/docsenlien/CCOMS-2014-FR-BD.pdf">recommended by the World Health Organisation</a>.</p>
<h2>The groups’ effectiveness</h2>
<p>Each HVG has its own way of working and its own personality. How can we assess their advantages and disadvantages? A questionnaire designed jointly with English voice hearers has been adapted into French. <a href="https://cper-ariane.univ-lorraine.fr/project/groupes-dentendeurs-de-voix-de-lorraine-gevoix">The study</a> compared the effects of HVGs with those of ordinary therapeutic groups. As the study took place during the Covid-19 pandemic, the groups ran slowly and only 20 of the 50 in France completed the study. However, the results were positive.</p>
<p>In particular, participants reported feeling better about themselves, more hopeful, less lonely and anxious and happier overall. The groups provided them with support that they had not been able to find elsewhere, as well as useful information to help them make sense of their experiences. Most of them now feel able to help other voice hearers in their turn. One participant even compared the setting to “Alcoholics Anonymous for schizophrenics”. Although this was not the aim, voice hearing even decreased for seven of the participants.</p>
<p>Are such positive reports enough to recommend such groups?</p>
<h2>Different methods, similar results</h2>
<p>The total satisfaction score was 74%. In parallel, a 14-person control group underwent metacognitive training, a method aimed at helping people with psychosis become more aware of thinking patterns contributing to their symptoms. Strikingly, their satisfaction score was also 74.5%. This indicates that HVGs are perceived to be as effective as scientifically proven practices.</p>
<p>HVGs hold the advantage of attracting people who do not have a psychiatric diagnosis or who do not fully accept it. In the absence of such spaces, these hearers would be more likely to bypass the medical-psychological circuit in favour of unconventional and poorly regulated forms of care, such as mediums who interpret voices as a <a href="https://theconversation.com/pourquoi-certaines-personnes-pretendent-elles-communiquer-avec-les-morts-154122">gift of communication with the dead</a>.</p>
<p>Ultimately, HVGs’ value lies not so much in their ability to <em>replace</em> existing treatments as to <em>complement</em> them.</p>
<h2>In the minds of carers</h2>
<p>As for HVGs’ integration within psychiatry, our research shows the field can do better. Surveying 79 staff from French mental health institutions, the <a href="https://hal.univ-lorraine.fr/hal-04108011">second study</a> confirmed the medical and caring personnel largely views them positively.</p>
<p>However, there are mismatches between what HVGs are and how professionals perceive them. There is an unhelpful tendency to reduce them to just another medical service, of little use in terms of symptom reduction, indicated only for psychotic patients who hear voices.</p>
<p>The more professionals familiarise ourselves with these structures, the more they stand to free themselves from such stereotypes. Through new eyes, yesterday’s madman becomes a fully fledged citizen.</p>
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<p><em>For those interested in learning more about this issue, the 14th <a href="https://www.paris2023.info/">World Intervoice Conference</a> will be held in Paris on 26 and 27 October 2023.</em></p><img src="https://counter.theconversation.com/content/208149/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Les auteurs ne travaillent pas, ne conseillent pas, ne possèdent pas de parts, ne reçoivent pas de fonds d'une organisation qui pourrait tirer profit de cet article, et n'ont déclaré aucune autre affiliation que leur organisme de recherche.</span></em></p>The international Hearing Voices Movement has spent the past decades campaigning to destigmatise a surprisingly common phenomenon.Renaud Evrard, Maître de conférences en psychologie, Université de LorraineArthur Braun, Psychologue clinicien, doctorant en psychologie clinique, Université de LorraineLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2060222023-06-06T16:35:14Z2023-06-06T16:35:14ZMagnet therapy for depression is available on the NHS – here’s how it works<p>Magnets to treat depression? It may sound bizarre, but this treatment is now <a href="https://www.bbc.co.uk/news/uk-england-somerset-65609340">available on the NHS</a>. It’s called transcranial magnetic stimulation, or TMS. </p>
<p>People who have tried antidepressants but they haven’t worked, may be offered TMS. It involves zapping areas of the brain associated with depression with pulsing magnetic fields.</p>
<p>Treatment usually involves <a href="https://www.southernhealth.nhs.uk/our-services/a-z-list-of-services/repetitive-transcranial-magnetic-stimulation-rtms">daily half-hour sessions</a> five days a week for two to six weeks.</p>
<p>TMS is not just used to treat depression, it has been used as a diagnostic tool for <a href="https://pubmed.ncbi.nlm.nih.gov/36131925/">multiple sclerosis</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/10449127/">motor neuron disease</a>. And its effectiveness in treating <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6790310/">mood disorders</a>, such as depression and anxiety, has been under investigation for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4815479/">more than 30 years</a>.</p>
<p>It works by sending a magnetic pulse into the brain through a device placed on the skull. </p>
<h2>Developing the right device</h2>
<p>So-called “refractory depression” – depression that does not respond to antidepressants or talk therapy – can be effectively treated with <a href="https://theconversation.com/electroconvulsive-therapy-does-work-and-it-can-be-miraculous-76381">electroconvulsive therapy</a> (ECT). But ECT is fairly invasive, sending bolts of electricity through the skull and into the brain. With TMS, an electrical change in the brain happens because of the magnetic field happening outside of the skull. This is called electromagnetic induction and was <a href="https://www.britannica.com/science/electromagnetism/Faradays-discovery-of-electric-induction">discovered by Michael Faraday in 1831</a>.</p>
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<img alt="Photo of Michael Faraday" src="https://images.theconversation.com/files/530319/original/file-20230606-15-bln4rc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/530319/original/file-20230606-15-bln4rc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=863&fit=crop&dpr=1 600w, https://images.theconversation.com/files/530319/original/file-20230606-15-bln4rc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=863&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/530319/original/file-20230606-15-bln4rc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=863&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/530319/original/file-20230606-15-bln4rc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1085&fit=crop&dpr=1 754w, https://images.theconversation.com/files/530319/original/file-20230606-15-bln4rc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1085&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/530319/original/file-20230606-15-bln4rc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1085&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Michael Faraday discovered electromagnetic induction.</span>
<span class="attribution"><a class="source" href="https://wellcomeimages.org/indexplus/obf_images/86/76/b53d681751b952d72142c23a2b24.jpg">Wellcome Collection/Wikimedia</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>Over the <a href="https://journals.sagepub.com/doi/abs/10.1177/1073858413491145?journalCode=nroa">next century</a>, scientists and doctors such as Jacques-Arsèn d’Arsonval and Sylvanus P. Thompson created devices that sought to artificially stimulate the nervous system, the former for an early defibrillator device and the latter to stimulate the brain. But they were so bulky and the amount of power needed to produce the rapidly changing magnetic field that was required made their development difficult.</p>
<p>It wasn’t until 1985 and the work of medical physicist <a href="https://www.youtube.com/watch?v=1DI3EC2pQ44">Anthony Barker at Sheffield University</a> that led to the creation of a compact, relatively inexpensive device that allowed scientists to stimulate 1cm³ area of the brain at time intervals of their choosing for fractions of a second. It is safe and is applied while the patient is awake.</p>
<p>The technique is used to treat depression and anxiety in two specific ways. Sending repetitive pulses into the brain at different frequencies can have different effects. </p>
<p>In depression, we know that <a href="https://thebrain.mcgill.ca/flash/i/i_08/i_08_cr/i_08_cr_dep/i_08_cr_dep.html#:%7E:text=And%20indeed%2C%20in%20depressed%20people,such%20goals%20can%20be%20achieved.">activity is low in the left prefrontal cortex</a> – the area of the brain that is important in planning and thought processes. So using a higher frequency pulse switches on those neurons to help them work as they should, thus alleviating the depression symptoms. </p>
<p>In contrast, the prefrontal area on the right side of the brain, which is known to be overactive in cases of anxiety, is treated with lower frequencies to calm the activity in that area.</p>
<p>Using this effect of changing how neurons talk to each other (called neuroplasticity), it is hoped that with regular treatment, symptoms will be alleviated. </p>
<p>The treatment is administered as the patient sits in an armchair and feels something akin to a light tapping on the skull. </p>
<h2>Safe, but long-term results are needed</h2>
<p>A <a href="https://gpsych.bmj.com/content/32/4/e100074">review of TMS for treating depression</a> found mixed evidence and called for longer-term studies. But it is clear that there is <a href="https://pubmed.ncbi.nlm.nih.gov/30249416/">benefit</a> for people with refractory depression, and it is safe in older adults and pregnant people.</p>
<p>TMS is safe to administer to those who do not have metal, such as aneurysm coils, metal dental appliances or non-removable piercings in their head or metal-containing pigments on their faces. But it is not advised for people who have epilepsy. </p>
<p>The treatment has several advantages over ECT. With TMS, the patient does not need to be anaesthetised; they do not experience a seizure, and they do not have memory loss after the treatment.</p>
<p>Using TMS in more clinics will provide scientists with more data to determine when it works and for whom, and what protocols are optimal. For example, TMS may have greater and longer-lasting benefits when paired with cognitive behavioural therapy (a type of talk therapy) – as has been shown with <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3918025/">antidepressants combined with CBT</a>. </p>
<p>But it is certainly a technique – forged in the fire of cognitive neuroscience – that can have a great effect on those desperate for help.</p><img src="https://counter.theconversation.com/content/206022/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amanda Ellison does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Transcranial magnetic stimulation is a safe, well-tolerated way to treat depression.Amanda Ellison, Professor of Neuroscience, Durham UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2055872023-05-23T16:01:20Z2023-05-23T16:01:20ZFive rare and unusual psychiatric syndromes – including one where people believe they are dead<p>Most people are familiar with psychiatric disorders such as schizophrenia and bipolar disorder, but some conditions are so rare that many psychiatrists won’t come across a single case in their professional lives. Here I present five of the rarest – and strangest – syndromes known to psychiatry.</p>
<h2>1. Fregoli syndrome</h2>
<p>Fregoli syndrome is where someone believes that <a href="https://pubmed.ncbi.nlm.nih.gov/25219764/">different people</a> are in fact the same person who just changes their appearance. People with this syndrome often feel persecuted by those they believe to be in disguise. The disorder is named after <a href="https://en.wikipedia.org/wiki/Leopoldo_Fregoli">Leopoldo Fregoli</a>, an Italian theatre actor who was known for his remarkable ability to quickly change his appearance while on stage. </p>
<p>Fregoli syndrome typically occurs with other mental disorders, such as bipolar disorder, schizophrenia and obsessive-compulsive disorder. It can also be caused by brain injury and use of the <a href="https://movementdisorders.onlinelibrary.wiley.com/doi/10.1002/mds.21843">drug levodopa</a> in the treatment of Parkinson’s disease. </p>
<p>A <a href="https://ijanm.com/HTMLPaper.aspx?Journal=International%20Journal%20of%20Advances%20in%20Nursing%20Management;PID=2018-6-3-22">review in 2018</a> found that fewer than 50 cases worldwide had been reported since the condition was first described. However, a more <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7667346/pdf/BRB3-10-e01829.pdf">recent study</a> (2020) reported an incidence of 1.1% among patients following a stroke, so certainly more than 50 cases but still very rare. There is no known cure for Fragoli syndrome, but treatment with antipsychotic drugs may lessen the symptoms.</p>
<h2>2. Cotard’s syndrome</h2>
<p>Cotard’s syndrome, also known as “walking corpse syndrome”, is where people hold the delusional belief that they are dead and do not exist. Others believe that <a href="https://pubmed.ncbi.nlm.nih.gov/36575636/">body parts</a> are missing.</p>
<p>The syndrome is named after the 19th-century French neurologist <a href="https://pubmed.ncbi.nlm.nih.gov/12011289/">Jules Cotard</a>, who first described the condition in 1882. </p>
<p>Schizophrenia, depression and bipolar disorder are risk factors for Cotard’s syndrome. However, it has also been reported as a <a href="https://www.jns-journal.com/article/S0022-510X(13)02566-5/fulltext">rare side-effect</a> of the anti-viral drug acyclovir. </p>
<p>The syndrome is thought to originate from a disconnection between the areas of the brain that recognise faces and the areas that associate emotional content with such facial recognition. </p>
<p>This rare condition is usually treated with antidepressants, antipsychotics, and mood stabilisers, as well as electroconvulsive therapy.</p>
<h2>3. Alien hand syndrome</h2>
<p>Alien hand syndrome is one of the strangest neurological disorders. It is where a person’s hand appears to have <a href="https://www.youtube.com/watch?v=V0QbcROOv-E">a mind of its own</a> and acts autonomously, and where the person feels as though their hand doesn’t belong to them. </p>
<p>This syndrome was first identified in 1908 but was not clearly defined until the early 1970s. The term “alien hand syndrome” was <a href="https://link.springer.com/article/10.1007/s00415-013-6898-y">coined by Joseph Bogen</a>, an American neurophysiologist, to describe a curious wayward behaviour occasionally seen during recovery from certain types of brain surgery. </p>
<p>People with alien hand syndrome typically have <a href="https://www.brainbalancecenters.com/blog/signs-and-symptoms-of-sensory-processing-disorder">sensory processing disorders</a> and dissociate themselves from the actions of their hand. Research indicates that people with the syndrome often personify the alien hand, and may believe it is possessed by some other spirit or alien life form. </p>
<p>Causes of the syndrome <a href="https://link.springer.com/article/10.1007/s11910-016-0676-z">include</a> dementia, strokes, prion disease (a fatal brain disease), tumours and seizures. Cases of alien hand syndrome have also been reported among patients who have had surgery to separate the left and right brain hemispheres to treat severe epilepsy.</p>
<p>The syndrome is very rare. A review in 2013 found just <a href="https://link.springer.com/article/10.1007/s00415-013-6898-y">150 cases</a> in the medical journals.</p>
<p>Although there is no cure for alien hand syndrome, symptoms can be minimised and managed to some extent by keeping the affected hand occupied and involved in a task – for example, by giving it an object to hold in its grasp. Other <a href="https://link.springer.com/article/10.1007/s11910-016-0676-z">treatments</a> have included injections of botulinum toxin and mirror box therapy (see video). Stroke patients appear to have the best treatment success.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/1BnsQO7a4Og?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Mirror box therapy explained.</span></figcaption>
</figure>
<h2>4. Ekbom’s syndrome</h2>
<p>Ekbom’s syndrome is a tactile hallucination in which sufferers believe they are infested with parasites – often experienced as insects crawling under their skin. </p>
<p>The syndrome is named after Karl Ekbom, a Swedish neurologist who first described the condition in the late 1930s. </p>
<p>The exact number of people who suffer from this syndrome is unknown, but <a href="https://www.derm.theclinics.com/article/S0733-8635(05)70370-3/fulltext">one study</a> reported around 20 new cases a year in a large US referral clinic.</p>
<p>According to a <a href="https://karger.com/psp/article-abstract/28/5/238/283570/100-Years-of-Delusional-ParasitosisMeta-Analysis?redirectedFrom=fulltext">meta-analysis</a> of 1,223 Ekbom cases, the syndrome is more common among women (two-thirds women, one-third men), and more common in those over the age of 40. Symptoms typically lasted three to four years. </p>
<p>Ekbom’s syndrome is associated with several conditions, including paranoid schizophrenia, organic brain disease, neurosis and paranoid personality disorder. It has also been reported in some people undergoing alcohol withdrawal, cocaine misuse, strokes, dementia, and lesions in a part of the brain called the thalamus. </p>
<p>Psychological treatments are often not wanted by Ekbom’s syndrome sufferers, as they are convinced that the problem needs medical treatment.</p>
<h2>5. Alice in Wonderland syndrome</h2>
<p>Alice in Wonderland syndrome, also known as Todd syndrome, refers to when a person’s sense of body image, vision, hearing, touch and space/time are distorted. People with the condition typically experience objects to be smaller than they actually are, while people seem bigger than they are. Or the opposite: objects are perceived to be larger than they are and people appear smaller. These experiences may be accompanied by feelings of paranoia.</p>
<p>Little is known about how common this disorder is. Sufferers are most commonly <a href="https://cp.neurology.org/content/6/3/259.short">children and migraine sufferers</a>.</p>
<p>People with the condition can become frightened and panic-stricken, so successful treatment often includes rest and relaxation. In most cases, it is a relatively short-lived condition. The <a href="https://cp.neurology.org/content/6/3/259.short">most recent review</a> on Alice in Wonderland syndrome reported that close to half of all sufferers are treated successfully.</p><img src="https://counter.theconversation.com/content/205587/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Griffiths has received research funding from a wide range of organisations including the Economic and Social Research Council, the British Academy and GambleAware (formerly the Responsibility in Gambling Trust). He has also carried out consultancy for numerous gambling companies in the area of social responsibility, responsible gaming and player protection. Griffiths' university has received funding from Norsk Tipping (the gambling operator owned by the Norwegian Government) for his research evaluating responsible gambling tools. Views expressed here are his own and not those of these funding bodies.</span></em></p>Some people believe their hand doesn’t belong to them. Others think bugs are crawling under their skin.Mark Griffiths, Director of the International Gaming Research Unit and Professor of Behavioural Addiction, Nottingham Trent UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1966512023-03-29T00:56:43Z2023-03-29T00:56:43ZObsessive compulsive disorder is more common than you think. But it can take 9 years for an OCD diagnosis<figure><img src="https://images.theconversation.com/files/511868/original/file-20230223-25-gc8koi.jpg?ixlib=rb-1.1.0&rect=1%2C5%2C997%2C770&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-obsessive-compulsive-disorder-placing-corn-1838649955">Shutterstock</a></span></figcaption></figure><p>Obsessive compulsive disorder, or OCD, is a <a href="https://www.sciencedirect.com/science/article/abs/pii/S2211364916301579">misunderstood</a>
mental illness despite affecting <a href="https://pubmed.ncbi.nlm.nih.gov/18725912">about one in 50 people</a> – that’s about half a million Australians.</p>
<p>Our <a href="https://www.tandfonline.com/doi/full/10.1080/00050067.2023.2189003">new research</a> shows how long and fraught the path to diagnosis and treatment can be. </p>
<p>This initial study showed it takes an average of almost nine years to receive a diagnosis of OCD and about four months to get some form of help.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/no-ocd-in-a-pandemic-doesnt-necessarily-get-worse-with-all-that-extra-hand-washing-157961">No, OCD in a pandemic doesn't necessarily get worse with all that extra hand washing</a>
</strong>
</em>
</p>
<hr>
<h2>What is OCD?</h2>
<p>OCD affects children, adolescents and adults. <a href="https://www.nature.com/articles/mp200894">About 60%</a> report symptoms before the age of 20.</p>
<p>One misconception is that OCD is mild: someone who is extra tidy or likes cleaning. You might have even heard someone say they are “<a href="https://theconversation.com/you-cant-be-a-little-bit-ocd-but-your-everyday-obsessions-can-help-end-the-conditions-stigma-49265">a little bit OCD</a>” while joking about having beautiful stationery.</p>
<p>But OCD is not enjoyable. Obsessions are highly distressing and there are repetitive, intrusive thoughts a person with OCD can’t control. They might believe, for instance, they or their loved ones are in grave danger. </p>
<p><a href="https://iocdf.org/about-ocd/">Compulsions</a> are actions that temporarily alleviate, but ultimately exacerbate, this distress, such as checking the door is locked. People with OCD spend hours each day consumed by this cycle, instead of their normal activities, such as school, work or having a social life. </p>
<p>It can also be very distressing for <a href="https://www.tandfonline.com/doi/abs/10.1586/ern.11.200">family members</a> who often end up completing rituals or providing excessive reassurance to the person with OCD.</p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/reel/Cl7ElJqBg4f","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/you-cant-be-a-little-bit-ocd-but-your-everyday-obsessions-can-help-end-the-conditions-stigma-49265">You can't be 'a little bit OCD' but your everyday obsessions can help end the condition's stigma</a>
</strong>
</em>
</p>
<hr>
<h2>How is it diagnosed?</h2>
<p>People with OCD often don’t tell others about their disturbing thoughts or repetitive rituals. They often feel <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/%28SICI%291099-0879%28199905%296%3A2%3C80%3A%3AAID-CPP188%3E3.0.CO%3B2-C">ashamed or worried</a> that by telling someone their disturbing thoughts, they might become true.</p>
<p>Doctors <a href="https://www.ncbi.nlm.nih.gov/books/NBK56470/#ch2">don’t always ask about</a> OCD symptoms when people first seek treatment. </p>
<p>Both lead to delays getting correctly diagnosed.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1399443462152404993"}"></div></p>
<p>When people do feel comfortable talking about their OCD symptoms, a diagnosis might be made by a GP, psychologist or other health-care professional, such as a psychiatrist. </p>
<p>Sometimes OCD can be <a href="https://link.springer.com/article/10.1007/s10566-009-9092-8">tricky to differentiate</a> from other conditions, such as eating disorders, anxiety disorders or autism. </p>
<p>Having an additional mental health diagnosis <a href="https://www.nature.com/articles/s41572-019-0102-3">is common</a> in people with OCD. In those cases, a health-care provider experienced in OCD is helpful. </p>
<p>To diagnose OCD, the health professional asks people and/or their families questions about the presence of obsessions and/or compulsions, and how this impacts their life and family. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/more-than-a-habit-when-to-worry-about-nail-biting-skin-picking-and-other-body-focused-repetitive-behaviours-102263">More than a habit? When to worry about nail biting, skin picking and other body-focused repetitive behaviours</a>
</strong>
</em>
</p>
<hr>
<h2>How is it treated?</h2>
<p>After someone receives a diagnosis, it helps to learn more about OCD and what treatment involves. Great places to start are the <a href="https://iocdf.org">International OCD Foundation</a> and <a href="https://www.ocduk.org">OCD UK</a>. </p>
<p>Next, they will need to find a health-care provider, usually a psychologist, who offers a special type of psychological therapy called “exposure and response prevention” or ERP.</p>
<p>This is a type of
<a href="https://theconversation.com/explainer-what-is-cognitive-behaviour-therapy-37351">cognitive-behavioural therapy</a> that is a <a href="https://doi.org/10.1016/j.jocrd.2021.100684">powerful, effective treatment</a> for OCD. It’s recommended people with OCD try this first.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/511870/original/file-20230223-25-ge0aea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Man with dreadlocks sitting on sofa talking to therapist" src="https://images.theconversation.com/files/511870/original/file-20230223-25-ge0aea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/511870/original/file-20230223-25-ge0aea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/511870/original/file-20230223-25-ge0aea.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/511870/original/file-20230223-25-ge0aea.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/511870/original/file-20230223-25-ge0aea.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/511870/original/file-20230223-25-ge0aea.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/511870/original/file-20230223-25-ge0aea.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A type of psychological therapy known as ‘exposure and response prevention’ is recommended first.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/positive-black-man-talking-to-female-therapist-5699421/">Alex Green/Pexels</a></span>
</figcaption>
</figure>
<p>It involves therapists helping people to understand the cycle of OCD and how to break that cycle. They support people to deliberately enter anxiety-provoking situations while resisting completing a compulsion. </p>
<p>Importantly, people and their ERP therapist <a href="https://pubmed.ncbi.nlm.nih.gov/18005936/">decide together</a> what steps to take to truly tackle their fears. </p>
<p>People with OCD learn new thoughts, for example, “germs don’t always lead to illness” rather than “germs are dangerous”.</p>
<p>There are a range of medications that also <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4967667/">effectively</a> <a href="https://pubmed.ncbi.nlm.nih.gov/27663940/">treat</a> OCD. But more research is needed to know more about when a medication should be added. For most people these are best considered a “boost” to help ERP.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/brain-scans-reveal-why-it-is-so-difficult-to-recover-from-ocd-and-hint-at-ways-forward-74092">Brain scans reveal why it is so difficult to recover from OCD – and hint at ways forward</a>
</strong>
</em>
</p>
<hr>
<h2>But not everything goes to plan</h2>
<p>Delays in being diagnosed is only the start:</p>
<ul>
<li><p>treatment is challenging to access. Only <a href="https://www.sciencedirect.com/science/article/abs/pii/S0887618518301038?via%3Dihub">30% of clinicians</a> in the United States offer ERP therapy. There is likely a similar situation in Australia</p></li>
<li><p>many people receive therapies that appear credible, <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/cpsp.12337?casa_token=Wn3bgnvINSsAAAAA%3A2sqam0BKtCzFA680_f6ln4scp1SKVpN_cOB6Tg8vQyEiNDZPwS-Z-NNveLelKYF6iz4PFqQSXyHKZYJS">but lack evidence</a>, such as general cognitive therapy that is not tailored to the mechanisms maintaining OCD. Inappropriate treatments waste valuable time and effort that the person could use to recover. Ineffective treatments can make OCD symptoms worse</p></li>
<li><p>even when someone receives first-line, evidence-based treatments, <a href="https://www.sciencedirect.com/science/article/pii/S0005796722001413?via%3Dihub">about 40-60%</a> of people don’t get better</p></li>
<li><p>there are no Australian clinical treatment guidelines, nor state or national clinical service plans for OCD. This makes it hard for health-care providers to know how to treat it</p></li>
<li><p>there has been <a href="https://journals.sagepub.com/doi/full/10.1177/00048674221125595">relatively little research funding</a> spent on OCD in the past ten years, compared with, for example, psychosis or dementia.</p></li>
</ul>
<h2>What can we do?</h2>
<p>Real change demands collaboration between health-care professionals, researchers, government, people with OCD and their families to advocate for proportionate funding for research and clinical services to:</p>
<ul>
<li><p>deliver public health messaging to improve general knowledge about OCD and reduce the stigma so people feel more comfortable disclosing their worries</p></li>
<li><p>upskill and support health professionals to speed up diagnosis so people can receive targeted early intervention</p></li>
<li><p>support health-care professionals to offer evidence-based treatment for OCD, so more people can access these treatments</p></li>
<li><p>develop state and national service plans and clinical guidelines. For example, the Australian government funds the <a href="https://nedc.com.au/">National Eating Disorders Collaboration</a> to develop and implement a nationally consistent approach to preventing and treating eating disorders</p></li>
<li><p>research to discover new, and enhance existing, treatments. These include ones for people who don’t get better after “exposure and response prevention” therapy.</p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/seeing-a-psychologist-on-medicare-soon-youll-be-back-to-10-sessions-but-we-know-thats-not-often-enough-194338">Seeing a psychologist on Medicare? Soon you'll be back to 10 sessions. But we know that's not often enough</a>
</strong>
</em>
</p>
<hr>
<h2>What if I think I have OCD?</h2>
<p>The most common barrier to getting help is not knowing who to see or where to go. Start with your GP: tell them you think you might have OCD and ask to discuss treatment options. These might include therapy and/or medication and a referral to a psychologist or psychiatrist.</p>
<p>If you choose therapy, it’s important to find a clinician that offers specific and effective treatment for OCD. To help, we’ve started <a href="https://ocd.org.au/directory">a directory</a> of clinicians with a special interest in treating OCD. </p>
<p>You <a href="https://iocdf.org/ocd-finding-help/how-to-find-the-right-therapist/#:%7E:text=Tips%20for%20Finding%20the%20Right%20Therapist&text=Also%2C%20remember%20that%20some%20therapists,the%20phone%20or%20in%20person">can ask</a> any potential health professional if they offer “exposure and response prevention”. If they don’t, it’s a sign this isn’t their area of expertise. But you still can ask them if they know of a colleague who does. You might need to call around, so hang in there. Good treatment can be life changing.</p>
<p><em>If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.</em></p><img src="https://counter.theconversation.com/content/196651/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Iain Perkes is employed by UNSW, Sydney and the Sydney Children's Hospitals Network. He receives funding from Rotary Mental Health, the Mindgardens Neuroscience Network, National Health and Medical Research, the Tourette's Association of America, and the New South Wales Higher Education and Training Institute.</span></em></p><p class="fine-print"><em><span>David Cooper was funded by the UNSW Scientia PhD scholarship for his time on this article. David is also a clinical psychologist in private practice.</span></em></p><p class="fine-print"><em><span>Jessica Grisham receives funding from the Australian Research Council and Rotary Mental Health. </span></em></p><p class="fine-print"><em><span>Katelyn Dyason receives funding from Rotary Mental Health, and was funded by Mindgardens Neuroscience Network for her time on this article. </span></em></p><p class="fine-print"><em><span>Lara Farrell receives funding from Rotary Mental Health, National Health and Medical Research Council (NHMRC), and Medical Research Future Fund (MRFF). </span></em></p><p class="fine-print"><em><span>Lizzie Manning receives funding from National Health and Medical Research Council (NHMRC), Australian Research Council (ARC) and Tourette Association of America (TAA). </span></em></p>People can be reluctant to discuss symptoms with their doctor. When they do, their symptoms can be mistaken for other illnesses. Even when people are diagnosed, they don’t always get the right treatment.Iain Perkes, Senior Lecturer, child and adolescent psychiatry, UNSW SydneyDavid Cooper, PhD Candidate, UNSW SydneyJessica Grisham, Professor in Psychology, UNSW SydneyKatelyn Dyason, Project manager and psychologist, School of Psychiatry, UNSW SydneyLara Farrell, Associate Professor and Clinical Psychologist, Griffith UniversityLizzie Manning, Lecturer in Physiology and Neuroscience, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2011012023-03-15T16:56:45Z2023-03-15T16:56:45ZAntidepressant withdrawal should be taken seriously – we’re investigating ways to help people come off the pills<p>Misinformation about antidepressants <a href="https://www.psychologytoday.com/us/blog/side-effects/202004/antidepressants-and-online-misinformation">is rife</a> and is probably fuelling their rise in use. Chief among these false ideas are: </p>
<ul>
<li><p>Antidepressant withdrawal effects are mild and only last two to three weeks, with any severe symptoms interpreted as a relapse in depression. </p></li>
<li><p>Antidepressants are not addictive, so they can’t be that difficult to stop. </p></li>
<li><p>If you are having difficulty getting off your antidepressant, that shows you must need them. </p></li>
<li><p>You should be able to stop your antidepressants in a month or two.</p></li>
<li><p>Antidepressants work by growing new brain cells. </p></li>
</ul>
<p>It is now established that antidepressants produce withdrawal symptoms that often last for many <a href="https://www.nice.org.uk/guidance/ng222/chapter/Recommendations">weeks, months</a> or even <a href="https://journals.sagepub.com/doi/full/10.1177/2045125320980573">years</a>. </p>
<p>Claims that these symptoms only last for two to three weeks came from studies conducted by drug companies where people had only used antidepressants for a couple of <a href="https://link.springer.com/article/10.1007/s40263-022-00960-y">months</a>. A recent large <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2106356">study</a> found that people who have been on antidepressants for years reported having withdrawal symptoms lasting for nine months on average. </p>
<p>About half of the people who stop taking antidepressants experience <a href="https://www.sciencedirect.com/science/article/pii/S0306460318308347?via%3Dihub">withdrawal</a>. In surveys, half of the people who stop using these drugs report having severe withdrawal <a href="https://link.springer.com/article/10.1007/s40263-022-00960-y">symptoms</a>. </p>
<p>For some people, withdrawal symptoms are debilitating and prolonged. Symptoms <a href="https://journals.sagepub.com/doi/full/10.1177/2045125320967183?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org">include</a> dizziness, headache, problems with memory and concentration, emotional disturbance and neurological symptoms such as sensitivity to noise and light, muscle spasms and <a href="https://www.bmj.com/content/368/bmj.m754.long">sexual dysfunction</a>, all of which can persist for years after <a href="https://journals.sagepub.com/doi/full/10.1177/2045125320980573">stopping</a>. </p>
<p>The longer the drugs are taken, the more severe (and probably long-lasting) the withdrawal <a href="https://link.springer.com/article/10.1007/s40263-022-00960-y">effects</a>. </p>
<p>Withdrawal effects occur from antidepressants because the brain adapts to their presence. This is often called physical <a href="https://link.springer.com/article/10.1007/s40263-022-00960-y">dependence</a>. Dependence occurs even though antidepressants do not make people high or cause craving and compulsion, which is the technical <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1360-0443.2010.03144.x">definition</a> of “addiction”. </p>
<p>When antidepressants are stopped, the brain “misses” the drug and expresses this as withdrawal symptoms. These symptoms can last months or <a href="https://link.springer.com/article/10.1007/s40263-022-00960-y">years</a> because that is how long it can take for the brain to adjust to being without the drug. </p>
<p>Since withdrawal can cause emotional <a href="https://www.cambridge.org/core/journals/bjpsych-advances/article/distinguishing-relapse-from-antidepressant-withdrawal-clinical-practice-and-antidepressant-discontinuation-studies/AE99BDE4435521CE9F3D626AE14D1962">symptoms</a> such as anxiety, low mood, crying spells and panic attacks, people often misinterpret these symptoms as a return of their mental health problem - that is, a relapse. Doctors, too, are often unaware of how common and severe withdrawal symptoms can be, and often mistake them for a <a href="https://www.cambridge.org/core/journals/bjpsych-advances/article/distinguishing-relapse-from-antidepressant-withdrawal-clinical-practice-and-antidepressant-discontinuation-studies/AE99BDE4435521CE9F3D626AE14D1962">relapse</a>.</p>
<p>This can lead people who started antidepressants following a specific stressful event, like job loss, divorce or physical illness, to conclude that they have a long-term, relapsing illness when they do not. </p>
<p>There has also been a shift in understanding about how these drugs work. Many experts now agree that antidepressants do not work by correcting an underlying chemical <a href="https://theconversation.com/depression-is-probably-not-caused-by-a-chemical-imbalance-in-the-brain-new-study-186672">imbalance</a>. Some people suggest that antidepressants work by growing new brain <a href="https://theconversation.com/considering-going-off-antidepressants-heres-what-to-think-about-first-198880">cells</a> but these claims are based on animal studies and this has never been shown in humans. </p>
<figure class="align-center ">
<img alt="The prescriptions counter at a pharmacy." src="https://images.theconversation.com/files/515274/original/file-20230314-18-cmek1c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/515274/original/file-20230314-18-cmek1c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/515274/original/file-20230314-18-cmek1c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/515274/original/file-20230314-18-cmek1c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/515274/original/file-20230314-18-cmek1c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/515274/original/file-20230314-18-cmek1c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/515274/original/file-20230314-18-cmek1c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The number of antidepressant items prescribed over the past six years in the UK has increased by 35%.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/london-june-2-2014-prescriptions-counter-1724981035">Alex Segre/Shutterstock</a></span>
</figcaption>
</figure>
<p>There is also no clear evidence that the growth of new brain cells is desirable. Indeed, it could reflect a negative effect, as damage to the brain also causes the growth of new <a href="https://www.sciencedirect.com/science/article/abs/pii/S0014488615001314">neurons</a> (as damage to the skin leads to the growth of new skin cells). </p>
<p>There are other explanations for how antidepressants exert their effects that are more plausible and supported by evidence. Antidepressants subtly change normal mental states, producing emotional numbing among other <a href="https://www.eurekaselect.com/article/90929">effects</a>. This has been shown in healthy <a href="https://theconversation.com/ssris-emotional-blunting-may-be-part-of-the-process-new-research-198264">volunteers</a>, confirming that emotional numbing is an effect of the drug and not just the depression. </p>
<p>This effect and other mental changes may account for the effect of antidepressants by suppressing the intensity of negative emotions. Or these effects may cue people to know they are taking a drug, which can amplify the placebo effect.</p>
<h2>Guidelines are finally catching up</h2>
<p>Advice from the UK’s <a href="https://www.nice.org.uk/guidance/ng222/chapter/Recommendations#delivery-of-treatments">National Institute for Health and Care Excellence</a> (Nice) and the Royal College of <a href="https://www.rcpsych.ac.uk/mental-health/treatments-and-wellbeing/stopping-antidepressants">Psychiatrists</a> on how to safely stop antidepressants has changed markedly recently. Guidelines now recommend that after long-term use, antidepressants should be reduced in slow stages (tapering) over months and sometimes years down to very low doses. </p>
<p>As these doses are much smaller than can be made with widely available tablets, the guidelines call for the use of liquid versions of <a href="https://www.nice.org.uk/guidance/ng222/chapter/Recommendations#delivery-of-treatments">drugs</a> (specially made up smaller dose tablets are another option). </p>
<p>The approach to tapering recommended by these updated guidelines is called “hyperbolic <a href="https://www.thelancet.com/article/S2215-0366(19)30032-X/fulltext">tapering</a>”. It is based on the fact that very small doses of antidepressants have very large effects on the brain. This is often why the last few milligrams of a drug are the hardest to get <a href="https://journals.sagepub.com/doi/full/10.1177/2045125321991274">off</a>. </p>
<p>To account for the larger effects on the brain at lower drug doses, dose reductions have to be made in smaller and smaller amounts as you get down to lower doses – so that people make reductions of as little as 10% or 25% of their most recent dose. Studies show that this technique can help people who were previously not able to stop their medication with traditional approaches to <a href="https://journals.sagepub.com/doi/full/10.1177/20451253211039327">safely stop it</a>. We are currently testing this approach (hyperbolic tapering) in a large trial in <a href="https://medical-school.uq.edu.au/release">Australia</a>. </p>
<p>Unfortunately, other countries including <a href="https://www.ranzcp.org/files/resources/college_statements/clinician/cpg/mood-disorders-cpg-2020.aspx">Australia</a> and the <a href="http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf">US</a> have not updated their guidance and still recommend stopping antidepressants relatively rapidly. This can result in people experiencing severe withdrawal symptoms and falsely concluding that they cannot come off their medication. </p>
<p>The difficulty many experience in trying to stop antidepressants highlights the need to be much more careful in the prescribing of these drugs. The Nice guidelines <a href="https://www.nice.org.uk/guidance/ng222/chapter/Recommendations">recommend</a> that antidepressants should not be offered as a first-choice treatment in mild depression. Even in severe depression the guidelines now recommend eight non-drug alternatives, including problem-solving therapy, exercise and a <a href="https://www.nice.org.uk/guidance/ng222/resources/discussing-firstline-treatments-for-more-severe-depression-pdf-11131007007">variety of other therapies</a>. </p>
<p>This approach was also recently supported by NHS England in its <a href="https://www.england.nhs.uk/long-read/optimising-personalised-care-for-adults-prescribed-medicines-associated-with-dependence-or-withdrawal-symptoms/">announcement</a> of an initiative to move away from the “pill for every ill” approach, to fund non-pharmaceutical alternatives for mental health problems, and to provide long-awaited services to help people stop antidepressants.</p><img src="https://counter.theconversation.com/content/201101/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Horowitz is a Collaborating Investigator on the RELEASE trial in Australia investigating supported, gradual, hyperbolic tapering of antidepressants. He is member of the Critical Psychiatry Network and an Associate of the International Institute for Psychiatric Drug Withdrawal (IIPDW). He is a co-founder of Outro Health which helps people who wish to stop unnecessary antidepressant medication in Canada and the US using gradual, hyperbolic tapering.</span></em></p><p class="fine-print"><em><span>Joanna Moncrieff is a co-investigator on a National Institute of Health Research funded study exploring methods of antidepressant discontinuation. She is co-chair person of the Critical Psychiatry Network, an informal and unfunded group of psychiatrists and an unpaid board member of the voluntary group, the Council for Evidence-based Psychiatry.</span></em></p><p class="fine-print"><em><span>Katharine Wallis receives funding from the Commonwealth Department of Health, Medical Research Future Fund, Clinician Researchers Applied Research in Health - MRFAR000079</span></em></p>Antidepressants have been prescribed to millions of people with little thought about how those people will come off them.Mark Horowitz, Clinical Research Fellow in Psychiatry, UCLJoanna Moncrieff, Professor of Critical and Social Psychiatry, UCLKatharine Wallis, Professor, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2001062023-03-06T15:09:06Z2023-03-06T15:09:06ZBipolar disorder is poorly understood in Ghana: knowing the facts can help prevent suffering<figure><img src="https://images.theconversation.com/files/511380/original/file-20230221-24-ti86q1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Bipolar disorder numbers are rising in Ghana </span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p>Attitudes to mental health conditions are often influenced by matters of awareness and belief systems. Bipolar disorder is one of the conditions that’s frequently misunderstood and stigmatised.</p>
<p>This is the case in Ghana, where bipolar is generally referred to as <em>atenkabrane nsesae yaree</em> – a condition characterised by extreme changes in mood. A recent <a href="https://opus.govst.edu/cgi/viewcontent.cgi?article=1079&context=iujsl">study</a> estimated that less than 1% of respondents in the Volta Region of Ghana for example knew the signs and symptoms of bipolar. Some people believe it “runs in the family” or that it is contagious.</p>
<p>Because of these beliefs, when people with bipolar disorder are discharged from hospital, they are not always welcome among their family members. This leads to overcrowding in the psychiatric hospitals. Even in healthcare centres, people with bipolar are sometimes treated insensitively.</p>
<p>Tackling stigma requires challenging belief systems and norms by providing knowledge and creating awareness. As <a href="https://scholar.google.com/citations?hl=en&user=mRhuzPoAAAAJ&view_op=list_works&sortby=pubdate">mental health specialists</a>, that is what we hope to do here.</p>
<h2>Bipolar disorder facts</h2>
<p>Bipolar disorder is one of the commonest mood conditions, along with depression and anxiety. <a href="https://cdn.who.int/media/docs/default-source/mental-health/special-initiative/who-special-initiative-country-report---ghana---2021.pdf">Statistics</a> from the World Health Organisation suggest that in Ghana there are about 157,543 people with bipolar: 83,354 are females and 74,189 are males. Among them, 46,054 (29%) are young adults (20-29) and 3,257 (2%) are over 70 years of age. This condition is more prevalent in young adults than older people because of vulnerability and developmental changes. </p>
<p>Bipolar is characterised by both manic episodes, or hypomania, such as impulsive behaviour, and depressive episodes, such as sadness which disrupts the individual’s normal functioning. People with this condition feel normal in between these moods but may have difficulty with concentration and communication. </p>
<p>There are various types of bipolar conditions. To make a diagnosis, the affected person must meet the criteria stated in the <a href="https://www.psychiatry.org/psychiatrists/practice/dsm">Diagnostic Statistical Manual V</a> or the WHO’s <a href="https://www.who.int/standards/classifications/classification-of-diseases">International Classification of Disease 11</a>. Trained mental health professionals can make a diagnosis of bipolar condition.</p>
<p>It has been <a href="https://journal.gcps.edu.gh/index.php/pmjg/article/view/266">reported</a> that the presence of co-morbidities such as substance abuse disorder creates a diagnostic challenge. The symptoms may be similar. </p>
<p>The exact cause of bipolar condition is not known. Multiple factors may be at play: genetic or familial transmission, imbalance of brain chemicals or environmental factors like stress and trauma. </p>
<p>Bipolar condition can be well managed with appropriate treatment. It requires lifelong treatment, and it’s important to adhere to it to prevent relapse.</p>
<p>The condition is managed by a group of anti-psychotic medications called mood stabilisers and in severe cases through electro-convulsive therapy. Treatment is managed by psychiatrists, mental health nurses and clinical psychologists. Effective <a href="https://focus.psychiatryonline.org/doi/10.1176/appi.focus.20190004">treatment</a> combines pharmacotherapy such as lamotrigine and lithium carbonate and psychotherapy such as cognitive behavioural therapy. Psychotherapy can be delivered in a group or individual format to provide skills to manage psychosocial, vocational, interpersonal and cognitive challenges.</p>
<h2>Bipolar treatment in Ghana</h2>
<p>Unfortunately, less than <a href="https://cdn.who.int/media/docs/default-source/mental-health/special-initiative/who-special-initiative-country-report---ghana---2021.pdf">2%</a> of people with bipolar disorder get treated in Ghana. </p>
<p>Services are typically provided at Ghana’s three main tertiary psychiatric hospitals in Pantang, Accra and Ankaful. Regional hospitals and primary care facilities also provide treatment for the condition. Severe cases are referred to the tertiary psychiatric hospitals.</p>
<p>Beyond these care pathways, Ghanaians sometimes use complementary and alternative therapies, especially spiritual interventions. This may be influenced by the family caregivers’ <a href="https://ugspace.ug.edu.gh/handle/123456789/31019">understanding</a> of the condition. Spiritual interventions like prayer camps are sometimes provided under poor hygienic conditions. And there is an increase in relapse because the patients aren’t given the mood stabilisers and psychotherapy they need.</p>
<p>More <a href="https://doi.org/10.1080/16549716.2022.2112404">education and awareness</a> creation is needed at the community level in Ghana to tackle stigma and encourage the use of the correct medication and psychotherapy.</p><img src="https://counter.theconversation.com/content/200106/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Mental health still carries significant stigma in Ghana.Benedict Weobong, Senior Lecturer/Global Mental Health Epidemiologist, University of GhanaIrene Botchway, Clinical Psychologist , University of GhanaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2007172023-03-01T19:06:53Z2023-03-01T19:06:53ZExercise is even more effective than counselling or medication for depression. But how much do you need?<figure><img src="https://images.theconversation.com/files/512773/original/file-20230228-22-d09pc1.jpg?ixlib=rb-1.1.0&rect=26%2C26%2C5964%2C3961&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://images.unsplash.com/photo-1549576490-b0b4831ef60a?ixlib=rb-4.0.3&ixid=MnwxMjA3fDB8MHxwaG90by1wYWdlfHx8fGVufDB8fHx8&auto=format&fit=crop&w=1470&q=80">Unsplash/Anupam Mahapatra</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>The world is currently grappling with a mental health crisis, with millions of people reporting depression, anxiety, and other mental health conditions. According to <a href="https://www.abs.gov.au/statistics/health/mental-health/national-study-mental-health-and-wellbeing/latest-release">recent estimates</a>, nearly half of all Australians will experience a mental health disorder at some point in their lifetime. </p>
<p>Mental health disorders come at great cost to both the individual and society, with depression and anxiety being among the leading causes of <a href="https://www.sciencedirect.com/science/article/abs/pii/S0140673615003906">health-related disease burden</a>. The COVID pandemic is exacerbating the situation, with a significant rise in rates of psychological distress affecting <a href="https://pubmed.ncbi.nlm.nih.gov/33794717/">one third</a> of people. </p>
<p>While traditional treatments such as therapy and medication can be effective, our <a href="https://bjsm.bmj.com/content/early/2023/02/16/bjsports-2022-106195?rss=1">new research</a> highlights the importance of exercise in managing these conditions.</p>
<p>Our recent study published in the <a href="https://bjsm.bmj.com/content/early/2023/02/16/bjsports-2022-106195?rss=1">British Journal of Sports Medicine</a> reviewed more than 1,000 research trials examining the effects of physical activity on depression, anxiety, and psychological distress. It showed exercise is an effective way to treat mental health issues – and can be even more effective than medication or counselling.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/considering-going-off-antidepressants-heres-what-to-think-about-first-198880">Considering going off antidepressants? Here's what to think about first</a>
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</em>
</p>
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<h2>Harder, faster, stronger</h2>
<p>We reviewed 97 review papers, which involved 1,039 trials and 128,119 participants. We found doing 150 minutes each week of various types of physical activity (such as brisk walking, lifting weights and yoga) significantly reduces depression, anxiety, and psychological distress, compared to usual care (such as medications). </p>
<p>The largest improvements (as self-reported by the participants) were seen in people with depression, HIV, kidney disease, in pregnant and postpartum women, and in healthy individuals, though clear benefits were seen for all populations.</p>
<p>We found the higher the intensity of exercise, the more beneficial it is. For example, walking at a brisk pace, instead of walking at usual pace. And exercising for six to 12 weeks has the greatest benefits, rather than shorter periods. Longer-term exercise is important for maintaining mental health improvements.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1627380770233876480"}"></div></p>
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Read more:
<a href="https://theconversation.com/when-its-easier-to-get-meds-than-therapy-how-poverty-makes-it-hard-to-escape-mental-illness-114505">When it's easier to get meds than therapy: how poverty makes it hard to escape mental illness</a>
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<h2>How much more effective?</h2>
<p>When comparing the size of the benefits of exercise to other common treatments for mental health conditions from previous systematic reviews, our findings suggest exercise is around 1.5 times more effective than either <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4804177/">medication</a> or <a href="https://pubmed.ncbi.nlm.nih.gov/29451967/">cognitive behaviour therapy</a>. </p>
<p>Furthermore, exercise has additional benefits compared to medications, such as <a href="https://www.cambridge.org/core/journals/epidemiology-and-psychiatric-sciences/article/excess-costs-of-depression-a-systematic-review-and-metaanalysis/8F8EE6D5D23F62C56A302EAB378F7B4D">reduced cost</a>, fewer <a href="https://www.healthdirect.gov.au/antidepressant-medicines#side-effects">side effects</a> and offering bonus gains for <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-13-813">physical health</a>, such as healthier body weight, improved cardiovascular and bone health, and cognitive benefits. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/512772/original/file-20230228-4453-nl8frz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="people running up hill" src="https://images.theconversation.com/files/512772/original/file-20230228-4453-nl8frz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/512772/original/file-20230228-4453-nl8frz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/512772/original/file-20230228-4453-nl8frz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/512772/original/file-20230228-4453-nl8frz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/512772/original/file-20230228-4453-nl8frz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/512772/original/file-20230228-4453-nl8frz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/512772/original/file-20230228-4453-nl8frz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Exercise is cheaper than medication, with fewer side effects.</span>
<span class="attribution"><a class="source" href="https://images.unsplash.com/photo-1580058572462-98e2c0e0e2f0?ixlib=rb-4.0.3&ixid=MnwxMjA3fDB8MHxwaG90by1wYWdlfHx8fGVufDB8fHx8&auto=format&fit=crop&w=1742&q=80">Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<h2>Why it works</h2>
<p>Exercise is believed to impact mental health through multiple pathways, and with short and long-term effects. Immediately after exercise, endorphins and dopamine are released in the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5928534/">brain</a>. </p>
<p>In the short term, this helps boost mood and buffer <a href="https://psycnet.apa.org/record/2006-10949-005">stress</a>. Long term, the release of neurotransmitters in response to exercise <a href="https://pubmed.ncbi.nlm.nih.gov/31586447/">promotes changes in the brain</a> that help with mood and cognition, decrease inflammation, and boost immune function, which all influence our brain function and mental health. </p>
<p>Regular exercise can lead to <a href="https://www.sciencedirect.com/science/article/pii/S1087079218301023">improved sleep</a>, which plays a critical role in depression and anxiety. It also has psychological benefits, such as <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0134804">increased self-esteem and a sense of accomplishment</a>, all of which are beneficial for people struggling with depression. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/lets-dance-how-dance-classes-can-lift-your-mood-and-help-boost-your-social-life-197692">Let's dance! How dance classes can lift your mood and help boost your social life</a>
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</p>
<hr>
<h2>Not such an ‘alternative’ treatment</h2>
<p>The findings underscore the crucial role of exercise for managing depression, anxiety and psychological distress. </p>
<p>Some clinical guidelines already acknowledge the role of exercise – for example, the <a href="https://pubmed.ncbi.nlm.nih.gov/33353391/">Australian and New Zealand Clinical Guidelines</a>, suggest medication, psychotherapy and lifestyle changes such as exercise. </p>
<p>However, other leading bodies, such as the <a href="https://www.apa.org/depression-guideline">American Psychological Association Clinical Practice Guidelines</a>, emphasise medication and psychotherapy alone, and list exercise as an “alternative” treatment – in the same category as treatments such as acupuncture.
While the label “alternative” can mean many things when it comes to treatment, it tends to suggest it sits outside conventional medicine, or does not have a clear evidence base. Neither of these things are true in the case of exercise for mental health. </p>
<p>Even in Australia, <a href="https://journals.sagepub.com/doi/10.1177/0004867412466595">medication</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/33353391/">psychotherapy</a> tend to be more commonly prescribed than exercise. This may be because exercise is hard to prescribe and monitor in clinical settings. And patients may be resistant because they feel low in energy or motivation.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/netflix-psychiatrist-phil-stutz-says-85-of-early-therapy-gains-are-down-to-lifestyle-changes-is-he-right-195567">Netflix psychiatrist Phil Stutz says 85% of early therapy gains are down to lifestyle changes. Is he right?</a>
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<h2>But don’t ‘go it alone’</h2>
<p>It is important to note that while exercise can be an effective tool for managing mental health conditions, people with a mental health condition should work with a health professional to develop a comprehensive treatment plan – rather than going it alone with a new exercise regime. </p>
<p>A treatment plan may include a combination of lifestyle approaches, such as exercising regularly, eating a balanced diet, and socialising, alongside treatments such as psychotherapy and medication. </p>
<p>But exercise shouldn’t be viewed as a “nice to have” option. It is a powerful and accessible tool for managing mental health conditions – and the best part is, it’s free and comes with plenty of additional health benefits.</p><img src="https://counter.theconversation.com/content/200717/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ben Singh receives funding from the International Society of Behaviour Nutrition and Physical Activity. </span></em></p><p class="fine-print"><em><span>Carol Maher receives funding from the Medical Research Future Fund, the National Health and Medical Research Council, the National Heart Foundation, the SA Department for Education, the SA Department for Innovation and Skills, Healthway, Hunter New England Local Health District, the Central Adelaide Local Health Network, and LeapForward.</span></em></p><p class="fine-print"><em><span>Jacinta Brinsley does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>We looked at more than 1,000 research trials and found clear evidence to back exercise as a way to improve depression, anxiety and psychological distress.Ben Singh, Research fellow, University of South AustraliaCarol Maher, Professor, Medical Research Future Fund Emerging Leader, University of South AustraliaJacinta Brinsley, Postdoctoral research fellow, University of South AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1976382023-02-28T13:10:58Z2023-02-28T13:10:58Z‘Do the little things’: why St David’s advice is good for your mental health<p><em>Gwnewch y pethau bychain</em> or “do the little things” is a saying attributed to <a href="https://theconversation.com/st-davids-day-how-the-sixth-century-monk-inspired-centuries-of-devoted-followers-and-poets-198924">St David</a>, the patron saint of Wales. But what relevance does the advice of a sixth century monk hold in 2023? </p>
<p>In modern times, doing the little things certainly is important when we consider our mental health. It can make a difference in preventing ill health and sustaining a <a href="https://theconversation.com/ive-spent-years-studying-happiness-heres-what-actually-makes-for-a-happier-life-197580">sense of happiness</a>, as well as in treating mental illness. </p>
<p>A small thing may not have a decisive effect alone, but when many are put together, they can make an overall difference. Avoiding daily alcohol is an example. Having a drink may make you feel relaxed but, over time, regular alcohol will drag down your mood. </p>
<p>Excessive <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/gps.1357">gambling</a> and <a href="https://onlinelibrary.wiley.com/doi/abs/10.1080/09595230600944461">recreational drugs</a> are also to be avoided. In contrast, regular exercise and making time for relaxation have a positive effect on our mental health. </p>
<p>Doing the small things has a role to play in treating mental illness too. Medication and therapies such as <a href="https://theconversation.com/cbt-is-wrong-in-how-it-understands-mental-illness-175943">cognitive behavioural therapy</a> have roles to play in helping people to recover from mental illness. However, they are not so effective that they are always enough on their own. They are likely to work best when they happen in the context of a trusting relationship with a doctor.</p>
<p>When patients are surveyed about what they value in a doctor, <a href="https://pubmed.ncbi.nlm.nih.gov/9823053/">human qualities consistently outrank technical abilities</a>. Research supports the idea that <a href="https://www.researchgate.net/publication/327575093_Trust_and_Communication_in_a_Doctor-_Patient_Relationship_A_Literature_Review">relationship factors</a> are important in medicine. This applies across the whole of health care, to <a href="https://pubmed.ncbi.nlm.nih.gov/27503082/">medication</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/30265840/">physiotherapy</a> as much as it does to psychotherapy. </p>
<p>Human interaction may seem a small thing but it can make a difference to how well a treatment works. Placebo effects are powerful and they are not just due to fooling yourself that dummy tablets work. The effects of a placebo can be due to all of the helpful aspects of a <a href="https://pubmed.ncbi.nlm.nih.gov/17401033/">therapeutic relationship</a>.</p>
<h2>Suicide</h2>
<p>Suicide is a devastating event, which, in the setting of the UK, is often related to <a href="https://journals.sagepub.com/doi/10.1177/0004867414555419">mental illness</a>. However, while it is important to treat people with mental illness to avoid preventable deaths, there are limitations to how effective this can be in reducing the total number of suicides. </p>
<p>Sadly, mental health treatment does not always stop people from taking their own lives. In any case, many suicidal deaths occur without the person ever receiving help. And a proportion of people who take their own life are <a href="https://www.sciencedirect.com/science/article/pii/S0165032719306202?via%3Dihub">not mentally ill</a> at all. </p>
<p>Nonetheless, suicide prevention is possible. Actions such as making it harder for people to access the means of taking their own life have repeatedly been shown to <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60521-2/fulltext">reduce suicides</a>. When restrictions were introduced to the number of paracetamol tablets that could be purchased, there was a <a href="https://pubmed.ncbi.nlm.nih.gov/23393081/">measurable impact on deaths</a>. </p>
<p>Changes in the rate of unemployment, especially among men, have a <a href="https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(14)00118-7/fulltext">predictable effect on suicide rates</a>. When unemployment rises, there is an increase in suicides. When times are better and fewer people are living in poverty, suicide rates drop. </p>
<p>It is not necessary to completely remove access to paracetamol, nor does unemployment have to be abolished. By putting together packages of smaller measures, each of which is known to have a definite but limited effect, major improvements can be achieved. Lives can be saved without seeking one perfect but unrealistic solution.</p>
<h2>Breakthroughs</h2>
<p>Having worked in mental health for 42 years, I have seen the announcement of many breakthroughs in treatment. New medications, genetic advances and novel approaches like <a href="https://theconversation.com/treating-mental-illness-with-electricity-marries-old-ideas-with-modern-tech-and-understanding-of-the-brain-podcast-195071">transcranial magnetic stimulation</a> have all been subject to extravagant claims. None of them has delivered the promised transformation of mental health care. </p>
<p>Approaches that have definite usefulness have been hyped to the point where they crowd out other treatments. That leads to cynicism when they turn out to have limitations. The most recent example is mindfulness. It has a definite role, but <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5353526/">it is not for everyone, nor is it for every problem</a>.</p>
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Read more:
<a href="https://theconversation.com/the-problem-with-mindfulness-115648">The problem with mindfulness</a>
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</em>
</p>
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<p>The trouble with looking too hard for the one extraordinary breakthrough is that it takes attention away from properly implementing what we already know works. Those imperfect smaller approaches that have been shown to be beneficial, which, when taken together, can transform people’s lives. </p>
<p>Many of these lie outside the domain of psychiatrists or psychologists. They involve social contact, a meaningful role, places to go and things to do, where people with mental illnesses are not stigmatised or separated from everybody else. </p>
<p>The ordinary actions in life matter. So let’s heed the advice of St David and “do the little things”.</p><img src="https://counter.theconversation.com/content/197638/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rob Poole is a member of the Royal College of Psychiatrists Wales. He receives funding from UKRI, Health Care and Research Wales and Betsi Cadwaladr University Health Board. He is a member of the Labour Party </span></em></p>Doing the little things has a role to play in maintaining our sense of happiness as well as in treating mental illness.Rob Poole, Professor of Social Psychiatry, Bangor UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1983942023-02-08T21:03:53Z2023-02-08T21:03:53ZTo prevent child sexual abuse, we need to change our thinking — and stop exploitation before it happens<figure><img src="https://images.theconversation.com/files/508946/original/file-20230208-16-ag4mjm.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3498%2C2534&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Talking for Change is a government-funded national program that aims to prevent child sexual abuse. It provides an anonymous national helpline and treatment options for anyone concerned about their attraction to children.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Every year, thousands of children are victims of sexual abuse in Canada. The impacts of abuse can be long-lasting, with <a href="https://doi.org/10.2105%2Fajph.91.5.753">psychological</a> and physical consequences for victims, and significant <a href="https://doi.org/10.1016/j.chiabu.2018.02.020">economic impacts</a> on our society. </p>
<p>Recent research has shown a troubling rise in online sexual offences and abuse against children in Canada, particularly during the pandemic.</p>
<p>In a 2022 report, Statistics Canada found the number of online sexual offences against children reported to police had tripled compared to the previous six-year period. Statistics Canada compiled <a href="https://www150.statcan.gc.ca/n1/pub/85-002-x/2022001/article/00008-eng.htm">research from 2014</a> — the year when Canadian cybercrime data first began to be compiled nationwide — to 2020.</p>
<p>The numbers paint a worrisome picture. According to the research, police-reported incidents of online child sexual exploitation and abuse climbed to 9,441 in 2020 from 3,080 incidents in 2014 — a three-fold increase.</p>
<p>Statistics Canada reports that in 2020, the first year of the pandemic, the rate of online child sexual abuse material (CSAM) reported to police grew to 101 incidents per 100,000 population — a 35 per cent increase from 2019. </p>
<p>The rate of online sexual offences against children, which include luring a child and distributing images without consent, also grew. In 2020 there were 30 incidents per 100,000 population, a 10 per cent increase over the previous year.</p>
<h2>The urgent need for prevention</h2>
<p>But we know these numbers don’t even come close to telling the full story. Sadly, many experiences of childhood sexual abuse go unreported. Around <a href="https://www150.statcan.gc.ca/n1/en/pub/85-002-x/2017001/article/14698-eng.pdf?st=-Zyf7J47">93 per cent of childhood sexual and physical abuse experiences are not reported</a> to the police or child protective services for a host of reasons, as Statistics Canada acknowledges in its study.</p>
<p>The increase in reported abuse and exploitation online is likely only the tip of the iceberg. But these rising incidence numbers underscore the dire need to do more to prevent child sexual abuse in Canada. It is critical that we take action to intervene early, providing individuals at risk for offending with support through an anonymous helpline, as well as therapy, to prevent abuse.</p>
<p>It also underscores that traditional ways of stopping child sexual abuse may not be enough to prevent child sexual abuse from happening.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1579852045473153026"}"></div></p>
<p>Historically in Canada, counselling programs for individuals who are concerned about their sexual interest in children are only made available <a href="https://globalnews.ca/news/889043/canada-home-to-advanced-sex-offender-treatment-programs/">after abuse has already happened</a>. People who have committed a sexual offence <a href="https://doi.org/10.1177/0093854809338545">can change their behaviour</a>. <a href="https://doi.org/10.4073/csr.2017.8">Appropriate treatment</a> is effective at reducing sexual re-offending, and there are ways to make treatment as effective as possible.</p>
<p>But intervening after a child is hurt is intervening too late, especially when prevention is possible.</p>
<h2>Talking for Change</h2>
<p>To make a difference in preventing child sexual abuse in Canada, it’s essential to acknowledge that child sexual abuse is a <a href="https://doi.org/10.1177/003335491412900303">public health problem</a> that requires a public health solution, including various prevention strategies.</p>
<p>I recently led the development of a program focused on <a href="https://doi.org/10.1080/10538712.2019.1703232">stopping child sexual abuse before it happens</a>. <a href="https://talkingforchange.ca/">Talking for Change</a>, launched in August 2021 at the Centre for Addiction and Mental Health, is the first government-funded national program that provides treatment options and anonymous support to youth and adults who are concerned about their sexual interest in children, their risk to sexually abuse a child or their use of child sexual abuse material.</p>
<p>With the support of a team of psychologists, psychotherapists, social workers and academics, the program provides an anonymous national helpline for anyone concerned about their attraction to children or who are worried about engaging in online or offline offending involving a child. </p>
<p>Talking for Change also provides therapy directly and leverages an extensive referral network to offer suggestions for fee-for-service therapy outside the jurisdictions where coverage is provided. The program’s free therapy service is provided only to people who do not have current legal involvement for a sexual offence, who want to remain offence-free and who are ready to take the next step in identifying themselves to receive service. </p>
<figure class="align-center ">
<img alt="Close-up rear view of young man in streaming on videocall on a tablet" src="https://images.theconversation.com/files/508947/original/file-20230208-31-izs242.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/508947/original/file-20230208-31-izs242.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/508947/original/file-20230208-31-izs242.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/508947/original/file-20230208-31-izs242.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/508947/original/file-20230208-31-izs242.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/508947/original/file-20230208-31-izs242.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/508947/original/file-20230208-31-izs242.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The free therapy service provided by Talking for Change is offered only for people who do not have current legal involvement for a sexual offence, who want to remain offence-free and who are ready to take the next step in identifying themselves to receive service.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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</figure>
<p>While the helpline is national, the (often virtual) therapy program is currently available in Ontario, Atlantic Canada, Québec, Nunavut and Yukon, with plans to expand to additional provinces. </p>
<p>Over the past 18 months, our team has received more than 250 contacts from individuals seeking counselling or information to prevent child sexual abuse. We provided them with a safe space to talk. We listened and communicated, <a href="https://psycnet.apa.org/doiLanding?doi=10.1037/sah0000154">without judgment or stigma</a>. We helped them realize they are not alone and that they are not doomed or destined to offend. </p>
<p>Most importantly, we developed strategies to prevent them from hurting anyone.</p>
<h2>International prevention efforts</h2>
<p>Talking for Change is not the only prevention program. In the United Kingdom, Ireland and the United States, the program <a href="https://www.stopitnow.org/">Stop it Now!</a> provides similar prevention through an anonymous helpline. </p>
<p>In Germany, the <a href="https://www.troubled-desire.com/">Troubled Desire</a> program aims to provide prevention techniques through self-guided digital intervention. Early data indicates that prevention programs are a <a href="https://doi.org/10.1007/s11920-022-01375-8">promising technique to reduce child sexual abuse</a>.</p>
<p>In fact, an <a href="https://www.stopitnow.org.uk/wp-content/uploads/2022/02/stop_it_now_evaluation_summary.pdf">assessment study of the United Kingdom’s “Stop it Now!”</a> program showed that there is a clear demand for confidential helplines providing information, advice, support and guidance to people concerned about preventing child sexual abuse. </p>
<p>This includes people concerned about their own thoughts or actions as well as individuals concerned about a child or adult’s behaviour or a child who may be at risk. </p>
<p>The study found that: </p>
<blockquote>
<p>“the helplines can provide cost effective, quality advice and support to protect children directly, and to prompt behaviour change in adults and strengthen protective factors which can reduce the risk of offending.”</p>
</blockquote>
<h2>Breaking the silence</h2>
<p>Child sexual abuse is such a dark and taboo subject that it may be difficult for many people to extend the focus beyond the victims and try to understand what leads someone to offend against a child or to use child sexual abuse material. </p>
<p>People may prefer not to think about it, and find it easier to avoid difficult conversations. Sadly that means the problem may continue to grow worse in the silence.</p>
<p>The people we counsel in the Talking for Change program often tell us that they wish they didn’t have these feelings or urges. And they tell us that they do not want to hurt anyone, and that in many cases they want to help prevent child abuse in Canada.</p>
<p>Talking for Change has only begun to scratch the surface of this problem. But we’re confident, based on the impact we’ve made in our first year, that prevention is not only possible, it’s happening.</p><img src="https://counter.theconversation.com/content/198394/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ainslie Heasman works for the Centre for Addiction and Mental Health (CAMH). </span></em></p>There is a dire need to prevent child sexual abuse in Canada. It is critical to intervene early, and provide those at risk for offending with support through an anonymous helpline, as well as therapy.Ainslie Heasman, Clinical Forensic Psychologist, Centre for Addiction and Mental Health, and Adjunct Professor, Faculty of Social Sciences and Humanities, Ontario Tech UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1992902023-02-07T19:04:23Z2023-02-07T19:04:23ZThe TGA has approved certain psychedelic treatments: the response from experts is mixed<figure><img src="https://images.theconversation.com/files/508558/original/file-20230207-15-pxckyl.jpg?ixlib=rb-1.1.0&rect=16%2C16%2C3730%2C2247&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Collaborative care teams will need to be established for safe treatment.</span> <span class="attribution"><span class="license">Author provided</span></span></figcaption></figure><p>A few days ago, the Australian drug regulator – the Therapeutic Goods Administration (TGA) – surprised experts around the world when it announced the approval of certain psychedelic treatments. </p>
<p>From July this year, the TGA will <a href="https://www.tga.gov.au/news/media-releases/change-classification-psilocybin-and-mdma-enable-prescribing-authorised-psychiatrists">permit</a> authorised psychiatrists to prescribe psilocybin (found in “magic mushrooms”) for treatment-resistant depression, and MDMA (found in “ecstasy”) for post-traumatic stress disorder.</p>
<p>I head up Australia’s first <a href="https://www.monash.edu/turner-institute/paul-liknaitzky-lab">clinical psychedelic lab</a>, where we develop psychedelic-assisted therapies for treating various mental illnesses, test their safety and effectiveness, explore how the treatments work, and train therapists. </p>
<p>I’ve witnessed, up close, the rapidly accelerating developments within the field and in positive public sentiment, over a few short years. But this surprising announcement may have devils – and angels – in the detail. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ai-maps-psychedelic-trip-experiences-to-regions-of-the-brain-opening-new-route-to-psychiatric-treatments-179263">AI maps psychedelic 'trip' experiences to regions of the brain – opening new route to psychiatric treatments</a>
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<h2>In from the wilderness</h2>
<p>Just a <a href="https://theconversation.com/shroom-to-grow-australias-missing-psychedelic-science-17344">few years ago</a>, Australia had no psychedelic research, almost no professional interest, and negligible public awareness of the clinical potential of these treatments. </p>
<p>The <a href="https://www.svhm.org.au/newsroom/news/australia-s-first-psychedelic-clinical-trial-commences-recruitment">first psychedelic trial</a> in Australia was approved in 2019. We established the country’s <a href="https://www.monash.edu/turner-institute/paul-liknaitzky-lab/research">first clinical psychedelic lab</a> in 2020. And by the end of 2023 there will be more than 15 active clinical psychedelic trials nationwide.</p>
<p>While the TGA’s announcement was hailed as groundbreaking, there are actually a handful of places where psychedelic-assisted therapies have been approved for very limited clinical use outside of research trials (for example, compassionate or expanded access programs in the <a href="https://maps.org/news/media/press-release-fda-agrees-to-expanded-access-program-for-mdma-assisted-psychotherapy-for-ptsd/">United States</a>, <a href="https://www.canada.ca/en/health-canada/services/substance-use/controlled-illegal-drugs/magic-mushrooms.html#a22">Canada</a>, and <a href="https://maps.org/2019/02/04/israel-approves-compassionate-use-of-mdma-assisted-psychotherapy-for-ptsd/">Israel</a>, and a version of authorised prescribers in <a href="https://www.frontiersin.org/articles/10.3389/fpsyt.2022.863552/full">Switzerland</a>). </p>
<p>But this is the first time a government has changed the way these drugs are formally classified (“scheduled”). This may turn out to be a distinction without difference, as only so-called “authorised prescribers” will be approved to use these drugs outside of trials; or instead, it may turn out to be be a watershed moment with dramatic effects on the field globally.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/508525/original/file-20230207-15-n2ozy4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="mushrooms grown in red lit natural environment" src="https://images.theconversation.com/files/508525/original/file-20230207-15-n2ozy4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/508525/original/file-20230207-15-n2ozy4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/508525/original/file-20230207-15-n2ozy4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/508525/original/file-20230207-15-n2ozy4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/508525/original/file-20230207-15-n2ozy4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/508525/original/file-20230207-15-n2ozy4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/508525/original/file-20230207-15-n2ozy4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Only certain types of mushrooms produce psilocybin.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mushrooms-containing-psilocybin-grow-fairy-forest-1847112112">Shutterstock</a></span>
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</figure>
<h2>Emerging evidence</h2>
<p>Emerging evidence shows that, when used alongside psychotherapy, certain psychedelic drugs can be safe to administer and produce large, rapid and sustained benefits for a range of addiction and mental health conditions. These include <a href="https://www.nature.com/articles/s41591-021-01336-3">post-traumatic stress disorder</a>, <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2772630">depression</a>, <a href="https://journals.sagepub.com/doi/10.1177/0269881116675513">end-of-life distress</a>, <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2795625">alcohol use disorder</a>, and <a href="https://www.tandfonline.com/doi/abs/10.3109/00952990.2016.1170135?journalCode=iada20">nicotine dependence</a>. </p>
<p>While there are some important research limitations associated with these studies, the results have been compelling. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/albertas-new-policy-on-psychedelic-drug-treatment-for-mental-illness-will-canada-lead-the-psychedelic-renaissance-195061">Alberta’s new policy on psychedelic drug treatment for mental illness: Will Canada lead the psychedelic renaissance?</a>
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</p>
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<h2>Cautious optimism</h2>
<p>Since the announcement, I’ve spoken with numerous clinicians and researchers working in psychedelic trials in Australia, and all have expressed mixed reactions to the TGA news.</p>
<p>There’s excitement: about drug policy progress; about potential access for more people in need; about the prospect of being able to offer patients more suitable and tailored treatment without the constraints imposed by clinical trials and rigid protocols. </p>
<p>And then there are concerns: that evidence remains inadequate, and moving to clinical service is premature; that incompetent or poorly equipped clinicians could flood the space; that treatment will be unaffordable for most; that formal oversight of training, treatment, and patient outcomes will be minimal or ill-informed. </p>
<p>Many professionals working at the coalface are concerned that soon-to-be prescribers, therapists, and decision-makers probably <em>don’t know that they don’t know</em> about some of the essential elements of safe and effective psychedelic therapy. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1621434935419576324"}"></div></p>
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Read more:
<a href="https://theconversation.com/latest-trials-confirm-the-benefits-of-mdma-the-drug-in-ecstasy-for-treating-ptsd-173070">Latest trials confirm the benefits of MDMA – the drug in ecstasy – for treating PTSD</a>
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<hr>
<h2>Angels or devils</h2>
<p>The TGA announcement cites <a href="https://www.tga.gov.au/resources/publication/publications/independent-expert-panel-mdma-and-psilocybin">promising evidence</a> as the basis for its decision. However, its approach does not appear to account for factors that may be key to this evidence base, and leaves some critical questions unanswered. Here are a few things to watch:</p>
<p><strong>Who treats?</strong></p>
<p>The TGA decision permits only authorised psychiatrists to administer this treatment, and <a href="https://www.tga.gov.au/sites/default/files/2023-02/notice-of-final-decision-to-amend-or-not-amend-the-current-poisons-standard-june-2022-acms-38-psilocybine-and-mdma.pdf">states</a> “the product must not be supplied to other practitioners who prescribe or administer the product”. </p>
<p>While psychiatrists are an important part of a collaborative care model, they will need substantial psychedelic training to deliver this complex form of drug-augmented psychotherapy. What will constitute adequate psychedelic training is unlikely to be clarified, nor is there a requirement for practitioners to be supervised by psychedelic experts. </p>
<p>Psychedelic therapies are so dissimilar to general psychiatry that simply trusting that psychiatrists “<a href="https://www.tga.gov.au/sites/default/files/2023-02/notice-of-final-decision-to-amend-or-not-amend-the-current-poisons-standard-june-2022-acms-38-psilocybine-and-mdma.pdf">have the training and expertise […] to appropriately treat</a>” patients using psychedelics is ill-informed.</p>
<p>Moreover, any requirement to have psychiatrists attend all treatment sessions (dosing days typically last eight hours and a typical treatment model involves about <a href="https://maps.org/mdma/mdma-resources/treatment-manual-mdma-assisted-psychotherapy-for-ptsd/">40 hours of therapy</a>) will make this even less affordable. </p>
<p>Any prospective authorised prescriber will need extensive training and ongoing supervision from credible professionals who have experience delivering psychedelic therapy, and should establish collaborative care teams with qualified psychologists and psychotherapists.</p>
<p><strong>Who is treated?</strong></p>
<p>The evidence for safe and effective psychedelic treatments comes from trials with very strict eligibility criteria. Over 90% of applicants to these trials are typically excluded. </p>
<p>Trials are cautious, in part because we know these treatments can <a href="https://journals.sagepub.com/doi/abs/10.1177/0269881116662634?journalCode=jopa">destabilise people</a>, exacerbate certain symptoms, and increase suicidality. The excellent track record of safety across almost all modern psychedelic trials has been established in the context of extensive screening. </p>
<p>Authorised prescribing will open up the eligibility to a greater diversity of help-seekers. This is a good step, but should be well-informed, and taken with caution and transparency. </p>
<p><strong>What does treatment involve?</strong></p>
<p>Since 1999, clinical psychedelic trials have delivered psychotherapeutic support before, during, and after the drug administration, with one to three dosing sessions. The <a href="https://www.tga.gov.au/sites/default/files/2023-02/notice-of-final-decision-to-amend-or-not-amend-the-current-poisons-standard-june-2022-acms-38-psilocybine-and-mdma.pdf">TGA decision</a> does not mandate any of this, advising “there does not currently appear to be any established treatment protocols”. </p>
<p>This is a misunderstanding. While treatment protocols across trials are not all the same, they certainly exist, and there is considerable overlap in the therapeutic approaches used. Improved protocols will be developed over time, but a sensible approach is to start with an approximation of what has been done in trials that have shown safe and effective outcomes.</p>
<p><strong>Are patients informed before they consent?</strong></p>
<p>Practitioners need to make informed decisions about any departure from precedent, and be transparent about those details with patients. </p>
<p>For example, if a prescriber does not provide therapy, does not have psychedelic training or supervision, or offers more than three dosing sessions, patients need to know which aspects of their treatment sit outside the evidence base. </p>
<p>Wider prescribing will effectively entail a “community-based experiment”, and a basic right of all patients is that they are able to make informed decisions about their treatment.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/508554/original/file-20230207-29-qmn8xb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="chemical molecule" src="https://images.theconversation.com/files/508554/original/file-20230207-29-qmn8xb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/508554/original/file-20230207-29-qmn8xb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/508554/original/file-20230207-29-qmn8xb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/508554/original/file-20230207-29-qmn8xb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/508554/original/file-20230207-29-qmn8xb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/508554/original/file-20230207-29-qmn8xb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/508554/original/file-20230207-29-qmn8xb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">MDMA has been approved for treatment of PTSD.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/molecule-mdma-ball-stick-molecular-model-1964905126">Shutterstock</a></span>
</figcaption>
</figure>
<h2>A brave new world?</h2>
<p>There are many other questions worth grappling with over the next five months, including those regarding appropriate oversight and patient protection, affordability and reimbursement, and public expectations and awareness. </p>
<p>I feel cautiously optimistic that many more Australian patients may be able to access safe and effective psychedelic treatments, and that the Australian mental health care sector has an opportunity to learn how best to deliver them.</p>
<p>To those planning to work in this space in Australia, I urge you to start or continue climbing the steep learning curve with curiosity, to organise reputable training, support, and resources from those already doing the work, and to establish appropriate systems of governance, oversight, and transparency. </p>
<p>There’s so much potential here, plenty at stake, and work to be done. </p>
<hr>
<p><em>If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.</em></p><img src="https://counter.theconversation.com/content/199290/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Liknaitzky has received research funding from Incannex Healthcare Ltd, Dr Nigel Strauss, and the Multidisciplinary Association for Psychedelic Studies. He is a member of the Medical Advisory Board of Incannex Healthcare Ltd.</span></em></p>From July this year, some psychiatrists will be able to prescribe psychedelics to some patients. Responses from experts working in the field are mixed.Paul Liknaitzky, Head of Clinical Psychedelic Research, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1990542023-02-03T13:36:33Z2023-02-03T13:36:33ZShrinking: a psychiatrist doesn’t know the ‘truth’ and other issues with the show’s depiction of therapy, according to a clinical psychologist<p>Shrinking is advertised as the story of the grieving therapist Jimmy (Jason Segel) who has lost his wife and wants to try a new approach to his loss, one that involves honesty, including telling his clients exactly what he thinks of them and their problems. Humour (it is hoped), insight into human nature (presumably) and a thoughtful consideration of the role of honesty in therapy will follow.</p>
<p>Unfortunately, for this viewer at least, there was precious little humour, less insight and some rather bizarre assumptions about human nature in general. </p>
<p>As a clinical psychologist of many years’ experience, I can tell you Jimmy commits many major errors of judgment within the first five minutes of screen time.
Almost nothing of Segel’s character’s behaviour bore the faintest resemblance to the experience of real life therapy – even in the rather extreme environment of Hollywood.</p>
<p>The central conceit, that Jimmy tells his clients the truth, is clearly not only professionally unacceptable, it isn’t even true within the logic of the show. Jimmy does not “tell them the truth”, he tells them what he is assuming, what he’s fantasising about, what he wants to say, without filtering those thoughts to meet the needs of his clients. </p>
<p>I am no po-faced puritan. I like farce and I love the idea of puncturing the arrogance of therapists, psychologists and psychiatrists. I would have enjoyed being outraged. I wasn’t, I was irritated.</p>
<p>This is, of course, a work of fiction but many of the ideas are harmful (even when you know they’re fictitious). The central concept is of course based on professional misconduct, but that isn’t even the start of it. </p>
<h2>Professional malpractice is not funny</h2>
<p>I have worked as a clinical psychologist for over 30 years. I was also particularly struck by the purported reasons why people might end up seeking therapy and – most especially – what might actually help. My experience, as a client and as a therapist, is that most people come to therapy in considerable emotional pain, with significant real-world problems that are affecting their mental health; people who deserve a serious responses and for whom glib answers would be harmful. </p>
<p>On the (relatively few) occasions that I have been asked by a client to be honest, my truthful answer has been something along the lines of: </p>
<blockquote>
<p>If I were in your position, I would almost certainly find myself acting more or less like you are. My only advantage over you is that, simply because I’m not living your life and I haven’t been through what you’ve been through, I have the benefit of a little perspective. </p>
</blockquote>
<p>It’s a sign of huge arrogance to assume – and to put into the mouth of an actor –the idea that a therapist can not only see “the truth” but that somehow this could help a client. </p>
<figure>
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</figure>
<p>It is true that cognitive behavioural therapy (CBT, the form of therapy featured on this show) relies heavily on the ideas of “thinking errors” or “dysfunctional beliefs”, but even CBT practitioners are fully aware of the <a href="https://link.springer.com/chapter/10.1007/978-3-030-24386-9_12">limitations of their own perspective</a>. They know the risks they run when they make assumptions about what’s “really” going on, and serious commentators prefer to discuss the advantages of <a href="https://academic.oup.com/schizophreniabulletin/article/35/5/865/1912646">expanding the range of perspectives</a> on an issue, rather than imposing “the truth”. Even advice is usually seen as ill-advised; Jimmy’s behaviour is anathema.</p>
<p>Jimmy indulges in cocaine and alcohol to excess, as well as exhibiting other significantly worrying behaviour. He turns up at work high, drunk and sleep-deprived. He makes assumptions about his clients, and bullies them into taking part in supposedly therapeutic activities that would, in reality, only serve to harm most clients. Therapy involves <a href="https://psychotherapy.psychiatryonline.org/doi/full/10.1176/appi.psychotherapy.2016.70.1.125">sustained attention on the part of the therapist</a>, helping the client link ideas, drawing out the meaning and significance of details. Drug-addled and sleep-deprived therapists cannot function professionally.</p>
<h2>Poor practice</h2>
<p>If you are lucky enough to be referred to see a therapist, rest assured that even the worst-credentialed practitioners bear no relationship to Jimmy’s pre-adolescent jumble of emotions and behaviour. </p>
<p>There is poor practice, of course. Many of us are engaged in a deadly-serious campaign to root out <a href="https://www.bbc.co.uk/news/uk-63061077">abuses within the mental health system</a> and to bring in <a href="https://www.ohchr.org/en/press-releases/2017/06/world-needs-revolution-mental-health-care-un-rights-expert">more enlightened approaches</a>. </p>
<p>What we mean by “more enlightened” is moving away from the idea that people are distressed as a result of “disorders” that can be treated with the help of medication or, indeed, through the input of therapists who somehow (despite their own failings) can offer insights and advice unavailable to their clients.</p>
<p>Shrinking is entirely unrelated to that effort because it is so far from reality as to be irrelevant even as a form of parody of misconduct.</p>
<p>Jimmy is at least as flawed as his clients. I love the idea that we’re all human, but I found little humanity in this portrayal – here, everybody is portrayed as damaged. </p>
<p>The therapy industry is ripe for parody. But Shrinking fails to do that. If you want to see high-quality drama about therapy, watch The Sopranos. If you want to see a parody of infuriating craziness, watch It’s Always Sunny in Philadelphia. If you want to see unprofessional antics, watch the UK version of The Office. Taste is a very personal thing; I could see what the writers of Shrinking were trying to do. But I’m afraid – for this viewer and clinical psychologist – they missed the mark.</p><img src="https://counter.theconversation.com/content/199054/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Kinderman does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There is a lot to parody about psychiatry but this show falls short on many fronts.Peter Kinderman, Professor of Clinical Psychology, University of LiverpoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1950612023-01-15T14:36:13Z2023-01-15T14:36:13ZAlberta’s new policy on psychedelic drug treatment for mental illness: Will Canada lead the psychedelic renaissance?<figure><img src="https://images.theconversation.com/files/502616/original/file-20221223-30570-ki7ovk.jpg?ixlib=rb-1.1.0&rect=20%2C122%2C1901%2C1182&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Psychedelics are being held up as a potential solution to the growing need for mental health treatment. But, magic mushrooms are not magic bullets.</span> <span class="attribution"><span class="source">(AP Photo/Peter Dejong)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/alberta-s-new-policy-on-psychedelic-drug-treatment-for-mental-illness--will-canada-lead-the-psychedelic-renaissance" width="100%" height="400"></iframe>
<p><a href="https://www.cbc.ca/news/canada/edmonton/psychedelics-alberta-regulations-united-conservative-party-government-ketamine-psilocybin-mdma-1.6622674">Patients in Alberta</a> will now be able to legally consider adding psychedelic-assisted therapy to the list of treatment options available for mental illnesses. </p>
<p>Alberta psychiatrists and policymakers suggest that they are getting ahead of the curve by creating regulations to ensure the safe use of these hallucinogenic substances in a therapeutically supported environment. As of Jan. 16, the option is available only through <a href="https://www.alberta.ca/psychedelic-drug-treatment-service-provider-licensing.aspx">registered and licensed</a> psychiatrists in the province. </p>
<p>Alberta’s new policy may set a precedent that moves Canadians one step closer to accepting psychedelics as medicinal substances, but historically these drugs were widely sought out for recreational and non-clinical purposes. And, if cannabis has taught us anything, medicalizing may simply be a short stop before decriminalizing and commercializing.</p>
<p><a href="https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/hallucinogens">Psychedelic drugs</a> — including LSD, psilocybin (magic mushrooms), MDMA (ecstasy) and DMT (ayahuasca) — are criminalized substances in most jurisdictions around the world, but some people are suggesting it is time to re-imagine them as medicines. A few places are even <a href="https://bc.ctvnews.ca/stigma-against-psychedelics-could-fade-with-b-c-decriminalization-experts-say-1.6035470">considering decriminalizing psychedelics</a> altogether, claiming that naturally occurring plants like mushrooms, even “magic” ones, should not be subject to legal restrictions. </p>
<p>In the wake of cannabis reforms, it appears that psychedelics may be the next target in the dismantling of the war on drugs. Canada made bold strides internationally with its widespread <a href="https://www.justice.gc.ca/eng/cj-jp/cannabis/">cannabis decriminalization</a>, but are Canadians ready to lead the psychedelic renaissance?</p>
<h2>Early psychedelic research</h2>
<p>There is some precedent for taking the lead. In the 1950s and ‘60s, an earlier generation of researchers pioneered the first wave of psychedelic science, including Canadian-based psychiatrists who <a href="https://www.mqup.ca/psychedelic-prophets-products-9780773555068.php">coined the word psychedelic</a> and made headlines for dramatic breakthroughs using <a href="https://doi.org/10.1093/shm/hkl039">LSD to treat alcoholism</a>. </p>
<p>Vancouver-based therapists also used LSD and psilocybin mushrooms to treat <a href="https://www.anvilpress.com/books/the-acid-room-the-psychedelic-trials-and-tribulations-of-hollywood-hospital">depression and homosexuality</a>. While homosexuality was considered both illegal and a mental disorder until later in the 1970s, psychedelic therapists pushed back against these labels as patients treated for same-sex attraction more often experienced feelings of acceptance — reactions that aligned this particular approach in Vancouver with the gay rights movement.</p>
<p>Despite positive reports of clinical benefits, by the end of the 1960s psychedelics had earned a reputation for recreational use and clinical abuse. And, there was good reason to draw these connections, as psychedelic drugs had moved from pharmaceutical experimentation into mainstream culture, and some researchers had <a href="https://www.thecanadianencyclopedia.ca/en/article/mkultra">come under scrutiny for unethical practices</a>.</p>
<h2>Regulation and criminalization</h2>
<p>Most legal psychedelics ground to a halt in the 1970s with a set of regulatory prohibitions and cultural backlash. In public health reports since the 1970s, psychedelics have been described as objects of <a href="https://www.unodc.org/unodc/en/Resolutions/resolution_1968-05-23_6.html">unethical research, recreational abuse and personal risk</a> including injury and even death.</p>
<p>Underground chemists and consumers tried to combat this image, suggesting that psychedelics provided intellectual and spiritual insights and <a href="https://www.artsy.net/article/artsy-editorial-psychedelics-offer-artists-creative-boost">enhanced creativity</a>.</p>
<p>Most jurisdictions around the world criminalized psychedelics, whether for clinical research or personal experimentation. <a href="https://doi.org/10.2307/20067845">Indigenous and non-western uses</a> of hallucinogenic plants of course stretch back even further in history, and these too <a href="https://www.encyclopedia.com/history/united-states-and-canada/north-american-indigenous-peoples/native-american-church">came under legal scrutiny</a> through a combination of colonial pressures to assimilate and a looming war on drugs that did not distinguish between religious practices and drug-seeking behaviours.</p>
<h2>The return of psychedelics</h2>
<figure class="align-center ">
<img alt="Close-up view of long-stemmed mushrooms with reddish-brown caps" src="https://images.theconversation.com/files/503188/original/file-20230105-105030-6isavs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/503188/original/file-20230105-105030-6isavs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/503188/original/file-20230105-105030-6isavs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/503188/original/file-20230105-105030-6isavs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/503188/original/file-20230105-105030-6isavs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=508&fit=crop&dpr=1 754w, https://images.theconversation.com/files/503188/original/file-20230105-105030-6isavs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=508&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/503188/original/file-20230105-105030-6isavs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=508&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">At the moment, the next generation of scientific research on psychedelics still lags behind the popular enthusiasm that has catapulted these substances into the mainstream.</span>
<span class="attribution"><span class="source">(AP Photo/Peter Dejong)</span></span>
</figcaption>
</figure>
<p>In the last decade, regulations prohibiting psychedelics have started relaxing. The U.S. Food and Drug Administration has designated breakthrough therapy status to <a href="https://maps.org/news/media/press-release-fda-grants-breakthrough-therapy-designation-for-mdma-assisted-psychotherapy-for-ptsd-agrees-on-special-protocol-assessment-for-phase-3-trials/">MDMA</a> and <a href="https://www.livescience.com/psilocybin-depression-breakthrough-therapy.html">psilocybin</a>, based on their performance in clinical trials with post-traumatic stress disorder (PTSD) and treatment-resistant depression, respectively. </p>
<p>Health Canada has provided exemptions for the <a href="https://www.cbc.ca/news/canada/london/some-doctors-therapists-get-health-canada-permission-to-use-magic-mushrooms-1.5834485">use of psilocybin for patients with end-of-life anxiety</a>, and has started approving suppliers and therapists interested in working with psychedelic-assisted psychotherapy. <a href="https://michener.ca/ce_course/fpp/">Training programs</a> for psychedelic therapists are popping up across Canada, perhaps anticipating a change in regulation and the current <a href="https://www.ctvnews.ca/health/canadian-health-care-professionals-request-psilocybin-for-training-1.5801538">lack of trained professionals</a> ready to deliver psychedelic medicine.</p>
<p>At the moment, the next generation of scientific research on psychedelics still lags behind the popular enthusiasm that has catapulted these substances into the mainstream. <a href="https://www.smh.com.au/lifestyle/health-and-wellness/the-unparalleled-greatest-feeling-or-risky-drug-inside-the-celebrity-loved-psychedelic-20220331-p5a9oa.html">Celebrity testimonials</a> and compelling <a href="https://open-foundation.org/hear-about-psychedelic-clinical-studies-from-the-perspective-of-patients/">patient accounts</a> are competing for our attention. </p>
<p>Meanwhile, the growing burden of mental illness continues to <a href="https://www.ctvnews.ca/health/some-canadians-waiting-months-for-public-and-private-mental-health-services-1.6204350">overwhelm our health-care systems</a>. Psychedelics are being held up as a potential solution. But, magic mushrooms are not magic bullets.</p>
<h2>Beyond the medical marketplace</h2>
<p>Historically hallucinogenic substances have defied simple categorization as medicines, spiritual enhancers, toxins, sacred substances, rave drugs, etc. Whether or not Health Canada, or the province of Alberta, reclassifies psychedelics as a bona fide therapeutic option, these psychoactive substances will continue to attract consumers outside of clinical settings.</p>
<p>Canada has an opportunity to take the lead once more in this so-called psychedelic renaissance. But, it might be our chance to invest in more sustainable solutions to harm reduction and ways of including Indigenous perspectives, rather than racing to push psychedelics into the medical marketplace. </p>
<p><a href="https://www.culturalsurvival.org/publications/cultural-survival-quarterly/hallucinogenic-plants-and-their-use-traditional-societies">Indigenous approaches to sacred plants</a> are not only about consuming substances, but involve preparation, intention and integration, often structured in ritualistic settings that are as much about spiritual health as physical or mental health. </p>
<p>This cosmology and approach does not easily fit under the Canada Health Act, nor is it obvious who should be responsible for regulating or administering rituals that sit outside of our health-care system. These differences in how we might imagine the value of psychedelics is an opportunity to rethink the place of Indigenous knowledge in health systems. </p>
<p>We are well positioned to take a sober approach to the psychedelic hype, which has been driven in large part by financial interests, and consider what aspects of the psychedelic experience we want to preserve. </p>
<p>Now may be a good time to reinvest in our public institutions to ensure that psychedelics don’t simply become another pharmaceutical option that profits private investors. Instead, we have an opportunity with psychedelics to rethink how a war on drugs has harmed individuals and communities and how we might want to build a better relationship with pharmaceuticals.</p><img src="https://counter.theconversation.com/content/195061/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Erika Dyck receives funding from Social Sciences and Humanities Research Council.
She is a board member of the US not-for-profit Chacruna Institute for Psychedelic Plant Medicines.</span></em></p>Alberta’s new policy on psychedelic-assisted therapy for mental illness may set a precedent that moves Canadians one step closer to accepting psychedelics as medicinal substances.Erika Dyck, Professor and Canada Research Chair in the History of Health & Social Justice, University of SaskatchewanLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1910112023-01-09T19:09:03Z2023-01-09T19:09:03ZSecrecy, psychosis and difficult change: these lived experiences of mental illness will inspire a kaleidoscope of emotions<figure><img src="https://images.theconversation.com/files/502082/original/file-20221220-11-raywvl.png?ixlib=rb-1.1.0&rect=0%2C0%2C4000%2C2000&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> </figcaption></figure><p>The introduction to <a href="https://upswellpublishing.com/product/admissions">Admissions</a> states: </p>
<blockquote>
<p>There is no way to neatly summarise what Admissions is or what it contains. If we were to write shorthand case notes to hand it over to you as a reader, they would say… </p>
</blockquote>
<p>This is followed by a large paragraph of disjointed words, beginning with “Dolphins” and ending with “So many flipped moons”.</p>
<hr>
<p><em>Review: Admissions, edited by David Stavanger, Radhiah Chowdhury and Mohammad Awad (Upswell Press)</em></p>
<hr>
<p>Admissions is not an organised collection of stories, nor a thematic discourse or commentary on mental health. It is difficult to read if you are expecting a linear progression of ideas. </p>
<p>But overall, this is a text that can broaden our views on all sorts of aspects of mental health. The book contains a variety of perspectives from people with lived experience of mental health issues, presenting the content in a variety of ways including poems, prose, diagrams and sketches. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/501822/original/file-20221219-22-5i9wr3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/501822/original/file-20221219-22-5i9wr3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/501822/original/file-20221219-22-5i9wr3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=615&fit=crop&dpr=1 600w, https://images.theconversation.com/files/501822/original/file-20221219-22-5i9wr3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=615&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/501822/original/file-20221219-22-5i9wr3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=615&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/501822/original/file-20221219-22-5i9wr3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=772&fit=crop&dpr=1 754w, https://images.theconversation.com/files/501822/original/file-20221219-22-5i9wr3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=772&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/501822/original/file-20221219-22-5i9wr3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=772&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">One of the artworks included in Admissions is ‘Intricately and Intimately Fractured’ by Anthony Mannix.</span>
<span class="attribution"><span class="source">Upswell Publishing</span></span>
</figcaption>
</figure>
<h2>Honest truths and deep pain</h2>
<p>The honest truths about the deep pain suffered by many people with lived experience of mental health issues may be new to readers, even those working in healthcare. For example, Kobie Dee writes in Role Models about why alcohol and drugs bring some relief for pain – and how change is not possible without a role model. His story of how he learned to cope makes it obvious that change is truly challenging. </p>
<p>We get an honest view of the carer’s life in Roller Coaster by Kristen Dunphy, through in-depth descriptions of the awful experience and incredible sadness of being with a loved one who has episodes of despair and frantic behaviour. </p>
<p>The story, told by a wife, leaves the reader with the sense this relationship is doomed by the confusion and struggles in caring for a partner with mental health issues. The carer’s story is a rarely heard viewpoint in healthcare, but the views expressed by Kristen Dunphy are crucial to absorb.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/501760/original/file-20221219-37196-wbfujz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/501760/original/file-20221219-37196-wbfujz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/501760/original/file-20221219-37196-wbfujz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=840&fit=crop&dpr=1 600w, https://images.theconversation.com/files/501760/original/file-20221219-37196-wbfujz.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=840&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/501760/original/file-20221219-37196-wbfujz.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=840&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/501760/original/file-20221219-37196-wbfujz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1055&fit=crop&dpr=1 754w, https://images.theconversation.com/files/501760/original/file-20221219-37196-wbfujz.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1055&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/501760/original/file-20221219-37196-wbfujz.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1055&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p>The front cover is a commissioned piece of art by Amani Haydar (author of the memoir <a href="https://www.panmacmillan.com.au/9781760982454/">The Mother Wound</a>, about the aftermath of her father’s murder of her mother – and one of the book’s contributors). It depicts a woman’s face, crying on one side, blank on the other: rays of light are emitted from the crying eye. The evocative image is open to many interpretations – and this is the hallmark of the whole book. The reader can see in it whatever they wish to see. </p>
<p>For example, take the intriguing title. Initially, the term “Admissions” brings hospital (or <a href="https://theconversation.com/sexual-assaults-in-psych-wards-show-urgent-need-for-reform-14265">psychiatry ward</a>) admissions to mind. However, in this book, it seems to apply to all kinds of aspects of life that people want to admit to experiencing, feeling and believing.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/501823/original/file-20221219-14-uc1m0d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/501823/original/file-20221219-14-uc1m0d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/501823/original/file-20221219-14-uc1m0d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=816&fit=crop&dpr=1 600w, https://images.theconversation.com/files/501823/original/file-20221219-14-uc1m0d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=816&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/501823/original/file-20221219-14-uc1m0d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=816&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/501823/original/file-20221219-14-uc1m0d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1025&fit=crop&dpr=1 754w, https://images.theconversation.com/files/501823/original/file-20221219-14-uc1m0d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1025&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/501823/original/file-20221219-14-uc1m0d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1025&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Darby Hudson’s artwork accompanies their piece, ‘100 Points of ID to Prove I Don’t Exist’.</span>
<span class="attribution"><span class="source">Upswell Publishing</span></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-need-to-treat-borderline-personality-disorder-for-what-it-really-is-a-response-to-trauma-115549">We need to treat borderline personality disorder for what it really is – a response to trauma</a>
</strong>
</em>
</p>
<hr>
<h2>Confronting complacency</h2>
<p>The book begins with a short work by South Australian poet Manal Younus, titled “who is she”. This piece is a good place to start, as the poem creates an urge to self-reflect. The opening lines – “Who is she, the one who shares your face – but not your vision” – urge you to think about who could this be in your own life.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/501763/original/file-20221219-22-58vw6m.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/501763/original/file-20221219-22-58vw6m.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/501763/original/file-20221219-22-58vw6m.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=405&fit=crop&dpr=1 600w, https://images.theconversation.com/files/501763/original/file-20221219-22-58vw6m.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=405&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/501763/original/file-20221219-22-58vw6m.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=405&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/501763/original/file-20221219-22-58vw6m.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=509&fit=crop&dpr=1 754w, https://images.theconversation.com/files/501763/original/file-20221219-22-58vw6m.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=509&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/501763/original/file-20221219-22-58vw6m.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=509&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Manal Younus’s poem invites the reader to reflect on themselves.</span>
<span class="attribution"><span class="source">Booked Out</span></span>
</figcaption>
</figure>
<p>The many pieces in this book seem not to be structured together for a specific purpose. They are varied in length, style, even orientation: some pieces, like The Argument by Benjamin Frater and The Z-A of Crazy by Alise Blayney, are oriented in landscape style (rather than the usual portrait orientation). The initial effect is jarring; it keeps the reader from complacency. </p>
<p>Sestina: Rape by Stuart Barnes includes a picture of the word “<a href="https://theconversation.com/consent-laws-arent-the-reason-for-low-sexual-assault-conviction-rates-its-how-society-views-rape-itself-157689">rape</a>” spelled out in a confronting diagram, following a shocking story of a man’s repeated rape, and its denial by others. The presentation of the diagram is deliberately stark, to highlight the horror of what the author experienced.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/501771/original/file-20221219-22-jdaenu.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/501771/original/file-20221219-22-jdaenu.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/501771/original/file-20221219-22-jdaenu.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=287&fit=crop&dpr=1 600w, https://images.theconversation.com/files/501771/original/file-20221219-22-jdaenu.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=287&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/501771/original/file-20221219-22-jdaenu.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=287&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/501771/original/file-20221219-22-jdaenu.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=360&fit=crop&dpr=1 754w, https://images.theconversation.com/files/501771/original/file-20221219-22-jdaenu.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=360&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/501771/original/file-20221219-22-jdaenu.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=360&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p>The editors also contribute pieces. Chowdhury’s description of the secrecy about mental illness in Bengali culture is beautifully described. In one section, she writes: </p>
<blockquote>
<p>There’s no one word for love in the Bengali language. A cursory google will reveal more than thirty words of varying nuance […] I trawled through the ones I know to find a suitable one to describe a mother’s anchoring grip.</p>
</blockquote>
<p>Awad’s poem, Episode(s), cleverly and painfully illustrates the sense of gasping for oxygen during therapy and ends with: </p>
<blockquote>
<p>I am still trying to convince
My lungs,
Oxygen has not left the room.</p>
</blockquote>
<p>And Stavanger contributes seven brilliant paragraphs in his poem Suicide Dogs, which moves from describing dogs that leapt to their death in Scotland, to the many ways dogs prevent their owners from suicide. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/from-tough-love-to-interventions-what-works-when-a-loved-one-is-struggling-with-addiction-184138">From tough love to interventions, what works when a loved one is struggling with addiction?</a>
</strong>
</em>
</p>
<hr>
<h2>Shocking reflections</h2>
<p>There are some well known contributors to this book, including Torres Strait Islander singer Christine Anu (writing about being censored) and former Australian of the Year, and advocate for survivors of sexual assault, Grace Tame. </p>
<p>Tame’s contribution is a punchy poem, titled Hard Pressed, which compares the press and hungry hounds. Prolific author Sandy Jeffs has a piece called The Madwoman in this Poem. As always, Jeffs’ description of her experiences is written without fear or favour, giving the reader a clear sense of her own journey through episodes of psychosis. She graphically depicts experiencing beliefs that famous people can read her mind, and that she can feel spiders eating her brain, as well as fears her head is about to explode.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/there-is-great-strength-in-vulnerability-grace-tames-surprising-irreverent-memoir-has-a-message-of-hope-191074">'There is great strength in vulnerability': Grace Tame's surprising, irreverent memoir has a message of hope</a>
</strong>
</em>
</p>
<hr>
<p>Many of the pieces in Admissions may shock readers who have not read poems or pieces like this before, where rape, deliberate self-harm and suicide form the key content. </p>
<p>Images of one’s own dead body, as depicted in Bones by Luka Lesson, are difficult to deal with. Many pieces will sadden or frustrate. This is not a book to read lightly, or once, or in its entirety in one go: it requires several readings, at different times of life. It requires reflection between pieces. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/501824/original/file-20221219-12-epagh4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/501824/original/file-20221219-12-epagh4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/501824/original/file-20221219-12-epagh4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=556&fit=crop&dpr=1 600w, https://images.theconversation.com/files/501824/original/file-20221219-12-epagh4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=556&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/501824/original/file-20221219-12-epagh4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=556&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/501824/original/file-20221219-12-epagh4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=699&fit=crop&dpr=1 754w, https://images.theconversation.com/files/501824/original/file-20221219-12-epagh4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=699&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/501824/original/file-20221219-12-epagh4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=699&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Heidi Everett’s illustration accompanies her poem on schizophrenia, ‘Hon. Crazie Ship’.</span>
<span class="attribution"><span class="source">Upswell Publishing</span></span>
</figcaption>
</figure>
<p>Admissions presents a kaleidoscope of emotions that shift with your own state of mind, as I found when I read this book over time. </p>
<p>Some hit me with ferocity (like Flesh by Hope One), while others moved me to tears (People Die in Seclusion Rooms by Anna Jacobson) – or to rage on behalf of the author (The Queue by Rebecca Rushbrook), or to chuckles (100 Points of ID To Prove I Don’t Exist by Darby Hudson. I was bamboozled by some pieces, like Paleochannel by Omar Musa, but I decided the author would like us to live with that confusion. </p>
<p>This book is not mainstream, and not for everyone – but I am glad it exists. I urge you to read it and get what you want from it. Then reread it later, and I bet you will get something different!</p><img src="https://counter.theconversation.com/content/191011/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jayashri Kulkarni receives funding from NHMRC. She has worked with some of the authors in different contexts</span></em></p>Admissions, a varied collection by writers with lived experience of mental illness, is confronting, challenging, often surprising – and open to interpretation.Jayashri Kulkarni, Professor of Psychiatry, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1955672022-12-06T19:03:51Z2022-12-06T19:03:51ZNetflix psychiatrist Phil Stutz says 85% of early therapy gains are down to lifestyle changes. Is he right?<figure><img src="https://images.theconversation.com/files/498648/original/file-20221202-26-qgvmzl.png?ixlib=rb-1.1.0&rect=17%2C17%2C3817%2C2138&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Netflix/Stutz</span></span></figcaption></figure><p>Jonah Hill’s Netflix documentary, <a href="https://www.imdb.com/title/tt21819228/?ref_=fn_al_tt_1">Stutz</a>, is an insightful journey into the mind of his therapist, renowned psychiatrist Phil Stutz. Hill delves into Stutz’ model of care, creatively using visual depictions of key concepts and “<a href="https://www.netflix.com/tudum/articles/stutz-the-tools">tools</a>” drawn by Stutz himself. </p>
<p>This model is founded upon one’s relationship with their physical body. When he’s discussing the importance of health behaviours like exercise, diet and sleep, Stutz estimates 85% of the initial gains to someone with mental health concerns commencing therapy can come from focusing on these “lifestyle” factors. Surprised, Hill says in the film:</p>
<blockquote>
<p>When I was a kid, exercise and diet was framed to me in like, ‘there’s something wrong with how you look’. But never once was exercise or diet propositioned to me in terms of mental health. I just wish that was presented to people differently. Because for me, that caused a lot of problems.</p>
</blockquote>
<p>So, is Stutz right?</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/youve-got-a-friend-young-people-help-each-other-with-their-mental-health-for-3-5-hours-every-week-194530">You've got a friend: young people help each other with their mental health for 3.5 hours every week</a>
</strong>
</em>
</p>
<hr>
<h2>What does the latest evidence tell us?</h2>
<p>While the 85% figure is debatable, there is now good evidence therapies targeting lifestyle factors can be a critical part of treating psychiatric conditions such as depression. A recent <a href="https://bjsm.bmj.com/content/bjsports/56/23/1375.full.pdf">meta-analysis</a> (which brings together results from different research studies) shows exercise may be as powerful as anti-depressant medication for depression. </p>
<p>Our own <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0791-y?mod=article_inline">research</a> shows a modified Mediterranean diet can substantially improve symptoms and functioning of people living with moderate to severe depression. </p>
<p>The mental health benefits of these interventions occur <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0791-y?mod=article_inline">independent of weight loss</a>, can be used in combination with medications (such as <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/eip.12230">antidepressants or antipsychotics</a>) and are cost-effective because of societal gains such <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-5504-8">increased workplace productivity</a>.</p>
<p>And the benefits of these approaches can be be experienced relatively quickly, with effects evident in as little as <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0222768&utm_source=rss&utm_medium=rss">three weeks</a>. </p>
<p>Lifestyle changes can reduce the risk of common conditions such as heart disease and diabetes, which contribute to the <a href="https://www.thelancet.com/article/S2215-0366(19)30132-4/fulltext">20-year</a> life expectancy gap for those experiencing mental illness. </p>
<p>The strength of the evidence means it has now been cited in <a href="https://www.pc.gov.au/inquiries/completed/mental-health/report/mental-health-actions-findings.pdf%20Part%20I%20The%20Case%20for%20Major%20Reform">key policy documents</a>, <a href="https://www.equallywell.org.au/wp-content/uploads/2018/12/Equally-Well-National-Consensus-Booklet-47537.pdf">advocacy</a> and clinical practice guidelines in <a href="https://pubmed.ncbi.nlm.nih.gov/30257806/">Europe</a> and the <a href="https://www.nice.org.uk/guidance/ng222">United Kingdom</a>. </p>
<p>The principal organisation representing the medical specialty of psychiatry, the Royal Australian and New Zealand College of Psychiatrists, now <a href="https://journals.sagepub.com/doi/full/10.1177/0004867420979353">recommends</a> lifestyle modification should be considered the first step in treating depression. </p>
<p>Despite all of this, this approach has not been comprehensively taken up by mainstream mental health-care providers in Australia or in the setting of the Stutz documentary, the United States. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/UKCmefQdplI?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">‘You have to give somebody the feeling they can change right now.’</span></figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/treating-mental-illness-with-electricity-marries-old-ideas-with-modern-tech-and-understanding-of-the-brain-podcast-195071">Treating mental illness with electricity marries old ideas with modern tech and understanding of the brain – podcast</a>
</strong>
</em>
</p>
<hr>
<h2>Supporting clinicians</h2>
<p>The use of lifestyle therapies is a reasonably new area to psychiatry compared to other treatments such as antidepressant medication or talk therapy with psychologists. Our <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0791-y?mod=article_inline">randomised control trial</a> showing diet can be a treatment strategy for depression mentioned previously was the first of its kind and was only completed in 2017. </p>
<p>There are various barriers to its translation in mental health care: training, funding, access and variability in quality given the historical absence of guidelines. </p>
<p>In October, we published the first <a href="https://www.tandfonline.com/doi/full/10.1080/15622975.2022.2112074">international guidelines</a> that can be used across any clinical setting – from general practices, to specialist mental health care and by dietitians - in any country. They cover nine established and emerging lifestyle “pillars” to support whole-of-person care. These are: </p>
<p><strong>1.</strong> physical activity and exercise – improving aerobic and resistance training, yoga, reducing sedentary behaviours</p>
<p><strong>2.</strong> relaxation techniques – such as guided breathing exercises</p>
<p><strong>3.</strong> engaging (or re-engaging) with employment or volunteering</p>
<p><strong>4.</strong> getting enough sleep</p>
<p><strong>5.</strong> mindfulness-based therapies and stress management (including coping skills)</p>
<p><strong>6.</strong> healthy diet that includes intake of a wide variety of plant-based whole foods and minimises highly processed foods</p>
<p><strong>7.</strong> quitting smoking</p>
<p><strong>8.</strong> improving social connections</p>
<p><strong>9.</strong> interaction with nature – in green spaces such as forests and parks, and blue spaces like the ocean or creeks and rivers.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/498649/original/file-20221202-18-2bwhrg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="woman jogging in nature" src="https://images.theconversation.com/files/498649/original/file-20221202-18-2bwhrg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498649/original/file-20221202-18-2bwhrg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498649/original/file-20221202-18-2bwhrg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498649/original/file-20221202-18-2bwhrg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498649/original/file-20221202-18-2bwhrg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498649/original/file-20221202-18-2bwhrg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498649/original/file-20221202-18-2bwhrg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Exercise and engaging with natural spaces can yield mental health improvements.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-fitness-woman-running-morning-600w-608739416.jpg">Shutterstock</a></span>
</figcaption>
</figure>
<p>Clinicians can shape their approach in four key ways: </p>
<ul>
<li><p>increase lifestyle and social assessments. Our <a href="https://www.tandfonline.com/doi/full/10.1080/15622975.2022.2112074">guidelines</a> contain a list of recommended tools to capture changes in a patient’s health behaviours across the course of therapy as well as social screening tools to help understand their socioeconomic backdrop (such as stable housing, access to resources)</p></li>
<li><p>get input from allied health professionals (such as dietitians or exercise physiologists), patients’ support networks including other health professionals, community, family, carers and peers. It’s important to know, for example, how someone’s household or neighbourhood may shape their ability to give up smoking</p></li>
<li><p>identify behavioural change strategies. Each individual will have a different mindset in terms of their openness to changing their behaviours. Clinicians can use the guidelines to identify the best strategies for different individuals</p></li>
<li><p>help reduce stigma and/or assumptions that <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/hpja.677">lifestyle is a choice</a>. Instead, understand and explain to patients how individual, social and commercial factors can play a role and make it harder for them to make changes. This can make it feel less like a personal responsibility or fault and help navigate realistic changes. </p></li>
</ul>
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<strong>
Read more:
<a href="https://theconversation.com/pharmacists-could-help-curb-the-mental-health-crisis-but-they-need-more-training-192162">Pharmacists could help curb the mental health crisis – but they need more training</a>
</strong>
</em>
</p>
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<h2>Still more to understand</h2>
<p>While these guidelines and resources are an important first step, there are key questions in this field that remain unanswered. </p>
<p>These include how to best personalise treatments using a person’s unique physiology, genetics, demographics, background and individual preferences. </p>
<p>We need to examine how this approach compares to gold-standard care such as psychotherapy, especially for more severe depression. We are currently testing this question and <a href="https://foodandmoodcentre.com.au/projects/the-harmone-trial/">recruiting</a> participants for a national trial. </p>
<p>It is important to note medication and other therapies can play an important role in mental health treatment. Medications should not be ceased or changed without consulting a medical professional. We have also created a <a href="https://foodandmoodcentre.com.au/academy/">course</a> for health professionals who want additional support. </p>
<p>For now, our guidelines provide a way for health professionals to begin addressing Jonah Hill’s point – that lifestyle factors should be presented to people as critical to their mental health.</p>
<hr>
<p><em>If this article has raised issues for you, or if you’re concerned about someone you know, call <a href="https://www.lifeline.org.au/get-help/?gclid=CjwKCAiAyfybBhBKEiwAgtB7fga0ybZb91XDlLqKGHsCI_I1zcQ8Y6LU3VsvIJrAA1w_wrAZ1_hv3hoCeasQAvD_BwE">Lifeline</a> on 13 11 14.</em></p><img src="https://counter.theconversation.com/content/195567/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adrienne O'Neil receives funding from National Health & Medical Research Council Emerging Leader 2 Fellowship (2009295). </span></em></p><p class="fine-print"><em><span>Dr Sam Manger is the pro-bono Vice-President of the Australasian Society of Lifestyle Medicine</span></em></p><p class="fine-print"><em><span>Wolfgang Marx is currently funded by an NHMRC Investigator Grant (#2008971) and a Multiple Sclerosis Research Australia early-career fellowship. Wolfgang has received funding and/or has attended events funded by Cobram Estate Pty. Ltd and Bega Dairy and Drinks Pty Ltd. Wolfgang has received consultancy funding from Nutrition Research Australia and ParachuteBH.</span></em></p>Changing your eating, exercising, socialising and engagement with nature can help treat depression. Now mental health professionals have some guidelines to shape treatment around lifestyle therapies.Adrienne O'Neil, Professor & Co-Director Food & Mood Centre, Deakin UniversitySam Manger, Senior lecturer, James Cook UniversityWolfgang Marx, Senior research fellow, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.