We’re thrilled to announce the official release of Your Mental Health Repair Manual!
Check out the release announcement. (PDF)
Only one week to go until Your Mental Health Repair Manual is officially released!
We’ve finalized the text, uploaded it to our various distributors (Amazon, Draft2Digital, and Ingram), and have a bulk order in with a local printer. Working now on website updates, as well as various launch-date announcements.
Exciting (and very busy) times!
Incidentally, the ‘ad’ above is very tongue-in-cheek, initially inspired by the always-too-early Christmas marketing blitz you see everywhere before or at Hallowe’en and Remembrance Day. Several people got a kick out of it, so sharing it here. Please feel free to pass along or post on social media!
What do we do when we’re not working on finishing up our book? Yes of course, check out other books! Both of us had an opportunity to examine this new book from Dr. Diane McIntosh. Our review(s) follow.
An empathetic and optimistic hands-on tour through the world of depression.
Book titles can be obscure and misleading… not this one! Dr. McIntosh’s book fully delivers on its promise, giving patients and others most everything they need to know about depression. Definitely comprehensive, she covers a wide range of subjects: what depression is, what it looks like in all its diversity, how it’s diagnosed, what causes it, how to talk to people about it, where to find help, myths, and information on a broad range of treatments. The book covers talk therapy, supplements, electroconvulsive therapy, exercise and many others (kale enemas, incidentally, are not recommended). She extensively covers the confusing and misunderstood universe of medications. She tackles the real questions people have about how they work, what to expect, how to deal with side effects, and more.
The other keyword in the subtitle is “compassionate,” and this is the real strength of the book. It’s refreshingly positive, hopeful, and, most of all, human. Her explanations, intermixed with patient vignettes, treat the reader with respect and serve to empower. They normalize what can be a frightening and lonely illness for many people. Readers will also find actionable advice throughout the book. This includes specific recommendations and suggestions around where to go to find help, how to approach appointments, and talk to others, whether caregivers, family and friends, or someone that you’re concerned about. It’s clear that nurturing informed and fully engaged patients is her mission, unlike some doctors who are threatened or intolerant when patients step up.
While well-referenced, this is far from a dry and monolithic academic text. The writing is very accessible. It’s broken up into small sections and chapters, which makes it very easy to follow. Readers can skim through topics of less interest and take a deeper dive into others (budding genetics and neuroscience geeks will rejoice!). I especially like the extensive glossary. It helps not only when encountering an unfamiliar term in the text, but also helps when deciphering jargon from doctors or others. Items in the glossary are bold-faced throughout the book, which again makes it easier to skim through.
This is a very practical book, delving into medical evidence and standards when they’re useful, but not being constrained by their limits. She’s not shy about offering real-world advice based on her experiences with patients, which mostly works. At times though, it’s a challenge. There are great benefits in sharing what too rarely ends up written down, but some risks of over-generalizing with such diversity in patients and illnesses. For example, when briefly describing specific medications, she suggests “other SSRI options are better.” This may be a bit heavyweight and could shut down rather than open up a conversation with a prescriber. Limited space makes this difficult to pull off perfectly, though appropriate caveats are usually close by.
‘This is Depression’ covers a lot of ground in an approachable and relevant way. Anyone hoping to gain a better understanding of this illness and how to recover from it will benefit. Dr. McIntosh has done a superb job bundling everything together in one comprehensive, compassionate package.
A great resource for patients and families
So far, I’ve only had a chance to briefly flip through it, but I’m excited to have a book like this to recommend to my patients and their families. Like Diane, patients in my own psychiatry practice are always looking for more information about their illness. Too often, they end up finding a few things here, a few things there, not all of it reliable or easy to digest. She’s put together a great collection of solid and easy to read information on a very diverse range of topics. Most importantly, patients will be able to find answers to nearly all their questions in one place. I like that she doesn’t shy away from specific biological details for the many patients who are eager to learn more. I’m looking forward to going through this in more detail, and I’m sure will learn a few new things myself.
It’s now only one month until the launch of Your Mental Health Repair Manual, which will be available November 25th!
We’re busy working through some of the last details, and cannot wait to
finally get this done celebrate its release.
Both the paperback and ebook versions are already starting to percolate out to various bookseller websites for pre-order.
To read more or check out an excerpt, visit https://mhnav.com/book/
Mental health awareness week is normally focused on stigma, but we can’t forget that access to quality treatment matters too… and there’s lots more work to be done on that front!
With that in mind, we’re excited to announce the upcoming launch of:
Your Mental Health Repair Manual:
An Empowering, No-Nonsense Guide to Navigating Mental Health Care and Finding Treatments That Work for You.Pauline Lysak MD and Mark Roseman
This is the answer for all the patients, families, and healthcare providers who’ve been frustrated trying to access mental health services. Finally, the practical, real-world solutions to getting your care on track, in one easy-to-follow guide.
The book will be officially released in late November. To pre-order a copy, or to check out an excerpt, visit https://mhnav.com/book/.
As we get ready to launch our new book, it’s time to restart this blog. You’ll see a great deal of new information posted here over the coming weeks and months.
Put another way, note that everything prior to this posting was from 2014-2015, and likely somewhat out of date. We’ll keep them around, and some, like the article on ferritin and B12, are still quite popular. We don’t plan on updating them though.
Scientific evidence is treated as holy gospel by some people, and entirely discounted by others. When it comes to evidence for mental health, living at either end of this spectrum is a mistake. This article explains everything you need to know to understand mental health evidence, including its limitations.
This started out as a chapter in the book, but was eventually removed both because of length and complexity. It was replaced by a brief teaser in the “Paging Dr. Google” chapter, but we wanted to keep the original available for those who want the details.
Before proceeding, we’ll let you in on a secret about evidence. People tell you a treatment they want you to use has evidence. Doctors and other professionals may use an evidence-based approach. Science gives us objective confidence through evidence.
Evidence is important. However, hearing that there is evidence for a treatment often does not mean what you think it means.
Let’s say you’ve been diagnosed with major depressive disorder (MDD). You hear a statement like “There is strong evidence to support the use of HappyNow™ for treatment of MDD” or “HappyNow™ was shown to be significantly better than placebo (a sugar pill) at treating MDD.”
Most people would hear these phrases and think to themselves: “I have MDD. So if I take HappyNow™ it will help me! I’ll be better!” Unfortunately, most people would be wrong. This is not at all what they mean. We’ll explain, but here’s the bottom line:
If someone tells you that ‘X’ will treat your mental illness and that there is evidence or proof that it works, there is a high probability that will be of little help to you.
Most people need to try several different treatments before they find one or more that fully treats their illness. People are often surprised that science doesn’t provide the level of certainty they expect. Why?
* The understanding of what causes certain symptoms is still unclear compared with more established areas of medicine, e.g. cardiology. People used to think depression was all about serotonin, but now think many other factors contribute, e.g. inflammation. A faulty understanding of causation can make data that is collected less relevant.
Thorough testing that takes into account the variability found in the real world is practically impossible. Tools to examine and measure results are also limited. Evidence in mental health, therefore, has more caveats. Evidence cannot reliably predict what will or won’t work for someone. It’s not like evidence in chemistry class where all you’re checking is if adding A to B turns B purple.
Evidence in mental health is no guarantee. If you’re comfortable with that conclusion, please feel free to skip to the next chapter. If you want a deeper understanding of why evidence in mental health is less clear-cut, keep reading. This will also help if you need to argue with people about treatments. Compelled to justify why you’re not drinking 10 cups of tea each day made from a stinky plant that a persistent relative pulled from their garden? Read on. Or get them to read it. While they’re drinking their tea.
In medicine, people look for proof that a treatment will work. What they mean by proof is scientific evidence supporting the conclusion. The best treatments are evidence-based.
However, evidence-based is not a simple yes or no concept. The quality of evidence affects how much you should trust its conclusions. Determining the quality of evidence can be extremely challenging.
Evidence comes in different forms. You’ve likely heard of some, like randomized control trials (RCT’s). Medical evidence usually falls into one of the categories shown below.
|1a||Systematic review of randomized control trials|
|1b||Individual randomized control trial|
|1c||All or none|
|2a||Systematic review of cohort studies|
|2b||Individual cohort study|
|2c||“Outcomes” research; ecological studies|
|3a||Systematic review of case-control studies|
|3b||Individual case-control study|
Some levels of evidence.
Adapted from Oxford Centre for Evidence-based Medicine—Levels of Evidence (March 2009). Their website provides an excellent set of resources to learn more about how evidence can be used and misused in medicine.
Evidence has the potential to be stronger the higher up it is on the list. Be skeptical when someone tells you that a treatment will work because it’s “evidence-based.” This is not an unqualified endorsement.
We’ll describe a few of these levels below. Let’s say you are a researcher who is interested in whether a new medication helps treat a specific illness.
At the lowest (weakest) level of evidence, you might follow one or more people who took the medication and describe what happens. This is called a case report or case series.
A case-control study tries to identify the cause of an illness. It’s not about treatment so wouldn’t help you with the new medication. It takes one group of people who have the illness and another who doesn’t have the illness. Researchers look at the medical histories of both groups. They try to identify any differences that might explain why one group has the illness.
In cohort studies, you gather a pool of research subjects. Those who are already taking the medication go in one group, and those not already taking the medication go in another group. You follow both groups over time and identify the differences between them.
Randomized control trials are the most well-known evidence-based clinical studies. You gather a group of patients who all have the illness. Half of the people in the group, picked randomly, are given the medication, while the other half aren’t given the medication. You follow everyone over time and compare the outcomes of both groups. In a double-blind RCT, neither the patients nor the researchers that measure the results know which patients were given the medication.
Systematic reviews (SR’s) or meta-analyses start with a literature search identifying previous studies. These include RCT’s, case-control, or others. The similarities and differences between individual studies are analyzed and conclusions are drawn. These “studies of studies” can vary in quality depending on how the individual studies are selected, their quality, and their methodologies.
If you have ten studies using the same methodology, the same patient restrictions, etc., the meta-analysis can’t draw broader conclusions than the individual studies. But a meta-analysis could include many studies that varied greatly in overall study design. For example, it could include different medication doses, lengths of time, ages, genders, people with multiple physical and mental health conditions, and so on. A review of many large and varied studies that all show the same result is strong evidence.
Before trusting a study, you must review its methodology and quality. The size of the study, patient selection criterion, constraints, outcome measures, duration, dropouts, and many other factors of the study design have a significant impact on how results are interpreted. Have other researchers been able to take the same study design and replicate the results?
You may have a great study providing a low level of evidence. Or you may have a very flawed study which aims to provide a very high level of evidence. Neither are likely much help to you. How do you know if a study is comprehensive and methodologically sound or deeply flawed? Read articles that reference the published study and see if they support it or denounce it and why.
As you can see from even this very superficial overview, the reality of medical evidence is not straightforward. We’re not suggesting you need to be an expert in experimental design or statistics. Instead, recognize that evidence can mean many things and can evolve over time. You should look for strong evidence, ideally many large, long-term, independent, and well-designed RCT’s. Be cautious when relying on small observational studies or anecdotal reports, especially from only a single source.
When people claim that treatments are evidence-based, they aren’t lying to you. They’re not trying to deceive or mislead you. They’re just speaking a different language. The word significant is a perfect example. Significant has a technical meaning in statistics, which is something along the lines of “much more likely.” As in, we’re pretty sure the medication is better than nothing. How much better? That we don’t know. It could make you feel 0.1% better (i.e. who really cares) or 95% better (wow!). We’d refer to the latter as clinically significant, which is a completely different concept from statistical significance.
Here’s a silly example. Gather 5000 people. Give half of them, chosen at random, a placebo pill and the other half the medication you’re studying. Give them all a test of some kind. Let’s say that every single person who took the placebo scored 61/1000, while everyone who took your medication scored 62/1000. That is (statistically) significant because the likelihood the pill improved their score (vs. it being a random fluke) is very high.
Despite that, the result is likely not clinically significant. If someone offered you a 0.1% improvement in your mental illness, it’s not going to make a big difference in your life. Also, in real life, it would involve more than a single pill. To complicate matters even further, there are even different levels of statistical significance, e.g. “we’re confident it will be better 19 times out of 20” (ok, but not great) vs. “… better 999 times out of 1000” (very good).
Mental health studies follow one or more groups of people for a period of time. They then evaluate some aspect of their mental health, e.g. are people more or less depressed? It is these outcomes or results that provide the conclusions for the study. The question you have to ask yourself is if the outcomes matter to you. In other words, are the symptoms that improved the same symptoms you have? In many cases, the answer is either a clear “no” or the study doesn’t provide enough information for you to know.
Again, let’s assume you have MDD. If someone told you they had a cure for all mental illness (and an RCT to prove it!), you’d be thinking snake oil. If they said instead it was shown to be effective for mood problems, you might not completely ignore them. If they said (and you believe) there was statistically and clinically strong evidence their treatment helped with MDD? Now they’ve probably got your attention. Does it apply to you? Maybe.
Two people can have two completely different sets of symptoms, presenting in two completely different ways, and be diagnosed with the same mental illness. How different can they be?
Even a specific mental illness like MDD can be astronomically diverse. Studies that fully recognize this are inordinately expensive and complicated to run. Most studies can’t do that, so their reported outcomes are very general. At best, they can offer possibility and future promise.
Most studies use rating scales to measure symptoms before and after. A common one for depression (HAM-D) has 17 questions about different symptoms. Someone interviews you to determine a rating for each symptom. They give you a score between zero (you don’t have that symptom at all) and either two or four (you’re greatly suffering from that symptom). They add up all the questions and get a total score for how severe your depression is, as shown below.
|≥23||Very Severe Depression|
Interpreting scores on the Hamilton Rating Scale for Depression (HAM-D).
Imagine a study showed that a medication reduced MDD from severe to normal. This sounds spectacular! But if they measure it according to the total HAM-D score, that can happen by improving as few as three symptoms (out of 17).
By looking only at the total score, you have no idea which symptoms it improved or by how much. Errors in sampling may have led to more study participants with one set of symptoms. Even with a very large sample size, a medication that works really well on only a few symptoms would show a statistically significant effect. All this is great unless you have some of the symptoms that didn’t improve in the study. The medication has a much smaller chance of helping you than the overall result suggests. But you have no way of knowing because the study didn’t report individual symptoms, just the total HAM-D score.
Using a single number as a proxy for multiple individual measures is common. You ideally would like to see the effect on individual measures. That will help you determine if it’s (more) relevant to you. But if a study wants to look at many results, it needs to be much larger and more expensive. Achieving the same statistical significance as one with a single result increases the size and expense even further. There are other reasons why researchers like to report on a single measure. Saying “this medication is an effective treatment for depression” is a much better sound bite than “this medication effectively reduces feelings of guilt in patients with depression.” While the first has a better ring to it, it’s just not as useful when you’re making treatment decisions.
Encapsulating many symptoms behind a single score can hide a lot about what the study is actually measuring, as you just saw. But it’s not only the outcomes that you need to be concerned about. It’s also the inputs, otherwise known as the people who participated in the study. How varied was that “random sample” of subjects? Does it provide a true representation of the overall population? Most importantly, does it represent you?
It’s now generally recognized that for decades, medical studies had a very strong gender bias. Most studies used men as test subjects. There are statistical benefits of tightly controlling the pool of subjects. This helps strengthen the result, even though it applies to fewer people. It’s a stretch to broaden the conclusions without the data to back them up. Claiming that 70% of men who have a heart attack experience chest pain before based on evidence. Because nobody was studying women, everyone assumed they too had chest pain 70% of the time. When the studies were done, chest pain was much less common (around 58%). Other differences were even more pronounced.
A single study doesn’t need to cover every variation. But the more variations covered by multiple studies, the better. Other factors can include:
The list goes on. Do vegans react to a medication differently than carnivores? Is exposure to certain types of pollution a factor? Hair colouring? People can make educated guesses about what factors make a difference, but without the data, they don’t know for sure. They can only be 100% sure of the effect on everyone if they test everyone.
Even a large study with great variation can be tricky. Like with outcome measures, statistics can hide important variations in the subject population if not used well. If improvements were seen in the group as a whole, was it just one particular subset of test subjects that saw an improvement? Do they share something in common? Do you share that common factor? It could even be a different cause for their illness. This is something we neither understand well or can reliably measure. A treatment that affects MDD due to one cause may not touch MDD caused by something different.
Mental illness is diverse, complex, and rooted in multiple causes. All of these make reliable and informative statistical sampling more challenging.
We are not saying that evidence doesn’t matter—far from it. But it’s important to recognize there are limitations to the evidence available. More importantly, don’t be manipulated by deceptive language. You want to choose the treatments that have the best chance of helping you and treating your illness. Try to have realistic expectations. You don’t need more disappointment.
Some treatments are supported by strong evidence. This includes larger studies, broader sampling, and better outcome measures. Studies that can be independently replicated and high-quality meta-analyses are also important.
Evaluating the quality and applicability of research is something you should be doing with your doctor or other health professionals. Don’t just bring some paper and say you’re convinced the treatment it describes is credible and applicable to you, so you’re going to try it. Discuss with them which studies and treatments best apply to your illness. Remember that they have extensive expertise in interpreting medical literature. Use that to your (and their) advantage.
Accept that high-quality evidence isn’t available to answer every question. Sometimes doctors have to rely on gut instinct or clinical intuition. They’ve seen that “certain types” of people do well on one medication but not another, and that’s why they recommend it to you. They’re filling gaps in the evidence with (ad hoc, informal, and subconscious) observational studies of their own.
What we hope is to lower your expectations to match reality. Finding the right treatment for you may not be a quick or easy process. You will likely have to try several different things, some may partly work, some won’t work at all. It’s not a failure, it’s a necessary part of treating your illness.
What makes a good psychiatrist?
If you ask patients to talk about their bad experiences with psychiatrists (or just ask psychiatrists who have taken over care of a patient from a bad psychiatrist), you’ll certainly get an earful!
Herewith, a highly unscientific list of “sins” that can arise in psychiatric care.
“You didn’t hear a word I said!!!”
Whether due to unreasonably short appointments, or quickly focusing on only one small aspect of the problem(s), there’s nothing more infuriating than feeling like you haven’t been heard, or your concerns not taken seriously. If the sole response to a half hour of tearfully recounting your struggles in work and relationships is “you should drink less coffee”, you’d have a legitimate right to wonder why you waited six months for this appointment.
Good psychiatrists: Take the time to listen and acknowledge patient concerns. Even if they can only help with a small part of those concerns today, they’ll put small changes into a larger plan or context, and set overall expectations for moving forward.
Are you a person or just a diagnosis? While a specific diagnosis can be helpful to help narrow down appropriate treatments to consider, ultimately the bigger question is how your symptoms are impacting your overall quality of life. Not everything needs to be treated, and the success or failure of any treatment needs to be measured against that. It’s great if a medication can help with anxiety, but if it causes an athlete to gain 50 pounds or a writer to be unable to concentrate, is that really fixing the problem? This might be the equivalent of a surgeon’s “the operation was a success, but the patient died”.
Good psychiatrists: Look at the whole person. They don’t believe in “one size fits all” treatments, and are cognizant of potential side effects. Their goal is to help improve overall quality of life, as seen by the patient, not themselves.
For some psychiatrists, it’s too easy to just add medications to deal with every new problem, or every side effect of the previous medication that was added. It doesn’t take long before someone ends up on four different benzos, a few antidepressants, a couple antipsychotics, a mood stabilizer, and several other drugs to deal with akathisia, insomnia, etc.
Unfortunately, taking people off medications and trying others takes more time and has the potential of destabilizing them for short periods of time. And cleaning up an overly complicated medication regime can be a long-term process. Just adding something else to an existing mix is an easier way out.
Good psychiatrists: Don’t turn patients into walking pharmacies. They realize finding the right combination of medications for a patient, taking into account efficacy and side effects, is worth it in the long term, and will find ways to make sure that happens.
If someone has a broken limb it may be well enough to cast them up and send them on their way, but if it happens every few months because they have a habit of jumping off their roof, you might want to look at that. Similarly, prescribing something to control a panic attack may be useful in the short term, but it may be more helpful in the long run to also address the cause of those panic attacks.
Good psychiatrists: Consider root causes and context. They understand that learning better coping strategies or engaging in therapy (even if they aren’t the ones providing it) can help solve many problems in the long term. Medications can be part of the solution, and often are needed to get people to the point they can benefit from other techniques.
The old chestnut about “if all you have is a hammer, everything looks like a nail” can apply here too. A psychiatrist who specializes in mood may see everything in those terms, and overlook an obvious PTSD. More generally, some psychiatrists may assume every problem they see is as a result of a mental health cause, and try to solve it using psychotropic medications. Psychiatrists who forget they are physicians first may try a patient suffering from poor concentration and energy on five different antidepressants and give up when none of them work, but not bother to find out if their iron levels are in their boots. A psychopharmacology specialist may ignore therapy even when it may be more appropriate to the problem.
Good psychiatrists: Recognize other problems that can present with psychiatric symptoms. They understand that psychiatry makes up only one part in an overall health team, along with a variety of other professionals.
Some patients who see a psychiatrist regularly can walk out of the office each time with a different diagnosis and a different medication. If their psychiatrist only looks at the symptom of the day, and ignores the patient’s overall history, patterns and changing circumstances, they’ll end up on a never-ending medication roller-coaster.
Good psychiatrists: Take a thorough history and work in the context of an overall treatment plan. They often have frighteningly good memories of seemingly trivial statements or incidents from previous sessions. They differentiate between regular behaviour patterns for each individual, normal human reactions to external circumstances, and unexplained mental status changes requiring further investigation.
Beware the psychiatrist who knows everything, has no need of opinions or help from others, and prides themselves on knowing exactly how to solve a patient’s every problem within two minutes of meeting them. They see themselves on high, separate and better than their patients, dispensing wisdom to those patients who should feel fortunate enough to be seen. They are quick to dismiss advice or treatments you may have received from others in the past, as those people don’t know what they’re talking about.
Good psychiatrists: Become partners with their patients and other caregivers. They demonstrate empathy, not hubris. They recognize the limitations of their own knowledge and skills, and how much time it takes to really understand another human being. They value rather than shun other opinions and perspectives.
In the health care system, many people fall through the cracks. A lot of people shrug and say “that’s just the way it is”. Sometimes the consequences aren’t too severe. Sometimes though, they are.
Mental health writer Natasha Tracy vividly shared the story of her own suicide attempt (trigger warning). If you’re able to, read it.
If you’re one of the people working in mental health who goes out of their way to help people in need, know that it can make a difference.
If you’re one of the people in mental health who sometimes lets people slip through the cracks because “it’s not my problem” this should hit you like a punch in the gut.
If you’re a politician, health ministry worker, etc. in any position to influence how the system functions, understand that this one incident encapsulates what it means to have a mental health system in crisis.
Now multiply that by the hundreds and thousands in comparably dire circumstances.
Now multiply that by the hundreds of thousands who are suffering because they can’t get mental health help.
Okay, intellectually that may be useful to think about the scope of the problem, but it makes it too abstract. It takes the feeling out of it. Focus back on that one person, that one story.
Now focus on you.
One person can’t fix the system, and nobody should get trapped into thinking that they need to personally make up for all the flaws in the system.
But one person can make a difference.
And a lot of people pushing in the same direction can change a system.