Mental Health Advocacy: Empowering Lived Experience with Evidence — My presentation is yours to use!

Hello readers, and I especially welcome the wonderful parent and professional mental health advocates I met last Friday at the PPAL annual meeting in Marlborough MA — all 400+ of you! I thoroughly enjoyed my time there and came away very impressed with the “Massachusetts model,” a work in progress you point out, for supporting families and communities with mental health disorders.

Click on the link below to see my presentation (30 min) as a downloadable Slideshare file, below

Click on the larger version of this image, below, to see my presentation (30 min) as a downloadable Slideshare file.

Here I am addressing the annual meeting of Parent Professional Advocacy League, in Marlborogh MA on May 29, 2015

Here I am addressing the annual meeting of Parent Professional Advocacy League, in Marlborogh MA on May 29, 2015

As I said in my keynote, you are my tribe. Only those of us who’ve dealt with mental illness and addiction in ourselves and/or a family member can truly know how tough this journey can be — and the importance of social services and one-on-one parent support. I am grateful for everything you do and the lessons you pass on.

You may view, share and re-purpose any part of this presentation in your own work at no charge. If you do, please provide attribution to me as author, with this website as your source. I would also appreciate a heads up on where you’ll be sharing and/or publishing it. THANKS!

—– Victoria Costello

With attendees; among them mental health and social service professionals, parent advocates and youth advocates.

With PPAL Executive Director, Lisa Lambert

Signing copies of A Lethal Inheritance, at PPAL meeting.

Signing copies of A Lethal Inheritance, at PPAL meeting.

Which Websites Can Reduce Anxiety and Depression? Evidence and Recommendations from PubMed Editor Hilda Bastian

Readers: Here is Hilda Bastian’s terrific new post assessing which websites provide scientifically sound psychological help online. In addition to blogging for PLOS on Absolutely MaybeHilda’s day job is editor of PubMed Health and PubMed Commons. Follow her on Twitter@hildabast and at

—Victoria Costello

Painting of a sad womanBefore we go on, you should know there are no sunshine-y quick fixes coming in this post. The kind of websites we’ll be looking at take a lot of effort. And there’s no guarantee the effort will pay off. There isn’t with any therapy for anxiety and depression.

Anxiety and depression can be stinkingly tough conditions to budge. Life is so much tougher when one or both are dragging you down. Any demanding therapy is tougher, too. It’s odd, really, that so many are quick to judge others, and themselves, as weak when they struggle with this.

Extra obstacles, it seems to me, deserve extra recognition. It’s a bit like that classic cartoon by Bob Thaves, commenting on Ginger Rogers, the female half of the legendary Astaire and Rogers dancing duo. Sure, Astaire was great, but don’t forget she “did everything he did backwards…and in high heels.”

Despite the strength that life with depression and anxiety calls on, the stigma of weakness clings, along with the notion that you can just “snap out of it”. There are other ways to think about this. David Dobbs writes of one: “…the sensitivity that opens the person to depression becomes a strength that lets them overcome not just it, but other obstacles”.

Although it’s not easy to change, the way we think about things can affect our moods and behavior. We can get caught in uncontrollable brooding and ruminating about the future or past. All of that can get us caught in vicious cycles that keep us down.

Photo of rough tree barkThat’s not the cause of everyone’s depression and anxiety, nor the reason it continues. But it is common. And changing that kind of deeply ingrained pattern of thinking and behaving can help. Cognitive behavior therapy (CBT) is one way to work through that process.

Between any situation and our reaction or response to it, there is a choice, even if it’s made unconsciously. The work of CBT is to try to change those of our automatic reactions that are futile and misery-inducing.

Take catastrophizing, for example. That’s when we start imagining consequences we feel are likely – how this could lead to this and this and this – and that would be, inevitably, disastrous.

CBT techniques aim to lessen the impact of this kind of cognitive tailspin. And reduce the kind of self-talk that we would condemn as unacceptable bullying in others (“Why don’t you just get a grip, you…”).

I’m not a mental health professional. I became interested in online therapy when colleagues and I were analyzing studies of the internet’s effects. That was many years ago, so our study is way out of date. The internet hadn’t been around all that long then. But evidence suggested that CBT could work just as well in do-it-yourself (DIY) computerized or online form.

Photo of safe place signRigorously studying the impact of psychological therapies is critical. That’s not just so that we don’t waste our time with things that don’t help. Even good ideas with the best of intentions can end up hurting people.

That happened, for example, with “iChill”. That’s internet-based CBT that, it was hoped, would prevent generalized anxiety disorder. But a randomized trial found not only didn’t it prevent the condition, it might have caused worry and depression.

Adverse effects of psychological therapies are the subject of an interesting research program at the University of Sheffield, called AdEPT. They have yet to report the results of this work, but they have started an interesting website, Supporting Safe Therapy.

Time to answer the question we started with: Which websites can reduce anxiety and depression?

There have been dozens of trials now, particularly of CBT-based internet sites or computer programs – and for many conditions. There are also plenty of good systematic reviews, analyzing these trials. (I’ve written explainers aboutsystematic reviews and meta-analyses, if you’re interested in learning more about this kind of research.)

To find websites with evidence of benefit, focusing specifically on anxiety and depression, and not requiring therapist support, I relied on four systematic reviews published in 2013 and 2014. (They’re listed at the end of the post.)

Photo of sunlight and shadeAlthough there are quite a few, I could only find three that were free globally, in English – and they’re all from Australia:

If you’re in the UK, you might be able to get a prescription to websites endorsed after NHS review – like Beating the Blues (and FearFighter for panic and phobia). If you’re in Australia, there’s also the BRAVE-Online program for children and young people. There are solid resources available in the Netherlands and Sweden, but I don’t have the language skills for developing that list.

Some universities and colleges have programs available to their students. And you can see more resources here, but they might not have the scientific assessment behind them that the others do. There are books, too, which I hope to come back to in the future.

What can you expect if you try a website like this? It’s not a way to get instant relief from suffering. It requires work. But on average, many people who try them benefit – how many, and by how much, varies. And there’s not enough research for me to feel confident putting numbers around this.

Online CBT websites won’t suit everybody, though – maybe not even most people. Lots of people abandon them. We don’t really know if working at them harder or longer makes them more effective. And there hasn’t been enough research on how useful (or not) these are for people from different cultures, or for people who have addictions or other mental health problems as well as anxiety or depression.

There is online CBT therapy that’s therapist-guided as well as the DIY kind. Researchers are mixed in their opinions about whether therapists, face-to-face or supporting an online program, make a difference. That’s probably at least partly because they are often therapists themselves.

Photo of grasses against the sky

We collectively spend a great deal of time and money on books, websites, programs, counselors/therapists/gurus – endless theories, lots of people getting rich, on claims they can make us happier. A lot of that is wasted. Most of it isn’t backed up by good science – and much of it, we know, is going to be counter-productive or worse.

Yet, it’s still uncommon in most countries for information on anxiety and depression to even mention internet CBT is an option. Given how many people’s livelihoods are tied up in mental health care one way or another, it’s probably not surprising that free, DIY online therapy faces headwind. That’s a shame. Because even if only a small fraction of the people who try it benefit, it could ease much suffering.


Here’s a good detailed explanation of CBT.

If you know of somewhere there’s a directory of online therapy websites, linked with the sites and the evidence evaluating them, please add it in the comments or contact me.

The four systematic reviews I relied on for finding these websites:

  • Aleisha Clarke and colleagues on preventing mental health problems in young people (2014)
  • E Bethan Davies and colleagues on improving depression and anxiety in university students (2014)
  • Eric Dedert and colleagues on treating depression and anxiety (a review for the VA, 2013)
  • Dawn Querstret and Mark Copley on rumination and/or worry (2013)

I also found these very useful: “Internet-delivered cognitive behavior therapy for anxiety disorders is here to stay” by Gavin Andrews and colleagues (2015) and “Web-based intervention programs for depression: a scoping review and evaluation” by Tian Renton and colleagues (2014).

The “Why don’t you just…” image in this post is my own (CC-NC license)(Cartoons at Statistically Funny.) Photos also by me (CC-BY): The bark of a tree in California, the firehouse in Cleveland Park, DC and in my home.

* The thoughts Hilda Bastian expresses here at Absolutely Maybe are personal, and do not necessarily reflect the views of the National Institutes of Health or the U.S. Department of Health and Human Services.

“If you talk to God you pray, but if God is talking to you it’s schizophrenia.”

This email from “Emmanuel” is without a doubt the most poignant message I’ve ever received from a reader. 

With her permission, I share Emmanuel’s email with readers of this blog, including many (like me) who’ve dealt with a mental disorder in ourselves or a family member, so she might feel her struggle is being witnessed by others who care.

And, if you are so inclined, I ask that you keep Emmanuel in your thoughts and prayers this holiday season — as I will.

Victoria Costello

Hi Victoria
Life says for me to let you know this, I am schizophrenic and so am I.
I acquired schizophrenia in the first three months of my infancy. My mother got mentally ill shortly after I was born.
The illness had been there in the family tree for generations. My grandmother and her sister had suffered some form of schizophrenia.
My name is Emmanuel, I am suffering from paranoid schizophrenia. The spirit says “many are called but few are chosen”, because of the circumstances and conditions of their upbringing.
If you talk to God you pray,but if God is talking to you its schizophrenia.
There is a lot of mental  cases out there, a lot of them are schizophrenic. They need guidance and care.
The process of schizophrenia is invariably uphill struggle often lifelong duration,often incurable. 
Schizophrenia cannot be understood without understanding despair.
We are not only the victims of this paranoia,we are also its police force of it.
My dearest  sister,I need to join forces with you,to help heal the world in any way we can.
Through grace we helped not to stumble and through grace we are accepted,what more can we ask for.
I am looking forward for you response.
Yours in divine order

Pot may be legal for adults but it’s still dangerous for adolescents

Anyone who’s read my book A Lethal Inheritance knows I’ve consistently and strongly warned against teenagers smoking pot, because their brains have not finished growing, and research clearly shows negative effects when they smoke before 21 or 18. Especially if the young person is vulnerable to mental disorders due to heredity. Today’s NY Times has an excellent article by Tara Parker-Pope on the impact (or potential impact) of marijuana legalization on teen pot use. Please note, neither I nor the article are talking about adult use. This is strictly a maturing brain matter….

Highlights…from Parker-Pope’s article…


The brain is still wiring itself during adolescence, and marijuana — or any drug use — during this period essentially trains the reward system to embrace a mind-altering chemical.

Studies in New Zealand and Canada have found that marijuana use in the teenage years can result in lost I.Q. points. Mr. Pasierb says the current generation of young people are high achievers and are interested in the scientific evidence about how substance use can affect intelligence.

“You have to focus on brain maturation,” he said. “This generation of kids wants good brains; they want to get into better schools. Talk to a junior or senior about whether marijuana use shaves a couple points off their SATs, and they will listen to you.”

Because early exposure to marijuana can change the trajectory of brain development, even a few years of delaying use in the teen years is better. Research shows that young adults who smoked pot regularly before the age of 16 performed significantly worse on cognitive function tests than those who started smoking in their later teenage years.

Drug educators say that one benefit of the legalization talk is that it may lead to more research on the health effects of marijuana on young people and more funding for antidrug campaigns.

If you want to read the entire article go here:

Report: Proper SSRI Antidepressant Starting Dose Minimizes Suicide Risk In Young Adults




     A large, well-controlled pharmacoepidemiological study shows that three SSRI antidepressants do not increase suicide risk in 10- to 24-year-olds when given at the proper, recommended doses. Higher doses were associated with a 2.2-fold increase in suicide risk. No similar dose effect was seen in those age 25 to 64.   read »

From, the blog of David Kroll, a pharma expert who used to blog for PLOS Blogs, my current employer. I recommend you to read on!

More Americans Understand Mental Illness; Climate Change, Vaccines or the Big Bang…Not So Much

08klass-articleinlineI think my regular readers will find this new poll as interesting as I do! In the table below check out the results of a recent AP survey looking into the confidence Americans have in various concepts which are considered “accepted science.” And while I’m worried by the findings that 51% of those polled don’t think our world started with a Big Bang, and only 53% have confidence in vaccine effectiveness and safety, I find other numbers surprising and even encouraging. For example, 61%, nearly 2/3, are either very or fairly confident that the earth is warming due to human activities. Okay, better than I might have expected. But best of all… 71% say they are extremely or very confident that “a mental illness is a medical condition that affects the brain”.  Another 12% are somewhat confident of this fact, adding up to a whopping 92% who lean favorably towards a scientific understanding of mental disorders. When one considers how much stigma has been driven by an absence of this understanding, we have to be encouraged that things are indeed changing. But then, I am an optimist by nature. What are your thoughts on these questions and answers?

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A Psychiatrist Diagnoses “House of Cards” — Is Claire Underwood a Narcissist?

claire-underwood-blood-300x300I’m sharing the latest blog post from Stanford psychiatrist Shaili Jain, who uses  House of Cards husband and wife team, Frank and Claire Underwood (aka Kevin Spacey and Robin Wright) to teach us about some little understood psychological diagnoses. Here, in its entirety, from “Mind the Brain” on PLOS Blogs Network.

By Shaili Jain, MD

Last month I used the character of Frank Underwood as a “case study” to illustrate the misunderstood psychiatric diagnosis of Antisocial Personality Disorder, and many of you asked: Well, what about his wife, Claire? Good question!  You asked, and so today I will do my best to  answer.
SPOILER ALERT: For those of you who have not been on a streaming binge and watched all of Season 2 yet, consider yourself warned. 
Image: Netflix
Clinical lore would certainly support that Claire, herself, must have a personality disorder of some kind – a sort of fatal attraction, where a couple is drawn to each other because there is something in their personality patterns which is complementary and reciprocal. She does appear to have mastered the art of turning a blind eye to Frank’s more antisocial exploits.  She is a highly intelligent woman, and she must have some inkling that her husband may be involved in the death of Zoe Barnes and Peter Russo.  But if she has an inkling, she does not show it.
Claire, from what we know, does not engage in outright antisocial behavior.  Unlike Frank, she has not murdered anyone and we have not seen her engage in very reckless or impulsive outbursts. However, she rarely shows emotion—her smiles seem fake, her laugh empty, and her expressions are bland.  She is more restrained and guarded than Frank, and she does not reveal her inner thoughts to the viewer the way Frank does so it is much harder to know what could be going on in her mind. Still, I think I have seen enough to venture forth with an assertion that she may have a Narcissistic Personality Disorder.
What is Narcissistic Personality Disorder?

A pervasive pattern of grandiosity, need for admiration, and lack of empathy beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of 9 criteria.

Below are the five criteria that I think apply to Claire:

1) Has a sense of entitlement (i.e. unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations) 


  Image: NetflixShe expected Galloway to take the blame for the photos that were leaked and eventually claim it was all a “publicity stunt,” thus ruining his own reputation and image.  She expressed no regret that her ex-lover was cornered into having to do this, on her behalf, and no remorse that it almost ruined his life and his relationship with his fiancé. She was entitled to this act because she is “special” and expects that people will “fall on their swords” for her.

2) Is interpersonally exploitative (i.e. takes advantage of others to achieve his or her own ends)

  Claire manipulates the first lady, Tricia Walker, into believing Christina (a White House aide) is interested in the president. She pretends to be a friend, wangles her way into becoming the first lady’s confidant, and persuades her to enter couples therapy with the president.  All of this is actually part of an elaborate plan to help Frank take the President down so that he can become president and she (Claire) can usurp Tricia as first lady. Another example: Claire is pressured by the media into revealing that she once had an abortion, but she lies and states that the unborn child was a result of rape (presumably to save political face).  Again, she shows no remorse about her lie and instead profits from it, gaining much sympathy and public support.

3) Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

This was best seen in the way Claire deals with her former employee Gillian Cole’s threat of a lawsuit –  she pulls a few strings and threatens the life of Gillian’s unborn baby.  In fact, in addition to the obvious lack of empathy was the simmering rage she had toward Gillian for daring to cross her.  Again, entitlement, narcissistic rage, and a lack of empathy would explain that evil threat she made, to Gillian’s face, about the baby.

4) Is often envious of others or believes that others are envious of him or her

I think part of the reason Claire was so angry at Gillian was because, deep down, she was envious of her pregnancy.  We know that, in parallel, Claire is consulting a doctor about becoming pregnant and is told that her chances are slim.  This is such a narcissistic injury to Claire that she directs her rage at Gillian.  I don’t think she was even consciously aware of how envious she is of Gillian for being pregnant. Another example would be the look on her face when Galloway indicates he is madly in love with his fiancé and wishes to make a life with her.  For a second her face darkens – a flash of jealous rage – which then translates to indifference and almost pleasure at his eventual public humiliation.

5) Shows arrogant, haughty behaviors or attitudes 

Image: Netflix

Correct me if I am wrong, but Claire just does not appear to be that warm or genuine and has an almost untouchable air about her. Furthermore, we only ever see her with people who work for her (i.e. have less power than her) or with people more powerful than her (i.e. whose power she wants for herself). Other than Frank, where are her equals? Her oldest friends and colleagues? Her family? People who might not be influenced by her title or power?

One last comment – in Season 2 Claire certainly comes across as more ruthless and power hungry than the Claire in Season 1—whether she is now showing her true colors and is dropping her facade or just becoming more lost in Frank’s world and hence looking more like him is unclear to me… I suppose we will find out in Season 3!

Meanwhile, if you want to read Shaili’s diagnosis of Frank Underwood, go here.

Creative Commons License This work, unless otherwise expressly stated, is licensed under aCreative Commons Attribution 3.0 Unported License.

Becoming a Digital Media Sensation, While Struggling with Depression — a wise and touching post by Jennifer Pastiloff


“I’ve carved out a beautiful life and love what I do, but sometimes, especially lately, I feel the old tug of depression, that magnet of sadness which is buried somewhere next to the grief of losing my father at such a young age, but not relegated to that grief. “

This poignant line comes from an article I’d like to recommend by  She’s a young yoga teacher, inspirational speaker, and a digital media sensation (pictured above), who writes about her battle with depression, and how she’s making tough choices like staying on or getting off antidepressants (for her pregnancy and then after) and how (or even if) she can deal openly with her depression with her friends and many fans.  I’ve pasted another favorite piece of her post below followed by a link to the full post on xo jane…

“About a year after I had gone on anti-depressants, I quit the restaurant. I started leading inspirational workshops, which quickly turned into sold-out workshops and retreats all over the world. I developed this huge online following. It all happened very quickly — I went from career waitress to traveling around the world and being on Good Morning America and featured in New York Magazine. And all this success came while I was on meds.

I felt like a fraud. I felt like I should be able to use the tools I was teaching in my workshops and not have to be on anti-depressants. So I went off last summer, and about five minutes later got pregnant….” read the full post here:

New analysis of international suicide data repeats 10 year old finding; 85% suffer from a mental illness

Almost startling in its consistency, a new peer-reviewed study published in PLOS ONE (April 2, 2014) , a full decade after the often-cited McGill University metastudy on the relationship between mental illness and suicide risk, produced essentially the same major finding —  within 2%. The Australian and American scientists responsible for the new research paper, titled The Burden Attributable to Mental and Substance Use Disorders as Risk Factors for Suicide: Findings from the Global Burden of Disease Study 2010, compiled worldwide data from the World Health Organization (WHO) to show that 85% of people who die by suicide have a debilitating mental disorder. One difference: this study includes addiction as a major mental disorder, which reflects more recent classifications in the mental health field.

The underlying WHO data doesn’t fully represent mid to lower income countries so even this high a percentage linking suicide and mental illness no doubt underestimates the real numbers of people who die by their own hand in places where national and local health systems simply don’t count them. For better or worse, this research certainly covers most of us living in the US.

Sometimes the numbers provide important nuances to help us understand who, how, where, when and even why…

  • Nearly 1 million people complete suicide every year with over 50% aged between 15 and 44 years [14][15].
  • Over 80% of suicides occur in low to middle income countries and close to 50% occur in India and China alone [15][16].
  • the risk of suicide was 7.5 (6.2–9.0) times higher in males and 11.7 (9.7–14.1) times higher in females with a mental or substance use disorder compared to males and females with no mental health or addiction disorder
  • Suicide from firearms, car exhaust and poisoning are more common in high income countries and suicide from pesticide poisoning, hanging and self-immolation are more common in low to middle income countries [17].

There is also a telling graph of which disorders rank as the most and least dangerous in terms of suicide risk, with major depression leading the way: journal.pone.0091936.g004 Lastly, the authors also looked at prevention strategies, and found that equipping general practitioners to diagnose and treat major depression had the highest value as a strategy, with a few caveats, as usual having to do with the quality of care. ” This was one of the few interventions for which there was good evidence of effectiveness as a suicide prevention strategy in a recent review by Mann and colleagues. That said, ensuring that care from general practitioners is evidence-based requires further consideration, given findings that rates of minimally adequate treatment for depression are lower among patients treated solely by general practitioners or in the general medical care sector, compared to those treated by specialist mental health providers.”

The unavoidable point: treatable mental disorders if left untreated put you at a much higher risk for suicide. What else is there to say?

ADHD: a real disorder, denying it hurts children

This is a great article on the website “Real Clear Science” compiling the evidence to respond to those who fall on the overmedication of kids argument to deny the existence of this disorder: