Au Revoir

The survey final results will be my last post for a while. The time has come to polish my research paper and compile my powerpoint presentation. I will give a final summary of my project later in May. I hope to see some of you at my presentation! Thank you for your readership. As of now, I'm not sure who reads this, if anyone does, but I hope I provided an informative overview of the antidepressant controversy.

-Savannah

Survey Finale

 

The third question: In a typical doctor-patient relationship, would it be ethical for a doctor to prescribe a patient a pill that is a placebo but represent that pill as an actual medicine?

Now, the most important ethical point has been reached. Can a doctor give a patient a placebo and call it medicine? Can they lie in an attempt to produce a benefit? Is a placebo a reasonable treatment plan?

This time 67.9% of responders said it was unethical while 24.5% said it was ethical. 7.5% of people were unsure.

The final question: If you answered no to the previous question, please mark the answers below that best explain why.

58.3% of people said it was unethical because doctors should not lie to their patients.

83.3% of people said it was unethical because patients have a right to know what they are being prescribed.

69.4% of people said it was unethical because it is not medically safe for a patient to be in the dark about the prescription(s) he is on.

13.9% of people said they did not think inducing placebo effect is an effective medical treatment.

The last option was to write a unique reason that the responder thought it was unethical. I received five.

1. "The only case a placebo may be effective is if the patient is a hypochondriac, but even then its a very subjective thing to describe. Also, if the patient is actually experiencing symptoms that prompt the doctor to prescribe something, I'd prefer the doctor to actually prescribe a REAL drug then just test his own theories on me (giving me placebo instead of a real drug for his own reasons). I would feel like a lab rat."

This response takes into consideration the risk of doctors "experimenting" on their patients by giving them non-drugs without being clear about the treatment plan. However, valid as that observation is, it is not correct to claim that only hypochondriacs would be positively affected by a placebo. Perhaps, it is unlikely anyone but a hypochondriac would be completely cured by a placebo, but even that is not certain.

2. "I think that the patient should be informed that it COULD be a placebo, but maybe it's not."

This is a good idea. It gives the patient much more control over their treatment. If they objected to the possibility of receiving a placebo, they would be able to express that to their doctor.

3. "Patients has a right to know the medication prescribed by a doctor-name of medication, purpose, side effects, etc. A placebo is to be used only in a study to benefit the medical community, not support drug company study or misguide a patient."

This objection seems to focus primarily on the patient's right and need to have all the information about their prescriptions. The mention of supporting drug company study is interesting. One could argue that the use of placebos in clinical trials helps protect against drug company manipulation of success rates by providing a standard of efficacy.

4. "At that stage of the of the doctor-patient relationship, the doctor is a well-schooled and trained expert in his/her field. He/she is well-aware of all the treatments that would undoubtedly cure the patient permanently or temporarily of their problem. Thus, if any medical doctor who is trained to administer medicine or perform typical doctoral procedure even considers giving his/he patient a placebo to see if it builds patient confidence, then THAT doctor is merely treating a genuine, hurting patient as an essential "lab-rat" to see if the placebo actually works. The patient is paying a lot of money to be treated properly with proper medicine that will properly and safely cure his/her illness. A placebo would be unethical and unfair to the patient in this sense."

This responder brings up the factor of paying for treatment and not receiving genuine medicine as a problem. He or she also brings up the issue of unauthorized doctor-patient experimentation as being unethical.

5. "In a double-blind study, patients know that there is a chance that they are receiving a placebo, but this understanding is not part of the doctor-patient relationship."

This response also addresses the concept that the placebo administration would be more acceptable if the patient was aware of the possibility.

This review of placebo ethics is relevant to the efficacy of antidepressants because it is important to consider whether or not taking the  side effect risks of the current medications is superior to administering placebo in order to cure what many people view as a problem "in the patient's head."

However, it is clear that placebo treatment is ethically questionable in many cases as well as less effective than antidepressants. There are biological symptoms to be treated in the case of depression and it is unlikely that a placebo would be enough to seriously treat the condition.

A link to the survey is provided in the sidebar.

Survey Says

After my last posts about placebos, I was interested in what the general opinion of placebo ethics might be. It seemed that my opinions and those of majority of doctors did not match up based on the following image.

For this reason, I created and distributed a survey to gauge the opinions of my peers. Fifty-three people responded to the survey. I will examine the results of the survey in my final two posts before my conclusion post due to their relevance to the superiority of antidepressants over other treatments namely placebos.

The first question: Placebos are used to determine the effectiveness of medicine in many studies. A double blind study involves a group of patients with a condition who will be administered either a placebo or the actual medicine. Neither the doctors nor the patients know who is being given medicine and who is being given placebo until the end of the trial. The placebo effect successful responses and the actual medicine successful responses are compared to determine the clinical worth of the actual medicine. Do you consider this an ethical use of the placebo effect?

The majority of people (83%) considered this ethical, including me. The rest of the people either considered it unethical (7.5%) or did not have an opinion (9.4%). I thought these results were unsurprising and I asked the question mainly to present how placebos are usually used.

The second question: Now consider a basic doctor-patient relationship completely separate from clinical trials. Would it be ethical for a doctor to promote a treatment primarily to increase the patient's confidence in that treatment and thus the likelihood that the patient will experience a helpful placebo effect?

This is a more interesting question. A doctor's positive presentation of a procedure or treatment can seriously affect a patient's confidence, and thus possibly the placebo effect the patient experiences. What can that hurt? The answer is less clear. This is especially relevant in the case of depression, in which many patients are consistently hopeless and demoralized. Should the doctor be getting the patient's hopes up or is it worth the benefit to over-represent the possibility for success? I would even argue that in prescribing any treatment the doctor must advocate it to a certain extent so where do you draw the line?

This was still voted ethical though by a smaller margin (only 62.3%). 34% of survey takers considered this unethical and 3.8% were unsure.

A link to the survey is provided in the sidebar. More information will be provided in my next post.

Placebo Effect, Part 2

Not so fast, just how severe is the depression?

Maybe the placebo effect is not enough but can antidepressants actually beat it? Generally, in basic studies of adults, antidepressants are more effective than placebos. However, those who do not trust antidepressants are quick to say that the margin of effectiveness between the two is not enough to outweigh the side effect risks of the actual medicine. Some go so far as to say that a significant portion of antidepressants effectiveness outside of clinical trials can be attributed to placebo effect. This claim is supported by the risk of relapse after initial signs of remission during antidepressant treatment. The argument is essentially that patients feel better due to a placebo effect when first given antidepressants but that this improvement cannot last long term and therefore, the antidepressants are not better than a placebo. Personally, I do not think my research has supported that claim however. In a previous post,  I discussed a study that indicated that patients whose monoamines were more abundant (the main biological effect that antidepressants induce) were less likely to have recurring symptoms of depression after initial remission. Also, I have found a new study that indicates that the more severe the depression, the more the antidepressants outshine placebos. This study does mention that the difference in success between antidepressants and placebos can be almost nonexistent in more mild or moderate cases of depression.

While I have detailed a variety of alternative treatments for depression, the two options that are considered genuinely substantial are psychotherapy and antidepressants. This fact combined with the prevalence of depression as a condition means that psychiatry and psychology are fighting against a formidable foe with limited resources. Severe depression especially can result in death. Furthermore, these deaths tend to be suicides which can have a profound effect on the loved ones of the deceased, resulting in the propagation of depression in even more people. Depression has a certain stigma to it because it is easier to blame on personal weakness than more straightforward biological malfunctions, however, the condition must be seriously addressed. If severe depression really is treated more successfully by antidepressant medications than mild to moderate depression, the treatment of depression can only be improved by that fact and having an effective way to help the severely depressed is indispensable.

You have to have confidence in your placebo or it's unlikely to succeed.

Another thing that is relevant about the placebo effect in depression treatment: while the concept that a placebo effect in the treatment of depression can lead to later recurrence due to inadequate treatment may be a valid complaint, it is my opinion that patients should not let fear of placebo effects reduce their confidence in their medicine. It is unfortunate if a placebo effect that cannot be sustained long term causes the helpful effects of a medication to cease, however, the fact remains that the placebo effect is not likely to be harmful. In the event that one medication no longer works, it can either be determined that the patient might find more long term success with a different antidepressant or perhaps it can even be considered that the severity of that patient's depression is not high enough for the medication to have more than a possibly temporary placebo effect. So long as there are no intolerable side effects, even a placebo-effect induced improvement is better than no improvement at all. In addition, there is another way to improve the long term success of a drug depression treatment and that is by adding psychotherapy to the treatment plan.

Moran, Mark. "Does Placebo Effect Mask True Efficacy of Antidepressants?" Psychiatric News. 2 July 2010. Web. 25 Apr. 2012. <http://pnhw.psychiatryonline.org/content/45/13/17.2.full>.

Sipkoff, Martin. "Antidepressants Work Best For the Severely Depressed." Managed Care Magazine Online. Web. 25 Apr. 2012. <http://www.managedcaremag.com/archives/1003/1003.medmgmt_antidep.html>.

Nauert, Rick. "Placebo Effect Among Antidepressants | Psych Central News." Psych Central.com. Web. 25 Apr. 2012. <http://psychcentral.com/news/2007/08/15/placebo-effect-among-antidepressants/1131.html>.

Placebo Effect, Part 1

In double blind clinical trials, patients are split up into two groups. In the case of an antidepressant trial, some of the patients are given the antidepressant and some are given a sugar pill (called a placebo) but no one, including the doctors, knows who got which treatment. As mentioned in previous posts, this is how the effectiveness of antidepressants is usually measured: the effects on the patients taking the real antidepressants are compared to the effects experienced by those taking the sugar pill. The placebo effect (the amount to which the sugar pill is described as effective) in antidepressant trials has been known to range between 15 percent and 70 percent response rates. It also seems that over the time, as antidepressant trials have been performed, the placebo effects documented in the more recent trials are higher.





The placebo effect is a powerful though not well understood phenomena of medicine and of life. To what extent can the power of positive thinking and expectation produce medical results? The basis of the placebo effect seems to be that if a patient expects to be affected by a medicine or treatment in a specific way, they are more likely to perceive that effects. In a way, this is similar to the concept of confirmation bias in psychology: if a person has an opinion, they will be more likely to notice evidence that supports that opinion. However, the placebo effect in a condition like depression that is significantly subjective in some aspects cannot be underestimated. The extent to which psychology can affect illness, especially mental illness, is still mysterious due to the limited knowledge of the causes of depression and other mental illnesses. Why have the placebo effect statistics in antidepressant trials increased over time? It is possible that as the drugs became less new and more commonly prescribed, public opinion of their usefulness increased thus increasing the placebo effect.

In this way, the placebo effect seems like a very good thing. If belief in a medicine alone is enough to produce improvement in depression symptoms, why bother with risky complex medications at all? The reason why sugar pills are not just prescribed in everyday life rather than antidepressants is as follows. The placebo effect is reliant on the patient's belief that they are taking an effective medicine, so obviously if a doctor were to prescribe sugar pills to a patient to attempt to induce a helpful placebo effect, the ethical and practical issues may be tricky. It seems inherent that a doctor should not simply lie to a patient. As the person taking the pill, the patient needs to know what the pill he is taking contains for medical safety reasons and because it is his right. In a clinical trial, the situation is more controlled and the participants know that they might be receiving a placebo so the concealment is acceptable. In fact, as the main goal of the doctors has shifted from treating one patient's depression successfully to measuring how successful a certain drug is typically, the difference in objective makes the concealment more than just acceptable but also necessary. In the end, the placebo effect is used in clinical trials to determine the worth of the other medicine tested. To treat serious conditions like major depression, it is ideal to produce more improvement than the placebos can provide on their own even in the best case scenario. In studies, medicines are compared to placebos and the extent to which the success of the medicine exceeds the success of the placebo is measured. This measurement is extremely important. If the effect of an antidepressant is indistinguishable from a placebo pill then the medicine is no more helpful than a sugar pill while the antidepressant is more dangerous than a placebo due to the side effects of the former.

Or maybe my grasp on what is considered ethical in medicine nowadays isn't so on point?

Are antidepressants actually more successful than placebos? Survey says, hear more about the implications of the placebo effect on the efficacy of antidepressants in my next blog post.

"MedicineNet.com." Medterms. 14 Mar. 2004. Web. 24 Apr. 2012. <http://www.medterms.com/script/main/art.asp?articlekey=31481>.

 Kirsch, Irving. "Challenging Received Wisdom: Antidepressants and the Placebo Effect." McGill Journal of Medicine. Web. 24 Apr. 2012. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582668/>.

"Confirmation Bias." ScienceDaily. ScienceDaily. Web. 24 Apr. 2012. <http://www.sciencedaily.com/articles/c/confirmation_bias.htm>.

Lakoff, Andrew. "The Right Patients for the Drug: Managing the Placebo Effect in Antidepressant Trials." BioSocieties. Web. 25 Apr. 2012. <http://www.palgrave-journals.com/biosoc/journal/v2/n1/full/biosoc20075a.html>.

Hope After All?

Antidepressants can cause dangerous suicidal thoughts in people of all ages. The FDA requires labels and brochures distributed with the drugs to warn about all of the possible side effects. The question is: is warning the public enough or should more drastic measures be taken?

In the case of adults, I think that personal choice should be allowed. An adult with a prescription from a doctor should not be kept from taking antidepressants, despite the risks. However, I do not think the same is true for children. In children, the prescription of certain antidepressants should be discouraged, if not outlawed. The difference is that in children the odds of positive effects from tricyclic antidepressants are slim to none, making the risk of administering these drugs to children a foolish one to take. In doing more research, I found that while tricyclic antidepressants do not usually help children, fluoxetine (the SSRI usually known as Prozac) has been showed to be effective, especially when combined with cognitive behavioral therapy. This indicates that since the original FDA study claiming the effects of SSRIs was "clinically insignificant" in children the matter has been further researched in a way that may have encouraged doctors to prescribe the pills to children.

It is fortunate that the SSRIs were studied further as the need for an effective treatment in severely depressed children is great. It seems that the atypical antidepressant bupropion (often marketed as Wellbutrin) has also shown positive effects in children. It is interesting to consider why there is such a difference in effectiveness in children and adults. Most likely, the mechanism of depression on the brain is different in children than in adults due to the process of brain development.

In the end, I think that the question of personal choice versus social responsibility comes down to effectiveness. If there is a chance that the doctor-prescribed medication may help the patient, the patient should have the right to take that chance.

"Open Trial of Bupropion SR in Adolescent Major Depression." 25 Aug. 2004. Web. 20 Apr. 2012. <http://onlinelibrary.wiley.com/doi/10.1111/j.1744-6171.2003.00123.x/abstract>.

 "The Treatment for Adolescents With Depression Study (TADS): Long-term Effectiveness and Safety Outcomes." Archives of General Psychiatry, Oct. 2007. Web. 19 Apr. 2012. <focus.psychiatryonline.org/data/Journals/FOCUS/1833/foc00108000063.pdf>.

Think About the Children

 You are worried about seeing him spend his early years in doing nothing.  What!  Is it nothing to be happy?  Nothing to skip, play, and run around all day long?  Never in his life will he be so busy again.  ~Jean-Jacques Rousseau, Emile, 1762

They don't work? Why do we prescribe them?

One special subgroup of the depressed population consists of depressed children. As mentioned in my previous post, children (which we can consider anyone up to the age of 18) are depressed in large numbers. However, on the other hand, according to Peter Breggin's book Medication Madness: A Psychiatrist Exposes the Dangers of Mood-Altering Medication, antidepressants are currently considered by the FDA as no more effective than placebos in depressed children. In fact, Breggin claims that due to the risks of side effects, including increased suicidal tendencies, antidepressants are not helpful to children but are actually consistently harmful to them if there is any effect. So how do the depressed children get help? Some families have opted out of medicating their kids with antidepressants, favoring instead child psychologists. However, despite what Breggin seems to consider a decisive verdict of ineffectiveness for antidepressants in children, they are still commonly prescribed. I have mentioned highly sought after child psychiatrists who charge between hundreds and thousands of dollars for an initial assessment. The rest of this blog post will be an attempt to understand why this medicine continues to be prescribed to a vulnerable social group if it is known to be useless or harmful.

In 2004, the FDA applied a black box warning to antidepressants that states that they can increase "the risk of suicidal thinking and behavior in pediatric patients." By doing this, the FDA drew attention to a serious side effect and directly mentioned the group they considered the most at risk. It is definite that harmful antidepressant side effects have been documented in children. However, these risks also exist to a lesser extent in adults but, unless lethal or intolerable side effects are certain or overwhelmingly likely, I do not think the prescription of antidepressants should stop due to those side effect risks. There's still a chance that an adult individual will find an antidepressant that can help them with manageable or negligible side effects. Does this possibility for improvement not exist for children?

After examining the FDA-sponsored study, it seems that Dr. Irving Kirsch concluded that, in children, as compared to placebo, the effects of tricyclic antidepressants were statistically insignificant and that while SSRIs were statistically significant, they were not "clinically significant." The FDA has spoken. Who disagrees? I am not sure. I can find a variety of studies concluding that tricyclics are worthless for children and while most studies say more information needs to be ascertained about SSRIs for children, they admit that SSRIs are minimally effective, if at all. Even the drug company GlaxoSmithKline sent out warnings about prescribing paroxetine to children due to the suicide risks in 2003, before the FDA put out the black box warning.

Overall, it seems that science does not support the effectiveness of antidepressants in children. The fact remains that there are children, even small children, taking these drugs. SSRIs are considered by many in the medical profession as the safest antidepressant to prescribe to children despite the apparent lack of therapeutic reward that accompanies the drugs serious side effects. Why are children taking these medications? Perhaps, there is evidence of effectiveness that I have not been able to find. Perhaps, their lack of effectiveness is not widely known or agreed upon among the doctors actually making prescriptions. Perhaps, science cannot yet give us a full evaluation of the positive effects these drugs can potentially have, effects that could be observed in practice. Perhaps, doctors suppose that some cases of depression in children are severe enough to risk side effects to attempt to achieve even a slight improvement. I fear I do not have the resources to decisively explain why children are still prescribed antidepressants. In the end, the FDA did not create a ban, it simply issued a warning. If doctors continue to prescribe these pills to children, they do so at their own risk. Unfortunately, they also do it at the risk of the patient and his loved ones, who often rely primarily on the advice of their doctor. Should we allow parents and their children to collaborate with their doctors and make up their own minds or should the prescription of antidepressants to children be limited by law? This important juncture between social responsibility and personal choice in psychiatry will be discussed further in my next blog post.  

"Efficacy and Safety of Antidepressants for Children and Adolescents." BMJ Group. Web. 18 Apr. 2012. <http://www.bmj.com/content/328/7444/879.full>.

"Dr. Irving Kirsch and Dr. David Antonuccio on the Efficacy of Antidepressants with Children." Web. 18 Apr. 2012. <http://www.ahrp.org/risks/SSRI0204/KirschAntonuccio.php>.

Papanikolaou, K., C. Richardson, A. Pehlivanidis, and Z. Daifoti-Papadopoulou. "Efficacy of Antidepressants in Child and Adolescent Depression: A Meta-analytic Study." National Center for Biotechnology Information. U.S. National Library of Medicine, 3 Aug. 2005. Web. 18 Apr. 2012. <http://www.ncbi.nlm.nih.gov/pubmed/16075184>.

Tsapakis, EM, F. Soldani, L. Tondo, and RJ Baldessarini. "Efficacy of Antidepressants in Juvenile Depression: Meta-analysis." National Center for Biotechnology Information. U.S. National Library of Medicine, July 2008. Web. 18 Apr. 2012. <http://www.ncbi.nlm.nih.gov/pubmed/18700212>.

Hazell, P., D. O'Connell, D. Heathcote, J. Robertson, and D. Henry. "Efficacy of Tricyclic Drugs in Treating Child and Adolescent Depression: A Meta-analysis." BMJ Group, 8 Apr. 1995. Web. 18 Apr. 2012. <http://www.bmj.com/content/310/6984/897.short>.

"A Black-Box Warning for Antidepressants in Children?" The New England Journal of Medicine. 14 Oct. 2004. Web. 18 Apr. 2012. <http://www.nejm.org/doi/full/10.1056/nejmp048279>.

Let's Make This More Concrete

As a BASIS student, I cannot escape the fact that I am a junkie for numbers, just like my peers. For that reason, though I cannot stress enough that statistics cannot reflect the individual's experience with depression and antidepressants, I'd like to share some statistics anyway.

According to one site, "over 15 million people in the United States [are] suffering from depression." Furthermore, this is an epidemic condition that affects children as well as adults. Another site claims that "pre-schoolers are the fastest-growing market for antidepressants. At least four percent of preschoolers -- over a million -- are clinically depressed." The risk for depression increases in women, the elderly and people with pre-existing health conditions.

Why does there seem to be such a tendency in psychiatry to prescribe antidepressants often and to not let them go away? The answer is simple: depression isn't going anywhere. According to UpliftProgram.com, "depression will be the second largest killer after heart disease by 2020 -- and studies show depression is a contributory factor to fatal coronary disease." That's right. It will be a killer. Depression is often viewed by society as more within the control of the patient but we cannot allow lives to be lost while we blame people for being sad. This condition needs to be taken seriously. It does produce negative health effects including a weakened immune system. The prevalence of severe depression is no secret. According to indepression.com, "2 out of every 3 people who commit suicide already talk about it to friends or family."

Antidepressants can cause side effects increasing suicide attempts but they can also help those who are drowning in suicidal thoughts come up for air. It may seem like a risky paradox. It may seem like psychiatrists should be more cautious about who they prescribe these pills to but there can be no question that some people genuinely need the prescription. In fact, based on the statistics I have found, "80% of depressed people are not currently having any treatment." So while I cannot claim that these drugs are perfect, I think I can make the argument that they are better than nothing. "Antidepressants work for 35 to 45% of the depressed population" and no, that is not enough but like I've said before, the numbers mean little to the individual. Our treatment methods are inadequate. I came into this project skeptical of antidepressants and as the conclusion of the third trimester of school draws nearer, I find that overall, depression is not being treated effectively, whether drugs are administered or not.

Teen Depression Graph. Digital image. Web. 13 Apr. 2012. <http://www.at-risk.org/blog/wp-content/uploads/teens-with-mde.jpg>.


"Depression Statistics." Web. 13 Apr. 2012. <http://www.indepression.com/depression-statistics.html>.

"Depression Fact Sheet: Depression Statistics and Depression Causes." Depression Solutions with the Uplift Program: Depression Self Help, Relationship Help, Depression and Anxiety Resources, Treatment and Information. Web. 13 Apr. 2012. <http://www.upliftprogram.com/depression_stats.html>.


"Depression Statistics." Depression Statistics. Web. 13 Apr. 2012. <http://www.depressionstatistics.org/>.

The Importance of Cohesive Care

As I have previously discussed, it is likely that the combination of drugs and therapy is ideal. So where can a patient go to get both? Not many places. Psychiatrists and other medical doctors can prescribe medication. Psychologists and counselors are trained in talk therapy. Rarely do psychiatrists provide both services. This may seem like basic specialization, dividing tasks by education. At the very least, it's a new trend. A few decades ago, your psychiatrist would be your psychotherapist. What changed and why does it matter?

What happened?
1. Psychology developed in legitimacy and importance as an academic study over time and thus, more psychologists entered the market. They go through less school than psychiatrists, a fact that is especially important to the next point.

2. Prescribing drugs without performing psychotherapy became financially beneficial to psychiatrists. A psychiatrist is usually burdened with the debt of medical school. They often cannot afford to spend 45 minutes per client if they want to make good money and work reasonable hours. Also, certain insurance factors make it possible to charge more for a fifteen minute appointment to prescribe drugs that a longer appointment that includes therapy.

So what do we do now? Typically, if a family doctor or a psychiatrist prescribes a psychiatric drug, they will also refer the patient to some kind of psychotherapist. It is completely up to the patient whether they want to go and since the disconnect between the two professions, less people being treated for depression go through therapy. The first meeting with a psychiatrist includes a family history and gathering of information about the patient that lasts 45 minutes. The following meetings tend to be fifteen minute checkups in which the psychiatrist focuses on checking for any side effects to the drug and determining it's level of success. This alone can be very expensive. It seems that some patients have decided that to add a therapist on top of a psychiatrist is an unacceptable expense.

What does this have to do with the effectiveness of antidepressants? I have already discussed that antidepressants can be effective. I have discussed that they are usually better in conjunction with therapy, so the fact that less depressed patients are receiving therapy is not good. I have also mentioned that in rare cases the medications can have extremely serious side effects. Antidepressants, in many ways, are considered one of the less risky psychiatric drugs but this does not mean that the patients taking them do not need serious attention. Depression can not only be a destructive disease due to it's relation to a lack of motivation in life, but also because the side effects of the medication used to treat it can be serious. As it stands, according to an article written for The New York Times, psychiatrists not only spend little to no time in therapy with their patients, they also reach diagnoses ten times more quickly than they often would have in previous decades. Perhaps, part of this can be considered prompted an increase in psychiatric knowledge overall, but it is undeniable (and the psychiatrist interviewed even admits) that a psychiatrist is more likely to make a quick diagnosis because it is financially prudent to do so. This new method of psychiatry and psychology at the very least causes a disconnect between the person with insight into the mind of the patient and the person filling out the prescriptions. Is it not possible that ideal care would make the psychological insight a prerequisite for the prescription? Apparently some people think so! Not everyone has given up on the idea of combined psychiatry and psychotherapy. There still are options if you want one mental health professional in your life but at an astronomical cost. According to the New York Times, "top child psychiatrists charge $2000 or more for initial evaluations," including talk therapy.

This trend of separation, so motivated by the cold realities of economics, seems unstoppable. The kind of combined treatment that might both allow drugs more thorough monitoring in patients and ensure the constructive support of therapy is not in reach for the average citizen. However, mental health is a serious issue and depression is a common condition. It is not unreasonable to hope that society will begin to realize that it is in their best interest that therapy be brought back into the picture whether they have to pay extra or not. I believe the most effective way to take an antidepressant for major depression is as part of a cohesive and well-monitored treatment plan and part of that success relies on the expertise and attentiveness of both a psychiatrist and a psychologist.

"Psychiatrist, Psychologist, Counselor, Therapist: What's the Difference?" Lotus Group. Web. 12 Apr. 2012. <http://www.lotusgroup.biz/psychiatrist-psychologist-counselor-therapist-whats-the-difference

Harris, Gardiner. "Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy." The New York Times, 5 Mar. 2011. Web. 12 Apr. 2012. <http://www.nytimes.com/2011/03/06/health/policy/06doctors.html?pagewanted=all>.

Grohol, John M. "Psychiatry Doesn't Do Psychotherapy Anymore." Psych Central.com. Web. 12 Apr. 2012. <http://psychcentral.com/blog/archives/2011/03/06/psychiatry-doesnt-do-psychotherapy-anymore/>.

Shapiro, Linda A. "DRUG THERAPY PAYS. TALK THERAPY COSTS and Is Often Being Tossed." Wellsphere. 20 Mar. 2011. Web. 12 Apr. 2012. <http://www.wellsphere.com/mental-health-article/drug-therapy-pays-talk-therapy-costs-and-is-often-being-tossed/1388263>.

"Psychiatry, Psychology, Counseling, and Therapy: What to Expect." WebMD. WebMD. Web. 12 Apr. 2012. <http://www.webmd.com/mental-health/guide-to-psychiatry-and-counseling>.

Why the Market Can't Keep You Safe From Harmful Drugs (Unless You Have a Clue)

I would like to return to the question of why psychiatrists are increasingly leaving talk therapy in the hands of psychologists. However, I am waiting on a source that I think would illuminate the matter. For this reason, I will break the promise I made in my last post. Instead, I would like to discuss why my question is important and elaborate on the manner in which I asked it. Why do I feel it is important to consider the efficacy of antidepressants? What does that "efficacy" mean?


When I first began this project, I did not want to simply compare a bunch of studies. My goal is to determine the worthiness of antidepressants from a diagnostic perspective. I feel as if lately I may seem to be getting off topic to those who do not have the same picture of a finished project in mind that I have envisioned. My result can't be a catalog of statistics because when prescribing a medicine to the individual there is so much more to consider than how often it is successful statistically. In fact, so long as it is successful at all, there is a chance that it will help the patient. From that point, part of the problem is a subjective balancing of side effects. Is being less depressed worth it if you suddenly find it extremely difficult to sleep? Consider that possibility in the long run. Consider the side effects based on how they might be affected by age. Consider the side effects versus the severity of the depression. Every case of depression is unique. I have taken to finding out as much as I can about this type of medications and the way they are used and from that,  I will draw my own conclusions about how they should be handled to improve the success of depression treatment (with medication) and minimize severe adverse reactions. At the end of this project, all I will be able to offer is an opinion. I have not performed my own study in the traditional sense. I have no original data to present to you. I am examining the various stages of antidepressant distribution and making a value judgment on how things should occur.

The first stage is production. The drugs are produced for a profit by a pharmaceutical company. The FDA regulates this to a certain extent but I have already discussed that they do not have to preform their own studies on the drug. They review studies provided by the company. They provide the public with the facts through labeling and pamphlets. As a secondary function, they consider the safety of the drugs. How can an ineffective or harmful drug slip through this process? Either the studies were flawed or not representative enough or the studies were misrepresented to benefit the company.

Then, the drugs meet the psychiatrist, who reviews the information provided by the FDA and the drug company and decides in what situations he thinks it is worth prescribing. This cannot help being a subjective decision. How can an ineffective or harmful drug be readily prescribed? The psychiatrist, much like I must, must evaluate the risks, the side effects, the potential benefits, how these all interact with the situation of the patient.  They cannot have an infallible rule for prescription.

Finally, the drug reaches the consumer. Here, one might argue, the statistics are finally enough. If the consumer finds the side effects to overwhelm the effects, they will stop taking the drug. If the people who consume the drug are harmed, the drug will be taken off the market either due to regulation or lack of demand (from either psychiatrists or patients). Antidepressants are not a drug that people take for recreation. There is no apparent reason for the patient to keep taking the drug if they find it unpleasant, seriously harmful, or completely ineffective to their depression. So why do I insist upon reviewing the worthiness of these drugs? Would not the market determine their worthlessness and insist upon their removal naturally? I think not. I do not trust the producer to be honest or all-knowing about the product. I do not trust the doctor to always prescribe the drugs without making a mistake even if he has the best intentions. I do not trust the consumer to know that they are not being helped. It is possible for harmful drugs to reach the market. Anyone who has ever seen a class action lawsuit commercial could tell you that. People are given new drugs and later, it is discovered that they produce serious health problems. Legal action is taken and perhaps they're taken off the market. But these lawsuits are not only strategically avoided by drug companies, they are also much more likely to start in a drug that is producing obvious harmful effects like heart failure. Antidepressants may not have these drastic effects but does that mean that they are 100% safe? From my research up to this point, I have determined that antidepressants can have serious side effects and are not always effective or perhaps enough to alleviate depression. It's important to remember that our attitude towards the medicine can affect the safety of it's prescription. Without greater regulation, consumers must consider the risks of accepting the drug company at it's word (without reliable independent studies) and taking a drug from a doctor that they do not even sometimes partially understand. They must think for themselves. It is important to trust your doctor's knowledge of medicine but it is also important to understand your treatment and it's possible side effects to the best of your ability.  

Which Kind of Therapy is the Best?

The best therapy is determined by the situation of the individual depressed patient. A review of the most common types of therapy will shed light on the unique values of each.

• Psychodynamic Therapy and Psychoanalysis: The goal of psychoanalysis is to help patients recover repressed memories or feelings that might be affecting their mental health in the present. Modern day psychoanalysis is an in depth, frequently-scheduled form of therapy that is meant to inspire insight that will help the patient's situation. Psychodynamic therapy works towards same goals as psychoanalysis but is less frequent, perhaps once a week. The advantage of this therapy is that it is helpful in people with deeply ingrained habits or personality defects that they wish or need to change, a concept that easily applies to depression. Another variation of this is client-centered therapy, which is inspired by the humanistic theories of Freud's protege Carl Jung. Client-centered therapy attempts the same personality improvements but is characterized by a empathetic therapist rather than an objective therapist.                                     
•  Interpersonal Therapy: Interpersonal therapy focuses on identifying issues in the interpersonal relationships of the patient. Rather than examining the past and attempting to solve personality issues, this type of therapy attempts to help the patient find solutions for the relationship problems most detrimental to them in the present. This can be useful in cases of marital, parental, and workplace issues. Real time solutions to social problems can assist patients in coping with depression.

Shown Above: An Example of Irrational Negative Thought

• Cognitive Therapy: The aim of cognitive therapy is to alter the thought process of the patient when confronted with situations that could upset him or her. This type of therapy is based on the concept that negative thoughts produce negative moods, and therefore, depression. The ideal candidate for cognitive therapy is a patient with low self-esteem and self-defeating or even irrationally negative thoughts. Cognitive therapy both attempts to raise self esteem and equip patients with long term coping solutions for negative thought.                                                  
• Behavior Therapy: Behavior therapy is exactly what is sounds like: an attempt to help the patient alter his or her behavior in ways that will eliminate destructive behaviors and replace them with more constructive behaviors. The patient sees a therapist and tells that therapist about his or her routines. The therapist will suggest things that the patient can start doing that may improve his or her mood. Other methods of behavioral change include role-playing and reward-based behavior modification.

These methods are not alone and are often combined, most famously in cognitive-behavioral therapy. Each approach has it's own advantages and all of them are accepted as possible paths to overcoming depression. I cannot stress enough that there is no one cause of depression. Just as antidepressants can only treat one aspect of the disorder and do not work equally for everyone, the same is true of each of these therapies. It strikes me that the successful depression treatment plan is most likely to be a custom fit. The small child who has conflicts with his new stepmother may be at risk on a medication but may improve after interpersonal therapy. The overworked college student with no self confidence and diminished motivation may be best off trying antidepressants while also attending cognitive-behavioral therapy. The battered wife who continually returns to her abusive husband and is extremely depressed may need a proper antidepressant and a good bit of psychodynamic soul-searching. One thing that is certain about all of these therapies is that, they give the depressed patient a support system when he or she may not have anyone else. Therapy gives a patient with major depressive disorder someone to talk to about his or her feelings and even the effects of his or her medication. Perhaps, it is not too much to demand such attention from not just our psychologists but also our psychiatrists. Why aren't the people prescribing the medicine monitoring and assisting the psychological improvement of their patients on a regular basis? I don't mean to claim that there are not psychiatrists who are highly involved in their patient's progress. However, if you were to ask the next person you see after reading this blog post, I would be willing to bet that they would be more likely to predict a fifteen-minute interview followed by a prescription and a follow-up appointment in a month from a psychiatrist than a weekly or bi-weekly psychiatrist involvement. Is the disconnect between administering medicine and therapy a simple necessity of specialization or a problem that requires reform or an overestimated anomaly brought to the conscious of the public by a few bad psychiatrists among many better ones? I will examine these questions and their direct connection to the effectiveness of antidepressant treatment for depression in my next post.

Haggerty, Jim. "Psychodynamic Therapy." Psych Central.com. 2 Mar. 2006. Web. 07 Apr. 2012. <http://psychcentral.com/lib/2006/psychodynamic-therapy/>.

"Psychoanalytical and Psychodynamic Therapies." Counselling Directory. Web. 07 Apr. 2012. <http://www.counselling-directory.org.uk/psychoanalytical.html>.

Herkov, Michael. "About Interpersonal Therapy." Psych Central.com. 10 Dec. 2006. Web. 7 Apr. 2012. <http://psychcentral.com/lib/2006/about-interpersonal-therapy/>.

"Interpersonal Therapy for Depression." WebMD. WebMD. Web. 07 Apr. 2012. <http://www.webmd.com/depression/guide/interpersonal-therapy-for-depression>.

Matthew Hoffman, MDWebMD. "Cognitive Therapy Treatment for Depression: Techniques & Benefits." WebMD. WebMD. Web. 07 Apr. 2012. <http://www.webmd.com/depression/features/cognitive-therapy>.

 Herkov, Michael. "About Cognitive Psychotherapy." Psych Central.com. Web. 07 Apr. 2012. <http://psychcentral.com/lib/2006/about-cognitive-psychotherapy/>.

 Ford-Martin, Paula. "Behavioral Therapy." Medical Information for Healthy Living. Web. 07 Apr. 2012. <http://www.healthline.com/galecontent/behavioral-therapy>.

 "Humanistic Therapy: What Is It?" CRC Health Group. Web. 07 Apr. 2012. <http://www.crchealth.com/types-of-therapy/what-is-humanistic-therapy/>.

 On the Psychologist's Couch. Digital image. Web. 7 Apr. 2012. <http://www.palme.nu/comics/w4h-depression-treatment.html>.

Talk Therapy and Antidepressants

Antidepressants are often not enough to alleviate depression and prevent it's recurrence. In many cases, therapy is also beneficial. In fact, it has been shown that in teens, for whom antidepressants are risky and have not proved particularly effective, a combination of antidepressants and cognitive behavioral therapy can be extremely beneficial. Some advantages of therapy are the long term tools which many believe it provides to patients so that they can continue to cope with life even after treatment ends. Also, therapy does not have side effects like antidepressants often do. Is therapy alone as effective as medication in treating depression? One study says that cognitive therapy can match up to the drugs. In this study, those who took medication alone and those who underwent therapy alone both improved at the same rate but those who had therapy had less recurrences than those who took medicine. This is not such a surprisingly result. The chemical imbalance that antidepressants affect is not the sole cause of depression, if a cause at all, it is correlated with it, however, and the treatment of it has shown to help with depression symptoms. It follows though that if you stop treating the imbalance, recurrence is more likely if the patient has not had any therapy because the patient may not have ever dealt with the environmental causes of his or her depression. In my opinion, it seems that the best approach is to find an antidepressant that does not have unbearable side effects and that helps alleviate symptoms while also attending therapy of some kind to learn ways to cope with the causes of depression in the long term.

Sigmund Freud

Psychotherapy, also simply called therapy or talk therapy, has been used as a method to deal with all kinds of psychological phenomena ever since Sigmund Freud began the practice of psychoanalysis in the 19th century. While Freud's ideas still can be found in modern psychology, more types of therapy have developed in time. There is therapy that can be undergone individually, in groups, with family or with significant others. However, what perhaps is most pertinent to the effectiveness of the therapy is the goal of the therapist. In my next post, I will discuss in more detail a few different therapy methods characterized by the different approaches and goals of the therapist as I will not have room to do them justice in this post.


"Cognitive Therapy as Good as Antidepressants, Effects Last Longer." Medical News Today. MediLexicon International, 05 Apr. 2005. Web. 30 Mar. 2012. <http://www.medicalnewstoday.com/releases/22319.php>.

Johns Hopkins Medical Institutions. "Antidepressants Plus 'Talk Therapy' Are Effective Therapy For Teen Depression." ScienceDaily, 18 Aug. 2004. Web. 30 Mar. 2012.

Halberstadt, Max. Sigmund Freud. Digital image. Web. 30 Mar. 2012. <http://en.wikipedia.org/wiki/Sigmund_Freud>.

The Alternative Treatments of Depression (In Pictures)

There are a variety of treatments available for depression. The most well-known, of course, being medication and therapy. While therapy has several approaches and there are a plethora of available prescriptions, perhaps the various alternative treatments are indicative of the prevalence of and the attitude towards depression. The fact that there are so many alternative options would seem to indicate a certain level of dissatisfaction with more conventional methods. Many feel that the side effects of the antidepressants outweigh their therapeutic effects. Another factor in the popularity of alternative treatments is cost; for those with minimal insurance coverage or no insurance coverage, medication can be financially out of reach. Some people simply do not find therapeutic success with antidepressants at all and give up, exploring therapy and other alternatives instead. Some of the alternative options, like St. John's Wort, have actually been around longer than conventional methods. However, this does not automatically mean that they are safer or more effective.

In fact, even herbal remedies like St. John's Wort can have interactions when paired with antidepressants without caution. The bottom line about alternative methods for combating depression is that they are not very well studied and thus, reports of their efficacy vary. In general, credible sources like the Mayo Clinic urge those with depression not to rely on alternative methods alone. Therapy and medication are the mainstays of conventional depression treatment and they are currently accepted by the psychiatric community as the most effective options. However, many people see great potential in alternative methods due to their occasional success in treating mild and moderate depression.

Some of the alternative medicine options are:

St. John's Wort (Returns)

• St. John's Wort is an old herbal remedy that is not approved by the FDA for the treatment of depression but has become increasingly popular in recent decades and brags centuries-long usage in folk medicine. 

 

SAMe structure

• S-adenosylmethionine, known as SAMe (prounounced Sammy), is a chemical naturally produced in the body that is also not approved by the FDA to treat depression. It has similar effects as  antidepressants do on serotonin and epinephrine. SAMe often minimizes side effects but does not interact well with other antidepressants and can cause mania in those with bipolar disorder. 5-hydroxytrptophan (5-HTP) is a similar chemical.

Salmon contains Omega-3

• Omega-3 fatty acids, found in many fish, walnuts and flaxseed, are beneficial to the entire body and seem to be a good dietary supplement in addition to other depression treatment.

Chill

• Relaxation of the mind or body through yoga, meditation, and biofeedback methods designed to help patients control their heart rate can also prove beneficial. This, as with many of theses remedies, is also suggested for anxiety disorders.

Running is aerobic exercise

• Exercise has also been shown to help alleviate depression of all levels and to assist in preventing recurrence. More specifically, aerobic exercise is suggested. However, few, if any, doctors would recommend exercise alone as a treatment. A healthier diet can also help.

• Acupuncture is also lauded as an alternative treatment for depression but has not been studied significantly and much about it's effectiveness remains unclear.

Green leafy vegetables are one place to find folate naturally.

• Folate is a B vitamin that can slow patient's responses to antidepressants, perhaps assisting with side effects and general improvement. This can be taken as a folic acid supplement to antidepressants. Supplements of vitamin B6 and magnesium (both involved in serotonin production) can also be beneficial.

It does not seem that any particular alternative method is sweeping in to replace antidepressants and therapy. In fact, although a select few methods have interactions with antidepressants, most alternative methods are not considered sufficient treatment alone. In my next post, I will describe why therapy is so relevant in the treatment of depression as well as what types of therapy are typically employed.

Also, I'd like to announce that I have found the topic of antidepressant efficacy so complex and intriguing that I have found that I will not be able to cover both antidepressants and anti-anxiety medication, despite the common overlap between the two.

Frazer, Cathy J., Helen Christensen, and Kathleen M. Griffiths. "Effectiveness of Treatments for Depression in Older People." The Medical Journal of Australia. 17 May 2005. Web. 28 Mar. 2012. <https://www.mja.com.au/journal/2005/182/12/effectiveness-treatments-depression-older-people>.


Kessler, Ronald C., Jane Soukup, Roger B. Davis, David F. Foster, Sonja A. Wilkey, Maria I. Van Rompay, and David M. Eisenberg. "The Use of Complementary and Alternative Therapies to Treat Anxiety and Depression in the United States." American Journal of Psychiatry. 1 Feb. 2001. Web. 28 Mar. 2012. <http://ajp.psychiatryonline.org/article.aspx?articleid=174601>.

Davis, Jeanie L. "The Dangers of Alternative Depression Treatment." WebMD. WebMD. Web. 28 Mar. 2012. <http://www.webmd.com/anxiety-panic/features/alternative-depression-treatment-risks>. 


Mayo Clinic Staff. "Alternative Medicine." Mayo Clinic. Web. 28 Mar. 2012. <http://www.mayoclinic.com/health/depression/DS00175/DSECTION=alternative-medicine>.

Wong, Cathy. "Depression Remedies." About.com. 26 Nov. 2011. Web. 28 Mar. 2012. <http://altmedicine.about.com/od/healthconditionsatod/a/Depression1.htm>.

Do These Genes Make My NPY Count Look Big?

How could genetics affect depression? Well, in the study presented in my last post, a specific gene seemed correlated with a monoamine deficiency, which seems to be involved in depression. It has also been supposed that due to the differences in scans of the brains of the depressed and the non-depressed, the development of the brain structures affected could be involved.  Medicine has barely begun to research what genes are involved in depression and for what reason. What is known is that people with a relative with major depression are two to three times as likely to become depressed. This is not a statistic generated by that person's proximity to depression. In separated identical twins, there is a 40-50% risk of one twin developing major depression if the other twin has already done so.

Many studies of genetic predisposition of depression refer to the molecule neuropeptide Y (NPY). Studies have shown that people with less of this molecule have stronger brain responses to stressors. This sort of study identifies a factor that could contribute to the cause of depression that is completely unrelated to the monoamine theory, further convincing me that the cause of depression is multifaceted. This study also pointed out that those lacking NPY were "overrepresented in a population diagnosed with major depressive disorder," indicating a correlation between the two. However, sensitivity to stress can be a risk factor for more than just depression. In fact, this may be a connection between anxiety and depression, two disorders that are treated in similar ways and can coincide. Also, NPY has been shown to induce eating in animals injected with it. The hormone Leptin, which stimulates weight loss, decreases the output of NPY by the hypothalamus. This is especially interesting because depression is sometimes, but not always, accompanied by weight loss.

This article discusses, quite aptly in my opinion, that though the depression gene research is only in it's early stages, the prevalence of this disorder will inevitably lead to more and more research on the subject. An understanding of the genetic factors of depression would yield to a better understanding of the biology of depression generally and perhaps even of some of the environmental factors. The more we know, the better our treatments can become.

Digital image. Mayo Clinic. Web. 22 Mar. 2012. <http://www.mayoclinic.com/health/medical/IM00356>.

"Genetic Factors of Depression." Livestrong. Web. 22 Mar. 2012. <http://www.livestrong.com/article/102769-genetic-factors-depression/>.

"Natural Born Pessimist: Some People Are Genetically Programmed to Be Depressed, Scientists Say." Daily Mail Online. Feb. 2011. Web. 22 Mar. 2012. <http://www.dailymail.co.uk/sciencetech/article-1354811/Some-people-genetically-programmed-depressed-scientists-say.html>.

Zhou, Zhifeng. "Genetic Variation in Human NPY Expression Affects Stress Response and Emotion." Nature.com. Nature Publishing Group. Web. 22 Mar. 2012. <http://www.nature.com/nature/journal/v452/n7187/abs/nature06858.html>.

"Emotion Processing, Major Depression, and Functional Genetic Variation of Neuropeptide Y." Archives of General Psychiatry, a Monthly Peer-reviewed Medical Journal Published by AMA. Feb. 2011. Web. 22 Mar. 2012. <http://archpsyc.ama-assn.org/cgi/content/abstract/68/2/158>.

 "Study Closes In On Genes That May Predispose Some People To Severe Depression." ScienceDaily. ScienceDaily, 01 Feb. 2007. Web. 22 Mar. 2012. <http://www.sciencedaily.com/releases/2007/02/070201082225.htm>.

 "Neuropeptide Y." TheFreeDictionary.com. Web. 22 Mar. 2012. <http://medical-dictionary.thefreedictionary.com/neuropeptide Y>.

More Monoamines Needed

St. John's Wort

From the files of Dr. Jeffrey Meyer comes another monoamine deficiency study; this time around he and his team of colleagues have examined the effectiveness of MAOIs on the enzyme MAO-A Vt, which breaks down monoamines, and the effectiveness of traditional herbal alternative St. John's Wort on the same enzyme. They found that MAOIs were successful and that St. John's Wort did not have a clinically significant effect. This study also discusses how the antidepressant market has shifted to focus on the development of SSRIs, perhaps because they have less drug interactions and possibly less side effects, and has moved away from the development of new MAOIs. It is implied that the development of MAOIs would be useful due to their effects on more monoamines than just serotonin. This study states that SSRIs work for merely half of the depressed patients treated with them. This indicates that in many patients the correction of the lack of serotonin is not enough to help induce recovery if other monoamines remain in deficient quantities.

As you may have guessed, while there is not as much research on the subject of monoamine deficiency as I would like, Dr. Jeffrey Meyer is not the only scientist leading studies on the subject. Another significant study  was conducted to determine whether brain serotonin turnover was greater in depressed patients who were not medicated with SSRIs. This study found this to be true. Patients treated with SSRIs had decrease brain serotonin turnover. This, it seems, is not an uncommon or unexpected finding. After reviewing the work of Dr. Jeffrey Meyer and other scientists, I would venture to say that it is much less than ridiculous to theorize that monoamine deficiency is correlated with depression, and that the antidepressants that are currently on the market do target and positively affect this deficiency. This study also discussed the effects of a particular gene on monoamine deficiency. This finding is significant because it points to a very direct biological way in which some genes can predispose depression.

I have discussed the monoamine theory of depression much in my recent posts. However, I would like to reiterate that I would never go so far as to claim that depression is completely induced by this monoamine deficiency. The effects of the environment cannot be dismissed. I do not think that depression is a simple enough disease to have any one cause. As this malady is complex, so must be the remedy. In my next posts, I will further discuss genetic predisposition, alternative treatments, and talk therapy to illustrate the relation between a comprehensive treatment plan and a successful use of an antidepressant.

Meyer, Jeffrey, and Julia Sacher. "Monoamine Oxidase A Inhibitor Occupancy during Treatment of Major Depressive Episodes with Moclobemide or St. John’s Wort: An [11C]-harmine PET Study." Web. 21 Mar. 2012.

Barton, David A., Murray D. Elser, Tye Dawood, and Elisabeth A. Lambert. "Elevated Brain Serotonin Turnover in Patients With Depression: Effect of Genotype and Therapy." Archives of General Psychiatry, a Monthly Peer-reviewed Medical Journal Published by AMA. Jan. 2008. Web. 21 Mar. 2012. <http://archpsyc.ama-assn.org/cgi/content/full/65/1/38>.

Digital image. Methods of Healing. Web. 21 Mar. 2012. <http://www.methodsofhealing.com/files/2009/07/st-johns-wort.jpg>.

Studying Monoamine Deficiency

So why should antidepressants be allowed to remain on the market despite the occasional occurrence of devastating side effects? Because they may be the first step to understanding the biological symptoms of depression and using that understanding as treatment. When antidepressants were first placed on the market, their efficacy relied on the monoamine deficiency theory, what I have previously called the chemical imbalance theory. In it's simplest form, it states that a deficiency of certain monoamines (neurotransmitters like dopamine, serotonin, etc.) is correlated with major depression.

This simple theory is rejected by many people who reject antidepressants, such as Peter Breggin, Robert Whittaker and Joanna Moncrieff, writers of popular anti-psychiatry literature. Many have pronounced the theory as incorrect. However, I have found some studies that imply that they may have written their verdict too early. While I don't believe that anyone with knowledge on the subject would claim that monoamine deficiency causes depression, I do not think it is ridiculous to believe that the two may coincide. The first study I read with these implications I mentioned in a previous blog post. It was a study lead by Dr. Jeffery Meyer for the Canadian-Based Centre for Addiction and Mental Health that concluded the enzyme that breaks down serotonin was more prevalent in those who had untreated depression. (For more details, see my earlier blog post "Chemical Imbalance Theory: Fact or Fiction?") After reading a press release about this study, I decided I should examine the source so I found the original article in which the results were published. What I discovered was that the sample size was rather small, a comparison of seventeen depressed patients with seventeen control patients. This is a fact that many skeptics use to dismiss the results of this study and studies like it. However, as I continued my research, I found a follow up study by the same Dr. Jeffrey Meyer that focused even more closely on the effects of SSRIs.

In this second study, twenty-eight control subjects were compared with sixteen subjects suffering from major depression and another eighteen subjects in recovery from major depression. Those with major depression were treated with SSRIs and the activity of the enzyme MAO-A VT, whose activity would decrease the number of monoamines. It was shown that the depressed patients had higher enzyme activity than the healthy patients, and that patients in recovery who had more enzyme activity were more likely to experience recurrence. As the study states, this does not only imply the correlation between monoamine deficiency and depression but it also seems to indicate that continued SSRI treatment, even during remission, is advisable in order to prevent recurrence of the depressive episodes. This is a significant positive outcome towards the demonstration of the usefulness of antidepressants, all of which function by increasing the concentration of monoamines in the brain. Studies like these make me hesitant to dismiss antidepressants and convince me that they can be a productive part of a depression patient's treatment plan.

This is a diagram from the first study posted to better under the mechanisms of monoamine deficiency. Figure A demonstrates the enzyme and monoamine activity in a healthy person. Figure B demonstrates the enzyme and monoamine activity in a major depressive episode. Note the higher concentration of enzyme and the lower concentration of monoamines. Figure C demonstrates what occurs when the monoamine transporter that would normally take monoamines away from the site is low, partially balancing out the excess enzyme. Figure D demonstrates what happens when there is both excess enzyme and a high level of monoamine transporter.

I am not one to rely on one doctor's set of studies, so I will examine the two other relevant studies I found in my next blog post.

Nauert, Rick. "Depression's Chemical Imbalance Explained | Psych Central News." Psych Central.com. Web. 02 Mar. 2012. <http://psychcentral.com/news/2006/11/09/depressions-chemical-imbalance-explained/398.html>.

 Meyer, Jeffrey. "Brain Monoamine Oxidase A Binding in Major Depressive Disorder: Relationship to Selective Serotonin Reuptake Inhibitor Treatment, Recovery, and Recurrence." Archives of General Psychiatry, a Monthly Peer-reviewed Medical Journal Published by AMA. Dec. 2009. Web. 15 Mar. 2012. <http://archpsyc.ama-assn.org/cgi/content/full/66/12/1304>.

 Meyer, Jeffrey. "Elevated Monoamine Oxidase A Levels in the Brain: An Explanation for the Monoamine Imbalance of Major Depression." Archives of General Psychiatry, a Monthly Peer-reviewed Medical Journal Published by AMA. Nov. 2006. Web. 15 Mar. 2012. <http://archpsyc.ama-assn.org/cgi/content/full/63/11/1209>.

Medication Madness

This week, to further my knowledge of the accusations made against antidepressants and other psychiatric drugs, I read Medication Madness: A Psychiatrist Exposes the Dangers of Mood-Altering Medications, another product of Peter Breggin. While my critique of his last book may have seemed dismissive, I respect Breggin for his part in many complicated court cases dealing with what he calls "medication madness." I examined this idea in the second book of his. It seems that there are cases in which certain antidepressants and other psychiatric drugs can produce severe adverse reactions. We've all heard the television commercials warning that certain drugs may cause suicidal thoughts, but I doubt many have stopped to imagine the horrific reality that fact is derived from. In the rare occasions that suicidal thoughts are induced they are often severe and accompanied by other side effects like mania, akathisia, and psychosis. Information regarding these symptoms is provided with the prescriptions by the FDA, and the information is available online, however, Breggin laments that this knowledge is not openly acknowledged. I would agree that it is of the utmost importance that the drug companies are forthcoming with the risks of their drugs (the suicidal effects were not recognized until years of the drugs being on the market). Also, it is important that doctors make informed decisions in prescribing these drugs. It seems that the severe suicidal and manic symptoms occur at the beginning of the drug-taking period or after an increase in the dose of the drug. Because I am not as skeptical of the antidepressants' ability to be successful in many cases, I propose that these side effects are made more well known rather than the drugs being taken of the market. The main focus was on the SSRI class of antidepressants. While the disastrous results of these severe side effects are significant, they do not seem to have long-lasting physical damage in the cases where the drugs were prescribed as is clinically proper. For this reason,  I would suggest that the antidepressants serious side effects can be dealt with through a more comprehensive treatment plan. Those beginning to take SSRI antidepressants should be seen by their doctor within the first week of taking the drugs and also after any increases in dosage. Furthermore, I would recommend that the patient notify their loved ones about the warning signs of the severe side effects. Dr. Breggin often speaks about patients being "medication spellbound," in regard to the patient's complete obliviousness to the deterioration of their mental state. With a significant support group of loved ones and doctors, I think that the chances of noticing these more subtle yet serious side effects would be much higher. To emphasize the rarity of these side effects, I recall a study mentioned in Breggin's book that indicates only 8.5% of adults in a clinical trial experienced increased suicidal activity. In my second post this week, I intend to explain why my research has lead me to believe that medicine's antidepressants are on the right track scientifically despite prevalent skepticism and the unavoidable suicide risks. I would like to add that this risk is more profound in children, and the apparent lack of demonstrated efficacy of the drugs in children makes the prescription of SSRI antidepressants to children something I would not endorse.
 

Breggin, Peter Roger. Medication Madness: A Psychiatrist Exposes the Dangers of Mood-altering Medications. New York: St. Martin's, 2008. Print.