Archive for the ‘antidepressants’ Category

I didn’t realize this until I’d spent a summer around dogs, but they’re like people in some very relevant ways.  They get enthusiastic, they get angry, they feel down and icky, they misbehave and know it, they understand a small English vocabulary, and they look up at you adoringly whenever you have control over who gets chicken scraps and who doesn’t.

Let’s say you have a dog (let’s make him a mutt) named Barky (your six-year-old named him, not you).  You’ve had him for five years, you love him and your kid does too, and you know quite well that lying in one place, resisting going out into the sunshine for walks, and eating very little is not at all normal behavior for rambunctious, cheerful Barky.  He’s more than unhappy and you know him well enough to know that this is well outside the normal.  You take him to the vet and nothing’s physically wrong, but the vet suggests that he’s depressed and might benefit from Reconcile, the Prozac for dogs.

What do you do?  Your options include (this is not a complete set): reject the option because he’s a dog, not a human, and only humans feel real emotional pain and/or deserve treatment; reject the option because you ask about the side effects and decide they would be worse for Barky than how he appears to feel now; or accept the suggestion because you think that reducing pain, even animal pain, is desirable, and can be helped by medication. You can also go home and make fun of it. I know what I’d choose to do for someone I cared about, even if they weren’t human, or weren’t adults, or whatever we choose as the boundary line between living beings whose pain matters, and those whose pain we don’t consider real enough to matter.  It wouldn’t necessarily be to give them psych meds (that really would depend on the expected benefit and side effects), but I wouldn’t reject it based on the notion that dogs cannot have serious problems or painful emotional experiences.

The availability of Prozac for dogs is unquestionably an attempt for Eli Lilly to expand their market.  This is not different from other companies.  When you see an ad for life-saving drugs, it’s because they want more people to get those drugs.  When you see an ad for a new sports drink, it’s because they’re trying to get more people to buy it.  And so on.

The question here isn’t whether drug companies are exploitative – we already know they are, so that’s not really a question – but whether we want to use their products to reduce suffering.

Some therapists do not “get” the difference between having life problems, and having mental illness (plus, often, life problems).  My suggestions for dealing with this, if you are mentally ill and seeking therapy, are:

1) Look for therapists affiliated with hospitals, they tend to have more experience with psych patients.

2) Be leery of anyone who makes a big deal out of “situational” versus “chemical” depression.  It’s all chemical; it all happens in your brain and body.  Peter Kramer, a psychiatrist who is pro-therapy and writes books about therapy and books about medication, argues that research shows that depression triggered by repeated situational events comes to look no different from depression with a heavier genetic component.  It’s just that some people start higher or lower down the slope.

Those who start further down the slope – who some people would say have “chemical” depression – can still be helped by therapy.  For example, people who are more prone to depression following negative life events can learn to better anticipate and/or avert those events, and cognitive therapy can help people interpret those events in ways that are less damaging.  It’s not always enough, but it can be very helpful.

Continue reading ‘Situational versus chemical depression, and what it (doesn’t) mean for treatment’ »

Some researchers are arguing that often when someone’s antidepressant stops working, it’s because they were only getting a placebo effect off of it. They quote one of the researchers, Dr. Mark Zimmerman, as saying:

a message can be conveyed to patients who have repeatedly improved on medication and then lost its benefit that perhaps they are more capable than they think in bringing their own resources to bear to improve their depression

That edges awfully close to victim-blaming.  (I hope they were misquoting him.) If you’ve been on several medications that pooped out on you, it was your own ability all along!  So if you decide to stay depressed now, then it’s your fault for not getting it together. It’s a slightly sciencified version of “pull yourself up for your bootstraps”.
We don’t know a lot about the placebo effect, but it’s unlikely to be the same as bringing your resources to bear.   For example, the placebo effect in pain reduction is associated with greater expectation of a reward, but this has only been shown to be an individual-difference thing, that is, we don’t know whether trying to get people to expect a reward will lead to greater pain relief.  And it seems unlikely that trying to get people to expect a reward when they have no external reason to (i.e., medication or something similar) is going to make a difference.

(Imagine that you’re about to get your wisdom teeth pulled and your dentist says: “We’re not going to give you medication to reduce pain.  Instead, we want you to expect that you’ll get a reward.  Now, open your mouth.”)

If it’s accurate that most people who have antidepressants poop out are actually having a placebo effect poop out, that raises some interesting questions.  The most important might be “how can we replicate the placebo effect’s effects without having a placebo for peoples’ psyches to use?” and the second most important might be “why does the placebo effect keep pooping out and how can we make it last?”

Someone on the support forums I help with asked whether people who had their first hypomanic episode on antidepressants were already bipolar, or whether the antidepressants made them bipolar.

It’s an interesting question, and not one we know a definitive answer to. Here are my thoughts on it.
Let’s say we have a pair of identical twins, both of whom have pretty much identical major depressive episodes, without any hypomania. Then, twin A goes on antidepressants and starts having hypomanic episodes that persist even after she discontinues antidepressants. So she has bipolar disorder. If we say she’s always had bipolar disorder, then her twin who never goes on antidepressants and never has hypomanic episodes also (likely) has bipolar disorder, despite not meeting the relevant criteria. So we have a diagnostic problem, because now we can’t tell whether someone has unrevealed bipolar disorder or major depression, short of putting them on antidepressants which is usually a bad idea and will only induce hypomania/mania in 30-40% of people with bipolar disorder, anyway.

As an alternative scenario, perhaps all people who have apparent initial manic/hypomanic responses to antidepressants have actually had them before and just didn’t realize it. This would make everything much simpler, and it’s probably true in a lot of cases, but it sounds a little too simple to be true for everyone. I’ve read a number of studies that look at people whose first episode was a major depressive one versus a manic one, for example.

Another possibility would be to speak of some people with depression as being susceptible to bipolar disorder, which got unfortunately realized after antidepressants. A possibly faulty comparison here is to someone who is mentally healthy until they pull a week of all-nighters, have a psychotic break, and are eventually diagnosed as schizophrenic. We don’t speak of them as always having been schizophrenic. But it may not make sense to compare major depression -> bipolar disorder to mentally healthy -> schizophrenic.

I think this is what the researchers Alex Goodwin and Kaye Jamison have in mind when they talk about having a global category of “manic-depression” that includes both “bipolar disorder” and “recurrent unipolar depression” which there is good reason to believe are related to each other.

Any other guesses as to what’s going on?

In a study of more than 100,000 patients treated for depression, suicide attempts declined during the first month of treatment–whether that treatment consisted of medication, psychotherapy, or both. The findings, published by Group Health researchers in the July American Journal of Psychiatry, show a similar pattern for populations of adolescents and young adults (up to age 24) as for older adults.

Suicide attempts, overall, are not raised by medication, either for adults or adolescents/young adults. Nonetheless, some people do become suicidal despite never having been so before. The prof suggests that this is due to subgroups (duh, some of the 30-40% of bipolar patients who get hypo/manic/mixed, but I wonder if there’s anyone else – maybe we’ll find out eventually).

I do wonder, though, if some of the improvement isn’t regression to the mean – people frequently don’t start treatment until they’re quite bad off, and mood episodes tend to pass with time.

From Psychiatric News: Diagnosis, Treatment of Youth for Depression Fell After FDA Alert

It’s not just that children and adolescents are less likely to be prescribed SSRIs following the alert – it’s that they’re now less likely to be diagnosed and less likely to be treated at all (there has been no corresponding increase in psychotherapy, atypical antipsychotics, or anxiolytics).

You can view the original journal article here.

In the article they suggest it’s possible that in the wake of the recommendation families may not be fully disclosing symptoms, or filling prescriptions written for them.

They also note that the rates of diagnosis are lower than the published incidence rates (i.e. how many people get diagnosed if you go and look and see, instead of only diagnosing people who come to you). So it’s unlikely that we used to be overdiagnosing and overprescribing, and likely that we are now even further underdiagnosing and undertreating.