Empirical Insanity

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’ »

We knew this already, actually. And have for a while. It’s not the news it’s being presented as. But it’s good to see it getting more press.

I’m thinking about adding a “stuff we already knew” tag. It happens so often in science/health news.

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?”

This is post 2 of Dichotomy Week. Post 1 was on the psychological concept of a division between biological and situational depression.

Conflating what causes depression with whether behavior is someone’s fault is detrimental to everyone, because confusing science about etiology (and subsequent treatment) with moral judgments about blame confuses the science and confuses public understanding about science, and makes developing appropriate treatment and getting people to use it harder, because in that environment treatments also carry undertones of blame (medication = not to blame, meditation/yoga = to blame somewhat, nebulously-defined “life changes” = it’s your fault and you don’t need medication, rather than seeing all of these as useful, some of them as infeasible for some people at some times, and some of them both feasible and necessary, not necessarily in that order).

It’s very hard to disentangle moral judgments from science in most peoples’ minds, as opposed to working within the framework by trying to reclassify depressed people in terms of whether their depression is biological/real versus situational/to blame. I think the framework is the problem, but I’m not sure there’s a lot we can do about it; finding who deserves blame for their problems is a ubiquitous human thing to do, even when blame does not contribute to solving problems and other things do.

On the other hand, maybe giving people a distinct classification system to channel moral judgments into might help keep those judgments away from etiology. Personally, if we have to have one, I favor a system classifying people into those who are pursuing vs those who are not pursuing effective treatment, as measured by lowered depression, not by whether they’re pursuing a particular kind of treatment. If we’re going to have blame no matter what, we might as well try to channel it into a better, albeit still very imperfect and problematic, path.

It’s Dichotomy Week! Or at least Dichotomy Several Days.

The question (which I’m not going to answer):

Is it chemical depression, or situational depression?

Endogenous depression, or reactive depression?

Biological depression, or situational depression?

Depression, or normal low mood, sadness, or grief?

I hear these terms used by (for the most part) three sets of people. (Begin anecdotal assertions here.) The first consists of patients who are trying to explain that their problems yes, in fact, are serious enough to require medication, and that they do *not* fall in the (presumably lightweight ) situational/reactive depression category. They’re not necessarily questioning the dichotomy itself, just arguing that they’re on the side that shouldn’t be censured for using medication.

Continue reading ‘the two kinds of depression: depression that sucks, and depression that sucks’ »

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?

Environmental Connections: A Deeper Look into Mental Illness

I love when I see articles discuss environment/biology in ways that are cutting-edge, instead of “nature versus nurture” or even “nature and nurture are both important”. This one is a good one.

Last year I discovered that half an hour of nice fast walking can bring me down out of a hypomania or mixed state or whatever you want to call it when I start getting unpleasantly overenergized. (Heavy exercise can make some people hypo/manic, so be careful if you decide to try this at home.) I exercise a lot now because it does stuff for me and because I’m in good enough mental health to do so. When I’ve been depressed, no matter how many times I read that exercising was supposed to make me feel better, it never did in the short term, and (due to inability to find energy to do things like stay awake for long periods of time) I was not able to keep it up long enough to make a difference.

But it does help ease depression, on average, which means that some people are probably getting a lot of benefit from it, other people little or no benefit, and most people in between. (This doesn’t count the people who are not able to exercise due to depression, although possibly it should – if you cannot put the treatment into action due to the disease, the treatment is inappropriate for you at that time.)

Earlier today I read an article on a study showing that women on a *supervised* exercise regimen who were *also taking medication* improved more (on average) than women who were also taking medication but did not have the benefit of a supervised exercise regimen. Note “supervised” and “also taking medication”; they were not just told that if they exercised more they’d get better, but were actually provided with the support necessary to exercise. And they were not exercising-instead-of-taking-medication the way some well-meaning dumbasses tell depressed people to do. Supervised exercise was the supplement, not the treatment, and it helped.

I’m hoping there’s a follow-up comparing people with supervised exercise regimens + medication to people with supervised exercise regimens without medication. The women in the study were ones who had failed to show improvement on medication for two months – so was it that (on average) the supervised exercise made it possible for the medication to work? Or was the supervised exercise (on average) doing what the medication wasn’t?
My long-range pie-in-the-sky hope is that this takes off enough that eventually we’ll have government and insurance-company support for supervised exercise programs as an adjunct to other treatments. Helping with depression and making the rest of you healthier too…curative and preventive treatment at the same time.

Based on two surveys 11 years apart headed up by Dag Neckelmann of Haukeland University Hospital in Norway. Reuters article. Via Spikol. Insomnia at time 1 predicted anxiety disorder at time 2, but not depression, although depression and insomnia co-occurred.

I thought the fact that it wasn’t significantly predicting depression (despite predicting anxiety) was pretty interesting, since insomnia and depression are widely known to be related (and anxiety and depression can both co-occur and each cause the other). Maybe insomnia is a byproduct of early anxiety that isn’t yet diagnosable? Maybe it’s a version of the same phenomenon where lack of sleep can make bipolar people hypo/manic?

I wanted to title this entry “Duke Nukem Helps Detect Depression” but that would have been an exaggeration. However, the game in question was modeled after Duke Nukem, and it shows group differences in spatial cognition between depressed and normal people (but it is not sensitive enough to diagnose an individual).