Commentary About Study Questioning Anti-Depressants Effectiveness for Mild to Moderate Depression

An article just published in The American Journal of American Medicine (JAMA) questions the efficacy of the use of anti-depressant medications (ADM) with mild to moderate depressions. The article is not an easy read! Here is an abstract from JAMA.

It looked at six studies with randomized control groups. Three of the studies evaluated imipramine (an older anti-depressant) and three evaluated Paxil. The conclusion is that ADM may be no better than placebo for mild to moderate depression. Further, that there was greater change with ADM as the depression was more severe. The authors reported that it has been known for more than 50 years that more severe medical and psychiatric conditions respond to a greater degree than less severe conditions.

It was also reported that FDA studies of ADM study only those with severe depressions, which they correctly report are not the impressions that Pharma's advertising gives us.

One statement in the Abstract is questionable: “Antidepressant medications represent the best established treatment for major depressive disorder.” Studies comparing ADM with several brief psychotherapies show that the latter are equally effective to ADM. Other studies show regular exercise to also be very effective. Further, therapy and exercise have dramatically lower relapse rates.

So what does this mean if you are on ADM? My suggestion is that if it is working, continue it. Don't suddenly stop altogether. Direct your questions and concerns to your prescribing physician. However, be aware that much of what many physicians know about medications, especially newer ones, is given to them by drug representatives.

email reponse to feature on depression by WCPN

This morning, there was a segment on depression treatments on our local public radio station (WCPN). It was 99% about medical (brief reference to exercise at end) treatments, i.e., anti-depressants, deep brain stimulation, etc. This unbalanced and shallow report bothered me enough to email WCPN. Below is the email I sent to them. I am interested in how YOU feel about this.

Your brief report on depression was woefully lacking. One was left with the impression that the only treatments for depression depression are medical. It is clear that Ms. Cuda had little prior knowledge about depression and that her sources were MDs, medical websites, and/or drug companies.

There have been debates in the past that depression was biological OR psychological. For 25 years, most acknowledge it is BOTH. It would be more accurate to describe it as a bio-psycho-social process.

Trauma can alter one's biology. Negative thoughts can also alter one's biology. Turning the negative thoughts around can IMPROVE one's biology. Schwartz showed this about 20 yrs ago with PET scans of those treated for OCD.

I missed ANY reference to brief psychotherapies that have proven at least equally effective as the anti-depressants. There is about 35 yrs of research that prove this. The research with exercise is another 5 to 10 yrs longer.

A good place to get a more balanced understanding of depression is http://www.nimh.nih.gov/health/topics/depression/index.shtml

While a study reported this week questions the efficacy of anti-depressants for mild to moderated depression http://blogs.consumerreports.org/health/2010/01/antidepressants-most-effective-for-severe-depression-best-buy-drugs-for-treating-depression.html do NOT make the mistake that this message is an attack on medications. Rather, it is a criticism for a lack of depth and balance. I expect MUCH better from WCPN.

Mike Miller, PhD
Psychologist

http://drmikemiller.com/depression.html

Seasonal Affective Disorder for Dummies book review

While some may be put off by the “For Dummies” series title, I have found most to be excellent starting points. Seasonal Affective Disorder for Dummies by Laura Smith and Charles Elliot is where I would suggest you begin if you have questions or interest in Seasonal Affective Disorder (SAD). It references up to date research in a practical, readable manner. It is very well organized and written.

While there is a very good chapter on Light Therapy, what I appreciate most is that most of the book addresses other interventions. What is known to date, is that effective treatments for depression are effective treatments for SAD. Another thing I like is how the authors give examples of negative thoughts in various chapters, followed by healthier thinking. Many will see their own negative thoughts and then see how they can begin to change it to healthier thinking.

If SAD is an issue for you, I highly recommend Seasonal Affective Disorder for Dummies.

Happy Holidays,

Mike

http://drmikemiller.com/sad.html

Online Cognitive Behavioral Therapy effective when delivered in real time by a therapist

Online therapy or “eTherapy” has been provided by some therapists in a number of different ways, ranging from email, to computerized therapeutic programs (one to be posted here soon), to real time video, for over 10 years. A brief history from 1972-2002 can be found at http://www.metanoia.org/imhs/history.htm

A number of questions remain fully unanswered. Probably the most critical question is how to ensure confidentiality. Additionally, there are questions of how effective these interventions are.

A study in England looked at 297 adults who were diagnosed with depression. Half of these people (149) received online cognitive-behavioral therapy and “usual care” (presumed to mean anti-depressant medication) and half (148) received “usual care” from their general practitioner while on an 8-month waiting list for online CBT. At fourth months, 113 in the CBT group and 97 in “usual treatment” completed a four month follow-up, where 38% of the CBT group were considered recovered from depression compared to 24% of the second group. There was a small increase at eight months to 42% for the CBT group and 26% of the second group.

The authors conclude: “The number of patients for whom online CBT is feasible and attractive will grow. It could be useful in areas where access to psychological treatment is scare, and for patients whose first language is not English. It could make access to psychotherapies more equitable by providing a service to patients in areas or even countries where psychological treatment is not readily available. Real-time online CBT offers the flexibility and responsiveness of face-to-face CBT and is appropriate for people with severe symptoms. It affords an opportunity for reflexion and review as part of the therapeutic process, which could enhance its effectiveness.”

There are some limitations to this study. There was no no-treatment control group. The summary did not report how much improvement there was or was not in the majority of people who were not considered “recovered.” It is also unclear whether online CBT would be as effective as in-person treatment. Many questions for further studies.

For a summary of the study http://www.bristol.ac.uk/news/2009/6502.html.

Best wishes,

Mike

http://drmikemiller.com/depression.html

Get on Your Feet

If you are dealing with anxiety and/or depression, exercise is something that you should begin, increase, or continue. There is 40 years of research that exercise is not only be very helpful, but some studies indicate they work better than anti-depressant medications, especially in follow-up studies! The self-help group Recovery, International (formerly Recovery Inc.) has taught for over 70 years that when depressed to "move your muscles.” Sleep quality and insomnia often improve with exercise.

It is best to consult with your physician before beginning a mild to moderate exercise program. Often, walking is a great place to begin. No special equipment is necessary and you can do this year round. In winter, many go to indoor malls to walk. Start at a comfortable pace and don't over do. Even 10 minutes has been shown to be beneficial.

The trick is to find something that you don't hate and preferably enjoy. Studies generally utilize 20 to 60 minute sessions at least three times a week, although you may not be ready to begin at that length of time. Nor do you necessarily have to join a gym. Finding someone to exercise with can be very helpful, but should not be an excuse to not exercise. Consider walking with your spouse or a friend. Bike ride with your kids. Consider exercise classes.

Having different things that you sometimes do can help keep things from getting boring. However, if you say love and want to primarily do one activity, Great! Changing where you walk, run, bike, etc. can also help keep things more fresh. Another advantage of sometimes doing different things is using different muscles.

Exercise is not guaranteed to beat your anxiety or depression alone, but it frequently is very helpful.

Best wishes,
Mike

What is Your Recovery Plan for Anxiety and Depression?

What is your recovery plan? What is it that you will do to get past your depression, anxiety, or whatever? This may be a foreign concept to you. Many may wonder, “What is it that I CAN do to improve my anxiety, mood, or whatever? Non-medication possibilities include (but are not limited to) exercise, self-help reading, tracking and challenging negative thoughts, self-help group involvement, facing your fears, affirmations, diet, spiritual practices, relaxation exercises, yoga, and journaling.

Whether or not you are seeing a therapist, generally, the more you do the kind of things just mentioned, the more quickly you get better. If you are working with a therapist, it is best to check your activities with them. Most of the time, you will get encouragement and possibly tips. Many to most therapists will gladly make suggestions of thing they think you will find helpful.

If you have experienced a lot of trauma and/or very severe trauma, then trying to recall memories and some self-help reading may take you at a faster pace than you can manage. In these cases, it is better to go too slow than too fast. However, it does not preclude you from doing most of the other activities listed above.

Activities that are often suggested and helpful are to think about different things related to what you want to change, to notice the times when things are actually better, as well as trying to picture in your mind how you would like things to be.

Best wishes,
Mike

Drugs vs. Therapy

As I touched on in my previous posting about depression, there are interesting studies comparing the treatments of medications and psychotherapy/counseling. One sees medication ads almost any tie you turn on the TV, look in a magazine, etc. Research proves that the advertising works. Increasing numbers of people are taking medications for depression, stress, etc. The number of people seeking counseling may be decreasing.

Many of the studies with depression, even severe depression, show them to be about equally effective. Therapy has been shown to have greater durability, with lower relapse rates following the end of treatment. There are also lower drop-out rates for therapy, due to medication side-effects. It is common practice for people to receive both treatments. One might think this to be more potent than either treatment by themselves. Some studies do support this, but other studies do not.

There is some evidence that therapy may be the better choice for those experiencing panic attacks. One study "found higher treatment effect sizes, lower attrition rates, and favorable cost profiles for talk therapy as compared to medication treatment for this disorder." There are fewer studies for panic than for depression. Therefore, one should be slower to declare a conclusion.

It may be surprising (including to many mental health professionals) that therapy can also be very helpful in the treatment of schizophrenia. An examination of many studies (a meta-analysis) "found that people treated with talk therapy in addition to medication were significantly better off than those treated with medication alone."

There are several other interesting findings from the huge muti-site research on depression. More effective therapists focus less on medications. Also, that the relationship with the psychiatrist is predictive of how helpful medication will be. There was a parallel with some behavior therapists, years ago. The parallel is that the medication or behavioral treatment are what is important and that the relationship is not. Behavior therapists have come to understand this. Some psychiatrists still have this lesson to be learned.

What can one conclude? First, that treatment works for most people. Second, the relationship with any mental health (and probably non mental health) providers is critical. Third, that the drug companies have great influence on what treatments people seek. This posting is not intended as anti-medication. I have encouraged numerous individuals to try medications for a variety of conditions. Rather, medications are not the only choice and sometimes the lesser choice. Lastly, if you are unhappy with your provider, try to make your complaints known to that person.

Best wishes,
Mike

For full report: http://www.talkingcure.com/archives.asp?id=129&fragment=0&SearchType=AND&terms=depression+relapse

Depression Patients’ Brain Circuitry Makes Them Vulnerable to Relapse

"Using brain imaging, NIMH researchers have produced direct evidence that people prone to depression -- even when they're feeling well -- have abnormal mood-regulating brain circuitry. This makes them vulnerable to relapse when levels of certain key brain chemical messengers plummet.

To test this directly and identify any brain circuit abnormalities, the researchers studied 15 un-medicated subjects in remission who had a history of depression by giving them a drug that temporarily depleted their brains of dopamine and norepinephrine.

These subjects experienced an increase in depression symptoms and a decrease in the ability to feel pleasure. PET scans showed that this was accompanied by an increase in activity in a depression-implicated brain circuit. By contrast, activity decreased or remained unchanged in the same brain circuit with depletion in 13 healthy participants who experienced only minor mood effects. Activity in specific brain structures in the circuit corresponded with a set of mood effects (see graphics below)."

This offers some evidence of why there is such a high relapse rate in depressed individuals. However, there are many studies that show while therapy and medications are about equally effective treatments, that there is a high relapse for those receiving meds only, if they discontinue the meds. Those receiving therapy, have a much lower relapse rate.

This is further evidence that depression is a bio-psycho-social disorder (generally has biological, psychological, and social factors) and that effective psychological interventions ALSO positively effect one's biology. The reality is that the psyche affects the soma, the psychological effects the biological, or the mental effects the physical. In other words, there is an endless loop where both effect the other.

Best wishes,
Mike

For full report: http://nimh.nih.gov/science-news/2008/depression-patients-brain-circuitry-makes-them-vulnerable-to-relapse.shtml