- The depressive phase of bipolar.
- A highly recurrent depression, having more in common with bipolar than classic unipolar depression.
- A personality disorder, such as borderline.
- Your true personality - your "normal" baseline self - rather than an exception to your personality.
Clearly, most of you reading this should never have been put on an antidepressant in the first place. A placebo would have worked a lot better and with no side effects. At least you wouldn't be feeling worse. But maybe you're one of the "lucky" ones, with classic depression. An antidepressant for depression is just what the doctor ordered, right? Um, uh, define depression. This edited extract from a Feb blog post elaborates:
The DSM-II of 1968 viewed depression as both separate from (in the sense of “depressive neurosis”) and as part of manic-depression (in the sense of “manic depressive illness, depressed type”) and tied into anxiety (in the form of “involuted melancholia” and as the driving force of “neurosis”) as well as embedded into personality (as in “cyclothymic personality disorder characterized by depression”).
Moreover, the DSM-II distinguished between depression seen as a result of the mysterious biology of the brain (“endogenous”) and depression seen to be caused by a reaction to events (“exogenous”).
The DSM-III of 1980 replaced all that with a monolithic view of unipolar depression, separating it out from manic-depression and anxiety and personality and doing away with the endogenous-exogenous distinction. Instead, for the first time, we were treated to the famous and extraordinarily arbitrary nine-item symptom checklist.
In my book, "Living Well with Depression and Bipolar Disorder," I cite a 2004 article by Gordon Parker MD, PhD of the University of New South Wales in support of the proposition that this one-size-fits-all view of depression results in clinical trials that indiscriminately lump all patients together, with no regard to critical distinctions that may spell the difference between success and failure.
We know for instance that an SSRI such as Paxil gets 50 percent of patients with “major depression” 50 percent better over a period of about six weeks. This is good enough for the drug companies, who now have a license to print money, but what about the patients? Who wants a 50 percent chance of success? And who wants to be just 50 percent better?
What do we know about Paxil, anyway? Does it work better on a patient whose depression is marked by sadness? If so, is it possible to target this group of patients? Maybe then we would be seeing 80 percent of these individuals getting 80 percent better.
And try this on for size. Maybe a patient whose main feature is lack of motivation (about which the DSM has nothing to say) would benefit from something else, as would depression brought on by stress (the type of “exogenous” depression axed from the DSM-III). Maybe these drugs don’t exist. Maybe Pharma would be encouraged to develop them. As Dr Parker in a 2007 piece concludes:
Depression is a diagnosis that will remain a non-specific "catch all" until common sense brings current confusion to order. As the American journalist Ed Murrow observed in another context: "Anyone who isn't confused doesn't really understand the situation."
***
To tie this in a bow: It's not enough that a clinician accurately diagnoses depression, as the term is at best an umbrella designation, the way "infectious disease" is an umbrella designation. Yes, an antibiotic may be useful against many types of infectious disease, but we cannot make the same claim for an antidepressant for the zillion different things going on inside our brains that we happen to lump together as depression. The best we can say for antidepressants is that they work for some individuals with DSM depression. The catch is we don't know in advance who these people are.
More to come ...
Previous articles
Are Antidepressants Bad for You?
Are Antidepressants Bad for You? - Part II
Are Antidepressants Bad for You? - Part III
Are Antidepressants Bad for You? - Part IV
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14 comments:
So is prescribing an antidepressant for a person with a personality disorder helpful or is it pointless for those groups of people?
Hi, Porcelaine. I know there is a use for off-label meds with personality disorders, but first everyone needs to recognize the condition being treated.
SSRIs such as Prozac and later Paxil have provided relief for my chronic depression, but no one knows better than I that they are not a cure-all. Half a century of experience has led me to conclude that my depression is a symptom of a general disturbance in my mind/body continuum rather than a disease that can be isolated and eliminated, like diseases caused by bacteria or viruses.
Charles Sakai
I don't suffer from depression (except for the situational one which can follow a hospitalization... when my life is broken and I am back to square one...). I have had an unfortunate series of psychotic breaks. I tend to get misdiagnosed with schizophrenia.... Long story short, I am stubborn and fortunate in that each time I am watching carefully to discern which of the medications in the cocktail actually works? Realizing that it is the powerful anti-anxiety medications that clear my brain, I now am experientially skeptical that the antipsychotics are as necessary at the professionals believe. As for the etiology of my brain disorder? I don't have laboratory data, from the exact time of the breaks, because no one was looking for low blood sugar or asking whether I was in perimenopause. In't think doctors really get that lack of sleep is not the illness but the catalyst for psychosis for some of us, and the emotions (especially anxiety/ lack of trust issues) may also play a role in bringing on the storm that I consider to be psychosis. I have experienced all of the above as triggers. My multiple experiences and my ability to persevere and come of medications each time I stabilized, have helped me learn a great deal.
I am less likely to look at reactions in the brain for solution today, and more likely to look at good sleep hygiene, stable blood sugar, regular exercise, and work on my thinking... so as to prevent the perfect storm with my behavior, and not medications. It takes time to get to this place, not everyone has the good stable home life I have and the motivations I have. Also, up until the time I was first hospitalized with "mental illness" I'd always treated my illnesses wholistically. I just could not accept the model that said I had a broken brain. It made no sense intuitively. But psych doctors don't exactly like working with patients like me. We don't fit into a diagnosis category. I don't believe the anti-psychotics are doing what the doctors say they are. For me, they simply slow down thoughts and put me to sleep. Yeah, yeah..correcting dopamine, tell me another fairytale.
Hey, Charles. With you all the way. In all my time with support groups, I can't recall a single person who was "cured" by an antidepressant. I think the consensus from people in support groups is they can give you a leg up, but then you have to climb out of the hole yourself. You mention you have chronic depression. We don't have a decent evidence base on this, but your type of depression (as opposed to recurrent depression) may be the safe group for antidepressants. At least they aren't going to turn your depressive disorder into bipolar disorder.
Hey, Smitty. I hear you. Psychotic breaks don't equate with schizophrenia. Too many docs think otherwise. Like you, I do a lot of sleep hygiene, watching my blood sugar, exercise, and mindfulness to manage all the stuff going on in my head. The circumstances in my life right now are putting all my tools to the test.
There is a biology of the brain, but it is enormously complex. Psychiatry has bought into an over-simplified biological psychiatry model that posits it you're feeling depressed, it must be depression, ergo antidepressant. Likewise, if you're feeling anxious you must have anxiety, ergo anti-anxiety med, and so on.
The brain science is pointing to infinite possibilities, but it boils down to the idea that a number of us are wired to make us vulnerable to whatever life throws our way. Thus, if things get too much to handle, I may crash into depression, you may flip into psychosis. Another person, with a more resilient brain, may be just fine. Back in the bad old days, we were thought to be "maladaptive" and at fault for not adjusting to life, and I would hate to see a return to that.
I think we need to recognize that we are biologically vulnerable in some way and that trying to live normal lives in a crazy world is a challenge for us. The best management tools - such as sleep hygiene - have nothing to do with meds, but they are mediated through the brain and therefore have a biological component.
In short, the modern brain science is validating our recovery tools, and at the same time is seriously challenging the simplistic biological psychiatry paradigm.
I'm hoping that as we better figure out what is going on, we can both refine our recovery tools, change mental health services, and come up with targeted meds that do what they're supposed to do.
I won't hold my breath waiting for the latter two to eventuate, but we can all work on our individual recovery right now.
Hope this makes sense. Please feel free to reply.
You make good sense, John. I want to mull over some fine points. I'll come back after I get over the bit of euphoria I am experiencing at seeing the blog on the National Institute of Mental Health website from Dr. Thomas Insel
http://www.nimh.nih.gov/about/director/2010/from-cognition-to-genomics-progress-in-schizophrenia-research.shtml
Hey, Smitty. Thanks for the Insel heads-up. Just read his blog and will check out the Nature edition. I attended an international schizophrenia research conference in 2009. It blew me away. I'm guessing the Nature articles will too. Then I'll report back.
OK, John, I got over my optimism. Reading out loud is a good reality check.
I want to tell Ensil the connection drawn between genomics and treatment is far too indirect. Why not give credit to those that can save us health dollars in the long run? Let's focus on the molecules that fuel the brain that are derived from whole foods that maintain stable blood sugar. And the brain's substrate (where the circuitry resides) requires quality fats from whole foods, particular fish that is not raised on corn (as it may not have a suitable Omega-3 content for healthy brain surface structure). Let's finally credit Dr. Andrew Stoll for this seminal contribution; is he now buried in some obscure location in the Harvard triumvirate, where no media can reach him?
Ensil refers to retraining schizophrenic brains... well, I do believe we are getting excellent results already from new innovations in cognitive behavior therapy. Let's credit that committed work as well. And let us remember it can't be patented or forced down anyone's throat. Effective CBT is based on a trusting relationship between patient and therapist. Psychiatry right now is reimbursed for 15-minute medication management. The trusting relationship between doctor and patient is frayed, unless you are one highly educated patient who knows how to talk back to the meds and use just the right words.
The heart to heart communication necessary for real healing and that addresses the real truth--that most folks who have "mental" problems really have emotional problems. Those create powerful chemicals indeed, that are injurious to health throughout the entire human body. Since the brain is connected to the body, it is entirely logical that the brain too would be impacted.
Sadly, when patients would cry, they were frequently told too that was a brain disorder. But crying at least gave the doctor cause to revise a schizophrenia diagnosis to something more optimistic, like manic depression.
You laugh? But it happened to me in 1991. And I still respect the doctor who did this. After all, those were the only medical tools he was given. But the doctor was humble, and old school and added listening and loving care to the mix. In the end, he changed the diagnosis again, and I was healed.
Hey, Smitty. I'm with you all the way. I actually had the nerve to tell psychiatrists in a talk I gave that sending patients out the door with just a prescription is not treatment. Do you think they listened?
An NIH trial found that a certain blend of vitamins slowed down ocular degeneration. Guess what - I'm now taking those vitamins. It stands to reason that nutrients work equally well for the brain. The catch is the brain is way more complex than the eye, so we're not likely to come up with convincing trial results. But it's fairly obvious what we need to be doing.
The retraining brains, as I recall, is about honing executive function - improving working memory, reflexes, making connections, etc. This works on a different set of cognitive skills than cognitive therapy. A lot of the new brain science is driving this retraining. Hopefully, the people who put up the money will find value in this.
I do not believe my vulnerability to psychosis is going to be proven to be in my So for me personally, there's not much power in that line of research. Nor do I see hope in that "new" line of research, for "cognitive rehabilitative therapy." I though by cognitive therapy, Ensil meant CBT. No, this is special cognitive therapy for schizophrenics, which is likely to be rehabilitation for people whose cognitive ability has been destroyed by incorrect psych treatments.
The paper, which stressed the need for funding of this kind of therapy, in my humble opinion, has low expectations for patients, that I personally would have found humiliating. It is about improving patient's ability to memorize long strings of numbers, divide the numbers into groups of four and do simple tasks. I am a writer, and I am a slow typist because I don't have great hand dexterity. They'd better have people like me in that control group for the study, to be sure they don't have their ladder up the wrong wall.
I am not a numbers person, and that would be meaningless to me. What do they want these people to learn to do, quality control?
I am not wowed by new toys or old hackneyed approaches. The kind of cognitive therapy is frankly a way of corrupting the public's idea of what cognition is!
The paper has the audacity to ask for a new line of funding, for cognitive remediation therapy that is so poorly designed I was appalled. Many people mis-diagnosed with schizophrenia, who've languished on medications for years, were creative and may have been highly intelligent people who have been cut off from their creativity and their voice of opposition to medication...for years.
Please treat these people with love and care and validate their stories instead.
Myself, I am a writer. If I were given multiple digit images to memorize and regroup into groups of four, or were tested on simple tasks, I would think I really had died and gone to hell.
Hi, Smitty. It isn't about learning numbers, though numbers may be part of these exercises. I too am horrible at math. I hope you're not saying you oppose brain research because it won't benefit you immediately.
Not sure what to say on that one John.
I am just not sure if they'll have success with this kind of way of rehabilitation, at least as described.
Have we diagnosed people as having schizophrenia, who may actually have developmental orders, not just psychosis? Or have the medications done so much damage to cognition that that this work is actually about repairing iatragenic injury?
Things to think about...
I do not believe my vulnerability to psychosis is going to be proven to be in my genes. So for me personally, there's not much power in that line of research. Nor do I see hope in that "new" line of research, for "cognitive rehabilitative therapy." I though by cognitive therapy, Ensil meant CBT. No, this is special cognitive therapy for schizophrenics, which is likely to be rehabilitation for people whose cognitive ability has been destroyed by incorrect psych treatments.
The paper, which stressed the need for funding of this kind of therapy, in my humble opinion, has low expectations for patients, that I personally would have found humiliating. It is about improving patient's ability to memorize long strings of numbers, divide the numbers into groups of four and do simple tasks. I am a writer, and I am a slow typist because I don't have great hand dexterity. They'd better have people like me in that control group for the study, to be sure they don't have their ladder up the wrong wall.
I am not a numbers person, and that would be meaningless to me. What do they want these people to learn to do, quality control?
I am not wowed by new toys or old hackneyed approaches. The kind of cognitive therapy is frankly a way of corrupting the public's idea of what cognition is!
The paper has the audacity to ask for a new line of funding, for cognitive remediation therapy that is so poorly designed I was appalled. Many people mis-diagnosed with schizophrenia, who've languished on medications for years, might still be creative and may have been highly intelligent people who have been cut off from their creativity and their voice of opposition to medication...for years.
Please treat these people with love and care and validate their stories instead.
Myself, I am a writer. If I were given multiple digit images to memorize and regroup into groups of four, or were tested on simple tasks, I would think I really had died and gone to hell.
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