Monday, November 15, 2010

Are Antidepressants Bad for You? - Part IV

The story so far:

In his blog Mad in America, author Robert Whitaker drew attention to a recently published review article by Fava and Offidani that came to this startling conclusion:

When we prolong treatment [with antidepressants] over 6–9 months we may recruit processes that oppose the initial acute effects of antidepressant drugs (loss of clinical effects). We may also propel the illness to a malignant and treatment-unresponsive course that may take the form of resistance or episode acceleration.

In support of their view, Fava and Offidani cite studies that show that staying on antidepressants longer than three months has no effect at reducing the risk of recurrence and may, in fact, make the illness worse. What may be occurring, they hypothesize, is "oppositional tolerance," where, over time, the brain pushes back against the antidepressant.

But the authors also note that our lack of scientific understanding of depression leaves room for interpretation.

In his book, "Anatomy of an Epidemic," Whitaker helps us out by noting that, historically, depression had been regarded as a rare illness with a good prognosis. Then antidepressants became the rage. Despite this, too many patients only seemed to be getting worse over the long haul rather than better. According to Whitaker, instead of questioning the med, psychiatry questioned the diagnosis. Overnight, the new consensus was that antidepressants are okay, but the illness is highly prevalent with a poor prognosis.

Thus, ironically, depression became an epidemic.

But what if depression is the wrong name for this epidemic? What if most of what we are observing is not clinical depression at all? And what if not all depressions are the same? These are questions I have been asking on this blog and elsewhere. 

Let's start with the obvious, with the unipolar/bipolar distinction. All too often, people with bipolar walk in the door depressed, are misdiagnosed with unipolar depression, and given an antidepressant. If they are lucky (as I was), the antidepressant will quickly flip them into mania, which will put even the dumbest clinician on notice to change both the diagnosis and treatment.

If the patient is unlucky (as many are), the antidepressant may initially make that individual feel better before feeling worse. Then that individual endures the heartbreak and frustration of being tried on one antidepressant after another, years on end. Ten or 11 years later (the time it usually takes to make an accurate bipolar II diagnosis), a smart clinician finally considers the obvious.

There is now widespread agreement that an antidepressant, even with a concomitant mood stabilizer, does nothing (as a general rule) to improve bipolar. Moreover, we know these meds run a high risk of making it worse.

There is also an emerging consensus that this may be the case for many so-called unipolar depressions, as well. These are individuals that Goodwin and Jamison in their second edition to "Manic-Depressive Illness" characterize as "highly recurrent." In other words, there is a cycling nature to the course of their illness, much like bipolar, even if the "ups" fall well short of mania or hypomania. But give these individuals an antidepressant and that may change. In effect, an antidepressant may turn an unsuspecting unipolar into a bipolar, a point that Whitaker visits in Chapter Nine of his book.

Obviously, psychiatry needs to light a match to the DSM and start over. Whether one calls highly recurrent depression a new form of depression or a new form of bipolar hardly matters, so long as clinicians are put on notice to think twice before prescribing an antidepressant. But that is not the end of the story. Four years ago, I had this to report, from a lecture delivered by Joel Paris of the University of Toronto at the 2006 APA:

In true Axis I depression, Dr Paris explained, when patients come out of a depression, they are nice people again. Individuals with personality disorders, by contrast, can come out of a depression and still have problems with life. Unfortunately, clinicians prefer not to want to hear about personality. It means trouble. They would rather throw more meds at the problem.

Dr Paris was talking about borderline personality disorder, which is often misdiagnosed as a mood disorder. With psychiatry at long last showing signs of breaking off its love affair with Pharma (thanks to psychiatric meds losing their patent protection), personality disorders are starting to get a lot more respect.

Let's take this a step further. Suppose, in some cases, that depression itself could be considered a personality disorder, as some experts are proposing (a rather controversial view) or (much less controversially) as part of one's baseline temperament? (See my January blog post on this.) In this context, depression is a natural (and possibly even healthy) part of a person's personality rather than a deviation from from one's normal healthy state.

To wrap this up for now, imagine a patient walking into a psychiatrist's office manifesting depressive symptoms. Assuming the cause is not physical (such as a thyroid condition) or neurological (such as dementia), we have five (not necessarily mutually exclusive) possibilities, namely:
  1. Classic unipolar depression.
  2. The depressive phase of bipolar disorder, either I or II or cyclothymia.
  3. Something in between, or overlapping with, classic depression and classic bipolar.
  4. A personality disorder, such as borderline.
  5. A personality trait or temperament.
Five possibilities. Four chances to get it wrong. Only one chance to get it right. Is it any wonder that doctors get such bad results or that patients undergo so much misery? But even if the clinician spins the wheel correctly, we are talking numerous sub-possibilities within the one possibility that holds out promise. In other words, even more chances to get it wrong.

Stop this game of antidepressant roulette right now! one wants to cry out.

Next: The game goes on, anyway ...

Previous articles

Are Antidepressants Bad for You?
Are Antidepressants Bad for You? - Part II
Are Antidepressants Bad for You? - Part III


Smitty said...

I think you miss an important part of Robert Whitaker's book. The antidepressants may not be unmasking bipolar, they are potentially creating it. Have you read the book in its entirety?

John McManamy said...

Hi, Smitty. I read the whole book, many parts of it several times. Whitaker and I are basically on the same page re antidepressants. We may not perfectly align, but that's to be expected. From where I'm coming, a lot of so-called unipolar depression is in the bipolar spectrum. Whitaker doesn't go into this. I do. So, yes, antidepressants may both unmask bipolar and turn a good many unipolars into bipolars. But there may be a certain population of unipolars who do fine on antidepressants. The problem is that in psychiatry all depressions are the same so we just don't know.