anti-depressants as fancy placebos

JuliusCaesar

this has come up several times, but what the hell, here it is again:

“You’re sick; you have this diseased brain”—that seems stigmatizing to me. “You’re in a lousy situation” seems less stigmatizing. In treatment, many depressed people talk about economic problems. Sometimes depression might be a normal response to an abnormal situation.

Freiheit

The Manufacturing of Depression, the secret history of a modern disease,by Gary Greenberg is a book I'd recommend to anyone on this topic. Brillant read
http://www.guardian.co.uk/books/2010/mar/28/manufacturing-depression-gary-greenberg-review
http://www.democracynow.org/2010/3/1/gary_greenberg_manufacturing_depression_the_secret

*Simone*

I personally don't believe in the use of medication to treat depression. At least not as a stand-alone treatment anyway.

MUSEIST

*Simone* wrote: »

I personally don't believe in the use of medication to treat depression. At least not as a stand-alone treatment anyway.

Even if it actually helps people ???????

I agree that most of the positive results of ad's are probably just the placebo effect, but if it actually helps some people it can't be a bad thing surely.

*Simone*

If it helps someone, it helps, and that's great.

I just said I personally don't believe in it's effectiveness. I also said I don't think it should be used on it's own. I really think counselling is needed too.

Again, just my opinion.

John

I agree that anti-depressants shouldn't be used as a standalone treatment, therapy and lifestyle changes need to be incorporated into treatment and the drugs used to aid in treatment, not be the sole course of treatment. I question the validity of their mode of action. I firmly of the opinion that depression is a biological problem (whether it is triggered by a biological or environmental event is of course dependent on the case) but based on the pharmacological and molecular literature, I think the anti-depressant effect of drugs like fluoxetine are actually side effects of their action on serotonin/noradrenaline concentrations at synapses.

Depression has been strongly linked with changes in synaptic plasticity (obviously mainly in animal research for the electrophysiological and pharmacological data); chronic treatment with anti-depressants cause changes in synaptic plasticity and promote the expression of proteins called neurotrophins (which are involved in the formation of new synapses (synaptogenesis), maintenance of existing synapses and promote neuron survival). The changes in neurotrophin expression usually coincides with changes in mood (I can't remember the reference for this but I'll look it up when I get a chance) and other known anti-depressant treatments such as exercise also have an effect on neurotrophic factors.

There's a lot more to it of course but personally I think there will be a more effective family of anti-depressants in the next decade or two but for the meantime the current generation of anti-depressants only work sporadically because they are not actually working directly on the biological underpinnings of depression.

hotspur

JuliusCaesar wrote: »

this has come up several times, but what the hell, here it is again:

Is this even in serious doubt at this stage? I just wish sometimes that the nature of the debate spend a little more time on the positive implications of it for mind-body healing and a little less on polemical attacks on antidepressants (we can't just do away with them and start prescribing pills with placebo printed on them).

I have read a lot of Irving Kirsch's books, on this topic I recommend his populist book The Emperor’s New Drugs - it's quite a good little read.

He did an interview on behaviortherapist.com podcast this sumer, you can find it here (scroll down a bit):
http://behaviortherapist.podbean.com/

Odysseus

hotspur wrote: »

Is this even in serious doubt at this stage? I just wish sometimes that the nature of the debate spend a little more time on the positive implications of it for mind-body healing and a little less on polemical attacks on antidepressants (we can't just do away with them and start prescribing pills with placebo printed on them).



I have read a lot of Irving Kirsch's books, on this topic I recommend his populist book The Emperor’s New Drugs - it's quite a good little read.

He did an interview on behaviortherapist.com podcast this sumer, you can find it here (scroll down a bit):
http://behaviortherapist.podbean.com/

I fully agree, whilst it is important to acknowledge any negative impact/effect often these debates are one sided monologues. Often the people who are totally against there use do not have much experience of a severe depressive episode.

Even at the level I work with people, [by that I mean that the depressed patients I work with do not require hospitalisation] I have no problem in acknowledging that the use of SSRI's has in some cases facilitated the person in being able to engage in therapy.

Torakx

I had a nervous breakdown years ago, related to my diet and too much anti biotics.
But i did notice the placebos i got didnt work as well as the anti depressants.
I didnt know it was a placebo at the time but when i was on my second try of anti depressants i noticed a change in that i was able to handle it a little easier.I do think it is sometimes a good crutch for people but only as a crutch while you deal with the underlying issue.
My issue happened to be cured with a change of diet alone.But back before i knew what was wrong with me the meds this help although they were of no use to my solution.
This showed me they can work in certain cases,but imo are over precribed before seeking other alternatives,like looking at diet and medical history.
Depression to me is a symptom not a sickness itself.
Many things cause it and doctors from my experience across the country have been too quick to prescribe anti depressants to try make a symptom go away when they could be checking what enviornmental causes could be involved before advising a counselor.
Now that i think about it,if doctors werent allowed to prescribe for depression and counselors were we might see doctors focusing more on the physical causes before passing them on to the next person who could help them or prescribe anti depressants.
Just how it appears to me from my experience anyway.

Valmont

hotspur wrote: »

...spend a little more time on the positive implications of it for mind-body healing and a little less on polemical attacks on antidepressants

I agree entirely. While I do enjoy a good anti-depressant bashing, we could say the message hasn't really gotten across and that it's time for a new strategy. I've been reading a lot about CBT lately and I'm very impressed. It seems like it has massive potential to grow into a real force for helping people with mental "illnesses", even more than in it's current manifestation. Ah but that's a bit off topic.

hotspur

Valmont wrote: »

It seems like it has massive potential to grow into a real force for helping people with mental "illnesses", even more than in it's current manifestation. Ah but that's a bit off topic.

I'm not sure I would call it potential, it has been doing it for years. If you like it I suggest taking a look at 3rd wave therapies which focus less on trying to change the content of thoughts and more on changing how people relate to their thoughts like Acceptance and Commitment Therapy, Mindfulness Based Cognitive Therapy, Metacognitive Therapy, elements of Dialectical Behaviour Therapy. This is where CBT is going imo.

Odysseus

hotspur wrote: »

I'm not sure I would call it potential, it has been doing it for years. If you like it I suggest taking a look at 3rd wave therapies which focus less on trying to change the content of thoughts and more on changing how people relate to their thoughts like Acceptance and Commitment Therapy, Mindfulness Based Cognitive Therapy, Metacognitive Therapy, elements of Dialectical Behaviour Therapy. This is where CBT is going imo.

It's a tad ot, but as you know I have returned to study. We have a module on mindfulness, we haven't started it yet, however, there are various references to it.


I'm really struggling with the topic, it seems very wishy wahsy to me. As I know you are quite open and informed around various therapies; I just wondering what are your thoughts on?

We cover the topic in relation to self-care, all this talk of relaxation skills and yoga etc doesn't fit into psychotherapy for me. I'm not saying these things are helpful for some people, but I see them as something that may occur outside of therapy.

Gibs

JuliusCaesar wrote: »

this has come up several times, but what the hell, here it is again:

hotspur wrote: »

Is this even in serious doubt at this stage?

Depending obviously on who you are talking to, I think that unfortunately the answer is, yes; for a huge number of people in many different mental health-related fields and areas of expertise, this opinion proposed by Kirsch and others is typically rejected and is treated as being extreme and outlandish and as not being in line with the evidence from studies or clinical practice.

This rejection is not because the evidence doesn't clearly support it, but because the view of Kirsch and others challenges an accepted and widely-held belief in the specific mode of action of antidepressants as being a chemical one and not an active placebo, which is Kirsch's main point.

It's only a guess on my behalf and I don't have any figures to back it up but I would suspect that most G.P.'s and most psychiatrists would subscribe to the notion that there is something else going on other than a placebo effect in patients who are on antidepressants. That is a mainstream medical view, even if it has been tempered in more recent years to being confined more to patients with severe depressive symptoms. Kirsch's point is that the evidence simply does not support that view. He is not saying that antidepressants don't work. In fact he says they do work - they just don't differ from placebos in terms of how effective they are and therefore one does not need to infer a chemical mode of action to explain their efficacy (or effectiveness).

I'm not trying to say people should not use antidepressants - in fact in my practice I encourage clients to use them beause they do work. They just don't work in the way that proponents of a biochemical treatment model of depression say they do.

hotspur wrote: »

I have read a lot of Irving Kirsch's books, on this topic I recommend his populist book The Emperor’s New Drugs - it's quite a good little read.

I also read "the emperor's new drugs" a couple of months ago and, while not entirely new information, it is a very coherent and comprehensive account of the evidence supporting the active placebo account of the mode of action of antidepressants. It's particulalry good because it looks at the STAR*D data and also unpicks much of the statistical sleight of hand that goes into 'demonstrating' efficacy and effectiveness. The devil is certainly in the detail. It also places the debate, correctly imho, in the social context within which all of the research and treatment of depression takes place.

Freiheit

In the book mentioned Gary Greenberg say's that the chemical formula for depression is unknown. Thus to echo earlier sentiments, some anti-depressants can help, but not for the reasons that the medical professions claim.

JuliusCaesar

Odysseus wrote: »

We have a module on mindfulness, we haven't started it yet, however, there are various references to it.

I'm really struggling with the topic, it seems very wishy wahsy to me.

Hi, I'm not a natural yoga/meditator person myself, being a little too Type A, but I've found this really useful - partly it backs up the behaviourist 'just do it' part of me, and partly as a way of dealing/not dealing with thoughts that just interfere (what ifs, and if onlys, and all the cr*p that goes on in our heads).

Jason Luoma, one of the ACT people, has a Mindfulness meditation on his website which is downloadable. It's only about 15 minutes long. It's basically to stop people ruminating on the past and the future, and getting them to focus on the present moment. And can be done anywhere, anytime. (The ACT people rather admirably do not charge for their materials but freely share them - a nice difference from the normal American attitude!)

hotspur

Odysseus wrote: »

I'm really struggling with the topic, it seems very wishy wahsy to me. As I know you are quite open and informed around various therapies; I just wondering what are your thoughts on?

We cover the topic in relation to self-care, all this talk of relaxation skills and yoga etc doesn't fit into psychotherapy for me. I'm not saying these things are helpful for some people, but I see them as something that may occur outside of therapy.

How come relaxation skills doesn't fit into psychotherapy for you? We all exist on a biological continuum in respect of how sensitive we are to anxiety. It strikes me as a useful and beneficial thing if a therapist can help a client to strengthen their parasympathetic nervous system so that they can experience less dysphoric arousal. They are unlikely to learn it from their postman.

With respect to mindfulness I think it has become so popular because it has been shown to work for various things. Originally (as far as the West in concerned) it was shown by Kabat-Zinn to work very well for reducing stress pain management with those in chronic pain.

It did this by cultivating an alteration in how people related to their experience. The first step in this, naturally, is to become aware of what one is actually sensing and experiencing in the present. Then the goal, in respect of pain and anxiety, is not to fight it. The founder of ACT Steven Hayes uses the metaphor letting go of the rope in the great tug-of-war we engage in with ourselves and our suffering. It is not fighting it but rather holding it in a larger vessel and thus diminishing it.

So Kabat-Zinn's mindfulness based stress reduction programme for chronic pain worked very well. You can read about this in his book "Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness" (I was listening to this on audio book only today).

Then Marsha Linehan created Dialectical Behaviour Therapy with a mindfulness component to work with BPD clients and has some success (I don't know if a component analysis study has ever been done with DBT), along with Hayes using it with ACT, and Segal, Williams, and Teasdale using it with cognitive therapy for recurrent depression.

I like the Buddhist descriptions of why mindfulness is beneficial, but I also like Hayes's relational frame theory informed language which speaks to the issue of cognitive fusion. Cognitive fusion is about people getting too wrapped up in their thoughts, which is considered to be a factor in a range of psychological problems.

Psychological distancing is considered to be remedial for this cognitive fusion and involves seeing one's thoughts as merely thoughts rather than their being true by virtue of our thinking them or needing to wrestle them into submission.

Mindfulness can involve merely paying a friendly attention to thought processes and their content without becoming embroiled in them. ACT uses lots of interesting metaphors to describe this process such as our thoughts being chess pieces while the self can be considered to be the chess board, or different thoughts being like clouds in the sky but we are the sky itself and so we ought not to identify ourselves with our thoughts per se.

I also like the metaphor and technique of relating to our thoughts as if sitting on a grass bank or bridge while watching a river flow by with each leaf flowing along having a thought written on it and just observing these thoughts flow by.

I think this psychological distancing also has a more profound effect in respect of how we stand epistemologically to the veracity of our self-generated thoughts - if we merely view them as transitory thoughts produced by a wandering mind which ebb and flow they begin to lose the quality of being considered important, correct, and demanding of engagement.

I imagine some of your addicted clients might benefit from that kind of stance in relation to their addictive cravings and urges. If they identify completely with these thoughts and impulses and locate the "I" within them they are probably more likely to act addictively than if they had some distance from the thoughts and were aware that they are the observing self and not the thoughts - they are the sky, not the clouds which pass by.

Whether all of this is just attention training, whether it is a social construction of self and its relation to cognition, or whether it is, as Buddhism claims, a recognition of a fundamental truth about us I'm not sure.

Another aspect of it which is beneficial and might be helpful for addiction clients is that mindfulness is good for inculcating embodiment in people. Since it is about being mindful of what one is experiencing in the present moment then it includes paying attention to the felt sense of self physically and in respect of feelings.

It should improve attention, which I believe is an underappreciated thing. It is difficult to cultivate awareness of different aspects of the self, Other, and the world if one cannot actually well direct one's own conscious attention in the first place.

I am currently doing a meditation course in the Dublin Buddhist Centre. I am enjoying doing the loving kindness meditation at the moment. As someone whose brain is overactive in the threat / protection system and underactive in the both the compassion and approach / resource seeking systems I am doing the loving kindness meditation every day to help redress the imbalance.

The above speaks to the increasing congruence between neuroscience, evolutionary psychology (perhaps also Jungian theory), and Buddhist psychology. If I didn't believe that this stuff had a grounding in firm science with a good rationale and which can be empirically tested then I wouldn't be bothering with it. I'm not one for being away with the fairies

There are a couple of Google talks which you might enjoy. One is by the neuroscientist Rick Hanson (he also has a good website www.wisebrain.org) on the neuroscience of this:
http://www.youtube.com/watch?v=0EM45CpeQb4

Another is by Jon Kabat-Zinn on mindfulness:
http://www.youtube.com/watch?v=3nwwKbM_vJc

And this podcast interview with Mark Williams who co-founded MBCT is good (maybe I'm including it because it's where I started from):
http://www.octc.co.uk/content.asp?PageID=458&topID=458

krankykitty

Very interesting and thorough post Hotspur!

I have to say I am only starting out in this field but I have a great interest in the area of mindfulness, even just if from the point of view of practicing it myself. I find personally it helps me to become more present when I work with clients, to be aware of my own anxieties but not to get caught up in them as such, which I find allows me to listen and respond more effectively. I'm sure some of the techniques would also be helpful for clients in their day to day life also.

Kabat-Zinn also did a program of mindfulness as part of the treatment of depression: Mindful Way Through Depression

Valmont

That's it! I'm going to try and pencil myself in for some mindfulness somewhere soon. My experience was that god awful and so many people claim it is just that brilliant, then I'm willing to admit there must have been something wrong with the sessions I did. They were really that infuriating.

edit: hotspur for psychology post of the year!

Odysseus

hotspur wrote: »

How come relaxation skills doesn't fit into psychotherapy for you?

Cheers, a very informative post on the topic Hotspur. To answer your question and please take into consideration my lack of knowledge on the topic in hand; I just don't sit it as something I would incorporate into a therapy session.


From what I know on the subject currently I can see how it would benefit both a client and therapist. In a former life I used to manage a day program for addicts and used to have people come in to teach relaxation skill and introduce people to topics such as yoga; so I do believe in the efficacy of such techniques.

Whilst is would be impossible to work within a strict Freudian/Lacanian context with addicts on a methadone program, I do strongly believe in the concept of therapy being a taking cure, [or whatever a cure is] so I would strictly situate psychotherapy as working with words. I know you have studied Lacan, so you with have a sense of what I mean.

I try to avoid any type of psycho-educational input from myself; I suppose in a perfect world I would have access to project workers to do this work with clients. I'm not against it, or another therapist doing this in their sessions However, for me I think it would be taking me out of my therapeutic position. In Lacanian speak; I would be moving out of the discourse of analysis into the discourse of the university or even worse the discourse of the master. I would imagine you are familiar with Lacan's discourse theory.

It's one of the difficulties for me at the moment; I'm one psychoanalyst in a class of 20 other students who love this approach. I'll still get what I want out of the course, but there is a lot of stuff I find difficult. Their seems to be a shift in bereavement therapy now which does its best to avoid seeing anything as pathological; it appears to be saying that whatever the person feels/does is normal no matter how long the goes on for.

I had to shut myself up when I heard the lecturer tell a student that Mourning and Melancholia was written up on one person, guess who Anna O. However, I'm not there to learn about psychoanalysis, yet I do find it hard when I hear stuff like "you should not worry too much about theories, a good therapist can put material from all theories". I'm of the without a solid theory behind you, your lost at sea. Does that answer your question?

hotspur

Actually it was rather silly of me to ask why you didn't see relaxation skills as part of your therapy as I know you're a Lacanian analyst. It would indeed necessitate you functioning for the client other than you do.

Odysseus

hotspur wrote: »

Actually it was rather silly of me to ask why you didn't see relaxation skills as part of your therapy as I know you're a Lacanian analyst. It would indeed necessitate you functioning for the client other than you do.

Ah but the important thing is you got me thinking about how I function which is the important thing.

Odysseus

hotspur wrote: »

Actually it was rather silly of me to ask why you didn't see relaxation skills as part of your therapy as I know you're a Lacanian analyst. It would indeed necessitate you functioning for the client other than you do.

Ah but the important thing is you got me thinking about how I function which is the important thing.

iguana2005

did a mindfulness course - wasnt my cup of tea but did pick up some good tips. suffer from depression since very young age...alcoholic parents + history of suicide in my family..my communion morning gave me my first crippling panic attack...been down the suicide route..seen the inside of GF in Cork

lots of councelling and i regularly take antidepressents - have tried them all and i swear to you if i didnt take them i would be 5 foot under. thankfully i have found an SSRI which works for me

Thing i didnt like about mindfulness is that teacher believes that depression is caused my negative thinking only and if you turn that around with mindfullness you'll be sweet..drove me mad as class full of 'alternative' styled thinkers who wouldnt known what its like to be at the brink or probably never been in a psychiatric ward for treatment

i incorporate lots of 'chill out' time, excercise, good diet into my lifestyle. Am in my 30's - I know when im getting ill and no ammount of 'reversal of negative thinking' would make me feel 100% better alone

just my thoughts

Mooo

http://www.amazon.co.uk/Beyond-Prozac-Healing-Mental-Distress/dp/1898059632

Beyond Prozac is a book by an Irish doctor, Dr.Terry Lynch

-its a fantastic book about anti depressant use in ireland, the biopsychosocial model and a look at the power of the pharmacological industry

i think ill go read it again! its good to know how the industry has come about, its worth, who is paying for the research that supports anti-d use and their effectiveness with and without therapeutic intervention.

Odysseus

iguana2005 wrote: »

Thing i didnt like about mindfulness is that teacher believes that depression is caused my negative thinking only and if you turn that around with mindfullness you'll be sweet..drove me mad as class full of 'alternative' styled thinkers who wouldnt known what its like to be at the brink or probably never been in a psychiatric ward for treatment

I have to say that has been my experience too, I often wonder about certain "experts" and their experience. I would really love to throw them into my job from a month, or even spend a day in our waiting room and see the typical presentations that we get.

I think it may have something got to do with the luxury of private practice as there is a very distinct differene between those who end up for treatment in public and private practice. It would be very visible within my own area, it's not always the case, but there is a significant difference between those who end up in my waiting room and those who are awaiting assessment in places like the Rutland Center.

dissed doc

Mooo wrote: »

http://www.amazon.co.uk/Beyond-Prozac-Healing-Mental-Distress/dp/1898059632

Beyond Prozac is a book by an Irish doctor, Dr.Terry Lynch

-its a fantastic book about anti depressant use in ireland, the biopsychosocial model and a look at the power of the pharmacological industry

i think ill go read it again! its good to know how the industry has come about, its worth, who is paying for the research that supports anti-d use and their effectiveness with and without therapeutic intervention.

I am always wary of self-appointed experts, or experts appointed after intense lobbying.

He is a GP with no training in psychiatry or mental health assessment. I wouldn't go aroudn complaining why my GP didn't do a blood test for swine flu but instead recommended the treatment based on clinical sysmptoms.

Remember: people like him have been in charge of directing mental health policy in Ireland, not psychiatrists - he was appointed to the expert group on mental health in Ireland in 2003.

What do we have now? Crappy services, lower numbers of psychiatrists than anywhere in western europe and rising suicide rates. Don't forget to link someone's action to the outcomes.

Freiheit

While Terry Lynch started out as a G.P. he has since studied Psychotherapy or Psyhiatry,I'm not sure which, but my point is that he has training in the field. Isn't a self appointed expert.

hotspur

On the issue of depression the American Psychiatric Association published their new treatment guidelines for major depressive disorder this week (opens pdf of it):

http://www.psych.org/guidelines/mdd2010

Mooo

i would say the epidemic of escalating suicide rates has such a huge number of contributory factors that the poor psychiatric services in Ireland couldn't surely be the main perpetrator?

id be concerned about what is going on at the grassroots level of how people are experiencing their world around them and why

dissed doc

Freiheit wrote: »

While Terry Lynch started out as a G.P. he has since studied Psychotherapy or Psyhiatry,I'm not sure which, but my point is that he has training in the field. Isn't a self appointed expert.

From my reading, he has no formal training in mental health, psychology or in psychiatry through being a medical doctor.

He has a Masters in Humanistic and Integrative Psychotherapy. This is classed as counselling and psychotherapy training, but is definitely not the equivalent of formal clinical psychology or medical+psychiatry training.

So no, he doesn't have training in the field judging by publicly available information. He was still appointed to an expert group on mental health however.

Odysseus

dissed doc wrote: »

From my reading, he has no formal training in mental health, psychology or in psychiatry through being a medical doctor.

He has a Masters in Humanistic and Integrative Psychotherapy. This is classed as counselling and psychotherapy training, but is definitely not the equivalent of formal clinical psychology or medical+psychiatry training.

So no, he doesn't have training in the field judging by publicly available information. He was still appointed to an expert group on mental health however.

Whilst I have no time for anyone who takes the role of an expert [or the [person in question], it is an open question as to whether a psychotherapist is a mental health professional. For example I'm part of a clinical team within the HSE and the mental/psychological health of our clients is my brief.

Edit: Just to add most psych's I know would be of the opinion that a GP should able to treat mild to moderate depression.