Sunday, June 29, 2008

Sad

Okay, maybe it won't be about Viagra. The papers I was going to read from have been filed somewhere with the rest of the housemoving stuff and consequently be seen again in this age of the earth.

As an aside - I was at the local Good Samaritans shop looking at the second hand books and I bought myself a shirt, a nice subdued purple one to wear to work, for only two dollars. I was thrilled at this, but when I bought it home Sarah pointed out it was one I myself had donated only a month back.

Anyway - been reading about depression, and thinking about the whys and wherefores of the medications.

A lot of my patients are depressed. This will not surprise a lot of people, but the fact is most people on the methadone programme are not depressed. Some are anxious, some have schizophrenia and the related illnesses, a lot of them have PTSD, but there is a (small) number of opiate injectors who are happier and calmer than most other people I know: people who just really really like the feeling that heroin gives you. They have their problems, of course, but the problems seem to be the normal domestic ones plus a few that revolve around getting and keeping the stuff.

And forget what you've heard about drug users being unmotivated. Most of my patients have levels of motivation that would put anyone in the Fortune 500 to shame. In fact, the parallels don't stop there, but that's a subject for another post.

Anyway - depression. Whenever the topic of depression is brought up, antidepressants get mentioned. Patients either say they are depressed and need antidepressants,

And the more I hear about anti-depressants, the less confident I am about them.

I'm not saying they don't work. I think it's quite likely that they do, I have seen people who are quite profoundly depressed start to get better after taking them. I think they can be a valuable part of the therapy some of the time in some people with some conditions.

But there's a lot going on. See, earlier this year, probably the most important paper on anti-depressants of the last five years came out. The authors used freedom of information laws to get hold of data that is usually inaccessible - data from studies the drug companies perform and then either don't publish or suppress, depending on your level of paranoia. When you look at all the evidence, not just the stuff the manufacturers choose to tell you about, details leap out at you.

Antidepressants do not work any better than placebo for most people - people who are in the initial stages of moderate depression. They work a bit better for severely depressed people. They work better than placebos for people who are very very depressed - but it might even be that that is because placebos don't seem to work on severely depressed people.

Now, for a start, placebos are damn fine medications - they are efficacious and cheap to produce. They are relatively safe, although some quite serious reactions have occured - in one clinicla trial, almost a quarter of the people taking placebos discontinued because they couldn't take the side effects any longer. And I believe there have been cases of dependency. Sooner or later there'll be a string of deaths and the stuff will have to be withdrawn.

Anyway - placebos certainly work well in depression - in most trials, people who get anti-depressants and people who get placebos both tend to improve quite dramatically over a course of therapy. I'm not saying that people don't get better if they are given anti-depressants, I an not saying prescribing them is a bad idea... I am just saying it's clearly a lot more complicated than we thought.

I don't know. Another thing - a lot of things work as well as the antidepressants. Exercise works as well as sertraline/zoloft (he says, typing while the exercise thingy sits unused a few metres away). Plus good exercise gives you back the libido and body that depression and antidepressants took awy. Swimming with dolphins is apparently an efficacious anti-depressant therapy, but few pharmacies stock them. One intervention I found useful for some of my earlier patients was getting a divorce.

And that's the other thing. There are assumptions behind the whole anti-depressant thing that bother me. There seems to be this model in some people's head that says "My patient is depressed - she suffers froma mental illness that distorts her perception, her concentration, her motivation, wrecks her sleep and appettite, profoundly disturbs her emotional state. Depression is caused by abberant concentrations of neurotransmitters in the brain, by chemical errors. We can give medication that will correct these chemical errors. When we do, the depression will resolve, and the person will be happy."

I find it difficult to take this train of thought seriously, let alone believe it. It does not accord with what I see. I could write a book on what is wrong with it, but ofor today, the assumption that the normal state is happy, that most people live lives and believe things that under normal circumstances mean they should be happy - it's like those grotesque, shape-changing half-animal creatures, those ones that scream when you shine a light on them. The ones that had that reign of terror that frightened everyone half to death back in the eighties... what were they called again?

Oh yes, Republicans.

Anyway. Most people's lives, I suspect, are not set up to produce ongoing happiness. Most people. Most good people I know worry about what they have done and what they have failed to do, sins of omission and commission. Most people, I suspect, think of others as being happier and more confident than they are. Most people have more responsibility than power.

I don't know. I don't know that we should even if we could, pathologise or medicate away what I suspect in a fair percent of the depressed people I see are normal emotional states. I don't know that we always do people a service by pathologising sadness, or frustration, or rage. What is are we saying when we say to someone "this is not normal, this is an illness, you are an ill person?" Are sorrow and pain part of wellness and normality? What about ways of coping with this without transforming someone from person to mental illness patient? Where is the borderline between discomfort, distress and disease, and what does it cost us when we cross it?

Anyhow. I do not have answers to these questions. I don't know who has. I don't know if my senior doctors do, or if my patients do - I suspect any answers will be individual, true for one person at one time, not easily transferrable. I don't know who holds the truth here, but the more I read, the less certain I am that it's Pfizer and Glaxo Smith Kline.

Thanks for listening,
John

7 Comments:

Anonymous shrike69 said...

'Most people's lives are not set up to produce ongoing happiness'

So true. Is it pathological to have a life like this? I think we view mental illness much like diabetes, in that we have drawn a line in the sand with diabetes on one side and normality on the other. In reality it is a continuum.

It is very hard to get people to change.

Medications may help, as can psychotherapy. The medications are probably overused but I wouldn't throw the baby out with the bathwater just yet.

Good to see you writing again. Keep it up.

7:31 PM  
Blogger Benedict 16th said...

1) Purple shirt - yes I very much believe it, actually you should donate it back to them, but before you do, come in to the store about once a week - asking for a shirt like that one. When they get it - they will put it out on grand display. Hey $2 for cleaning a shirt - not a bad price!
2) I suspect the SSRIs (and the SNRIs) basically seem to decrease anxiety - without the sedation and side effects of Benzos and Antipsychotics. I also suspect they are way over prescribed, and remember that in Australia the SSRIs and SNRIs are all restricted benefit - in that they are all to treat MAJOR Depressive Disorder. I suspect they decrease anxiety in a way not dissimilar to speed/ice/meth users who tend to undertake much more risky behaviour than non-users.
3) I suspect happiness and EQ/IQ are inversely related. But then I am a born cynic.

9:09 PM  
Anonymous Rach said...

i like your blog. very insightful. which is very rare nowadays. =D

9:49 PM  
Blogger Juanita said...

Well, my "up close & personal" experience with depression did not turn out well, and I don't know what would have made a difference. Institutionalization perhaps. What about the cases in which the patient deteriorates further after starting on medication? That seems to be little-publicized. I think we're on the wrong track with the meds we've developed so far. Interesting subject, that's for sure.

7:46 AM  
Anonymous Milo said...

I really wanted to agree with the Benedict 16th's comment on how antidepressants reduce anxiety... I am not a medico but as a person who has been taking them for a long time, I think that they are very effective in that particular area. And the best thing is, since you dont get sleepy, you can actually go out and do things with your life. Antipsychotics are good... but unfortunately you cant do much in your sleep.

12:25 PM  
Blogger Dragonfly said...

That is hilarious about the shirt.....at least you have donated $2 to a good cause :-)
And I tend to distrust anything said by GSK and Pfizer, on principle.

8:47 PM  
Blogger Camilla said...

Hurrah! It's great to see you back :D I hope the house moving is going smoothly, and I'm glad to hear Sarah is doing so well. When you've got a moment, plz can you send me your new address and (if applicable) phone number?

What you said about depression is dead-on, IMO. I think half of what causes depression is the idea that depression is abnormal. We're stuffed so full of this idea that life is supposed to be consistently happy and satisfying, that when we meet with what are perfectly normal emotions such as frustration, anger, sadness and depression, brought about by perfectly normal life events (crap job, relationship break-up, etc.), we immediately assume we must be sick or there must be something wrong with us.

Also, I've always wondered: do the brain chemical imbalances cause the depression, or is it the other way around? Or is it some kind of horrible feedback loop thingy?

I think when we ditch this idea that we're "supposed" to be happy, or that we "deserve" a life that's consistently happy and snag-free, then we'll probably lose a large portion of depression problems in the general population. Unfortunately, while pharmaceutical companies are making money hand over fist with anti-depressants, this is unlikely to happen. (I wonder whether any pharmaceutical companies have their fingers in the advertising pie? Drive this car, so you can be Happy. You can't afford the car? Ok, have some of these nice drugs instead.)

On a sort of related thing, someone somewhere the other day made the horrible observation that research into curing some truly awful sicknesses or developing vaccines is falling way behind because there's so much more money in anti-depressants. Isn't it a far more effective anti-depressant to not have thousands of small children in the third world dying every day from preventable disease?

Phew. I guess that rant must have been stopped up behind my ears somewhere.

Anyway, brilliant to see you back! Hogs to you and Sarah :D

Camilla

(ps I am not including all depressions in my anti-anti-depressant rant. I know some are serious illnesses in need of medical treatment. I just don't think they all are.)

5:12 PM  

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