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Thursday, January 6, 2011

Over-Reliance on Pills: A Review of an Article about Depression by Dr. Picciotto of Yale University

Dr. Picciotto is a professor of Psychiatry at Yale University

Summary of Dr. Picciotto's Article:
     Dr. Picciotto begins her article with statistics about suicide, arguing that we spend a lot of money trying to reduce the murder rate, so therefore, we should spend even more trying to treat the "central cause of suicide: major depressive disorder" since there are about 1.5 times as many suicides as homicides each year (about 20,000 reported homicides v. about 30,000 reported suicides)

Dr. Picciotto includes the findings of the single largest study on antidepressants by the National Institute of Mental Health (NIMH) STAR*D study that

less than 50% of people who take an antidepressant 
get "completely well,"and that the proportion of people who 
get better with a second medication decreases each time 
the person switches to another medication.

There's not such thing as a chemical imbalance that can
be fixed with "medications." Taking anti-depressants
amounts to coping with your feelings
or your life by using a pill or behavior, but the
placebo effect is behind the improvement.
From the STAR*D study and the suicide statistics, Dr. Picciotto concludes that "there is still an urgent need for new medications." She points out some recent research on IL-6 and p11 which may help increase motivation in animals or make antidepressants work better. She also mentions that Ketamine, a horse tranquilizer and a recreational drug, may help people feel less depressed "almost immediately." Finally, she mentions that drugs that block acetylcholine may help cure depression. [(Ketamine may help ECT work better than regular tranquilizers) but will they be careful to avoid marketing another prescription heroin like Oxycontin?].

Dr. Picciotto also mentions a study about zebra fish who seemed to be cured of stress related depression by taking Prozac. Finally, she calls for more research into the "cause of depression" so that people will no longer have to suffer from this "disease" and that the day may come when we "death from depression... is no longer more likely than death by murder."

Commentary on Dr. Picciotto's Article:
     What exactly is Dr. Picciotto's agenda? Her article is a persuasive argument for more money to be spent towards new medications to treat the disease of depression. The key to his argument is connecting depression to suicide, and that current medications are not effective enough. Suicide has been the 11th leading cause of death for many years; each year, nearly twice as many Americans commit suicide than die from HIV. On the surface, it makes sense for more money on research to help prevent death by suicide? But, the argument that we should spend more money on new medications is misdirected.

I completely disagree with Dr. Picciotto that we need to 
direct our resources towards finding new medications 
to treat depression, for many reasons, as follows:

1) Pharmaceutical corporations should fund their own research and development, not the American public, unless these corporations share their profits with the public and stop their deceitful marketing practices. Pharmaceutical corporations push new Anti-Depressants every ten years. First it was Tri-Cyclics, then MAO inhibitors, then SSRI's, then SNRI's, the dopamine agonists, lately it's been anti-psychotics like Seroquel and Abilify to be taken with anti-depressants. None of these classes of drugs has worked better than the one's before it, and none of them work better than a placebo. But with each new class of drugs, they criticize the previous class and promote the "novel" drugs as wonder-drugs, and the cycle repeats itself.

2) Medications for depression have been tried for over 50 years with poor results. The idea that depression is like a disease that can be cured with pills has mostly failed. There is no such thing as a chemical imbalance. This fact requires scientists and physicians to confront the failure of the application of the disease model for depression and rethink their theories of the nature of depression. Psychiatrists have moved from one neuromodulator to the next (Dopamine, Serotonin, Nor Epinephrine, Acetylcholine, etc...) with claims of being able to cure depression, but no pill has been better than the next and none of them have performed much better than taking a sugar pill, which is taking nothing. It is a myth that drugs and psychotherapy work better than drugs or therapy alone.

3) More effort should be spent on prevention, education, and studying other types of therapies for depression. TCMS, VNS, and other therapies may help, but poor stress management, lack of meaningful relationship and supportive relationships, low self-esteem, poor economic conditions, distorted thinking, negative beliefs about the self, others, or the world, poor sleep, lack of adequate exercise, and poor diet are substantial causal factors of depression. CBT and Interpersonal Therapy for depression has been found, in numerous, extensive studies, to work better than drug therapy in the short and long-term. Even exercise has been show to work better than medications. Efforts should be made to expand psychotherapies and exercise and treatments for depression.

4) Psychotherapy was not mentioned at all in Dr. Picciotto's article. This is upsetting to me, a psychotherapist. I successfully treat people for depression all the time and without medication. A therapist who effectively uses Cognitive Behavioral Therapy (CBT) can effectively treat depression, as well as anxiety disorders. Dr. Picciotto and other medical doctors seem to be only interested in pills and chemicals. When will they learn that depression is a human condition that is caused by many factors that are effectively treated with psychotherapy? Psychotherapy has no side effects and a very low relapse rate.

5) Cause and effect with suicide is extremely complicated. "Depression" does not "cause" suicide. Suicide is often an unpredictable event that occurs in people who have an unfavorable balance of risk and protective factors. There are over a dozen risk factors associated with suicide. Depression is a syndrome consisting of about 10 symptoms. Some of those symptoms may be more correlated with suicide than others, and medication may not be the most appropriate intervention for those symptoms, like feeling hopeless about your situation or your life.

Regarding the cause of suicide:
There is no single cause of Suicide. "Depression" does not cause suicide. Suicide is a symptom of depression. Major Depression is a set of symptoms, such as sadness, hopelessness, and loss of feelings of pleasure.

There are many risk factors related to suicide. When these risk factors are present, then there may be a greater risk of suicide; however, it is impossible to determine a person's level of risk since risk factors have to be weighed against protective factors, too. People who have the intention to commit suicide are probably at much greater risk for suicide than someone who has no intent. But, there are people who commit suicide while under the influence of alcohol or drugs who probably had no intent to commit suicide when they were sober.

It may not be possible to reduce the suicide rate to any lower than it is now. That may sound like a hopeless statement, but, nearly 1/2 of all people who commit suicide visited their primary care doctor in the month prior to their suicide. This means that physicians are not assessing people for depression or suicide, or that people are withholding information, or that people are offered treatment and do not follow it, or that people do follow-up with treatment but it does not help. In my experience, people are not reporting symptoms to their physicians and physicians are not conducting assessments for it. Physicians may also be quick to offer medications for which some people will feel put-off or not willing to try and for others, it may contribute to their suicide ideation and behavior.

Rather than spending billions more on research and marketing of new drugs which may not work in the long run, we're better off spending our time and money promoting what we already know does work, such as Cognitive Behavioral Therapy, and other types of psychotherapy as well as anti-depressants (but not as the first line of treatment).

Mental Health Advice Disclaimer
The information included in this post and blog are for educational purposes only. It is not intended nor implied to be a substitute for professional mental health treatment or medical advice. The reader should always consult his or her mental health provider to determine the appropriateness of the information for their own situation or if they have any questions regarding a mental health or medical condition or treatment plan. Reading the information on this website does not create a therapist-patient relationship.

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