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Friday, August 22, 2014

Is Depression in Old Age Normal?

According to the National Institute of Mental Health (from their website, link below):

Depression is not a normal part of aging. Yet depression is a widely underrecognized and undertreated medical illness. Depression often co-occurs with other serious illnesses, such as heart disease, stroke, diabetes, cancer, and Parkinson's disease. Because many older adults face these illnesses as well as various social and economic difficulties, health care professionals may mistakenly conclude that depression is a normal consequence of these problems — an attitude often shared by patients themselves. These factors together contribute to the underdiagnosis and undertreatment of depressive disorders in older people. Depression can and should be treated when it co-occurs with other illnesses, for untreated depression can delay recovery from or worsen the outcome of these other illnesses (http://www.nimh.nih.gov/health/topics/older-adults-and-mental-health/index.shtml).

However, the idea that depression is not a normal part of aging is false. 

Here's a decent info-video about aging. Aging is a decline of all aspects of our selves - aging is not just "normal," per se, aging is a universal human experience https://www.youtube.com/watch?v=jc4yK0zZ-cQ. There's no escape.

Why would the authors of the article about depression and aging at the NIMH claim that depression in old age is abnormal? To begin with, the definition of "normal," is part of the problem. Normal is defined as what is statistically common. So, issues that are statistically uncommon or that are outside the "norm" of human behavior or experience can be labeled "abnormal." Once something is labeled abnormal, it can then be studied. Biological or genetic causes are presumed to be the cause of the abnormal problem and medications are developed and tested. This process is referred to by Sociologists as the "medicalization" of the human condition.

Another problem is the definition of "depression." Depression is a medical term for sadness. That's right: depression = sadness. The amount of time you are are sad affects the label - for example, if you are moderately sad most of the time by at least two weeks, then you can be labeled with "major depression" (majorly sad) category, while less than two weeks would be in the "depression nos," category. So, is sadness a normal part of aging? Yes! What is normal is not always good, but it is normal. I actually think it would be abnormal to be happy during old age - who would be happy with losing everything important to them including (inevitably) their life? Sure, there are happy old people - many of us will face oblivion with grace and calm, but there are good reasons many people do not.

Another aspect of this problem is drug companies. In order to increase their market share, pharmaceutical companies are often working to create new mental health disorders or medical conditions. About 7 of every 10 studies in mental health are funded by pharmaceutical companies, and between 30% and 60% of all of these studies are never published or made available to the public (http://www.nytimes.com/2008/01/17/health/17depress.html?_r=0). One comprehensive evaluation of anti-depressant research discovered that 40% of all studies were not published; when these studies were included in systematic review of all studies, the researchers found that anti-depressants did not work better than placebos (e.g., sugar pills or Benedryl) (http://www.amazon.com/The-Emperors-New-Drugs-Antidepressant/dp/0465022006).

Pharmaceutical companies have worked with prestigious doctors who they call, "Key Opinion Leaders" to promote new diagnosis, like childhood bipolar disorder. Pharmaceutical companies then expand their marketing to new groups of "sufferers," who are encouraged to buy their products and use them for their entire life. Childhood bipolar disorder was never an official diagnosis, but was promoted by Dr. Joseph Biederman from Harvard Medical School. It was discovered that he had lied about not accepting 1.6 million dollars from drug companies (http://www.thecrimson.com/article/2011/7/2/school-medical-harvard-investigation/). In the DSM V, a new diagnosis is suggested to replace the misdiagnosis of childhood bipolar disorder, Disruptive Mood Dysregulation Disorder. How many children diagnosed with this new disorder will grow up to have Bipolar I or II disorder cannot be known for at least 25 years. However, even the Director of the NIMH agrees that the long-term use of bipolar drugs may cause more harm than good (Risperdal, Zyprexa, Seroquel, Abilify, Geodon, Lithium, and many others (http://www.madinamerica.com/2013/08/nimh-director-acknowledges-antipsychotics-worsen-long-term-outcome/).

The process of expanding markets for new and existing drugs started with children and now it is including the elderly - two vulnerable populations (ADHD in the 1980's, now Adult ADHD). Emergency room visits and deaths from these dangerous drugs have sharply increased in the last 10 years (http://www.foxnews.com/health/2014/07/10/psychiatric-drugs-cause-nearly-0000-er-visits-annually/). The FDA has released many new black box warnings to help provide consumers and physicians with information that pharmaceutical sales representatives have not shared with them. Also, the public service organization, www.ProPublica.org (under a new disclosure law) has worked hard to provide the public with information about money and gifts that doctors receive from pharmaceutical companies as well as their prescribing habits. You can see how much your doctor has received from drug companies here: http://www.propublica.org/series/dollars-for-docs.

It is assumed that doctors with very high rates of brand name prescriptions are more influenced by pharmaceutical companies than those who prescribe generics. It is also assumed that doctors who receive more money from drug companies will be more likely to prescribe that company's expensive brand name drugs.
     One egregious, but actually quite common example of a doctor corrupted by drug company money is Dr. Reinstein (http://www.propublica.org/article/high-prescribing-chicago-psychiatrist-faces-federal-fraud-suit). Although he was probably more corrupt than others, the relationship he had with drug companies is probably fairly common for many psychiatrists. I actually witnessed Reinstein's prescribing habits first hand: his associate psychiatrists would provide "in-services" (seminars) to the nurses at residential facilities and instruct them to "be sure to write BMN on the prescription" so that the pharmacy would prescribe brand name Clozaril instead of the generic version - costing taxpayers more money through medicaid (the letters, BMN instruct the pharmacist to fill the Rx with "brand name only"). Reinstein's communication with drug companies seemed clear - more money for more prescriptions; however, for most psychiatrists, the relationship is less obvious - "speaking fees" and research grants and monitoring of the doctor's prescribing habits by the drug company (yes, that's right, drug company sales reps have direct access to the prescription records of all doctors).


Psychiatrist, Dr. Michael Reinstein found
guilty of taking kickbacks to prescribe a
brand name drug.
In the United States, mental health diagnosis and treatment is influenced by pharmaceutical companies. The process works like this:
     Human conditions or experiences (shyness, sadness, worrying, resentment, aging, childhood impulsivity) are categorized into syndromes where the hypothesis is that they are "caused" by genetics or chemical imbalances. People are then told that they have a disease (medicalization) and need a drug to "fix" their "chemical imbalance." All that is really happening is that people are taking prescription drug to manage their mood (sometimes behaviors or other "symptoms"). But these pills are not without consequences. For example, 1 in 50 people who take an SSRI will experience suicidal thinking or suicidal behavior because of the drug and 1 in 20-40 will experience some other negative side effect, like serious weight gain, bleeding, stomach upset, or other problems, and only 1 in 7-8 will experience a better mood (http://www.ncbi.nlm.nih.gov/pubmed/19588448). The side effects tend to be much worse in the elderly who may be prone to increased bleeding, blood pressure, diabetes, and sudden death from combining psychotropic drugs with other types of medications.

I'm not minimizing the suffering or seriousness of human problems; but, there are better ways to categorize and study human emotional and behavior problems than promoting out-dated hypothesis (chemical imbalances) and prescribing drug therapies.

The elderly in America have a relatively high suicide rate, especially for white men, 70 and older (https://www.afsp.org/understanding-suicide/facts-and-figures). There are societal issues that present themselves during this time that probably contribute to this problems - a loss of meaning to their life, for example, grandmothers tend to be more involved with grandchildren than grandfathers. Another issue is might be painful regrets. Instead of trying to increase profits by developing and prescribing more psychotropic drugs, our society could try to encourage more active and important roles for elderly men who feel empty as they enter retirement. Self-esteem is a clear, obvious and major factor in depression (sadness); the loss of self-esteem during the aging process is a national tragedy, and the lack of a vital role in society is a waste of a great resource for younger generations.

Loss is a primary cause of sadness (depression). Aging represents the gradual and pending loss of everything you have every loved or held dear to yourself; but, simply labeling this as "not normal" and prescribing a drug amounts to missing the forest for the trees. Different forms of psychotherapy for depression in old age is probably a better idea than drug treatment. For example, group therapy, couple therapy, and family therapy that focus on resolving undefined roles, improving family relationships (bonding), improving self-esteem, and coping with loss would probably be more effective and humane. We can't leave it to pharmaceutical companies to treat depression because behind every prescription they see a stock price, whereas behind every diagnosis of depression, therapists see a human.

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