Bernards Voices

Related to the same theme of “caregiver connections,” Dr. Pauline Chen published an article January 21st in The New York Times about the disconnect between physicians and their patients’ caregivers, and the need for more attention to be paid to the physical and mental stresses of caregivers.

Caregiving duties place tremendous stresses on an individual, and not all of those stressors are simply physical and emotional.   “Some of these 37-going-on-40 million family caregivers have had to give up their own jobs in order to care for the patients,” Dr. Hood said.   “That means they aren’t going to be able to put aside money for their retirement.  Who is going to take care of them and their medical problems in the future?”

DeRubeis and Fournier, authors of the original study published by JAMA, critique Friedman–they simply say he is wrong, and then add that he fails to:

acknowledge findings consistent with our own from two previous reviews

It would have been nice if they provided a reference to those 2 reviews.

Ken Pope, a colleague of Dr. Leslie Becker-Phelps, pointed out this article Monday posted in The New York Times.  In the article the author, Dr. Richard Friedman, adds more commentary on the JAMA study, much of which is similar to Peter Kramer’s on Slate’s XX.  It is good to hear criticism from multiple sources.

The study was narrow:

• only 6 of 23 qualifying studies allowed access to data (for a total of 718 subjects)
• only 2 anti-depressants were studied when there are “25 or so on the market.”
• the study excluded trials with a “placebo washout period … (often the first two weeks)”–which therefore muddied the picture by combining the first two week effect with the placebo effect.
• and after all this filtering and narrowing, only a few subjects remained in the study with “very mild depression,” so the conclusions were based on minimum data

Friedman writes:

And the real test of an antidepressant is not just whether it can lift someone out of depression; it is whether it can keep depression from returning. For a vast majority of people with depression, the illness is chronic. Relapses and low-level symptoms between episodes are common.  Scores of studies show that antidepressants are highly effective in preventing relapse; on average, the risk of relapse in patients who continue on an antidepressant is one-half to one-third of those who are switched to a placebo.

Experts may disagree about what constitutes the best treatment for depression, and for whom. But there is no question that the safety and efficacy of antidepressants rest on solid scientific evidence.

Judith Warner wrote this op-ed January 9th, The Wrong Story About Depression, in response to CNN’s and MSNBC’s “startling” news about “sugar pills.”  (Here is a link to The New York Times piece. )   Peter Kramer also reacted immediately to popular press’s coverage, posting this article on Slate’s XX.   Kramer writes “the undertreatment problem is the real news.”

I felt the same way Warner & Kramer did when I read the MSNBC article, which I posted on, but they did a much better job saying and defending the point.  Warner writes:

This is the big picture of mental health care in America: not perfectly healthy people popping pills for no reason, but people with real illnesses lacking access to care; facing barriers like ignorance, stigma and high prices; or finding care that is ineffective.

But here is something new I hadn’t focused on:

That people have come to believe otherwise may be in part because most patients with depression are treated by general practitioners, not psychiatrists. Studies have shown that these primary care doctors don’t strenuously enough screen their patients for depression before prescribing drugs, or closely monitor their care afterward.

In Peter Kramer article on Slate’s XX, Kramer writes “the undertreatment problem is the real news.  As for drugs not working—that’s a complicated story.”  (I quote extensively from the piece.  You may be better served just going straight to his article and reading it.)

Reasoning that it is well-established that antidepressants work for dysthymia—chronic or frequently recurring minor depression—the researchers next eliminated trials in which that sort of mood disorder played a role. The exclusion is important. Of the 1,000 or so studies of depression treated with an FDA-approved drug, the Penn researchers threw out almost 600 for this reason.

When the researchers finished filtering their sample set, Kramer writes that “their analysis [applied] to only six of the original 2,000-plus trials.”

It is this summary of six studies of two medications that has led the press to report more or less conclusively that antidepressants do little for minor mood disorders.

For an answer, we might look to this month’s issue of the Archives of General Psychiatry. A study conducted at Northwestern University appears therein that, had it been published sooner, might well have been included in the Penn research. The trial uses the same outcome measure relied on in the Penn overview. It has no washout period. And it tests Paxil. The core finding is straightforward: While Paxil did moderate depression, the drug’s greater effect was in changing personality.

Kramer draws these conclusions from the Penn study:

They help with acute severe depression. They help with chronic minor depression. And yet they do little for acute, isolated bouts of minor mood disorder. Still, overall, they make patients resilient in a general fashion having to do with personality traits.

Then Kramer says even this conclusion isn’t persuasive, and the study should have been better designed. If you reread the MSNBC article, that’s not what it says. This is why we need more intelligent mental health reporting. Thanks to Warner, Kramer, The New York Times, and Slate’s XX.

Finally at the risk of being repetitive, I quote Kramer again:

To me, the real news of the month comes in another study, from the University of Michigan, in the Archives of General Psychiatry. It found that only one in five Americans with depression has received even one adequate course of treatment in the past year. The criteria for adequate treatment are modest: 60 days of an antidepressant with four doctor or nurse visits over the year or (for talk therapy) four mental health visits lasting 30 minutes or more.

To me, that’s the story that matters. Most depressed people don’t get evaluated; most who are evaluated don’t get treated; and most who are treated are treated poorly.

MSNBC reports: Meds no better than placebos for all but most severely depressed

CHICAGO – Mild, moderate and even some cases of severe depression might be better treated with alternatives to antidepressant drugs, which do not help patients much more than an inactive placebo, researchers said on Tuesday. But for those with the most severe forms of depression, the medications have significant benefit.

(Only) 2 families of anti-depressants, paroxetine (paxil) and imipramine, were studied.

The so-called placebo effect is powerful in treating depression, where people believe they are helped even though they are taking an inactive sugar pill, DeRubeis said.

My own personal experience is that depression is a very hard nut crack. I like what Peter Kramer says in Against Depression–that it should be attacked vigorously before it deepens and becomes chronic.

Don’t let articles like this one at MSNBC be an excuse not to get treatment.

At least 27 million Americans take antidepressants, nearly double the number that did in the mid-1990s, according to a study by Columbia University and University of Pennsylvania researchers reported in the Archives of General Psychiatry.

More than 164 million prescriptions for antidepressants were written in 2008, totaling nearly $10 billion in U.S. sales, according to IMS Health. Global sales were twice that.

We need more science.   I’m all in favor of science.  Prozac, not mentioned in the MSNBC article, may have an unanticipated mechanism for helping.

From the New Scientist:

At Yale University, Ronald Duman and his colleagues began to see ways of adapting the old theories to take account of the new brain findings. After all, treatment with Prozac and other antidepressants is often amazingly successful. Maybe the monoamine theory was not entirely wrong. They noticed that Prozac and some of the other drugs increased levels of a substance called brain-derived neurotrophic factor, or BDNF, in the hippocampus. BDNF was originally identified as a “growth factor” involved in the development of the nervous system, but it is now known to be important for sustaining and protecting neurons in the adult brain. Duman, along with his colleagues George Henninger and Eric Nestler, now at the University of Texas Southwestern Medical Center in Dallas, proposed a “neurotrophic theory” of depression, in which the antidepressant effects of drugs like Prozac could be attributed to the way they keep cells alive in the hippocampus.

A hard science article from the National Academy of Sciences on the pharmacology of prozac.

A short survey of depression research at Yale. When you are reading the literature you also see things like the combination of anti-depressants, when combined with talk therapy, yield the best results. Dr. Sanacara at Yale is exploring whether the meds are increasing the brains plasticity, and therefore more receptive to therapy.