PsychiatryTalk

Are Antidepressants Overrated?

Posted on January 20th, 2010 by Dr. Blumenfield

OVerrated pillsRecent Research of Studies of Antidepressant Medications

A recent study in the Journal of the American Medical Association reviewed six well-done research studies, which  looked at  double blind placebo of antidepressant treatment for at least six weeks  with adult outpatients who had  minor and major depression. The usually reliable Hamilton Depression Rating Scale ( HDRS ) was the instrument used for measuring depression.

Medication Works Best With Severe Depression

The researchers concluded that the  magnitude of benefit of antidepressant medication compared with placebo increases with the severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial. It is important to note that this information does not deny that many or probably most of the patients in these studies as they do, in doctors offices all the time, felt much better after taking antidepressant medication. The placebo effect of taking the medication and/or various forms of psychotherapy or general support caused improvement in people who also were taking antidepressants. Only in those patients with severe depression was the improvement clearly (or statistically) better than those were taking the placebo.

Considerations Whenever Depression is Diagnosed

The implications of this research should not be a surprise to most practicing psychiatrists. When treating depression, one must take into consideration many other factors in addition to the presence of depression symptoms.

Medical  Conditions stethsocope-2

Is there an underlying medical condition, which might be causing the depression, or contributing to it?  If  there is such a condition, it is quite possible that any antidepressant treatment will have limited effects unless the underlying condition is addressed. While there might be some improvement above and beyond placebo effects with medication, the chances would be much better if attention were directed to the organic conditions. Even just the recognition that there is a medical cause will often help to alleviate the depression as the patient begins to understand the nature of their illness.

The list of medical conditions, which can cause depression,  is quite long. Some examples which are far from inclusive are as follows:

  1. Thyroid condition particularly hypothyroidism
  2. Other endocrine abnormalities such as parathyroid disease and even diabetes
  3. Various forms of epilepsy
  4. Brain trauma or vascular insufficiency to the brain including stroke
  5. Brain Tumor can often first be manifested as depression
  6. Infectious processes particularly those that can effect the brain such as Lyme Disease or Syphilis
  7. Parkinson’s Disease and other degenerative diseases such as Alzheimer’s; Disease or Huntington’s Disease
  8. Cancer of Pancreas is known to first show itself as depression but so can other cancers
  9. More exotic diseases such Wilson’s Disease, Huntington’s Disease or even Pellagra, a rare vitamin deficiency

Bipolar Disorders

Of special  importance are Bipolar Disorders where the  depressive phase can be indistinguishable from a severe depression other than by a  history of a manic phase. Antidepressants if used in these conditions may actually make things worst by precipitating   a manic phase whereas mood stabilizers can bring about great improvement.

Schizophrenia

While Schizophrenia is usually relatively easy to diagnose, there can be a depressive component to this disorder. At times if the underlying schizophrenia is not recognized, the use of antidepressants alone will most likely not be effective . These patients usually require an antipsychotic medication to put the condition into remission.

Obsessive-Compulsive Conditions and Phobias

Obsessive-Compulsive conditions and severe Phobias may respond to antidepressant but specific classes of these medications have been shown to be most effective. Thus if these conditions are not recognized, the wrong medication may be chosen. In addition these disorders usually require additional forms of specialized psychotherapy.

Dependency & Addictions

The failure to recognize alcoholism and drug dependency and to just direct treatment towards the depressive symptoms with antidepressant medication is doomed to failure. Since such conditions can ultimately be fatal such an omission is quite serious. Other dependency conditions such as compulsive gambling , sexual addiction, and even eating disorders while perhaps not technically classified in this category are similar in that specialized treatment is absolutely required . Antidepressants may also be helpful but by themselves will not significantly improve these conditions.

Character Disorders, Interpersonal,  Psychodynamic Issues & PTSD

People with these conditions can appear in a psychiatrist or other mental health professional’s office or they can even be recruited into a drug study. If they have depressive symptoms they may be put on antidepressant medications. They may have some improvement  because they have a dual diagnosis with a depressive condition or because of placebo effect. However,  if the underlying condition is not addressed with a meaningful psychotherapy, which is effective for them, the depression will most likely reoccur. In a large percentage of these patients the use of antidepressant may very well be judged to be ineffective. As in all the above conditions unless both diagnoses are addressed it is most likely that the antidepressant will fall short of significantly helping the patient.  On the other hand sometimes in many of  these conditions and those mentioned above, if a serious  depressive component is recognized and treated, the patient will become more able to relate and engage in treatment of the co-existing conditions.

Grieving

I left this condition for last because the manifestation of it  can often resemble major depression with insomnia, poor appetite, and diminished interest in the world, severe depressed mood. Obviously, the history of the loss as well as other specific characteristics distinguish grieving. In most cases it is time limited. Sometimes supportive therapy or even specialized groups are helpful. If these symptoms become incapacitating, or if there is a history of previous depression a trial of antidepressants may be used.

Dual Diagnosis

As was mentioned above, there can be two conditions present at once and one of these may be a major depression which requires antidepressant medication as well as treatment of the other conditions. Therefore, when treating any psychiatric problem a careful history should always explore for previous signs of depression as well as family history of it.

Suicidal Thoughts

The other special condition that should always be considered during diagnosis and treatment of any patient where there is a depressive component is the possibility of suicidal ideation. Obviously, this is a serious and difficult condition to detect and manage and I won’t go into detail here other than to emphasize it should always be in the mind of the treating psychiatrist or mental health professional involved in treatment.

pscyhotherpaySplit Treatmentwriting rx-1

Any discussion about the treatment of depression with medication should mention split treatment which mostly occurs when  another mental health professional is treating the patient with some form of psychotherapy and a psychiatrist is  prescribing the medication. In view of all the other complicated and interacting factors mentioned above including the manifestations of suicidal ideation  there must be very good communication between both professionals if there is this type of a treatment arrangement. Some of my colleagues are not comfortable in sharing such treatment. I have found that if you have a good working relationship with the other professional such a treatment plan can work effectively. Similarly at times a psychiatrist is a consultant to another physician or another mental health professional will work with non psychiatric physician. In the future I shall try to examine various potential pitfalls and advantages of split treatment .

Conclusion

I believe the antidepressant medications that we have today to treat patients with depressive condition can be extremely effective. I know that they have saved many people’s lives and relieved an untold amount of suffering. If used indiscriminately and not properly monitored they can be dangerous and also allow conditions that require other treatment to go undiagnosed.

I welcome your comments on any aspect of this subject whether you are a mental health professional, a patient or anyone  interested in this subject.

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