Posted by dj on February 18, 2001, at 16:19:34
Treatment of Depression", Richard O'Connor's newest book which was cited above and which one can find more on at:
http://www.undoingdepression.com/Active-intro-chapterone.html I'd be interested in particularly hearing Cam, Sunnely and Dr. Bob's comments on the following...
For instance, here are a couple of further excerpts from Chapter 1, which is excerpted in whole at the link cited above:
"Seventy percent of antidepressant prescriptions are written by general practice MDs (Yapko, 1997a). This extraordinary popularity comes about chiefly because of marketing of the newer medications by the pharmaceutical industry, the economics of health care, and the stigma of depression (Kirkpatrick, 2000). Research shows that selective serotonin reuptake inhibitors (SSRIs) and other new medications are in fact no more effective than the older antidepressants, and despite their reputed lower side effect profile, the dropout rates are similar for both treatments (AHCPR, 1999a).
MDs in general practice have been encouraged to believe that it's more acceptable to patients who present with depression to give them a pill rather than refer them to a specialist. Meanwhile, studies comparing the effectiveness of newer antidepressants with psychotherapy, or researching the effects of the two combined are few and far between (Keller et al., 2000). Only a few projects have studied the effects of combined psychotherapy and pharmacotherapy (see Thase et al., 1997, for a review).
The Surgeon General's Report to the Nation on Mental Health apologizes for the brevity of its review of psychotherapy for mood disorders, noting that psychosocial interventions "are much less studied than the pharmacotherapies" (U.S. Department of Health and Human Services, 1999, p. 265). It's as if psychotherapy has become irrelevant. This is despite the fact that we have known for a long time that psychotherapy is more effective than medication alone at preventing relapse (Blackburn, Eunson, & Bishop, 1986; Evans et al., 1992; Fava, Rafanelli, Grandi, Conti, & Belluardo, 1998).
It seems reasonable to ask, if the new antidepressants really are effective, shouldn't we see some decline in the suicide rate by now? Perhaps we are not because the actual effects of the drugs have been magnified by the way we conduct research. There are some serious problems with the generally accepted research that documents the efficacy of antidepressant medications, both the newer SSRIs and the older tricyclics (Antonuccio, Danton, DeNelsky, Greenberg, & Gordon, 1999; Moore, 1999). Pharmaceutical manufacturers support, authors submit, and journals publish articles that demonstrate a positive effect of treatment more readily than those that do not disprove the null hypothesis. Thus meta-analyses that report 19 of 21 studies show that medication X is more effective than a placebo may present a distorted picture; there may have been 15 studies which failed to show the effect of treatment but didn't get published.
Further, placebo responses to depression are generally high; up to 60 percent of patients improve on placebo alone. Efforts to control for these effects bias the investigation in favor of the active agent, by including a pretreatment "washout" phase in which all patients are taken off their active medication and given a placebo; those who have a positive placebo response during this phase are then eliminated from the study (Brown, 1994). The sample is thus skewed from the outset by excluding those who are the most active placebo responders, but even so almost as many people in antidepressant trials respond to placebo as to the active agent (Talbot, 2000: Thase & Howland, 1995).
Most studies also exclude from the data all subjects who drop out before the conclusion of treatment, skewing the sample further by eliminating many who may be dissatisfied or experiencing negative side effects. Finally, the double-blind procedure itself is open to question when patients and clinicians can generally determine whether the subject is receiving active treatment or a placebo on the basis of the side effects. There are relatively few studies that use an active placebo mimicking the side effects of medication...
Although for the purposes of conducting treatment with patients in the real world of today we need to assume that antidepressant medications can often be effective, these issues seem to me to introduce enough doubt to question whether the difference between the typical 40 percent improvement rate with placebo and 60 percent with the active agent is really meaningful. In any case it seems remarkable how easily and wholeheartedly our society has swallowed the idea of antidepressant efficacy. I think the only reason for this is that there is indeed an epidemic of depression, and the pills have come along at the right time to help reassure us all.
...the British Journal of Psychiatry published studies demonstrating that sending an interested and well-meaning volunteer out to visit the depressed in their homes once a week for an hour helps them feel significantly less depressed (Harris, Brown, & Robinson, 1999a, 1999b). No fancy statistical analysis—the results are obvious. In the treated group, 65 percent attained remission of symptoms, as opposed to 39 percent of the control group. But no one is investigating such ideas in the United States You couldn't get that paper published here. Maybe it's because no one can make a buck off volunteers.
At the same time, there is growing evidence that the distinctions drawn in the DSM-IV between major depression, dysthymia, and "depressive disorder not otherwise specified" (a wastebasket diagnosis with an estimated prevalence of 14 percent of the population at any given time) distort our understanding of what is in reality a single disease that has different manifestations at different points in our lives. A twelve-year follow-up of 431 patients who had sought treatment for a major depressive episode found that although subsequent episodes occupied only about 15 percent of the patients' lives, still only 41 percent of their time was spent symptom-free (Judd et al., 1998a). The rest of the time was spent in states comparable to dysthymia (27 percent) and in subthreshold depression (17 percent). This is despite the fact that patients were being treated with medication or psychotherapy in 62 percent of the weeks.
Remaining in subthreshold depression was a powerful predictor of relapse into major depression (Judd et al., 1998b), suggesting that simply no longer meeting all the criteria for major depression is a very poor definition of recovery. Patients who had presented with their first lifetime episode of major depression had a higher proportion of time (54 percent) symptom-free, suggesting that adequate treatment early in the illness can prevent some suffering. We need to be preparing the public and the health insurance industry for the idea that depression is a chronic disease that waxes and wanes over a lifetime, especially if inadequately treated.
...there is precious little research going on about how we can prevent depression or other serious mental illnesses. British research shows the effects of childhood experience on development of adult depression. In a study of 1142 children who were followed from birth to age 33, it was found that factors like poor mothering, poor physical care, parental conflict, overcrowding, and social dependence were all highly linked with development of adult depression (Sadowski, Ugarte, Kolvin, Kaplan, & Barnes, 1999). Findings like these are unpopular in the United States; the emphasis on mental illness as "brain disease" suggests that developmental factors and the social environment are not to be looked into.
At a recent conference, the director of a major national mental health foundation told me she does not believe mental illness can be prevented. Yet adult patients keep coming into our offices, telling us that their depression feels as if it's related to past experiences of trauma and deprivation. Are we not to believe them? Are there not ways to help people improve their parenting so that their children will be less vulnerable to depression? Or ways to structure our society so that we all have less chance of becoming depressed?
...Depression rarely occurs alone. There is enormous overlap with other emotional problems, but this ugly fact gets in the way of "clean" research. The NIMH Epidemiologic Catchment Area study found that 75 percent of people who have had a major depressive episode also had a history of some other psychiatric disorder (Robins & Regier, 1991). Analysis of data from the National Comorbidity Study (Kessler et al., 1994; Kessler, et al. 1996) revealed that major depression developed secondarily to other psychiatric disorders in 62 percent of all cases. Among those who had suffered a major depressive episode within the past year, 51 percent had also suffered an anxiety disorder during the same time, 4 percent had experienced dysthymia, and 18.5 percent had also suffered a substance abuse disorder. Co-occurring anxiety disorder and dysthymia were both predictive of poor outcome for major depressive disorder. The WHO study (Goldberg, 1996) found a remarkably similar comorbidity between depression and anxiety: 68 percent.
Yet FDA trials require pharmaceutical manufacturers to focus on the effects on a single "disease" at a time. Researchers know, but clinicians, insurers, and legislators forget, that there are several equally respectable explanations for the co-occurrence of depression and other mental illnesses. It could be that when a person has been excessively anxious for some time, feeling unable to cope with life, depression is a natural result. It could also be that vulnerable people react to stress differently, and that what our diagnostic systems classify as anxiety and depression are manifestations of the same process.
It could be that alcoholism leads to depression, or that depression leads to alcoholism, or that both drinking excessively and depression are the same person's unsuccessful attempts to cope with life.
If we have a diagnostic system that allows 26 different kinds of depression, as the ICD-9 does, we will observe 26 different kinds of depression, and we may think they are all different animals, but we would be foolish to do so. If we want to study "pure" depression and not measure the impact of our treatment on the patient's anxiety, substance abuse, or problems in living, we may be tempted to do so because it's easier to draw statistical conclusions, but we won't be helping patients much.
In the end, we must keep in mind some simple facts. People often want psychotherapy. Life is hard and we need all the help we can get. But training in psychotherapy rarely benefits from the results of empirical research, because the research isn't being focused on real-world issues. Turf, money, and politics have driven American science away from a meaningful investigation of how best to help our patients cope with real problems. People with depression can't overcome their symptoms without solving their problems; in my experience, most of them don't even want to."
Now, there are a few considerations to ponder, which often are not. Maybe Dr. Bob and RZip would like to get some discussion of these issues going in their classrooms with some of the people who may be a position to consider and do something meaningful about changing these situations. Imagine, that... : )
P.S. - Here's a bit of background on Mr. O'Connor from:
R ichard O'Connor is the author of two books, Undoing Depression: What Therapy Doesn't Teach You and Medication Can't Give You and Active Treatment of Depression. For fourteen years he was executive director of the Northwest Center for Family Service and Mental Health, a private, nonprofit mental health clinic serving Litchfield County, Connecticut, overseeing the work of twenty mental health professionals in treating almost a thousand patients per year. He is a practicing psychotherapist, with offices in Canaan, Connecticut, and New York City. He currently is working on his third book -- about pain, anxiety, and depression.
"I was moved to write Undoing Depression out of some frustration with my career. I've always believed that we know a lot about how to prevent the suffering that conditions like depression cause, but for 20 years in mental health I - and everyone else - have been kept busy trying to help mend people who are broken already; there's no time for prevention."
A graduate of Trinity College in Hartford, O'Connor received his MSW and Ph.D. from the University of Chicago, followed by postgraduate work at the Institute for Psychoanalysis and the Family Institute. He has worked in a wide variety of settings, from inner-city clinics to wealthy suburbs.
R ichard O'Connor and his family live in Lakeville, Connecticut. He participates as a leader and a member in a free self-help group in Sharon, Connecticut, for victims of depression.
I also speak to private groups on various mental health issues and am available for personal and telephone consultation. For scheduling information, call (860) 824-7423