![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 39. This is the beginning of the thread.
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... : )
Cheerio,
dj
P.S. - Here's a bit of background on Mr. O'Connor from:
http://www.undoingdepression.com/theAuthor.htmlR 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
Posted by dj on February 19, 2001, at 0:50:16
In reply to Cam etc, Some interesting ??s raised in Active..., posted by dj on February 18, 2001, at 16:19:34
For those of you still pondering the above here is an interesting piece from some time back, to reflect on as well...
http://tabletalk.salon.com/webx?13@@.eeaa3d6
Will Eli Lilly Kill PROZAC Rather Than Letting it Go Generic?
( Subscribe | Discussion summary )McCamy Taylor - 06:58 am PST - May 10, 2000
Justice Scalia is an Oxymoron
In today's news. Eli Lilly has admitted that PROZAC, its cash cow for 15 years increases the risk of suicide in some people. Approximately 1 in 100 non suicidal people will develop severe side effects that may lead to suicide attempts. One study estimates 50,000 sucessful suicide attempts were probably attributable to Prozac. By a strange coincidence, Prozac is ready to go generic, and Eli Lilly has already manufactured its replacement, R-fluoxetine which Eli Lilly is marketing by stressing that it does not increase the risk of suicide.Any comments?
Posted by Cam W. on February 19, 2001, at 9:44:47
In reply to For those still pondering, from Salon..., posted by dj on February 19, 2001, at 0:50:16
dj - I think that some of the facts in the statement below are skewed and do not address the true nature and complexity of depression and suicide. Better recheck the source reference to ensure it's scientific validity. This is exactly the same type of rhetoric that the Scientologists were releasing to the news media in the mid-1980s, and has since been proven wrong. I guess someone else has picked up the ball.
> For those of you still pondering the above here is an interesting piece from some time back, to reflect on as well...
>
> http://tabletalk.salon.com/webx?13@@.eeaa3d6
>
> Will Eli Lilly Kill PROZAC Rather Than Letting it Go Generic?
> ( Subscribe | Discussion summary )
>
> McCamy Taylor - 06:58 am PST - May 10, 2000
> Justice Scalia is an Oxymoron
>
>
> In today's news. Eli Lilly has admitted that PROZAC, its cash cow for 15 years increases the risk of suicide in some people. Approximately 1 in 100 non suicidal people will develop severe side effects that may lead to suicide attempts. One study estimates 50,000 sucessful suicide attempts were probably attributable to Prozac. By a strange coincidence, Prozac is ready to go generic, and Eli Lilly has already manufactured its replacement, R-fluoxetine which Eli Lilly is marketing by stressing that it does not increase the risk of suicide.
>
> Any comments?
Posted by Cam W. on February 19, 2001, at 10:14:14
In reply to Cam etc, Some interesting ??s raised in Active..., posted by dj on February 18, 2001, at 16:19:34
dj - Read the following article (available at your nearest medical library):
Parker G, et al. Assessing the comparative effectiveness of antidepressant therapies: a prosepective clinical practice study, J Clin. Psychiatry 2001 (Feb); 62(2): 117-125.
Yes, not all antidepressants will alleviate the "symptoms" of depression. This is because depression is a number of disorders (breakdowns of the body) that manifest in similar symptoms.
Besides, as I have said (several times) on this board, that antidepressants (in acute or reactive depressions) are a bandage. They "put the floor under you feet" so that you are able to deal with and come to terms with the problems that caused the depression in the first place.
Treating a disorder (any disorder) is not a passive activity on the part of the afflicted. To heal from or live with a disorder requires hard work on the part of the patient via compliance with drug regimens, lifestyle changes and a real desire to get better.
I am assuming that Dr.O'Connor charges for these lectures he gives, so his website is just a means of employment and revenue for him. If this is the case, I guess he'd have to make controversial statements in order for people to be interested in his topic. Perhaps he truly believes in his views, but this does not make them scientifically correct.
Two type of psychotherapy (cognitive-behavioral therapy and interpersonal therapy) have shown to have efficacy in treating depression. Psychoanalysis, Dr.O'Connor's field of training, has not been shown to be effective. People may "want" psychotherapy, but many cannot afford it and many of those who can are not willing to do the homework required to make it effective. The effectiveness rate of psychotherapy is no greater than that of antidepressant medication (which themselves are not usually used properly). You say that psychotherapy has not been scientifically analyzed. There are hundreds, if not thousands. of article in the literature on psychotherapy. Also there are several scientific, peer-reviewed journals for the psychotherapy field.
There are problems inherent in the way clinical trials are done, but they are only a stepping stone to naturalistic studies and post-marketing surveillence. The methods of scientifically evaluating the effectiveness of a new chemical compound in a disease are improving, but the system we have now, is the best that there is.
Posted by dj on February 19, 2001, at 11:05:20
In reply to Re: For those still pondering, from Salon..., posted by Cam W. on February 19, 2001, at 9:44:47
What I did not realize when I posted that late last night, after viewing a lot of articles at Salon was that this was a posting by a reader and not an offshoot of an article there. So as to the validity of the poster's facts, I don't know what source they may have cited.
However, there may be some legitimate concerns about the effects of Prozac and other SSRIs on some people, as discussed in the non-fiction book: "The Power to Harm : Mind, Medicine, and Murder on Trial" by John Cornwell. Though the drugs themselves may not be the sole issue it seems that the way they are used can sometimes be, in conjunction with other the interplay of other elements. No easy or clear answers and I believe that is what O'Connor is attempting to elicit discussion of...
Posted by dj on February 19, 2001, at 11:27:03
In reply to Re: Cam etc, Some interesting ??s raised in Active..., posted by Cam W. on February 19, 2001, at 10:14:14
Cam, As always thanks for your thoughtful comments.
> dj - Read the following article (available at your nearest medical library):
>
> Parker G, et al. Assessing the comparative effectiveness of antidepressant therapies: a prosepective clinical practice study, J Clin. >Psychiatry 2001 (Feb); 62(2): 117-125.Anybody have access to a digital version of this which they could link us all to...??
>
> ...depression is a number of disorders (breakdowns of the body) that manifest in similar symptoms.
...antidepressants (in acute or reactive depressions) are a bandage. They "put the floor under you feet"...To heal from or live with a disorder requires hard work on the part of the patient via compliance with drug regimens, >lifestyle changes and a real desire to get >better.I don't think that Mr. O'Connor would disagree with any of your prior comments, based on my understanding of what I've read of his.
>
>...Perhaps he truly believes in his views, but >this does not make them scientifically correct.I don't doubt that he truly believes in his views which are based on practical personal experience dealing with depression and helping others do so, as well as reviewing and referencing lots of scientific studies and noting the contradictions and flaws. Careful observation, review, discussion
and forming hypothesises based on the same are part of the scientific process, which then need to be tested out. He has oulined in his writings some of the systemic and growing biases and distortions in our existing system, toward biological and medicinal approaches to the detriment of other approaches.>
> Two type of psychotherapy (cognitive-behavioral therapy and interpersonal therapy) have shown to have efficacy in treating depression. Psychoanalysis, Dr.O'Connor's field of training, >has not been shown to be effective.That may be his field but I believe the clinic he ran used various approaches including medicinal and he does make and explore the point you cite in his excerpts on his website, in terms of validated effectiveness of therapy models.
"...The effectiveness rate of psychotherapy is no greater than that of antidepressant medication (which themselves are not usually used properly). You say that psychotherapy has not been scientifically analyzed. There are hundreds, if not thousands. of article in the literature on >psychotherapy..."
Those are not my contentions they are Mr. O'Connors and it would be great if he would comment further on his conclusions, in this forum.
> ... The methods of scientifically evaluating the effectiveness of a new chemical compound in a disease are improving, but the system we have >now, is the best that there is."
Is it truly or is it just what we've settled for??? I don't know, just raising the question which many more familiar with the field have done in much more detail in the NY Times, scientific journals, the O'Connor text and elsewhere... More grist for the mill...
Sante!
dj
Posted by niborr on February 19, 2001, at 11:32:06
In reply to Re: Cam etc, Some interesting ??s raised in Active..., posted by Cam W. on February 19, 2001, at 10:14:14
HI, IT'S ME, NIBOR. THIS IS A DISCLAIMER: I AM NOT A THERAPIST, I AM A COPYEDITOR AND I WORK ON MY HUSBAND'S WEBSITE. HE IS A THERAPIST. SO I HAVE LEARNED SOME FROM HIM...AND FROM MY OWN EXPERIENCE WITH DEPRESSION, ANXIETY...ZOLOFT, XANAX, PAXIL...MY PERSONAL PACKAGE. I wonder if I should even send this message...I think I am rambling a bit. When Cam implied that Dick is being controversial just for financial gain, I sort of freaked out. Anyone who knows him, including patients and those in his self-help groups, would be able to set you straight. He does one weekly group for free. He sees people for incredibly low fees when they have no or bad insurance. He ALWAYS helps when there are children or suicide dangers. We interrupt dinners and other activities all the time when someone is in trouble.
So, yes, he does get paid for a lecture that we get in the car and drive for three hours to get to, then he talks for a couple of hours, answers questions for another hour, stays and talks privately to as many as are there who were too shy to talk in front of everyone.NIBOR: Cam, I believe what you say in the two paragraphs below is totally in line with what Richard O'Connor says. But OUCH...Paragraphs 3 and 4.........
>
CAM: (1) Besides, as I have said (several times) on this board, that antidepressants (in acute or reactive depressions) are a bandage. They "put the floor under you feet" so that you are able to deal with and come to terms with the problems that caused the depression in the first place.
>
(2) Treating a disorder (any disorder) is not a passive activity on the part of the afflicted. To heal from or live with a disorder requires hard work on the part of the patient via compliance with drug regimens, lifestyle changes and a real desire to get better.
NIBOR: Keeping the website going costs us about $50 a month. We earn about $40 a month from amazon.com through a deal about people buying our book from the site...however, since the first of this year alone, I have sent out 9 free books to people who claimed they couldn't afford it and thought it would help them.
And sure, we charge for lectures. Sheesh, that's his job. But the website is very rarely the way these lectures are set up. Besides, and you can believe this or not, we are not getting rich doing this work. It truly makes us happy because we can see that we are being useful.
Dick definitely believes what he writes. He is not one of these slick salemany types who go on Oprah and have boxes labeled with problems that he hits with a baseball bat to show how he can get rid of them. He was asked by an Oprah producer and the View show to come on "with a patient or two," and he absolutely refused...even if a patient would agree to. He said How could he ever expect anyone to trust him if he were to do such a thing, exploit someone even when they were "better." He was even unwilling to go on alone and help people who raised their hands from the audience. He said that looks like a quick answer from an answer-man is all a suffering person needs--get all better in 15 minutes, right. An appearance on one of those shows would have certainly helped our finances.
CAM: (3) I am assuming that Dr.O'Connor charges for these lectures he gives, so his website is just a means of employment and revenue for him. If this is the case, I guess he'd have to make controversial statements in order for people to be interested in his topic. Perhaps he truly believes in his views, but this does not make them scientifically correct.
NIBOR: No, NO, NO. His field is NOT psychoanalysis. He is a social worker. He has both masters and Ph.D. in SOCIAL WORK. He would need to tell you...but it's interpersonal therapy I believe that he does. But he doesn't limit, he uses the best of all methods.
And just read any of his material to see how he feels about the outrageousness of people not being able to get the treatment they need because of managed care and other evils of the system.
About the psychotherapy studies, it is easy to study cognitive because there is a set of "rules." Not so with interpersonal, which is more flexible and so cannot be studied acurately. Some things cannot be measured easily.
>
CAM: (4) Two type of psychotherapy (cognitive-behavioral therapy and interpersonal therapy) have shown to have efficacy in treating depression. Psychoanalysis, Dr.O'Connor's field of training, has not been shown to be effective. People may "want" psychotherapy, but many cannot afford it and many of those who can are not willing to do the homework required to make it effective. The effectiveness rate of psychotherapy is no greater than that of antidepressant medication (which themselves are not usually used properly). You say that psychotherapy has not been scientifically analyzed. There are hundreds, if not thousands. of article in the literature on psychotherapy. Also there are several scientific, peer-reviewed journals for the psychotherapy field.
>
NIBOR: Yes, people take their meds and then can focus on their therapy...but meds alone, given by a GP, are NOT a solution. And the meds don't work on everyone who needs help, and sometimes they work for a while and then stop working.(5) There are problems inherent in the way clinical trials are done, but they are only a stepping stone to naturalistic studies and post-marketing surveillence. The methods of scientifically evaluating the effectiveness of a new chemical compound in a disease are improving, but the system we have now, is the best that there is.
Posted by dj on February 19, 2001, at 12:08:04
In reply to Re: ??s raised in Active..., posted by niborr on February 19, 2001, at 11:32:06
Nibor,
What you have stated was evident to me from my reading of "Undoing Depression" and your website about your husband's motivation. As for his specific credentials, thanks for clarifying that... I believe his interest in psychonanalyis is based on his own experience with it, is it not.
Thanks for clarifying the record.
Sante!
dj
Posted by dj on February 19, 2001, at 12:25:17
In reply to Re: ??s raised in Active... » niborr, posted by dj on February 19, 2001, at 12:08:04
There are many interesting, questioning and provocative articles in Salon about mental health and treatments, which one can find by poking about, perhaps starting at:http://search.salon.com/
For example at: http://www.salon.com/health/feature/1999/08/23/depression/index.html is an article by another Dr. Bob (Dr. Robert Burton, who is a neurologist and novelist)who writes that: Many people who claim they are clinically depressed may only be disgruntled and concludes his article with the following commentary/summary which I suspect both Cam and Mr. O'Connor would concur:
"Depression is not about ideas and postures. It isn't about laziness and a languorous desire to spend the day in bed. It is a feeling of sickness. It is brain chemistry gone awry. In someone who is clinically depressed, functional MRI scans would show areas of altered brain metabolism. The spinal fluid might show decreased levels of vital neurotransmitters; there would be alterations in hormonal levels.
But, having said that, we still haven't solved the chicken-and-egg dilemma. Did some psychological malfunction trigger bad feelings that, in turn, triggered the biological response, or was the chemical aberration primary?
If you believe the biochemistry came first, then you opt for anti-depressants. If you think that some psychological malfunction triggered the chemical response, you opt for therapy. Already you can sense the problem of treatment. The patient immediately is subject to his own bias for/against the psychological. Ditto the doctor.
One possible answer is to look for biological markers -- like a strongly positive family history, or a pattern that suggests one of the classical mood disorders, such as a history of manic behavior pointing to a true bipolar (manic-depressive) disorder. Soon there will be more precise genetic markers, maybe even nice neat lab tests that indicate predisposition.
But even if there were such lab tests, would we really understand the triggering mechanisms beyond saying that someone was predisposed? If you knew you had a tendency toward depression, could you control it with therapy, exercise, meditation, mind control, willpower? Or would you opt for the latest serotonin modulator?
There is no easy answer. Not to recognize depression is to misdiagnose a wide variety of chronic complaints (headaches, back pain). To diagnose depression when the problem is based in character is to create a drug-dependent nation. Pretty soon Prozac will be added to public drinking water. To not acknowledge the complex interplay between psyche and chemistry is to abandon any sense of personal responsibility, and create a generation of victims.
At the same time, we must recognize that depression may be beyond a person's control, can be a serious medical problem.
At bottom we are struggling with the very notion of how to define our sense of self. We see our chemicals as not being a part of us; only our psyche counts, is responsible. But this line of reasoning reduces each of us to a machine with a superimposed little man or woman sitting at the top, wearing the driver's hat but not really having a grip on the wheel. It's not a very healthy self-image. It's even a bit depressing."
salon.com | August 23, 1999
Posted by Cam W. on February 19, 2001, at 14:25:39
In reply to Re: ??s raised in Active..., posted by niborr on February 19, 2001, at 11:32:06
Nibor - I am terribly sorry for the insinuations. I really respect people who do help others for free. I do not believe that people should profit off of people with chronic illness (I also disagree with the "for profit" approach of community pharmacy, but I am a community pharmacist - but would never own a store), but hey, I can't change the world and we have seen that communism doesn't work if the people won't.
Most websites are "for profit" as well, and my "knee-jerk" reaction was wrong. I have read your posts and believe you when you say that Dick is not like most others, who hawk "cures" for mental disorders online.
•I apologize here and, if you wouldn't mind, would you apologize to Dick for me•.
I do agree that, in themselves, antidepressants are not a "cure". There are no cures in pharmacy. I also don't believe, in many cases, that psychotherapy alone will work in major depressive disorder. There is proof of both therapies working and my point to dj was the proof is out there in the "hundreds, if not thousands, or journal articles". dj had seemed to imply that not enough research went into psychotherapies because of the influence of major drug companies and I was trying to say that the research has been done.
Our thinking on depression has to change. We have to come to the realization that, in most cases, depression IS as chronic condition, like diabetes. The difference between depression and diabetes is, is that depression is usually periodic in nature and not a constantly occuring disorder.
We have the tools to separate out the different sub-types of depression and their causes, but until some smart cookie comes along with a method of using our science to differentiate these causes, we will need to use our indirect methods of fixing the biochemical malfunction. Both drugs and psychotherapy can correct this malfunction, but the trick is to KEEP it corrected; to prevent recurrences and relapses.
I also agree that most GPs are ill-equipped to deal with patients who have depression, especially depression that have comorbid illnesses. In my little part of the world I am trying to change this (and yes, I too am paid for my lectures; they are part of my job). by giving presentations to GPs in small towns. The drug companies may pay for the hotel room, gas and a meal (to entice the GPs to come - which also gives me a different type of gas), but other than that, I get very few stipends from drug companies (although I did get a cool cordless screwdriver from a drug company about 10 years ago).
I have been paid by drug companies for two presentations I did give, but after all the research and writing it up, the honorarium added up to about 50˘/hour. So, the "paid lecture" comment was really unfair, on my part.
Again, I apologize to Dick; and maybe, if I ever catch up on my work, will read his book. I am definitely going to look at the website more closely now. If Dick would like to bounce a few ideas off of me or needs a couple of article references, I'd be glad to oblige (esp. since I trashed him in my last post).
Sincerely - Cam
Posted by niborr on February 19, 2001, at 15:39:47
In reply to Re: Apologies to Dick » niborr, posted by Cam W. on February 19, 2001, at 14:25:39
Thank you for your apology, Cam. I guess I took your criticism so to heart because I always thought your messages were so thoughtful and intelligent in the past. Now, all is better...since you were able to visit our website and see for yourself that we are not like so many others that are out to sell something as their prime function.
Dick won't even know what I'm talking about if I apologize for you. In fact, he would be highly embarrassed that I told you how wonderful he is.
Posted by dj on February 19, 2001, at 16:02:44
In reply to Re: Apologies to Dick » niborr, posted by Cam W. on February 19, 2001, at 14:25:39
>dj had seemed to imply that not enough research went into psychotherapies because of the influence of major drug companies and I was >trying to say that the research has been done.
Cam,
I did NOT imply that but quoted Mr. O'Connor who does seem to indicate such. The excerpts I posted were from the first chapter of his book (at http://www.undoingdepression.com) so when you've a moment please first go read his entire excerpt from that chapter, check his references and reasoning and then refute his argument or not, as you so desire.
Sante!
dj
Posted by dj on February 19, 2001, at 21:59:30
In reply to Re: Apologies to Dick » Cam W., posted by dj on February 19, 2001, at 16:02:44
In the intro. to his latest book, which is focused toward mental health practitioners and helping them broaden their perspective on effectively treating depression, Richard O'Connor mentioned some core concepts he discusses with the depressed folks he helps treat. These were not posted on the site and I was curious about them and asked Robin to share them with me, as the book is not yet available here in Vancouver.
Robin aka Niborr kindly provided me with the first two pages of Chapter 13 which contains that information and I am sharing an exerpt of it here for people to ponder and do with as they may or may not...
"Just as we do not recognize that the skills of depression are acquired behavior, we have trouble recognizing that we can learn new, more adaptive skills. These will seem awkward at first, like trying anything new, but eventually they become integrated into the self... We owe it to our patients to provide direction and to give them a cognitive map of how they will be expected to recover. One of the best ways we can help them is by reminding them to go to the psychic gym: that they are developing new muscles, new coordination, and the way to do that is through practice.
To help my patients understand how they can best help themselves, I often provide them with a list of aphorisms about depression, which can serve as a stimulus for thought and discussion. These ideas are discussed in more depth in the remainder of the chapter. I find that the following flat assertions, presented as statements of fact, have a way of getting around defensiveness.
The patient learns that these observations are manifestations of his condition, not weakness or lack of character on his part. He can become involved in the task of identifying how these phenomena are manifested in his case, rather than feeling he is being assaulted piecemeal by the therapist who keeps unpleasantly surprising him with new interpretations of his own behavior that he thought he understood.
Aphorisms of Depression
Problems and symptoms are not the same
Depression is a disease
If I change what I do, I can change how I feel
I need to reconnect with my emotional life
I need to identify and correct self-destructive thinking and behavior patterns
I need to let my guard down
I need to learn to take care of myself
I need to practice detachment
Change can come from anywhere
There is a part of me that doesn't want to get well
I am more than my depression
Depression is a social problem"
So there you have them, make of them what you shall.
Sante!
dj
Posted by Cam W. on February 20, 2001, at 8:45:46
In reply to Re: Apologies to Dick » Cam W., posted by dj on February 19, 2001, at 16:02:44
Sorry deej - I thought I had posted an apology to you yesterday, but obviously didn't hit confirm.
I had thought that the second to last paragraph was yours. It wasn't. There are quite a few journal articles on the efficacy of psychotherapy, but only the most recent ones (in the past couple of years) have been controlled trials. The jury is still out whether a combination of therapies (AD + psychotherapy) is better than monotherapies of either. I would imagine that controlling for psychotherapy would be tough, especially if the control group receives informal psychotherapy (eg from talking things over with a family member or close friend).
Again, sorry for the misread - Cam
> >dj had seemed to imply that not enough research went into psychotherapies because of the influence of major drug companies and I was >trying to say that the research has been done.
>
> Cam,
>
> I did NOT imply that but quoted Mr. O'Connor who does seem to indicate such. The excerpts I posted were from the first chapter of his book (at http://www.undoingdepression.com) so when you've a moment please first go read his entire excerpt from that chapter, check his references and reasoning and then refute his argument or not, as you so desire.
>
> Sante!
>
> dj
Posted by dj on February 20, 2001, at 8:56:10
In reply to Re: Apologies to dj » dj, posted by Cam W. on February 20, 2001, at 8:45:46
> sorry for the misread - Cam
Thanks, Cam. No worries. You've got lots on your plate so the occasional misread is understandable.
dj
Posted by Chaston on February 20, 2001, at 9:38:16
In reply to Re: Apologies to dj » Cam W., posted by dj on February 20, 2001, at 8:56:10
Fascinating thread!
It is sincerely heartening to realize that there are professionals in this field who really DO care about helping people with depression, and honestly think and debate about how best to accomplish that.
Posted by dj on February 20, 2001, at 23:37:12
In reply to Re: Apologies to dj, posted by Chaston on February 20, 2001, at 9:38:16
> Fascinating thread!
> It is sincerely heartening to realize that there are professionals in this field who really DO care about helping people with depression, and honestly think and debate about how best to
> accomplish that.Isn't it though!
The O'Connor books provide a good overview of some of the themes underlying those differences in opinion, as no doubt, other books, articles and mental health professionals do as well.
Certainly "Undoing Depression" comes at it from that angle, and from what I'v read of "Active Treatment..." it focuses on doing that in more detail and with more references in an effort to encourage a broader perspective on the behalf of mental health practitioners - both the 'professonals' and those whom they treat (us)...In O'Connor's asphorisms about depression, quoted above in '1 other brief excerpt on depression framework... ' one of the more challenging of his statements is the one that asserts: "There is a part of me that doesn't want to get well"
I find there is truth to that though more in the form that: 'My efforts at dealing with depression are often futile and frustrating and leave me wondering about the payback on my efforts' or something along those lines.
I'm curious what others think about O'Connor's asphorisms??? Anybody awake and wanting to publically ponder the veracity of O'Connor's assertations? RZip here's your chance to don your public thinking cap once again...along with anyone else who cares to comment... And btw, RZip how about continuing to educate us to the themes underlying the T/F poll you had posted...
Sante!
dj
Posted by dj on February 26, 2001, at 14:59:39
In reply to Re: thread and O'Connor's asphorisms...., posted by dj on February 20, 2001, at 23:37:12
These from his website...
"8. Do you believe that therapy or medication is the solution?
Therapy and medication are the solution. I would advise anyone seeking treatment to be open to both. Medication can help more quickly than therapy alone, and can help to prevent the out-of-control mood swings that will come during recovery. Therapy can help us resolve the problems that led to the depression and help us learn how to prevent future episodes. Research shows that medication and therapy together are more effective than either by itself. Some people do recover on either medication or psychotherapy alone, but I'd really recommend being open to both. After recovery, sometimes a maintenance dose of medication or a periodic check-in with a therapist is helpful..."
http://www.undoingdepression.com/faq.html
"Medication Marketplace
Depression is a growth industry now. Prozac and its cousins Paxil and Zoloft are now three of the top six largest selling prescription drugs. Considering that these pills are really only slightly more effective than their predecessors - that is, only a little more effective than placebo - their acceptance by both healthcare professionals and the public has been amazing. New reports suggest it's not just amazing, it's corruption.
Ever since Arrowsmith there's been a question about whether for-profit pharmaceutical manufacturers can sponsor truly objective scientific research. Dr. Martin Keller of Brown University has been a respected researcher into depression for decades. He has many, many publications and grants to his credit, some of which have been the foundation for much of our current knowledge about the course, causes, and treatment of this disease. Now the Boston Globe reports that Dr. Keller has been getting rich on payments from some of the drug companies whose products he's been researching. In 1998 alone, Dr. Keller pulled in $556,000 in consulting fees from these companies. That's not grants to fund research, or reimbursement for expenses, or even lavish little conferences in the Caribbean - that's direct cash money into his pocket.
In addition, the Globe reports that Dr. Keller did not disclose the extent of his relationships to these companies to the medical journals that published his findings or to the professional associations that sponsored the conferences where he presented his findings.
There's no evidence yet that Dr. Keller cooked his data or slanted his conclusions because of these payments. But we know that kind of thing happens often enough in science just because researchers have an emotional investment in reaching a certain conclusion. Dr. Keller's whole body of work, much of it probably quite good, is now open to question because of these revelations.
Pharmaceutical manufacturers are constantly telling us that the high prices we pay for prescription medicines go to help them fund research into new drugs. I don't know about anyone else, but I'd be willing to pay a lower price and a higher tax, and let the government fund research. < Excessive - my emphasis > Profits and healthcare are a dangerous combination."
http://www.undoingdepression.com/news05.html
Posted by pat123 on March 10, 2001, at 13:18:47
In reply to Some more of O'Connor's quotes...., posted by dj on February 26, 2001, at 14:59:39
Prozac and its cousins Paxil and Zoloft are now three of the top six largest selling prescription drugs. Considering that these pills are really only slightly more effective than their predecessors - that is, only a little more effective than placebo -
False statements here. Paxil, Zaolft and Prozac
are slightly more effective than the TCA's (not placebos) All AD's are MUCH MORE effective, ~60-70 % effective on first try, than placebos. Given a placebo the effective % is a few points, not tens of points. It bothers me that a book is published and held up as an answer with such poor and incorrect information. these fact are well known.Perhaps someone made a mistake when posting this, I hope so and that the book is correct on these facts.
Pat
Posted by dj on March 10, 2001, at 14:22:45
In reply to Re: Some more of O'Connor's quotes...., posted by pat123 on March 10, 2001, at 13:18:47
>... Given a placebo the effective % is a few points, not tens of points. It bothers me that a book is published and held up as an answer with such poor and incorrect information. these fact are well known.
>
> Perhaps someone made a mistake when posting this, I hope so and that the book is correct on >these facts.In my very first business class at university my professor quoted Disraeli or Mark Twain (I forget which) talking about how: "There are lies, dammed lies and then statistics." and then went on to show how they could be used to distort 'the facts'. The quote you refer to is one I posted and is taken directly from: http://www.undoingdepression.com/Active-intro-chapterone.html, which I've also cited at other places in this posting and others.
The author of the quote is Richard O'Connor who: "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."
http://www.undoingdepression.com/theAuthor.htmlIf you go to the prior quoted url you can read the full text of the intro.and first chapter of his new book, along with references. If you wish to dispute his interpretation don't just state what you believe to be well known, back it up with references. Until you can do that and do it well, I will take O'Connor's word as he obviously has thoughtfully reviewed many of the 'facts' and is and has been in a position to do so authoratively. As his wife and webmaster robin aka Nibor has stated in a thread below, both she and her husband use and benefit from ADs. That, however, doesn't mean they are as good as they are hyped to be, as with many things in our society and are a sufficient tool.
The NY Times has written many recent articles about the excesses of the pharmaceutical companies in the way they market ADs and other pharmaceutical products and how distorted and corrupt a process this can be and is at times, with doctors being paid to do research, which may be influenced by the payments made, etc... Check it out for yourself. For instance, in tomorrow's NY Times magazine, which is currently available on-line, there is a cover story on the marketing of Claritin which I haven't read but briefly scanned and assume it makes similar points.
For final word on this, for now, here's a bit more from Richard O'Connor's first chapter. Dispute it if you will but if you so attempt, do it with references and not just your opinion.
"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.
Most troubling of all, perhaps, is the appearance of conflict of interest among researchers who receive financial support from pharmaceutical companies. For instance, it was recently disclosed that Dr. Martin Keller of Brown University, whose studies are cited several times in this book, received over $550,000 in consulting fees—not research support, but personal income—from drug companies in 1998 (Bass, 1999). Despite professional journals' expectation that authors disclose conflicts of interest, Dr. Keller did not disclose the extent of his financial ties to drug companies. Payments on that scale inevitably raise the suspicion of bias, and we can only regret that a respected researcher has put himself in a position where his results can be questioned.
Dr. Keller is the principal author of a major new study (Keller, et al., 2000) demonstrating that combined treatment with Serzone and cognitive-behavioral analysis psychotherapy (McCullough, 2000) is markedly more effective than either alone, a result which supports a principle thesis of this book; unfortunately, as a result of drug industry influence, that support feels suspect to me.
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.
Misdirected Science
Market research suggests that most Americans, after decades of tobacco wars, marijuana scares, and debate about global warming, believe science is bought and paid for, so subject to the influence of the sponsors of the research that it has lost its objectivity (Lake Snell Perry & Assoc., 1999). If the public understood depression research, that same skepticism would only be reinforced. Politics, economics, turf, and the absence of independent thinking combine to prevent us from creative, meaningful work.
At the White House Conference on Mental Health in June 1999, Steven Hyman, the director of the National Institute of Mental Health, was interrupted twice with applause during his brief presentation. On both occasions he had alluded to the value of psychotherapy for the treatment of mental illness. The audience was moved to applause by surprise and relief. For far too long, NIMH has focused almost exclusively on research into the biochemical aspects of mental illness, ignoring other influences such as the well-known fact that the best single predictor of mental illness is poverty (Shore, 1994). This position has been politically popular: It supports the pharmaceutical industry, which has had a very close relationship with NIMH, and it is supported by the most vocal advocates for the mentally ill, who insist that these conditions are "no-fault brain diseases." But it has come at the cost of trivializing research, inhibiting research into effective psychotherapy, and making the idea of prevention a taboo subject.
NIMH, of course, is only a reflection of our society. There is a gee-whiz mentality about American culture that seems to favor technology over people..."
Posted by dj on March 12, 2001, at 0:03:07
In reply to ...lies, dammed lies, and statistics... » pat123, posted by dj on March 10, 2001, at 14:22:45
And from PB's archive of posts, a reprint of an article from the NY Post on the same as prior post:
http://www.drbob.org/babble/20000729/msgs/41771.htmlThe last line of the quoted article sums it all up very nicely...: "In the end, the clearest message of clinical trials may be that the drugs now available to treat depression are effective, but not effective enough."
Posted by pat123 on March 12, 2001, at 12:25:27
In reply to ...lies, dammed lies, and statistics... » pat123, posted by dj on March 10, 2001, at 14:22:45
> >... Given a placebo the effective % is a few points, not tens of points. It bothers me that a book is published and held up as an answer with such poor and incorrect information. these fact are well known.
> >
> > Perhaps someone made a mistake when posting this, I hope so and that the book is correct on >these facts.
>
> In my very first business class at university my professor quoted Disraeli or Mark Twain (I forget which) talking about how: "There are lies, dammed lies and then statistics." and then went on to show how they could be used to distort 'the facts'. The quote you refer to is one I posted and is taken directly from: http://www.undoingdepression.com/Active-intro-chapterone.html, which I've also cited at other places in this posting and others.
>
Reguardless of your verbage this statement is false "Considering that these pills are really only slightly more effective than their predecessors - that is, only a little more effective than placebo -"A lillle more than placebo would suggest 5-10 % as a placebo is 1-3 %. It is well proven that AD's are ~60 %, this is a difference of an ORDER OF MAGNITUDE ! TCA's have been out since the 1950's and are out gold standard, still, and effective at rate of ~ 60 %.
Pat
Posted by dj on March 12, 2001, at 12:30:36
In reply to Re: ...lies, dammed lies, and statistics..., posted by pat123 on March 12, 2001, at 12:25:27
> A lillle more than placebo would suggest 5-10 % as a placebo is 1-3 %. It is well proven that AD's are ~60 %, this is a difference of an ORDER OF MAGNITUDE ! TCA's have been out since the 1950's and are out gold standard, still, and >effective at rate of ~ 60 %.And again that is your opinion which you have not backed up with any sources, as I have...
Posted by pat123 on March 12, 2001, at 12:41:56
In reply to Re: ...lies, dammed lies, and statistics... » pat123, posted by dj on March 12, 2001, at 12:30:36
>
> > A lillle more than placebo would suggest 5-10 % as a placebo is 1-3 %. It is well proven that AD's are ~60 %, this is a difference of an ORDER OF MAGNITUDE ! TCA's have been out since the 1950's and are out gold standard, still, and >effective at rate of ~ 60 %.
>
> And again that is your opinion which you have not backed up with any sources, as I have...Common knowlage, in existance for 40 years, look it up yourself
Pat
Posted by pat123 on March 12, 2001, at 12:56:50
In reply to ...lies, dammed lies, and statistics... » pat123, posted by dj on March 10, 2001, at 14:22:45
> >... Given a placebo the effective % is a few points, not tens of points. It bothers me that a book is published and held up as an answer with such poor and incorrect information. these fact are well known.
> >
> > Perhaps someone made a mistake when posting this, I hope so and that the book is correct on >these facts.
>
> In my very first business class at university my professor quoted Disraeli or Mark Twain (I forget which) talking about how: "There are lies, dammed lies and then statistics." and then went on to show how they could be used to distort 'the facts'. The quote you refer to is one I posted and is taken directly from: http://www.undoingdepression.com/Active-intro-chapterone.html, which I've also cited at other places in this posting and others.
>
Reguardless of your verbage this statement is false "Considering that these pills are really only slightly more effective than their predecessors - that is, only a little more effective than placebo -"A lillle more than placebo would suggest 5-10 % as a placebo is 1-3 %. It is well proven that AD's are ~60 %, this is a difference of an ORDER OF MAGNITUDE ! TCA's have been out since the 1950's and are out gold standard, still, and effective at rate of ~ 60 %.
Pat
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