Tag: Depression

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Anxiety? Depression? Is medication the answer?

Let’s talk about drugs, placebos, “talk therapy” and new research…

Too many of us are anxious, depressed and stressed these days, with COVID worries piled on top of everyday stressors. We know COVID is here for a while yet, perhaps for a long while. So, how do we cope? Is medication the best answer? New research suggests that other treatments are just as effective, except in the most severe forms of these conditions.

Let’s start with a simplified explanation of anxiety and depression:

Depression is a low mood driven by dwelling on events of the past. Anxiety is a negative mood associated with worry about future events. Mindfulness is focusing on, enjoying and appreciating what’s good about the present moment. Mindfulness, relaxation exercises (like deep breathing), meditation, and “talk therapies” (like phychotherapy, and cognitive behaviour therapy [CBT]) seek to break the cycle of repetitive unpleasant thoughts that, over time, can make us depressed or anxious. The more we focus on these thoughts, the stronger these brain thought pathways become, the more often these thoughts pop into your mind, and the more difficult it can become to enjoy the present moment.

So, this is how psychotherapy (talk therapy) works: It helps you train your brain to block negative thoughts and focus on positive ones. I’m simplifying here, of course. Psychotherapy is a complex science that requires highly trained professionals for ideal results. But it’s important to know that your “self-talk” has an influence on your mood and happiness. It’s something that many of us can learn to control.

How antidepressants work

For decades, health professionals have been taught that low levels of the neurotransmitter, serotonin, were responsible for low mood and depression. I remember learning this at an education program for practicing pharmacists many years ago, probably back in the ‘80s when Prozac first came on the market. The education session was sponsored, I’m sure, by a pharmaceutical company that manufactured a drug that influenced serotonin. Most education sessions were paid for by companies, as our professional associations were not well funded, and it was a common way for manufacturers to educate health professionals about their products in those days.

I remember how they explained that depression was caused by an imbalance in brain chemicals, and antidepressant drugs would rebalance the brain chemistry. Drugs that increase the effects of serotonin have been a mainstay in the medical treatment of depression for decades and they are also used to treat anxiety, obsessive-compulsive disorder, post-traumatic stress disorder and other mental health conditions.

A new study says otherwise…

However, a large new study in the UK found no convincing evidence that low serotonin levels are responsible for mental illness. It seems that this was only one of several theories of the cause of depression proposed in the ‘60s. When serotonin drugs were developed beginning in the 1980s, health professionals (like me!) were taught the serotonin theory as if it were fact, when it was really just one of several unproven theories. The observation that these drugs seemed to help was used as “proof” of the serotonin theory.

But it turns out that half of the studies performed by antidepressant drug manufacturers were never published because they showed a negative result. This is called “publication bias” where study results that don’t give the desired result are simply not published. Science is not a democracy, where the majority of results “win”. In other words, any negative result should be questioned: why is the drug not producing a consistently positive result? In order to make the drug results show a significant improvement over a placebo (or sugar pill) they had to “cherry pick” the studies they published.

Another problem with the studies comparing drugs with placebo, is that they were difficult to “blind”. To make a proper comparison that eliminates bias on the part of patients, doctors and researchers, no-one involved in the study should know who actually received the drug and who took a placebo until it’s completed. But because of the side effects from the drug, it was difficult to blind the gathering of the data properly… another problem with the drug trials that could make the drug look better than placebo.

Added to publication bias, this could easily explain how manufacturers were able to sell their drugs despite the small differences found between drug and placebo in mild to moderate depression. Note that the American Medical Association (AMA) recommends using psychotherapy as first line therapy except in cases of severe depression.

But the drugs seem to work for many people…

But the drugs do work 80% of the time. It’s just that placebos were shown to work almost as well as the drugs in the studies—75% benefitted from the placebo, according to analytical researchers (but not mentioned in drug description monographs). This begs the question: why wouldn’t we use placebos as a treatment for anxiety and depression? They obviously work exceptionally well for mental health conditions, triggering our bodies to heal ourselves in the majority of cases without the side effects that drugs cause.

Note that psychotherapy/counselling has also been found to be equally effective to drug therapy in mild to moderate depression and has a longer-lasting effect than drug treatment. The exception would be in severe suicidal major depression where the emotion-numbing effect of these drugs can make a difference in the person’s safety, reducing suicide risk. Medication has been shown to work better than other therapies in more severe depression.

If you’re interested in reading more about this, check out reference #5 below… an article by Irving Kirsch, a researcher who has been examining the placebo effect for many years.

Back to the UK study…

“It’s not an evidence-based statement to say that depression is caused by low serotonin; if we were more honest and transparent with patients, we should tell them that an antidepressant might have some use in numbing their symptoms, but it’s extremely unlikely that it will be the solution or cure for their problem,” says study author, Mark Horowitz.

This seems to fit with the delay in action of these medications—it generally takes 2 or more weeks for them to start working. One researcher described it this way: emotional reactions are dulled by the drug, and begin to have less impact on mood. Eventually depression or anxiety improves because of lowered negative emotional input.

Interestingly, some experts in the field of psychiatry have stated this is nothing new… that they’ve known for years that low serotonin was not the cause of depression but that it is a complex condition with several contributing factors. However, it seems that this was not communicated to front line workers or patients, and the new study is causing quite a stir in the medical media.

Complex conditions often benefit from a combination of several treatment strategies, so simply handing a patient a prescription and advising a follow-up appointment in several weeks might not be an ideal approach to treatment. Working to change thought input can help to correct the patterns that led to a mood disorder in the first place, and could help to prevent a recurrence.

Brain “plasticity”

Meanwhile, other research into brain function has shown that our brains are much more “plastic” than was previously thought… meaning that we can change our thought patterns and the actual number and strength of connections between neurons (nerve cells in the brain) that connect thoughts, memories and emotions to our consciousness. The old statement that a person can’t think their way out of depression is likely not correct, although it could be difficult in severe depression. This suggests that “talk therapies”, like psychotherapy, cognitive behaviour therapy (CBT) and counselling, may be the preferred approach to mental health instead of medication, with medication added only in more severe cases.

And the American Medical Association (AMA) recommends psychotherapy as the first line treatment for mild to moderate depression. In more severe forms of depression, especially when there is a risk of suicide, they recommend that drugs should be included in the first choice of treatments. But, all too often, doctors reach for the prescription pad when they hear a patient describe even mild symptoms of anxiety or depression.

As well, side effects need to be considered. In addition to a long list of side effects while taking antidepressant medications (including drowsiness or insomnia, nervousness, digestive complaints, anxiety, tremor, dizziness, sexual dysfunction, and more), a rebound effect often occurs when the drug is stopped. This has often been misinterpreted as a return of symptoms of depression in the past, resulting in patients staying on medication for years. Patients are now advised to taper their medication slowly, under the supervision of their doctor to reduce rebound effects when discontinuing antidepressants.

Of course, like any ailment, mental health conditions are best treated early, before they become severe. Just like a house fire, you’re better off putting the flames out before the entire house is on fire. Seeking counselling early can give a person the tools to rewire the brain before the nerve connection pathways to negative thoughts become more strongly entrenched, leading to a more severe depression/anxiety state that has a greater effect on the person’s life and is more difficult to treat.

What about natural treatments?
Another recent study looked at the use of vitamins B6 and B12 specifically for mild anxiety symptoms. It confirmed that B6 at relatively higher doses than normally consumed in food (100mg daily) could help reduce symptoms of anxiety. Vitamin B12, in comparison, made only a small difference in this study.

“Stress formulations” containing mainly B vitamins have been available for many years on pharmacy shelves. A vitamin B Complex-100 tablet, taken once daily, would also provide the amounts used in this study. For many years I have suggested women try taking this at bedtime (for middle of the night awakening) or at suppertime (for trouble falling asleep) when they have difficulty sleeping due to mild anxiety. Improved sleep has been found helpful in overcoming mood disorders.

A final caution:
It is important not to stop taking your medication abruptly. Be sure to discuss options with your doctor before making any changes to your medical treatment.

#depression #anxiety #SSRIs #Serotonin

References:

  1. No Evidence Low Serotonin Causes Depression?–Medscape
  2. Analysis: Depression is probably not caused by a chemical imbalance in the brain – new study—University College London
  3. What has serotonin to do with depression?–World Psychiatry
  4. A Popular Theory About Depression Wasn’t “Debunked” by a New Review—Neuroscience News and Research
  5. Antidepressants and the Placebo Effect—PubMed Central
  6. Prozac (official drug monograph) (Note side effects, warnings and the lack of data on effectiveness compared to placebo)
  7. Vitamin B6 may reduce anxiety symptoms, study shows—Medical News Today
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How to talk to someone with depression

Everyone has their ups and downs in life, but major depression is different than feeling sad for a short while after a negative event. Mood disorders, like depression, are very real illnesses that can have serious and sometimes fatal results. They are one of the most common mental illnesses and can affect the body as well as the mind, with physical symptoms like fatigue, stomach complaints, or muscle/joint pain as well as changes in mood.

There are several depressive mood disorders, including bipolar disorder (or manic-depressive illness), and perinatal depression, but major depression (also called clinical depression) is the most common mood disorder. The 2012 Stats Canada survey found that 4.7% of respondents met the criteria for major depression in the previous 12 months, and almost 1 in 8 (12.6%) met the criteria for a mood disorder at some point in their life. American statistics show that over 17 million adults (7.1% of the population) and 1.9 million children aged 3 to 17 experience depression in the United States each year. Women are twice as likely as men to be diagnosed with depression.

Causes

There is no single cause of mood disorders. Several risk factors interact to increase the chance of developing a mood disorder:

  • Family or personal history – Having already experienced an episode of depression or having an immediate family member who is affected don’t guarantee a person will develop depression, but they do increase the risk. Over 50% of those who have had an episode of major depression will develop a recurrence.
  • Traumatic life events – Some are more susceptible to depression when in a difficult or abusive relationship, after a divorce, after a death of a loved one, as a result of low income, poor housing or workplace stress or from other distressing major life events.
  • Chronic medical conditions – Chronic conditions such as stroke, heart disease, obesity, Parkinson’s disease, epilepsy, arthritis, cancer, AIDS, chronic obstructive pulmonary disease (COPD), and dementias like Alzheimer’s Disease can trigger depression, especially if the person suffers from more than one of these.
  • Physical changes – Changes in hormones, neurotransmitters (the chemicals that pass signals from one nerve to the next) or the immune system, a disability or poor quality of life itself are thought to be contributing causes. New research suggests that gut bacteria may also have an influence on brain function and mood.

Symptoms

Although each person is unique and will have different symptoms, there are some that are common:

  • Depressed mood
  • Feelings of guilt, worthlessness, helplessness, or hopelessness
  • Loss of interest or pleasure in activities usually enjoyed
  • Change in weight or appetite
  • Decreased energy or fatigue, even without physical exertion
  • Thoughts of death
  • Poor concentration or difficulty making decisions

Symptoms can be mild or so debilitating the person has difficulty getting out of bed. If these symptoms persist on most days for more than 2 or 3 weeks, it is advised to contact a doctor or mental health professional. It is very important to get medical help right away if a person has recurring thoughts of suicide.

What should you say to someone who has depression?

There are no magic words that will heal a major depression, although talking with a professional over time (“cognitive therapy”) is a form of treatment that can be successful. For family and friends, being comforting and supportive is the best way to help someone manage their symptoms.

Without being forceful or exerting pressure, it helps to ask a person with depression how they are feeling. This gives them space to talk and vocalize thoughts, making them less powerful. Not everyone feels like talking all the time, though, and it’s important to respect that, so ask if they want to talk.

Sometimes just being there can help too. Ask if they’d like some company. Offer to do something fun to distract them from their thoughts, like watching a movie, sharing a meal, or going for a walk or outing. Even being there quietly without speaking can give comfort.

Let the person know you care, even if you don’t understand or know what to do or say. Ask them how you can help or what is best to do or avoid doing. Know that simply saying “I love you” can be supportive.

The best time to talk is when both of you are calm and not distracted or tired. Never bring up depression during an argument or times of high stress. Avoid spending all your time together talking about mood problems and be sure to take care of your own needs, too, if you feel uncomfortable. Often talking about good times or doing activities the person once enjoyed can be helpful.

What NOT to say…

But here are some examples of things you might want to say that are not usually helpful:

  • “Have you tried eating better/exercising more/ getting outside?” Although lifestyle changes can help improve the effectiveness of depression treatment, it is better to be supportive, leaving treatment to the professionals. Some people may find these suggestions disrespectful, as though you think a minor change in lifestyle could easily cure their major depression.
  • “It’s not that bad.” Or “But you look fine!” If you appear to doubt or disbelieve what they are saying, you are invalidating their feelings and they may be unlikely to talk about them in the future. Minimizing their feelings can make the person feel ashamed and alone.
  • “I know how you feel.” Even if you have suffered a major depression yourself, you cannot know what another person is feeling. You also don’t want to shift the discussion to yourself when a person is expressing their deep feelings.
  • “You’re making me feel bad.” While listening to a person sharing their thoughts and feelings of depression can be overwhelming, don’t blame them or make them feel guilty. However, loving a person who is depressed can be difficult and it’s OK to set boundaries if necessary or get external support for yourself from friends, family or a therapist.

Like everyone else, I’ve had times when life events have made me sad and depressed but, fortunately, not a major depression. My husband has always helped by encouraging me not to focus on the event for long periods of time and to keep it in perspective and balance with the good parts of life. We can all try to be that person for others, whether they are dealing with major depression or a depressing life event, by being loving and supportive and asking what they need.

References:

What to say to someone with depression – Medical News Today

What is Depression? – Government of Canada website

#depression

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Old Drugs, New Research

I’ve blogged previously about antidepressant medications which, while helpful for some with severe depression, are not as effective as we would like. One physician/author compared them to non-drug therapies that were equally effective but take longer to kick in. His well-referenced article was published in the Canadian journal, Pharmacy Practice. Here’s a link to that blog, in case you missed it.

But I’ve been reading about new research into some old medications that were being studied for use in those with mental illness in the 50s and 60s but set aside due to concerns about recreational misuse of the drugs. I’m talking about LSD (lysergic acid diethylamide) and psilocybin (also known as magic mushrooms). I was so surprised to learn these Psychedelic drugs had been studied in the past and were being studied again for treating mental health issues that I had to read more about them. In pharmacy school, these drugs were only discussed as drugs of abuse. I had no idea they might be useful medications. As in many other professions, the history of psychedelic medication studies for therapeutic uses had been erased, never to be mentioned.

“How to Change Your Mind” is a newly published book by investigative reporter, Michael Pollan, that shares information gathered from many interviews with researchers, therapists and people who have used the psychedelic drugs: LSD, psilocybin, mescaline, peyote and others. The word, “Psychedelic”, by the way is Latin for “mind manifesting”. Some of these drugs have a long history of ceremonial or religious use in many different cultures.

LSD is a synthetic drug, originally created in 1938 by researcher, Albert Hofmann, who was working for the Sandoz pharmaceutical company, but he only began testing its effects in 1943. The drug’s structure and actions were so unusual he didn’t know what to do with it. So, the company provided it for free to anyone who was able and willing to perform research with it from the date it was released under the brand name, Delysid, in 1947 until they stopped production in 1965. The withdrawal occurred in response to the drug being declared illegal by the US government due to its widespread recreational use – the “hippie” culture.

Although a small amount of research continued underground, it began again slowly after 2010, mainly as small quiet projects and efforts to recover information from past studies. In 2016 and 2017, larger studies in US and UK were officially sanctioned. Old research results were unearthed from archives and added to the knowledge bases that were being developed. Because of the baggage attached to LSD from its history of past abuse, the new studies mostly used psilocybin, the active ingredient in magic mushrooms.

Treatment with psychedelic drugs has been found to have positive effects on depression, anxiety, PTSD (post-traumatic stress disorder), palliative care (fear of dying), alcoholism and compulsive behaviours. However, it is not the effect of the drug itself, but the experience the person has while on the “trip” the drug produces that changes their behaviour. The same results can be achieved by any of the psychedelic drugs (in sufficient dose), by deep meditation (by an experienced meditator) or by the experience of profound awe (for example, as described by an early astronaut, when he first saw the earth from space). Experiments were also performed on healthy people – artists, musicians, writers – to see if it would enhance their creativity or improve their outlook on life.

Treatments results are described as being highly influenced by what is suggested before the drug is given, the mindset of the person and the setting in which is it given. A trained guide prepares the patient beforehand, stays with them during the time the drug is active in their system, and meets with them afterward to help interpret what they experienced. As such, the treatment is really a combination of medication and counselling, not just a drug treatment alone. This is different from standard drug treatments. Some refer to the therapy as drug-assisted psychotherapy.

So, the challenge in testing these drugs is that it’s not simply the drug effect, but the experience the person has while under its influence that makes the treatment effective. This makes it much more difficult to perform the standard studies used in Western medicine, where a drug is compared with a placebo (sugar pill) to determine how well it works.

The dosing is also much different: when the drug is successfully given once, the effect may last 6 months, a year or longer. Occasionally, only needed a single treatment is needed. People will often describe the “trip” experienced while the drug in active in their system as the most profound experience of their lives. One woman, when asked what she experienced, said she learned that “love was everything”. When the guide then asked what else she learned, she said “no you don’t understand; love is EVERYthing”. That sounds so much like the hippie movement of the 60s – “love is all you need” – when LSD was popular with the counterculture. It seems this is a common sentiment after a successful “trip” on a psychedelic drug.

Two common themes described by volunteers for the treatment were reconnecting with their feelings, core beliefs, values and with others and nature; and a new access to difficult emotions that depression blunts or shuts down completely.

Depression currently affects almost 1 in 10 in North America and is a leading cause of disability worldwide. There are over 42,000 suicides in US every year, more than deaths from either breast cancer or car accidents. Half of these have never received mental health treatment. Experts are describing the mental health treatment system as “broken”. (see reference, below)

Studies are currently being conducted at Johns Hopkins, New York University, Heffter Research Institute and others in US as well as centers in other countries. Research includes addiction treatment, benefits to patients with cancer, treatment-resistant depression. There is also some research in healthy volunteers to learn how the drug works in the brain and how it affects attention, perception and cognition. While it may be years until this therapy is proven safe and effective and becomes an accepted treatment for medical use, it is exciting to watch the development of what may be a significant break-through in treatment for mental illnesses.

References:

How to Change Your Mind, Michael Pollan

Multidisciplinary Association for Psychedelic Studies

ClinicalTrials.gov

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Needles are good for you…

Knitting needles, that is…

It’s been a busy week: a long haul back from Spain, dealing with lost and damaged luggage, unpacking, laundry… and jet-lag, of course.

But when I saw this article, I wanted to share it with you. You may know that I am an avid knitter – my grandmother taught me when I was 6 and I took it up in earnest at age 8 or 9 when I received a “how to” book on knitting. I’ve been knitting ever since! But did you know that knitting is good for your mental and physical health?

Research shows that knitting can reduce depression and anxiety, lower blood pressure, distract from chronic pain, decrease loneliness and isolation, and just generally make you feel good!

I’ve always found knitting to be soothing and relaxing – sort of a form of meditation. It’s something about the repetitious movements of forming the stitches, I think. And, if you choose a more complex pattern, you need to block out other thoughts and focus on the pattern or you may find yourself unravelling some of your work! It’s really a form of meditation at the same time as you are creating something…

Studies say that knitting can actually induce the “relaxation response” — I wrote about this back relaxation technique back in March of 2017. Click here to see it. So, from this point of view, it compares with other relaxing activities like meditation and yoga… except you are creating something beautiful and useful at the same time. And, if you give the item away, you add in some of that great feeling you get by helping others.

I guess this may be why, as researchers have discovered recently, knitting can help reduce anxiety, depression, chronic pain and more. And in addition, when you’re done, you have the reward of a useful knitted item like a hat, scarf, mittens, socks or sweater! What could be better than a relaxing activity that provides a sense of accomplishment?

So, ff you’ve never knitted, give it a try. Pick up an inexpensive ball or two of colourful yarn and a pair of knitting needles (the label on the ball will tell you what size to buy!) and Google “how to knit”. Or just ask a friend who know how. I’m sure they’d be excited to help you learn!

Mental Health America article:

http://www.mentalhealthamerica.net/blog/mental-health-benefits-knitting

Inspiring anecdote from writer Chloe Grundmeier:

https://dailyevergreen.com/52666/life/try-knitting-for-your-mental-health/?fbclid=IwAR2vqUm6HA20x2wXtp-UDiBnzhZZyZLQHN_ABsqvGh–paXQk5z2o7L-N0Y

Here’s the science:

https://www.medicalbag.com/home/lifestyle/knit-one-purl-one-the-health-benefits-of-knitting/