Sunday, February 14, 2010

Sanity Suppliments

This week's issue of Newsweek has a very interesting article concerning the nation's use of anti-depressants. Actually, there are two articles. One appears at first to be a lengthy expose' about how many doctors prescribe the medications based on a few studies that aren't really comprehensive and they are not allowed to see the rest of the studies that suggest the medications aren't very effective at all. The other, an opposing piece, is a short account written by one doctor who personally took antidepressants and feels better now.

The position of the magazine is clear, if for no other reason than that the "Why antidepressants don't work" article is three times longer than the "Why antidepressants do work." I will say that the first piece, by Sharon Begley, is very well researched and documented. Most of piece focuses on the results of research that most doctors rely on. Here is the heart of it though - the benefits of anti-depressants are only marginally higher than a placebo pill in every single study performed. But, because there is a slightly higher percentage of patients that seem to have improved symptoms with these medications the results can legally say "this medicine is better." What isn't told to the public, or even the doctors, very often is that the actual percentage is less than 2%.

All of the studies determine the effectiveness of the medication as compared to a placebo pill (a sugar pill with no active ingredients.) When dealing with mental disorders, especially conditions like depression, the results can only be based on the experiences of the patient. A doctor can ask questions and make statements based on observations, but on the whole, the level of depression is decided by how the patient answers certain questions. Basically the research runs like this - a group of people are gathered together. They take surveys and questionnaires concerning their mood, their emotions, their habits, and their thought patterns. (Are you sad? Do you sleep more than X hours per day? Do you think about killing yourself?) The entire group is given medication to take but everyone is told that half of them will be receiving real medicine and the other half will be given a placebo. No one but the doctors know who gets what. Throughout the duration of the research, each of the patients is given the same survey or questionnaire again and the results are compared to their original scores. 

The comparative results of these studies are skewed to begin with simply because of the "placebo affect." This is when a patient improves simply because they believe they are being given medicine that will help them.  Certain conditions have been known to be affected more than others by placebos. For instance, hypertension and pain can be successfully treated with placebos while cancer and high cholesterol can not. When a condition can be effectively treated treated simply because they patient thinks it is being treated, it can be pretty hard to determine whether a new medication is actually working or not.

Patients that believe they are getting real medication improved almost half the time regardless of what they are actually taking. To prove the point even more, people who got real medication but believed they got a placebo didn't improve half the time. Instead of proving the effectiveness of one medication, these studies seem to show the effectiveness of the mind to control its own chemical and emotional balance.

Here is the part that worries me the most. Doctors still prescribe the medications more and more frequently, even with the research out there that doesn't really show one way or another that they work. An improvement of 1.8% of antidepressants over placebos doesn't really prove a whole lot to me. It doesn't seem to get any better when the levels of depression are worse, either, except in the case of the most extreme forms of depression. Even then, only 13% of severely depressed patients are helped by these medications.

To make matters more confusing, consider this - the study that the entire science of antidepressants is based on was highly consequential and has even been disproved recently. All anti-depressants act on the same basic principal - that depression is caused by a deficiency of a particular chemicals in the brain - serotonin, melatonin, and nor epinephrine - and by increasing one of these chemicals, you will improve the overall mental health of the patient. The study that determined this was held over 50 years ago. Some patients with lower serotonin levels seemed to be more depressed so the doctors assumed the connection was there and printed the results. Since then, more studies have been held trying to figure out the exact relationship of chemicals versus depression and the results were completely different and actually opposite at times. Lowering the level of serotonin didn't seem to make people depressed any more than raising it seemed to make them happier. There is even a new drug being used overseas that appears to help depression by lowering the serotonin levels.

Even studies that show certain medications are more effective than others can't really be trusted. When one medication doesn't work and the patient is switched to another, and another, and another,  the percentage of improvement gets lower with each change. Sometimes changing medications brings improvement, but is this because of the medication, or because the depression was already lifting, or because life styles have improved so the patient is able to cope better? There has never been a study comparing multiple changes of drugs to placebos so it is very hard to make an informed conclusion about that.

This whole issue is very close to me. As someone who has been prescribed medications daily for nearly the past eight years, I have a lot to consider here. Bi-polar disorder runs in my family and it is obvious who suffers from it and who doesn't. I remember clearly the onset of my own issues and I can say that this particular condition can be debilitating. While I never liked the idea of throwing drugs at a problem instead of trying to figure out the root of it, but by the time I went to my doctor, I was in serious need of help. My doctor felt that medication would help, so I listened. My symptoms were moderate at the time but medication was the only treatment that was suggested.

It was five years before I was referred to a psychologist. That was only three years after I was referred to a neurologist for headaches. The neurologist prescribed medication that helped manage pain but also has been prescribed as a mood leveler. The psychologist coordinated medications with him in hopes to find some combination that would improve both my depression and my pain. It wasn't until the last year that I have actually found any relief from the depression and only the last month have I found an improvement in the pain.

So, according to the research that has been released (and also some that hasn't been published) the medications might not be the thing that has helped me at all. Perhaps the relief, much like the cause of my fibromyalgia pain, is all in my head. Now, I am not suggesting that everything is made up or that it is not real. On the contrary, I believe the pain is very real. The problem is how my brain interprets signals that my body sends. A normal brush against something is interpreted as if I were punched. A small disappointment or stressor - say bad traffic - can affect me as if it were much worse - as if it were a traffic collision.

The article I read mentioned repeatedly not to stop taking medications suddenly. I'm sure it was as much to prevent someone from filing suit as it was out of true concern, but that is my opinion, only. The overall mood of the piece was that maybe you shouldn't have been taking them in the first place. The unfortunate part of all this medication prescribing going on, is that the medications are the first line of defense for mad moods and sad Sundays. The same research that says antidepressants are not as effective as you would like them to be also say that therapy and lifestyle changes do far more to ease symptoms than medications do. Why don't doctors choose the most effective treatments first? It comes down to expediency and money. It is faster to give a patient something and send them away with a "cure" than it is to give them a referral to someone else and hope that they follow through. Also, insurance companies don't cover therapists or lifestyle doctors like they do for PCP's.

The whole issue is getting me a bit riled up. It feels as though patients are being taken advantage of. When you are in the deep, black, hole you really, really want something that will help. It looks like there are plenty of options out there other than medication, but it doesn't seem like doctors want to hear it. Or maybe, the patients don't want to hear it. This is starting to sound a whole lot like when a parent who demands their child get antibiotics for every illness, even when a virus is the culprit (and antibiotics are really no good.)  Years after the practice has become common, we find that taking the wrong medication too often is actually creating germs that aren't defeated by normal antibiotics anymore.

Is a rise in depression and related illnesses really the problem or does it have to do more with the practice of giving the wring medication too often and not attacking the real root of the problem? This "root" is most likely different from one person to the next but I really feel that doctors - and patients, for that matter - should probably look deeper into the real reason for the depression rather than sick a band-aid over the problem and move on to the next person.

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