TREATMENT FOR DEPRESSION
MORE ON MEDICATIONS THAT AFFECT THE NERVOUS SYSTEM
Following up on the previous posting, I would like to mention a fine article on antidepressants, “In Defense of Antidepressants”, that appeared in the New York Times last Sunday. Here is the link: http://www.nytimes.com/2011/07/10/opinion/sunday/10antidepressants.html
This is a good and thoughtful article and a needed antidote to the scare stories that have been written in the popular press. Depression is truly a disease rooted in the neurobiology of the brain. Though it is not totally understood, a lot is known about it. Modern treatment for depression is a great medical success story. The two best recent advances are 1) anti-depressants and 2) electro-convulsive therapy (ECT).
“Talking therapies” can also have an important role. But by “talking therapies” I mean mainly cognitive behavioral therapy and what is now often called “interpersonal therapy,” not the traditional psychoanalytic psychotherapy. Experts debate what these therapies entail. I would say that cognitive behavioral therapy is therapy based on learning theories. It takes the stance that a lot of mental illness is due to maladaptive learning, not just of facts but of patterns of behavioral as well as learned attitudes, feelings, and ways of reacting to life. The therapist attempts to re-educate the patient. Interpersonal therapy focuses on how a patient relates and interacts with others. But it also can include how the patient reacts to situations and events. In some ways it resembles the old-time psychoanalytic therapy but it is much shorter and it does not attempt to dredge up a lot of material from the so-called “unconscious.” It does not get really “deep” in that sense. Though it has never been really proven, I think that long term psychoanalytic therapy can offer a lot to the depressed patient. But it rarely offers a rapid return to better functioning. It can be very expensive. Insurance rarely covers many sessions and many psychoanalysts do not even take insurance. So if you want to see your Freudian oriented psychoanalyst three times a week you may be find yourself paying, say, $750 per week indefinitely. That would make me even more depressed. But if you could do it, in addition to the more modern briefer therapies, this could give you valuable insights and in a long term sense I think it includes both cognitive behavioral and interpersonal therapy. It would not surprise me if psychoanalytic therapy helped a person maintain a remission from depression even if it was not what was used to treat the acute depression. Due to the cost, perhaps the only way to obtain this is to see a psychiatrist who has a good psychoanalytic background. Such people will often integrate some psychoanalytic insights into a combined cognitive behavioral, interpersonal and pharmacological approach.
I just took a Harvard Medical School review course in depression treatment. The Harvard imprimatur does not mean that everything I learned is correct, but I think it was essentially correct and up to date. I cannot give you the course here, but let me summarize some points
1) Mild depression: Two options a) talking therapy alone for 2 to 6 weeks. If that does not help, add antidepressants
2) Moderately severe to severe: Medication required. Talking therapy as an adjunct may help but may not add much in the short term.
3) Severe depression that does not respond to medication and talking therapy for 4 weeks or more. ECT is strongly recommended if the patient is in good enough shape to take it.
There are all sorts of nuances and twists and turns in the actual treatments. The above is just a thumbnail sketch that in no way should guide your own treatment. But it serves to lay out the basic outline of a modern, well accepted standard of care. Those who trash the medication and ECT simply do not know what they are talking about.
Previously I recommended a few sources of information about medications. My top pick was, perhaps surprisingly, the Consumer Reports Health, http://www.consumerreports.org/health/home.htm. It costs about $20 per year. eMedicine is great bargain for textbook type information. It’s free. The Merck Manual is relatively inexpensive (about $60 on Amazon for the professional edition and less than $20 for the home health edition). Here’s another good one, The Medical Letter, http://secure.medicalletter.org/. This one’s a bit pricey: personal edition $98/year, medical health information provider edition $395/year, private practice edition $695/year. I’m believe that my medical library is subscribing to a group use of the private practice edition, though possibly it is the medical health information provider edition. I think that the personal edition is probably enough for most people. The other editions give you certain alerts and updates that are relevant to practice but I am quite sure that you get all the basic information for $98/year.
Sunday, July 17, 2011
Wednesday, July 13, 2011
ONE PATIENT'S VIEW OF ALS
Amyotrophic lateral sclerosis (ALS, also called Lou Gerhig’s disease) is an extremely serious condition in which the motor neurons in the spinal cord, brain, and brainstem (which lies between the brain and spinal cord) die. Certain other neurons die as well but the main problem is caused by the gradual death of the motor neurons. This causes the patient to gradually get weaker and weaker. Eventually, he or she cannot move at all, swallow food, control the bowels or urinary flow, or breathe. Death usually occurs within four years of diagnosis. There is no effective treatment. Last Sunday the New York Times present an essay called “The Good Short Life” by a writer named Dudley Clendinen. You can read his gripping comments at http://www.nytimes.com/2011/07/10/opinion/sunday/10als.html?pagewanted=all. It appears that he has a suicide plan in place so that he will not have to linger on in a helpless condition. This is definitely not everybody’s choice. Many choose to go onto a respirator and fight it out for many years. There is, in my opinion, no absolute wrong or right in this. Here is a video he made earlier
http://www.baltimoresun.com/videobeta/?watchId=643baf6d-e2f4-4831-934e-7048532a7e38
Amyotrophic lateral sclerosis (ALS, also called Lou Gerhig’s disease) is an extremely serious condition in which the motor neurons in the spinal cord, brain, and brainstem (which lies between the brain and spinal cord) die. Certain other neurons die as well but the main problem is caused by the gradual death of the motor neurons. This causes the patient to gradually get weaker and weaker. Eventually, he or she cannot move at all, swallow food, control the bowels or urinary flow, or breathe. Death usually occurs within four years of diagnosis. There is no effective treatment. Last Sunday the New York Times present an essay called “The Good Short Life” by a writer named Dudley Clendinen. You can read his gripping comments at http://www.nytimes.com/2011/07/10/opinion/sunday/10als.html?pagewanted=all. It appears that he has a suicide plan in place so that he will not have to linger on in a helpless condition. This is definitely not everybody’s choice. Many choose to go onto a respirator and fight it out for many years. There is, in my opinion, no absolute wrong or right in this. Here is a video he made earlier
http://www.baltimoresun.com/videobeta/?watchId=643baf6d-e2f4-4831-934e-7048532a7e38
Monday, July 11, 2011
PROTECTING YOURSELF AGAINST FALSE MEDICAL INFORMATION
I am a practicing physician, a medical research scientist, and a medical school teacher and many of my close relatives are physicians and medical scientists as well. But anyone who thinks it is easy for me and my family to make decisions about how various medical conditions should be approached and treated for ourselves and our loved ones would be mistaken. These are very tough issues. Many decisions are tough because there is a lack of settled opinion. Recently I read an online blog which pointed a finger at misleading advertisements by pharmaceutical companies (http://commonhealth.wbur.org/2011/07/online-ads-psych-meds/). I answered the blog in a comment which I am repeating here.
Misleading advertisements may play a role but I do not believe they are the only factors to be considered. I have found that the availability of medical information via the internet is a two edged sword. One can find information much faster than ever before. But even for a physician judging the quality, validity, and context of medical information is difficult. As with most other products, one must be skeptical of advertisements for medications. It is also important to be on the alert for information provided by those with hidden agendas regardless of whether they are commercial firms, government entities, or other interested parties. I do not think there is any perfect answer.
The column at http://commonhealth.wbur.org mentioned some reasonable point but I would urge readers to be skeptical about some of its recommendations as well.
1) The advice, from a Dr. Harold Bursztajn (whom I know and who is a very intelligent and thoughtful person) advises the reader to become aware of “what ‘adjunct’ means — Beware of recommendations that focus on FDA approval of a medication as an “adjunct” treatment without mentioning that this means that it’s not a first-line treatment for the condition in question.” I think it is misleading to tell people to “beware” of such recommendations. Though it is never wrong to know the precise “indication” for which a drug has been approved, this should not be interpreted as meaning that it is wrong to use the medication for other purposes. What is the best drug under a given circumstance is often debatable, but knowledge of indications for various drugs under various circumstances is an important part of the ever changing knowledge that physicians learn in medical school, residency and continuing education. In neurology, which I practice, it is often indicated, necessary, and demanded by the generally accepted standard of care to use the so-called “adjunct” medicines as first line and often “stand alone” medications. It is also often very valuable to use medications that have been approved for completely different purposes and were not even approved as an “adjunct” for that purpose (though it would be illegal for the company to advertise the drug for that purpose). The same is true for many other medical areas.
Depending on the spectrum of one’s patients, many good doctors prescribe “off label” at least 50% of the time. In the cases that I typically see, I prescribe “off label” about 25% of the time and I would be subjecting my patients to harm if I did otherwise. There are numerous reasons for this. The usual reason is that after a drug is approved for one usage, subsequent clinical research shows that it is as useful or even more useful for something else. But unless a drug company (or some other entity) is able to spend a large amount of money getting an additional approval, the formal FDA approvals for the other usages is never obtained. This is an accepted practice. Most medications with which I am familiar have many, many important uses aside from the FDA indications. Both neurology and psychiatry are fields in which “off label” uses, either using the “adjunct” drug as a first line treatment or using a medication for a completely different purpose than the one for which it was approved, is very common and, in my opinion, often very necessary.
2) The Commnhealth column says that patients should be aware that “indicated” does not mean “necessary.” It is true that “indicated” and “necessary” are not precise synonyms, but I doubt that making such a distinction is very helpful and it could be confusing. There are really many slightly different definitions of both of these words. “Necessary” is often used by insurance companies and other payers, especially when they reject payment (i.e. “the treatment was not necessary and, therefore, it is not covered”). Probably more important than the idea that indicated and necessary do not mean the same in thing is the caution that a treatment deemed “not necessary” or even “unnecessary” (by an insurance company, Medicare, an advice columnist or even your own doctor) does not always mean that the treatment is really not necessary to save your life or preserve your health. In my experience, I have seen a large number of patients who have been severely harmed by being told that a treatment was not necessary. But I cannot say, and I doubt that anyone can honestly be sure, whether more patients are harmed one way or the other. Some are harmed both ways, they fail to get treatments that would really do them a lot of good and they receive treatments that harm them. Blindly following FDA guideline (or blindly following any guidelines) tends to lead to such problems
3) Googling lawsuits and side effects of a drug was recommended. This could well give you some important information and I would never tell you not to do it. But doing so usually turns up isolated, random tidbits that are sort of like the “sound bites” in a political campaign. It is very hard to figure out the overall context. If you have a disease or other medical condition (e.g. traumatic brain injury) there are some other sources that I would recommend much more highly than googling for side effects of the drugs you were recommended. You really need to start with more comprehensive, connected accounts of the type that used to be found in (of all things) books (remember those?). Here are some modern alternatives.
a) This one may surprise you because it is so old fashioned. Subscribe to Consumer Reports. They actually have a separate online subscription for health articles (many of which are not included with the regular subscription). Despite my access to two medical school libraries, numerous personal medical journal subscriptions, and personal ownership of over $15 thousand dollars worth of medical textbooks (which at today’s prices is not all that many books), I actually subscribe both to the regular and health Consumer Reports and I often read their articles on medically related topics when something comes up in my own family. I’m not too proud to think that a “consumer” publication can teach me something. They have no advertising and though no one in the world is completely unbiased I think their articles are about as unbiased as you can get.
b) Online medical textbooks are available. The cheapest of these is EMedicine, which is now called Medscape Reference. You can still get to it via www.Emedicine.com. This IS supported mainly by advertising. But medical school libraries also pay to subscribe. It is peer reviewed. I have written and edited articles for it myself (and I have been paid three or four hundred dollars a year for the past few years doing so). I think its articles are of quite good quality, comparable to what one may find in a very expensive medical textbook. You probably can get to the advertising free version if you were to go to the closest medical school library and ask the librarian if you could look something up on one of the library’s computers (though I cannot guarantee that you would be given access). Public libraries may also have this version. But the text of the articles is exactly the same in both. So unless you are a super purist I do not see the advantage of the advertising-free paid version. Medical school and some public libraries also have many other medical texts. There is another online textbook called “Up to Date.” You can use the patient’s version free online. If you want the professional version it will cost you $44.95 per month. Physicians and other health professionals can subscribe for $495 a year (I bet they would let non-physicians get a year’s subscription as well but probably the idea is that an individual patient would need it only for a short time every now and then).
c) A handy and relatively inexpensive, yet comprehensive, medical textbook is the Merck Manual. There is both a patient’s version and a professional version. One need not be a physician to buy the professional version. They also have a website though I believe one must be a physician to get the online physician’s version. http://www.merckmanuals.com/professional/index.html
d) You might also want to look at my page on finding medical information at a different part of this website: http://www.neurospotlight.com/id22.html
My best general advice would be to start by reading whatever you can find about a given medication or category of medication in consumer reports. Then consider other sources such as EMedicine, the Merck manual, and websites of professional organizations and medical schools. If necessary, spend a few hundred dollars (if you can) and purchase a “real” medical textbook on the subject of interest. These days, many such books also include access to a more comprehensive website.
Following these suggestions will cost you anywhere from nothing (for EMedicine) to several hundred dollars if you end up buying some resources (Consumers Heatlh is about $20 per year). But though this may cost you a little, you will get a better understanding of the overall context of the treatments than you will obtain by wading through thousands of disconnected “sound byte” quality articles dredged up by Googling.
I am a practicing physician, a medical research scientist, and a medical school teacher and many of my close relatives are physicians and medical scientists as well. But anyone who thinks it is easy for me and my family to make decisions about how various medical conditions should be approached and treated for ourselves and our loved ones would be mistaken. These are very tough issues. Many decisions are tough because there is a lack of settled opinion. Recently I read an online blog which pointed a finger at misleading advertisements by pharmaceutical companies (http://commonhealth.wbur.org/2011/07/online-ads-psych-meds/). I answered the blog in a comment which I am repeating here.
Misleading advertisements may play a role but I do not believe they are the only factors to be considered. I have found that the availability of medical information via the internet is a two edged sword. One can find information much faster than ever before. But even for a physician judging the quality, validity, and context of medical information is difficult. As with most other products, one must be skeptical of advertisements for medications. It is also important to be on the alert for information provided by those with hidden agendas regardless of whether they are commercial firms, government entities, or other interested parties. I do not think there is any perfect answer.
The column at http://commonhealth.wbur.org mentioned some reasonable point but I would urge readers to be skeptical about some of its recommendations as well.
1) The advice, from a Dr. Harold Bursztajn (whom I know and who is a very intelligent and thoughtful person) advises the reader to become aware of “what ‘adjunct’ means — Beware of recommendations that focus on FDA approval of a medication as an “adjunct” treatment without mentioning that this means that it’s not a first-line treatment for the condition in question.” I think it is misleading to tell people to “beware” of such recommendations. Though it is never wrong to know the precise “indication” for which a drug has been approved, this should not be interpreted as meaning that it is wrong to use the medication for other purposes. What is the best drug under a given circumstance is often debatable, but knowledge of indications for various drugs under various circumstances is an important part of the ever changing knowledge that physicians learn in medical school, residency and continuing education. In neurology, which I practice, it is often indicated, necessary, and demanded by the generally accepted standard of care to use the so-called “adjunct” medicines as first line and often “stand alone” medications. It is also often very valuable to use medications that have been approved for completely different purposes and were not even approved as an “adjunct” for that purpose (though it would be illegal for the company to advertise the drug for that purpose). The same is true for many other medical areas.
Depending on the spectrum of one’s patients, many good doctors prescribe “off label” at least 50% of the time. In the cases that I typically see, I prescribe “off label” about 25% of the time and I would be subjecting my patients to harm if I did otherwise. There are numerous reasons for this. The usual reason is that after a drug is approved for one usage, subsequent clinical research shows that it is as useful or even more useful for something else. But unless a drug company (or some other entity) is able to spend a large amount of money getting an additional approval, the formal FDA approvals for the other usages is never obtained. This is an accepted practice. Most medications with which I am familiar have many, many important uses aside from the FDA indications. Both neurology and psychiatry are fields in which “off label” uses, either using the “adjunct” drug as a first line treatment or using a medication for a completely different purpose than the one for which it was approved, is very common and, in my opinion, often very necessary.
2) The Commnhealth column says that patients should be aware that “indicated” does not mean “necessary.” It is true that “indicated” and “necessary” are not precise synonyms, but I doubt that making such a distinction is very helpful and it could be confusing. There are really many slightly different definitions of both of these words. “Necessary” is often used by insurance companies and other payers, especially when they reject payment (i.e. “the treatment was not necessary and, therefore, it is not covered”). Probably more important than the idea that indicated and necessary do not mean the same in thing is the caution that a treatment deemed “not necessary” or even “unnecessary” (by an insurance company, Medicare, an advice columnist or even your own doctor) does not always mean that the treatment is really not necessary to save your life or preserve your health. In my experience, I have seen a large number of patients who have been severely harmed by being told that a treatment was not necessary. But I cannot say, and I doubt that anyone can honestly be sure, whether more patients are harmed one way or the other. Some are harmed both ways, they fail to get treatments that would really do them a lot of good and they receive treatments that harm them. Blindly following FDA guideline (or blindly following any guidelines) tends to lead to such problems
3) Googling lawsuits and side effects of a drug was recommended. This could well give you some important information and I would never tell you not to do it. But doing so usually turns up isolated, random tidbits that are sort of like the “sound bites” in a political campaign. It is very hard to figure out the overall context. If you have a disease or other medical condition (e.g. traumatic brain injury) there are some other sources that I would recommend much more highly than googling for side effects of the drugs you were recommended. You really need to start with more comprehensive, connected accounts of the type that used to be found in (of all things) books (remember those?). Here are some modern alternatives.
a) This one may surprise you because it is so old fashioned. Subscribe to Consumer Reports. They actually have a separate online subscription for health articles (many of which are not included with the regular subscription). Despite my access to two medical school libraries, numerous personal medical journal subscriptions, and personal ownership of over $15 thousand dollars worth of medical textbooks (which at today’s prices is not all that many books), I actually subscribe both to the regular and health Consumer Reports and I often read their articles on medically related topics when something comes up in my own family. I’m not too proud to think that a “consumer” publication can teach me something. They have no advertising and though no one in the world is completely unbiased I think their articles are about as unbiased as you can get.
b) Online medical textbooks are available. The cheapest of these is EMedicine, which is now called Medscape Reference. You can still get to it via www.Emedicine.com. This IS supported mainly by advertising. But medical school libraries also pay to subscribe. It is peer reviewed. I have written and edited articles for it myself (and I have been paid three or four hundred dollars a year for the past few years doing so). I think its articles are of quite good quality, comparable to what one may find in a very expensive medical textbook. You probably can get to the advertising free version if you were to go to the closest medical school library and ask the librarian if you could look something up on one of the library’s computers (though I cannot guarantee that you would be given access). Public libraries may also have this version. But the text of the articles is exactly the same in both. So unless you are a super purist I do not see the advantage of the advertising-free paid version. Medical school and some public libraries also have many other medical texts. There is another online textbook called “Up to Date.” You can use the patient’s version free online. If you want the professional version it will cost you $44.95 per month. Physicians and other health professionals can subscribe for $495 a year (I bet they would let non-physicians get a year’s subscription as well but probably the idea is that an individual patient would need it only for a short time every now and then).
c) A handy and relatively inexpensive, yet comprehensive, medical textbook is the Merck Manual. There is both a patient’s version and a professional version. One need not be a physician to buy the professional version. They also have a website though I believe one must be a physician to get the online physician’s version. http://www.merckmanuals.com/professional/index.html
d) You might also want to look at my page on finding medical information at a different part of this website: http://www.neurospotlight.com/id22.html
My best general advice would be to start by reading whatever you can find about a given medication or category of medication in consumer reports. Then consider other sources such as EMedicine, the Merck manual, and websites of professional organizations and medical schools. If necessary, spend a few hundred dollars (if you can) and purchase a “real” medical textbook on the subject of interest. These days, many such books also include access to a more comprehensive website.
Following these suggestions will cost you anywhere from nothing (for EMedicine) to several hundred dollars if you end up buying some resources (Consumers Heatlh is about $20 per year). But though this may cost you a little, you will get a better understanding of the overall context of the treatments than you will obtain by wading through thousands of disconnected “sound byte” quality articles dredged up by Googling.
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