Sunday, July 17, 2011

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.

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