Feb 20

“Lost Connections”: Johann Hari on Depression/Anxiety

Through a breath-taking journey across the world, Johann Hari exposes us to extraordinary people and concepts that will change the way we see depression forever. It is a brave, moving, brilliant, simple and earth-shattering book that must be read by everyone and anyone who is longing for a life of meaning and connection. Eve Ensler, on Lost Connections by Johann Hari

In journalist Johann Hari‘s Lost Connections: Uncovering the Real Causes of Depression – and the Unexpected Solutions, he tells readers his own long-term depression has been blamed on a chemical imbalance in the brain. However, at some point in his therapeutic process “…he began to investigate whether this was true – and he learned that almost everything we have been told about depression and anxiety is wrong.”

Hari’s research led him to this basic conclusion (HuffPost): “I learned that there are in fact nine major causes of depression and anxiety that are unfolding all around us. Two are biological, and seven are out in here in the world, rather than sealed away inside our skulls in the way my doctor told me…I was even more startled to discover this isn’t some fringe position – the World Health Organization has been warning for years that we need to start dealing with the deeper causes of depression in this way.”

According to Fiona Sturges, The Guardian, the factors cited by Hari that contribute to reactive depression “include hardship, trauma, loneliness, lack of fulfilment, absence of status and disconnection from nature.”

Particularly salient is what Hari gleaned about one of these from physician and researcher Vincent Felitti‘s work (HuffPost): “Childhood trauma caused the risk of adult depression to explode. If you had seven categories of traumatic event as a child, you were 3,100 percent more likely to attempt to commit suicide as an adult, and more than 4,000 percent more likely to be an injecting drug user.”

Hari, furthermore, makes this helpful point:

One day, one of Dr. Vincent Felitti’s colleagues, Dr. Robert Anda, told me something I have been thinking about ever since.
When people are behaving in apparently self-destructive ways, ‘it’s time to stop asking what’s wrong with them,’ he said, ‘and time to start asking what happened to them.’

In the case of more endogenous depression, or the biologically based type, Hari now believes Big Pharma and prescribers take advantage of the popularized but not necessarily accurate notion of the brain having a chemical imbalance. There is a significant body of research that disputes both this theory and the efficacy of the prevailing remedy, antidepressant medications.

If meds aren’t always effective, what other kinds of solutions to depression/anxiety did Hari find and thus present in Lost Connections? Kirkus Reviews reports the author’s view that there are “immense (natural) antidepressive benefits of meaningful work, social interaction, and selflessness.”

For further details we have to read the book.

Jun 28

Antidepressants Do Work “Ordinarily Well”

In “Ordinarily Well,” Dr. Kramer, who has written so well about the curse of melancholia — that thief who steals your blood and slyly replaces it with lead — has done something very valuable: He has waded into the contentious debate about the efficacy of antidepressants. It’s an important and confusing subject. One in eight Americans rely on these medications, hardly a trivial number. Jennifer Senior, New York Times, on the idea that antidepressants do work

Ordinarily Well: The Case for Antidepressants by psychiatrist Peter Kramer, who has sometimes been dubbed “Dr. Prozac” by the media, returns to a subject he famously visited before in Listening to Prozac (1993). Antidepressants do work, Kramer claims in this newest book, opposing the views of some other experts in the field.

Why Kramer Wrote Ordinarily Well

Publishers Weekly cites one incentive for this book: “…Kramer’s more captivating story is about the resistance to antidepressants that emerged in the 1970s and was further stoked by Irving Kirsch’s 1998 essay, “Listening to Prozac but Hearing Placebo,” which took direct aim at Kramer’s work.”

Miller offers another:

The book is written as a response to the ‘research’– now seen so often in headlines – that antidepressants are as effective as sugar pills for mild to moderate depression, and they should be prescribed only for severe major depression. He gets even more specific: The book is written partly in response to an article by Dr. Marcia Angell, former editor in chief of the New England Journal of Medicine, published in June 2011 in the New York Review of Books, and Dr. Angell’s assertion that psychiatric medications are no more effective than placebo. Since psychotropics come with more side effects than placebos, the next logical conclusion is that they are not only ineffective – they are harmful.

Kramer’s Main Conclusions

Kramer’s conclusion, states Miller, is that “(m)ost patients with depression, be it mild, moderate, severe, or long-standing dysthymia, have a good response to antidepressants. It’s the minority who don’t respond.” Antidepressants do work, in other words.

‘This book is about two influences on medical practice,’ he writes, ‘rigorous trials and clinical encounters.’ Kramer worries that overemphasis on rigorous trials and statistical analysis of outcomes is eroding the doctor-patient relationship, not allowing for a more flexible, case-by-case approach to treatment. ‘A tiny fraction of what doctors do finds direct representation in research,’ he writes. While the efficacy of antidepressants combined with psychotherapy is well-established, how long to maintain their use following recovery is still under debate. It is a question of achieving a balance between preventing the recurrence of depression and side effects such as the occurrence of cataracts and lowered calcium absorption.

Thomas R. Insel, MD: “Antidepressants work, keeping depression at bay. For some they are not sufficient. And for an unfortunate few, they are not effective. But remembering the hopeless state of treatment only a few decades ago, Kramer reminds us with compelling prose and compassionate insight that today millions of us are much better off with access to these medications.”

Jun 17

“The Noonday Demon”: Andrew Solomon Examines Depression

Listen to the people who love you. Believe that they are worth living for even when you don’t believe it. Seek out the memories depression takes away and project them into the future. Be brave; be strong; take your pills. Exercise because it’s good for you even if every step weighs a thousand pounds. Eat when food itself disgusts you. Reason with yourself when you have lost your reason. Andrew Solomon, The Noonday Demon

Recently I posted about Andrew Solomon‘s new TED talk “Forge Meaning, Build Identity.” Also pertinent to Minding Therapy is his 2001 The Noonday Demon: An Atlas of Depression, a book that’s both personal and sociocultural in scope.

Last year he gave the following TED talk, “Depression, The Secret We Share”:

If you’ve neither watched the above talk nor read The Noonday Demon, you may be interested in some of these quotes from The Noonday Demon:

The Opening Lines

“Depression is the flaw in love. To be creatures who love, we must be creatures who can despair at what we lose, and depression is the mechanism of that despair.”

The Nature of Depression

“Antonin Artaud wrote on one of his drawings, ‘Never real and always true,’ and that is how depression feels. You know that it is not real, that you are someone else, and yet you know that it is absolutely true.”

“Grief is depression in proportion to circumstance; depression is grief out of proportion to circumstance.”

“The most important thing to remember about depression is this: you do not get the time back. It is not tacked on at the end of your life to make up for the disaster years. Whatever time is eaten by a depression is gone forever. The minutes that are ticking by as you experience the illness are minutes you will not know again.”

What Helps Depression  

“The people who succeed despite depression do three things. First, they seek an understanding of what’s happening. They they accept that this is a permanent situation. And then they have to transcend their experience and grow from it and put themselves out into the world of real people.”

“A sense of humor is the best indicator that you will recover; it is often the best indicator that people will love you. Sustain that and you have hope.”

“It is important not to suppress your feelings altogether when you are depressed. It is equally important to avoid terrible arguments or expressions of outrage. You should steer clear of emotionally damaging behavior. People forgive, but it is best not to stir things up to the point at which forgiveness is required. When you are depressed, you need the love of other people, and yet depression fosters actions that destroy that love. Depressed people often stick pins into their own life rafts. The conscious mind can intervene. One is not helpless.”

Being on Medication

“Since I am writing a book about depression, I am often asked in social situations to describe my own experiences, and I usually end by saying that I am on medication.
“Still?” people ask. “But you seem fine!” To which I invariably reply that I seem fine because I am fine, and that I am fine in part because of medication.
“So how long do you expect to go on taking this stuff?” people ask. When I say that I will be on medication indefinitely, people who have dealt calmly and sympathetically with the news of suicide attempts, catatonia, missed years of work, significant loss of body weight, and so on stare at me with alarm.
“But it’s really bad to be on medicine that way,” they say. “Surely now you are strong enough to be able to phase out some of these drugs!” If you say to them that this is like phasing the carburetor out of your car or the buttresses out of Notre Dame, they laugh.
“So maybe you’ll stay on a really low maintenance dose?” They ask. You explain that the level of medication you take was chosen because it normalizes the systems that can go haywire, and that a low dose of medication would be like removing half of your carburetor. You add that you have experienced almost no side effects from the medication you are taking, and that there is no evidence of negative effects of long-term medication. You say that you really don’t want to get sick again. But wellness is still, in this area, associated not with achieving control of your problem, but with discontinuation of medication.
“Well, I sure hope you get off it sometime soon,” they say.

Life with Recurrent Depression

“The opposite of depression is not happiness, but vitality and my life, as I write this, is vital even when sad. I may wake up sometime next year without my mind again; it is not likely to stick around all the time. Meanwhile, however, I have discovered what I would have to call a soul, a part of myself I could never have imagined until one day, seven years ago, when hell came to pay me a surprise visit. It’s a precious discovery. Almost every day I feel momentary flashes of hopelessness and wonder every time whether I am slipping. For a petrifying instant here and there, a lightning-quick flash, I want a car to run me over…I hate these feelings but, but I know that they have driven me to look deeper at life, to find and cling to reasons for living, I cannot find it in me to regret entirely the course my life has taken. Every day, I choose, sometimes gamely, and sometimes against the moment’s reason, to be alive. Is that not a rare joy?”

Aug 31

“Coming of Age on Zoloft”: Our Youth On Antidepressants

Coming of Age on Zoloft (2012) by writer/journalist Katherine Sharpe takes the issue of “the medication generation” into more specific territory, “the antidepressant generation.” She includes her own story of using Zoloft for 10 years, starting in college. From the book description:

She explores questions of identity that arise for people who start medication before they have an adult sense of self. She asks why some individuals find a diagnosis of depression reassuring, while others are threatened by it. She presents, in young people’s own words, their intimate and complicated relationships with their medication. And she weighs the cultural implications of America’s biomedical approach to moods.

Among other concerns, Sharpe is afraid that mental health professionals may in effect pathologize and/or squelch the normal emotions of children and adolescents when prescribing antidepressants too readily for psychic pain. What she says about her own experience (wsj.com): “For me, antidepressants had promoted a kind of emotional illiteracy. They had prevented me from noticing the reasons that I felt bad when I did and from appreciating the effects of my own choices.”

The most challenging topic to write about in Coming of Age On Zoloft was her choice to discontinue the antidepressant, which she’s been off now for about six years.

Selected Reviews of Coming of Age on Zoloft

Dr. David Healy, author of Let Them Eat Prozac: “Beautifully written…This is a book for anyone taking or thinking about taking antidepressants, anyone who prescribes them, anyone who wonders about their suitability–or anyone who wants a mirror held up to our time.”

Kirkus Reviews: “Balanced and informative—an education for any parent considering psychiatric medication for a troubled adolescent.”

Publishers Weekly: “This is a fine book that nicely weaves together personal, sociological, and philosophical perspectives for a thoughtful view of how antidepressants are shaping many people’s lives.”

Aug 30

“The Medication Generation Grows Up” (Medicating Kids)

In the past couple decades, prescribing psychotropic medications for children and adolescents has pretty much become business as usual. Dosed: The Medication Generation Grows Up, by journalist/blogger Kaitlin Bell Barnett, “takes a nuanced look at the issue as she weaves together stories from members of this ‘medication generation,’ exploring how drugs informed their experiences at home, in school, and with the mental health professions.” Notably, the author herself is part of the story, as she started taking antidepressants in her teens.

Claudia M. Gold, MD, author of Keeping Your Child in Mind: “Dosed is a fascinating, well-researched, and very important book. After reading it, I hope that no parent, pediatrician or psychiatrist will give psychiatric medication to a child or adolescent without very careful consideration of the potential long-term consequences. Bell Barnett shows that these medications are often not a ‘quick fix,’ but rather have deep, lasting impact, not only on physical and emotional health, but also on a person’s core sense of self.”

From the description of “The Medication Generation,” more about the effects on these kids:

The questions we all ask growing up—’Who am I?’ and ‘What can I achieve?’—take on extra layers of complexity for kids who spend their formative years on medication. As Barnett shows, parents’ fears that ‘labeling’ kids will hurt their self-esteem means that many young children don’t understand why they take pills at all, or what the drugs are supposed to accomplish. Teens must try to figure out whether intense emotions and risk-taking behaviors fall within the spectrum of normal adolescent angst, or whether they represent new symptoms or drug side effects. Young adults negotiate schoolwork, relationships, and the workplace, while struggling to find the right medication, dealing with breakdowns and relapses, and trying to decide whether they still need pharmaceutical treatment at all. And for some young people, what seemed like a quick fix turns into a saga of different diagnoses, symptoms, and a changing cocktail of medications.

All of the above has occurred within a changing treatment model that often makes the meds overly accessible and inadequately monitored. An excerpt from the book (for use in Salon):

As psychiatrists switched from forty-five-minute visits with time for psychotherapy to fifteen-minute ‘med checks,’ prescriptions often came with little continuing discussion about how kids felt about taking medication, or how it was affecting them. That was fine by some, but not by others. One young woman I interviewed, who received her prescriptions from time-crunched psychiatrists who scheduled fifteen-minute appointments they often cut short, wished there had been time to ‘talk about feelings, not just symptoms.’ One young man told me that even though psychiatric medication is ‘so much a part of our culture,’ he could ‘probably count on one hand’ the conversations he’d had about his medication use, or anyone else’s.

In a Huffington Post article, Barnett advocates, among other helpful suggestions, that parents seek a therapist for their kids if they’re on medications:

Many studies have shown that the combination of therapy and medication beats either treatment alone. But beyond that fact, I recommend trying to find a therapist who’s open to discussing not just feelings, relationships, thoughts and other traditional therapy topics, but also kids’ opinions and attitudes about being on medication. Taking psychiatric drugs can be stressful and confusing, and often children and teens don’t have anyone with whom they feel comfortable discussing their concerns. If the child is open to it, therapy can be an ideal venue.

But what about the kids whose parents aren’t actually available, whether to offer guidance on such matters or otherwise? A very recent post by Barnett takes on “one relatively small but prominent group,” our country’s foster children, who evidently are significantly more likely than other kids to be put on drugs. Although this problem is currently being tackled in various ways, Barnett singles out a brand new resource from the federal Children’s Bureau for its fresh and needed approach:

‘Making healthy choices: a guide on psychotropic medications for youth in foster care’ aims to give foster children the information necessary to look out for their own best interests when it comes to mental health treatment. The guide, appealingly illustrated and written in plain, accessible language for pre-teens and teenagers, can’t magically fix the systemic problems that contribute to such high rates of psychotropic prescribing. Nor is it likely to help children who are too young or too disturbed to absorb its advice. But it is a wise and much-needed step toward molding troubled and vulnerable kids into well-informed self-advocates.