Anatomy of an Epidemic: Medication and mental illness

Great Debates
1

I recently read the book Anatomy of an Epidemic, and found it fascinating. Here are a couplereviews that touch on some key points. Here is the author’s website.

The basic premise of the book is this

First he looks at schizophrenia, and the well-known fact that schizophrenics in developing countries generally have better outcomes than those in developed ones. How can this be? He argues that the very drugs used to treat schizophrenia often have massive irreversible effects on the brain, causing actual brain damage that makes people who may have simply had a single episode- what we might have once called a nervous breakdown- to become disabled for life. The current view is that schizophrenia is always devastating and barely controllable with only continuing use of the most heavy-hitting of drugs. But is this true? He cites a number of studies that say that those who do not use their drugs have better outcomes.

Then he turns to anxiety. Anxiety (and a number of people who probably were not particularly mentally ill) has often been treated with benzodiazepines (Valium, Xanax, and the like.) Time has shown that these are some of the most physically addictive drugs know to man, and the main withdrawal symptom is…increased anxiety. Although many doctors recognize the pitfalls, benzos are still used in “drug cocktails” used to treat various disorders.

Then comes what I see as the real meat of the book- SSRIs. He outlines the history of SSRIs and how they work medically. He concludes they are not targeted drugs “just like insulin for diabetics.” Rather, they cause various broad changes in brain function. They disrupt any number of systems, which may or may not make you feel better for a bit. Of course, he also cites the numerous studies that show SSRIs are not much more effective than placebos, and also the fact that most depression studies are short term enough (three weeks) that they do not record the episodes of depression that resolve themselves without treatment within a month or two.

He points out that in the past, even people who were hospitalized with severe depression were expected to and often did recover. We did not have large groups of people too depressed to work. Now, we consider depression a “chronic disease” requiring continued medication for life. As proof, we are told that people who discontinue their drugs tend to get depressed again. But is this a function of depression or is this a function of the changes the drugs have made to the brain? Depression seems to come immediately after withdrawal. Doesn’t this seem suspicious? Could depression drugs be actually making us more depressed? Are they making what may be a single bout of depression into a chronic life-long disease?

Even when people on medication relapse, we attribute to the idea that “the medication needs to be adjusted” and do not consider that the medication may be contributing to relapses. In short, we know the SSRIs have poor long term outcomes with almost sure relapses. But for some reason we still keep saying that they work as a long-term solution.

He then tackles the alarming rise of bipolar disorders. He looks at how the definitions have changed and broadened, and then at the possibility that SSRIs and other drugs are actually triggering manic episodes, which are then treated with more drugs, which may lead to even more disruptions. We know the drugs used to treat biploar disorder have numerous devastating effects on the body in the long run. Are they also causing devastating effects on the brain?

Finally, he looks at childhood behavior problems, and especially at the way ADHD has an alarming tendency to morph into bipolar disorder. We already know that both stimulants and anti-depressants have the possibility of causing manic episodes. We then treat those manic episodes with long courses of heavy drugs. Could these drugs be causing children to develop chronic mental illness?

Personally, I recognize the value of psychological medication for individuals, and have seen people transformed by them. At the same time, I have chosen to deal with my own problems on my own, with stunning success. I believe that often depression actually does have some underlying cause that can be consciously changed- often just a couple of bad patterns or an unresolved problem that needs to be processed. Drugs may help you get past the hard part, but if you don’t address the problem underneath you are going to keep having problems. I found the book to be quite compelling. We acknowledge that any other drug that acts on the brain- from alcohol to ecstasy- has the chance of causing harmful permanent changes. Drugs prescribed by doctors are no different.

2

I’d like to see that graphed out, because at least in my state I’d bet that most of that came in the earlier part of that interval. I see a lot of people who were put on disability 15 years ago or so for dubious reasons, but in my five years of practicing I haven’t seen anyone get disability for mental illness who isn’t obviously incapable of functioning in society (and I’ve seen plenty of them get turned down).

Depression is a chronic disease, but it differs from most of the chronic diseases that we understand (like diabetes and hypertension) in that it’s episodic. So people who are having depressive episodes can be expected to recover, but they can also be expected to relapse.

That makes disability due to depression a very difficult prospect. If someone is unable to get out of bed for months at a time, it’s going to be difficult for that person to hold down a job even if he’s fine for months in between.

You’re right that this makes it hard to judge whether the meds are working. Most guidelines recommend stopping the SSRIs after a few months (six, usually, IIRC) if symptoms have improved, but if there’s one thing we primary care doctors are bad at it’s stopping medicines. Inertia is a powerful thing, especially when the patient is afraid or just unwilling to stop the meds.

3

This is from the author’s website:

The last twenty years has seen incredible “advances” in the treatment of mental illness. If we are so much better at treating it, why is it rising so much? We can argue that a lot of it is getting better at identifying mental illness, but presumably the people who were so incapacitated that they could not work would have also been readily identifiable in the past.

The question is, why is depression a chronic disease and why does it relapse?

On his website the author provides pretty compelling evidence that depression did not used to be considered a chronic disease. He points out “relapses” often happen directly after withdrawing from SSRIs- much like withdrawing from benzos causes intense anxiety. Furthermore, staying on SSRIs also leads to “relapses.” Finally, he provides evidence that depression that is not treated with SSRIs has a much smaller chance of relapsing.

4

No one knows yet, including your author. Medicine is an evolving field.

We’ve discussed this book a few times before. You could do a search for the previous threads. Here’s one I posted to a few months ago - link

This is the fundamental point Whitaker gets wrong. We don’t have a simple blood test for “depression.” Not all all anti-depressants affect the brain in the same way. We don’t know enough about brain chemistry to know which drugs to use on which person at which dosage. “Depression” itself is a catch-all phrase for a collection of metal disorder symptoms. There is no magic bullet for curing it. The best we can do is try a bunch of medicines that work sometimes and hope we find a drug & dosage that helps. That’s not the same thing as saying anti-depressants are a scam. But it does mean that, until our understanding of mental illness and brain function increases, finding the right medicine can be a crap shoot.

In that previous thread I linked above, I pointed out that the actual study of placebos and anti-depressants doesn’t conclude what the Whitaker says it does. Here’s a link to the study again (you’ll need a JAMA subscription or maybe your library carries JAMA to read the full article.)

The -actual- conclusion of that study reads as follows:

5

Thanks for the link. I’m not sure how I missed those threads!

There are two theads that prompted me to bring this issue up. One is the so, apparently I have PPD. Boo.. I was kind of surprised that the OP just wholesale writes off CBT, saying it doesn’t seem necessary when drugs can do the job. It seems to me like if this is something that is happening over and over again, it’d be damn smart to take a closer look at the causes of it and how you can prevent it rather than seeking something to help you wait it out. Sure, maybe it is just out of whack hormones. But perhaps there are ways to break out of negative thinking patterns, build support systems, improve your coping methods, etc. that will serve you throughout your life. While I sympathize with the OP, it just struck me as kind of odd- the whole “I just thought I was sad, but then I realized it was postpartum depression and it all made sense.” and all the back-patting “Yeah, it’s PPD and has nothing to do with you as a person” that follows. Uh, aren’t you still just basically sad? Sticking a label on it doesn’t radically change or solve anything. The truth is we still don’t have much of a meaningful understanding of what is going on or how to cure it- depression is a symptom of some poorly understood brain misfunction, and our current drugs are more like cluster bombs than guided missiles.

The other is How Did You Overcome a Psychological Problem where a number of people shared their experiences beating these problems on their own. A number of people jumped in to say “That’s impossible. The ONLY thing that can help is a therapist and/or drugs.” It just strikes me as a bit of Kool-Aid drinking.

I think that people have gotten REALLY invested in the idea that “mental illness is just like diabetes,” when that is not really accurate. It is rarely a simple or easily understood “chemical imbalance” that can be directly solved by adding or subtracting the right chemical. Indeed, mental symptoms are the product of any number of complicated brain functions that we are nowhere near understanding. Nor do the current drugs simply provide something that is missing- they change a lot of stuff, and we have very little understanding of how or why these changes affect the mood symptoms. Anyway, nobody wants to hear that they have some control over their mental illness, because they’ve become so invested in the idea that it’s completely out of their control.

6

First, I am guessing that we had just as many mentally ill people in the past as we do now. However, we now address the issue differently. My mother, for example, suffered from clinical depression, but nobody – especially not she – would talk about it. Ever. My sister and I figured out the situation a few years after her death when we started comparing our own symptoms of the same diagnosed disorder with what we had observed in our mother. Suddenly it all fit and a lot of things were explained.

This is just one anecdote, but there are enough cases in both fiction and non-fiction to lead me to the opinion that people simply used different labels. The person was possessed by some good or evil spirit, was the village idiot, the crazy relative locked in the attic, the sad recluse, the person who was somehow “just not right.”

The idea of meds often being needed to break a vicious cycle of illness so that the sufferer can become accessible to therapy is a frequent pattern and in my amateur observation of a limited number of cases is often very effective.

Can some people work their own way out of a mild case of depression, etc.? IMHO very likely. More power to them. Are others unable to do so for one reason or another? Most certainly. And these folks should not be seen as “weak” or in some way responsible for their own illness.

I am one of those who tried everything possible, in true and good faith, and nothing worked until I was prescribed Paxil. If there had been a placebo effect, any one of the other remedies I tried would surely have worked. Also, please disabuse yourself of the idea that PPD or clinical depression are in any way equivalent to being “basically sad.” Sliding over a cliff, grasping desperately for any handhold is not the same as tumbling down the stairs even though both are “basically falling.”

Finally, I take objection to the following statement:

Anyone I know who is in this situation would like nothing more than to be able to control it and to be able to be rid of it.

7

Since there is at least one professional in this thread who can keep us from going too far over the edge, I’ll ask two questions that may or may not shed light on the apparent inscruatbility of mental illness.

  1. What happens to people with clinical depression if they are in a physically-demanding situation in which they are continually being compelled to do things against their will? An example might be a prisoner-of-war in a work camp. If a prisoner were clinically depressed and couldn’t get up to perform the labor, how might this prisoner respond to overwhelmingly severe physical threats?

A related scenario might be escaping from a dangerous situation. If a clinically depressed person hasn’t gotten out of bed in a month, but then finds that their house is on fire, can we expect the depressed person to get out of bed and exit the premises? Or can clinical depression be expected to prevent “fight or flight” self-preservative action?

What I’m getting at with both examples is this: when “Depression” meets “Survival”, which typically wins out? And is this understood empirically (i.e. do actual case studies like this exist)?

  1. Has their ever been an “experiment” in which a clinically-depressed person was, as much as feasible, shielded from life’s difficulties? I quoted “experiment” because there’s no way this could be done ethically by researchers – but it may have possibly been done in real life by a wealthy family for a clinically depressed family member. If you can set up a clincally-depressed person’s life so that they don’t have to work (or if they do, it’s extremely personally fulfilling somehow), they don’t have to deal with bills, anyone who interacts with them is extremely careful to say and do the right things, and so forth. I guess if the clinically depressed person is aware of this special treatment, that in itself can be an impetus for further depression. But anyway … in short: can a charmed life alleviate clinical depression,even in a small way? If not, is a charmed life better for depression than a frightfully stressful life of abuse? Does clinical depression “react” in any way to the outside world?

…

Thanks in advance to any responders. I know this is a long post, and the questions I’m asking might not be the most intelligent questions.

.

8

And the worse the initial situation was, or the more serious the consequences of upsetting the treatment applecart are, the more resistance you get from the patient about changing a therapy that seems to be working, even if it might be causing other problems. It’s something that’s hard to truly explain to someone who’s never had a condition so serious you’d rather die than go back to how things were, but after a certain level of impact on your life, the devil you know is far more horrifying than the devil you don’t know could ever dream of being.

The thing you have to keep in mind is that, yes, most of the psych drugs we have right now are more like cluster bombs and guided missiles. But when you need to blow something up, and the consequences of not blowing it upl are way worse than those of blowing up more than is strictly necessary…well, if a cluster bomb is all you’ve got, you’re going to use that instead of bemoaning the lack of guided missiles, ya know? I mean, if someone were to say to you “Hey, I have this pill that might or might not make you feel better, but it could cause problems 10 years down the road,” you can’t expect me to believe you’d say “No thanks, I’d rather keep laying here unbathed, feeling like a burden to everyone and everything I care about, and thinking about killing myself.”

I think MLS is probably right–the incidence of psych disorders has stayed fairly constant, but our labels and diagnostic tools and criteria have changed radically over the years and attitudes have shifted from “well, that’s just how it is” to “this is a problem we can try to fix.”

And we always, always have to be wary when talking about mental disorders not to fall into the trap of thinking about clinical depression the same way we think about having a situational depressive episode like grieving or being dumped or even having a quarter- or mid-life crisis.

9

Without wanting to comment specifically on another person’s medical condition, I would say that part of the confusion here stems from applying the word ‘depression’ to ‘post-partum depression.’ Chronic or acute depression is unrelated (well, not primarily related, let’s say) to a specific event or hormone fluctuations. OTOH, PPD, if I understand correctly, is related to the wild hormone storm that a woman’s body encounters during the stage of pregnant - giving birth - not pregnant suddenly. So PPD has a clear precipitating event and, if all goes well, an eventual return to equilibrium. That being the case, I can see why one might prefer to just treat the symptoms and wait for things to clear up.

I like CBT a lot myself; I’ve found it very helpful, personally, and I’ve recommended it before in other threads. But no one therapy is going to be right for everyone in every situation. If someone wants to try the medicines first, well, it’s none of my business really.

I don’t get that impression from that thread. I see people saying that depression can be managed, not cured, which something else entirely.

Again, in my experience, what people mean by that is that there’s no cure for chronic, acute depression. It can sometimes be managed, sometimes with drugs or therapy, and sometimes it goes into remission, so to speak. But there is no silver bullet that will make it all better.

To that extent, yes, mental illness is like diabetes: the medicine we have treats the symptoms, hopefully well enough that other therapies can be more effective as well.

At the same time, we know that many people can control their diabetes through a strict exercise and diet regimen. Would you therefore insist that insulin is unnecessary and people with diabetes are just lacking self control? Personally, I think it’s no one else’s business whether a patient takes medicine or uses non-medical means to achieve success. If a person needs medicine, it’s not my place to argue with them about why they don’t need it.

As the study I cited showed, we don’t know exactly how they work but we do know that they can be helpful for people with a certain type of profound depression.

It’s like Jenner discovering the cowpox/smallpox vaccine before Pasteur postulated germ theory. Jenner and his 19th century peers didn’t know why cowpox worked. But it did, and they would have been fools to ignore it. We don’t know why some people are helped by adjusting their serotonin or lithium or dopamine. But we know that some people are helped, in proportion to the degree of their symptoms.

So yes, we don’t fully understand the mechanism behind mental illness or why certain medicines can be helpful to certain individuals. That doesn’t mean that the medicines should not be used by the individuals who are helped by it. It certainly doesn’t mean that we can categorically announce that anti-depressants are useless and people who use them are lazy and lack willpower.

You’re generalizing beyond your evidence. If I maybe be excused for doing the same, what mentally ill people don’t want to hear is random strangers spouting off about how -they- know all about what treatments we should pursue and how it’s all our own fault for not exercising self-control.

10

There is the defensiveness. Nobody ever brought blame into things. Acknowledging that our current paradigm has flaws does not mean that we have to go back to the old “depression is a personal failure” meme. Nobody is threatening you with that. Nobody is saying “you can’t use drugs” or “there is something wrong with using drugs.” We are having a rational discussion about the efficacy in the long term of a specific popular medical treatment. I know meds save lives and am not discounting anyone’s personal experiences. But I think it’s useful to have a discussion about how the prescribed. How a person chooses to control their diabetes may be a personal thing, but how their doctor advises them is something up for valid debate.

And for the record, I am not stranger to depression. My experiences many years ago are well documented here, including the extremely hostile reaction I got for my choice not to use medication. My low point was about as low as it gets. I found a path towards treating it, and I’d go as far as to say it is cured. While I don’t think my path is better than any other’s or that it is right for anyone besides me, I would like to have my experiences validated just as much as you would.

It seems like the evidence is pretty solid that for mild and mid-grade depression, medication is relatively ineffective. We are still debating if it can actually be harmful. I know when I saw a psychologist, he gave me meds in about ten minutes. I see this as a problem.

11

I had a few “bipolar” “manic” episodes in my early 20’s, coupled with depression that has been ongoing for years. Mainly these problems cycle around my mestrual periods.

They put me on Abilify (mood stablizer/anti-psychotic) against my wishes. (so to speak… I told them I disagreed, but finally succumed and did what they said).

After three years on this medication, I finally had enough, and tapered my dosage (without dr. approval, since my doc would not approve it).

I’ve been Abilify free for 4 months and I feel SO MUCH BETTER. No mania, I can concentrate better, think more clearly and function properly.

12

I’m a co-leader of a local anxiety disorder support group (in fact, I have to leave to go to a meeting in a few minutes), and while what you’re saying is true, in my experience of six years of working with this group, people won’t do what it takes to get off of their medication, even with support and encouragement of people who have done just what they’re trying to do. It is an ongoing struggle in our group; people have anxiety and are uncomfortable, their doctors give them meds, the meds make them feel better as long as they take them, and they never get off the meds because coming off the meds is uncomfortable again. I still haven’t found a way to convince them that yes, you’ll feel uncomfortable for a while, but in the long run, you’ll feel better for the rest of your life. Short term pain for long term gain is something that you just can’t sell to people these days, it seems. Having a few people telling you one thing, and having the whole medical and pharmaceutical industry telling you another leaves people confused, unfortunately. We volunteer with this support group, mind you; doctors and Big Pharma make money on people continuing on benzodiazepans and SSRIs for long periods.

I frequently recommend CBT here, too. It has worked very well for me, and I agree that just about everyone in North America could use some help straightening out their thought processes, even if you don’t have pathological anxiety or depression.

13

This thread has so much wrong with it that it is frightening.

I mean no offense to sven whom I have admired for years. Besides, I think we are both from the same part of the country – West Tennessee, so I know that he usually has profound insight.

Because…we are so much better at treating it now. People didn’t want to submit themselves to medications that didn’t work or that had lasting negatiave effects. They didn’t want to see doctors who didn’t know how to help. They didn’t want to go through the horrors of extreme insulin shock and gain 60 pounds.

Also, having a mental illness had more of a stigma. People didn’t talk about it openly.

Now medicines often do work. Hospitals are warm, clean and supportive places that provide exercise, group counselling, relaxation therapy, snack rooms, friendships, and entertainment.

Naturally, since it is not as frightening to seek help, people are more likely to admit that they may need help and families may not feel as guilty trying to find help for them.

Not so for depression. There are many people who seem at peace with everything right up until the moment that they end their own lives.

And another weird thing about depression is that people who have had it before sometimes don’t recognize that they have it again. That’s because their judgment is affected by the disease itself. It all happens in the same part of the brain.

Please remember that mental illness doesn’t always show.

My understanding is that not everyone who has depression has chronic depression. It may be recurrent or you may have only one bout of it. Nevertheless, there is no cure for it.

Many people who have chronic depression – and have it all of the time – have a very low grade depression. That doesn’t even mean that they are sad. People can have depression without being sad all the time. We are talking about a mental illness, not a symptom. I have chronic low grade depression. I experience a lot of confusion, problems with sleep irregularities, weight, and some of the other symptoms. And sometimes I do feel detached and numb.

There have been times in my life when I have experienced a deep depression including the sadness. Some people refer to it as “double depression.” I used to feel suicidal and just out of my mind. Prozac put a stop to my feeling that way. In fact, SSRIs have put me in touch with the strong side of myself that I didn’t know I had. Not “happy” – just centered.

About two years ago, a substitution was made for the generic prozac that I was taking at that point. I have felt less and less in control and independent, but it didn’t occur to me until recently that it might be the change in medication. (As I said earlier, it’s hard to have judgment about ourselves.) So this week, I have begun to change over to the generic prozac again.

I haven’t been hospitalized since O.J. was in that white Ford Bronco.

Not me! Just the opposite!

Absolutely! That’s true of anyone whether they are depressed or not. But mental illness cannot be “healed” with a positive attitude. It’s possible that time may bring relief from your bout with clinical depression. And it is a pretty smart cookie who goes into therapy in the meantime and learns how to deal with life’s realities. Some people just have no idea of what is emotionally intelligent until they have therapy.

I hear that CBT is very good and I have a sneaking suspicion that is what my psychiatrist used without giving it a name.

If you minimize PPD by saying it is “just sadness,” you are doing yourself and new mothers a disservice. You don’t know what you are talking about. You just don’t. There is also PPP (Post Partum Psychosis). I think you’ve seen examples of what that can lead to. Are you going to take one of those mental illnesses seriously and scoff at the other?

Sven, that is something that you cannot possibly know. Why would anyone not want to control that much anquish? You are not making sense. Your posts make me think that you have had problems that have made you very sad and you were able to pull yourself out of it with help. But you don’t sound as if you have had clinical depression. Don’t confuse being depressed with having depression.

Please reread the quote before this one. Imagine that you are saying that to someone with Parkinson’s Disease. A doctor told me or I have read that Parkinson’s and clinical depression are “cousins.” (Sorry, I just don’t remember the source. I think it has to do with the connections in the brain that we can’t “will” to work.)

Finally, from Cat Whisperer:

I know that you had a really good experience with CBT and I think it’s great that you are staying involved and helping others. But maybe you shouldn’t be trying to convince them to change what has worked for them. There could be terrible consequences. After all, if they are still taking it, that is what their doctor is telling them to do.

14

But it’s not working for them - they don’t show up at my anxiety support group because they’re feeling fine. We always defer to their doctors in medication discussions, but as previously noted, inertia is a strong force, and most doctor visits involve five seconds of the doctor asking how they are and refilling the prescription.

15

Nobody is saying “change what is working for you.” The concern is for people for whom it is not working.

From my own experiences- yes, I was depressed. I’d have to leave classes early because I’d start crying uncontrollably. I don’t even remember my college graduation. I’d even wake up in the morning already crying, my cheeks rubbed raw from the wet pillow. This went on for a solid six months, including long periods where I could not get out of bed. Eventually my mom visited, took a look at me, and said “I’m losing my daughter. You are going to die soon.” That hit me hard, because I knew it was true.

That’s when I decided not to be depressed. It was the hardest thing I’ve ever done, but it worked brilliantly.

Obviously this is not a good plan for everyone, and perhaps not for anyone besides myself. I wouldn’t advise it to anyone, but I am also so grateful that I went down that particular path because I am pretty sure I pretty much solved a problem that had been plaguing me since childhood.

About PPD, don’t think I’m discounting that it is real or devastating. What I find odd is how the label seems to change everything in people’s minds. PPD is just a way of describing a certain pattern (depression after giving birth.) It’s not some magic word. While giving something a name can be comforting, it’s not like you are any different after being diagnosed than you were before. Your problem is not “PPD.” Your problem is still the same “feeling depressed after childbirth.” I don’t know- the whole “I was worried because I felt horrible all the time, but then I learned it’s just PPD” is kind of confusing.

16

People are not invested in that idea, pharmacorps are. People are just happy to buy it because it’s a simple (to understand and administer) and easy solution to a complex problem they don’t want to deal with.
Pharmacorps (and their downline cohorts who we address as “doc”) are also quite enthusiastic about a/ds being for life because it secures them customers for life.

But what are the alternatives? You’re saying that “snapping out of it” was basically what worked for you, and while it’s often thrown at depressed people, it is not that simple for many. You were fortunate in that you could take life and lifestyle altering steps to improve yourself, but there are many who are in committed lives/lifestyles and for whom the kind of changes they need are simply not viable.

17

No, but the naming process itself is magical because of the information it brings. It changes things from, in this case, “I feel bad all the time, I don’t know why, I don’t know whether it will ever get better, I don’t know what to do about it” to “I feel bad all the time, I know it was caused by delivering my baby, I know it will get better in a few weeks, I know I can ask people to help me with it and that there is medication that can help”.

If you woke up one morning feeling like someone had stuck an axe through your brain, knowing it’s a migraine will not make the pain go away but it will tell you what to do about it and it will tell you that the pain will not last the rest of your life. The knowledge of the pain helps deal with it.