Tuesday, July 8, 2008


For some people, simple changes of environment or lifestyle can permit the body & mind to heal itself. In this way, perhaps depression or anxiety can be the body's signal to make a healthier change. Perhaps this might be the "normal" role of negative emotions, to influence us to make a necessary or protective life change.

Many medical illnesses feature an over-reaction of the body's natural protective mechanism. In autoimmune or inflammatory disorders, for example, the body's protective mechanisms attack and harm normal tissue. It is not a matter of simply making a positive life change -- the protective mechanism itself is malfunctioning. In treating such disorders, steps have to be taken to change the abnormal inner process, not to change the environment.

Likewise, in depression or anxiety disorders (and probably many other types of mental illnesses too), the mind's normal tendency to experience negative emotion, perhaps in reaction to adverse events -- malfunctions, and becomes out of control.

There are a variety of treatments:
1) wait for the symptoms to pass. This is painful, the symptoms may be highly disruptive while they last, and they may cause other life disruptions that could take many years to repair.
2) Learn mental or behavioural techniques to calm the mind or control the symptoms. So-called "cognitive-behavioural therapy" is one of the most well-researched techniques for managing symptoms of the mind, and the results are very robust.
3) Medications. The various medications for mental illnesses can help substantially. Some of them relieve symptoms immediately (e.g. benzodiazepines), while others are thought to be "disease-modifying agents" that can relieve symptoms in the long-term and prevent relapses (e.g. antidepressants, mood stabilizers, and antipsychotics). This reminds me of the treatment of inflammatory diseases such as rheumatoid arthritis, in which there can be immediate anti-inflammatory treatments (e.g. prednisone), while there are long-term treatments which reduce relapses (e.g. gold salts and immunosuppressives). With arthritis, treatments such as prednisone can be powerful reliefs, but should be minimized because such treatments weaken the body if used frequently. Similarly, the acute treatments in psychiatry, such as benzodiazepines, are very important, but can be counterproductive if used long-term, unless an individual patient cannot manage without them.

4) Psychotherapy
A supportive relationship with a therapist can be a powerful source of comfort, safety, security, and a framework in which to focus on growth & wellness. There are many styles of therapy, some styles perhaps more theoretically dogmatic than others, but I think the most important features of a healthy therapy relationship are feelings of safety, confidence, reliability, feelings of being heard and understood. Sometimes this supportive relationship itself becomes the strongest factor leading to recovery.


Anonymous said...

Part 1-

I wanted to ask, from your experience with antidepressants in general, do different patients taking the same drug usually complain about the same negative side effects (especially at higher doses)? Are they the same complaints to varying degrees (dimensional) or are they completely different complaints (sort of categorical)?

Assuming the drug is working in the same way, I would assume that the complaints would be similar. But this is under the assumption that the cause of the depression is similar and that everyone's brain is similar, which I know they aren’t.

I ask because I feel guilty when I evaluate a drug and conclude that the negative side effects outweigh the positives. (I feel guilty that I may have to tell the people that care about me the fact that another antidepressant is just not what "I" want). Is this selfish? I am afraid that “they” maybe questioning my weighting scale. I am afraid that to “them” my decision isn't justified. Maybe I should be "sticking it out" even when I am tormented because I feel like I have lost my sense of self. I think--

1) Perhaps, I am giving up too soon, not giving it enough time, or coming to a conclusion too fast.

2) Perhaps focusing on the negatives and weighing them above the positives is just another tactic of "the depression"

3) I start to worry that maybe I don't want recovery. Maybe I am a masochist who likes pain.

4) Perhaps the my scale of side effect salience isn't right... or justified. (But then again it is only MY experience that is important and MY weighting scale that is important. I know.

I am struggling with how much I should give up to feel better. The cost of that currently is too much, the price too high (which respect to meds). Is it expected that I loose the very essence of me in order to feel better? Or is expected that I loose just a few parts of "me" to experience more happiness? Why does it always have to be a trade off? (Perhaps that is naive)?

Personally I wish I could interview a thousand patients on how they subjectively feel on medications or on medications they chose to discontinue. (I would be a great social experiment and therapeutic for me, but unfortunately it is just uncouth to go about asking people if they are depressed and what their views on medication are.) I know it shouldn't change my opinion about my current medication trial but It would make me feel a whole lot better knowing that people discontinue medications for reasons that are less serious than my own.

So this leads me to my next question, how do patients, who have been or are being treated successfully with antidepressants, subjectively describe their experience in the "un"depressed state. Do they describe it as being their "old self" again? Or do they describe some negatives and some positives but their positives out weigh their negatives?

The other problem I have is I don't really know when I have been "un"depressed (I like this word). I don’t really know if I have an “old self.” So how is it going to feel? I worry that perhaps meds are helping me feel like my "true self" again but because it's been so long I don't even know it? (However, this is a very unsettling thought of not knowing who you actually are.)

Lastly, I just want to ask one more thing. There is this rule... somewhat of an unaddressed rule that should be addressed. It is the "don’t change your medication without first consulting with your doctor" rule. Do you believe in this rule? I understand that this is useful for specific serious psychopathologies (ie: psychosis or severe mania..ect.) and may be necessary to abide by, especially when you see a doctor fairly regularly. But does it have to be generalized to everyone? Especially people who are fairly knowledgeable? (or perhaps think they are.)

Anonymous said...


What I don't like about this rule is that it makes patients feel subservient. If the goal of patient care or therapy is to allow the patient to speak his/her opinion and take control and responsibility shouldn't they have the "RIGHT" to decide on their own about a medication at any place and time?

This being said I am not advocating changing medications and doses everyday or when someone feels like is. This is just on the rare occurrence of not tolerating a specific drug or dose.

After all it is the patient's body and the patient's experience. The therapist/psychiatrist isn't living with the patient and being exposed to his/her experiences through out the day.

Sometimes I think this rule is condescending and supported only because a few medical professionals thought that their patients were unintelligent. (And yes I know this can be argued).

Or maybe it was just a drug companies scam to encourage people to keep taking their medications so that that the drug companies would keep making money. (The theory being- "Antidepressants are the opiate of the masses"-- Although I am pretty sure no drug company would support a Marxism philosophy)

Sorry, recently I have just felt like an anti depressant zombie.

Anyway-- you don't have to post this but your thoughts would be appreciated on the topic (s)


GK said...

I think some side effects of a given antidepressant invariably have dimensional similarity, for most anyone (e.g. nausea, sweating, sexual side effects, anticholinergic symptoms, etc.). But there are also different types of complaints between one individual and another, which could depend on differences in depressive symptoms, or which could be the result of random or unrelated physiologic, genetic, or cultural differences.
I have encountered many people who have described the effect of an antidepressant as very helpful, calming, energizing, leading to a sense of "normal self," etc. while others taking the same medication describe unwelcome sedation, agitation, emotional restriction, no effect at all, etc. Such benefits vs. side-effects cannot be accurately predicted in an individual case; the best we can do is give things a very careful try, with a discussion of potential benefits, risks, and side-effects, in advance. It is sometimes the case that negative side effects diminish over a few weeks or months, as positive effects accumulate. So this can be a reason to encourage longer trials despite an unhelpful beginning.
In terms of changing doses of prescribed medication, etc. I guess this issue has to do with a negotiation between two people (physician and patient). The negotiation optimally should be balanced, respectful, empathic, and fair. I support the idea of the physician having the least possible degree of paternalism with regard to advising or imposing dose changes. The physician ought to be well-informed about existing research regarding any given therapy or medication suggestion. Some “paternalism” may be needed, for example in prescribing methadone to treat opiate dependence, but even then I think it is most therapeutic and ethical for the patient to have the greatest possible degree of autonomy with respect to treatment decisions.