I've struggled with this debate ever since my psychiatry term and I still seem to sway toward the antidepressants are largely ineffective side of the coin. I'm not a conspiracy theorist, but the prevalence of some mental health conditions and the profit made through drugs is questionable, especially with the ever-expanding proportion of the population that is seemingly diagnosable. <br />
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Anxiety and depressive disorders seem particularly difficult, perhaps because of their prevalence while bipolar disorders and schizophreniform disorders seem less suspect.
    <a href=http://www.nybooks.com/articles/archives/2011/jul/14/illusions-of-psychiatry/?page=1>A second part to this series</a>, again by Maria Angell, former editor of the NEJM. It's not a new argument, but it does do a job of pointing out the elephant in the modern medical consulting room. This one focuses on the DSM and its questionable validity.<br />
    <br />
    I've heard all this article says before, and I mostly agree with it, but it offers little in the way of an alternative to treat the significant distress and disability experienced by people with mental illness. And for all the issues with antidepressants, they do seem to confer some benefit, even if small. Issues with childhood diagnoses are difficult. Mental health is difficult, and our methods are poor, but it's not like we can just ignore these patients.
      I'm not sure if anyone else is following this dialogue in the NY Times/Books but the latest is <a href=http://www.nytimes.com/2011/07/17/opinion/sunday/l17dialogue.html>series of letters</a> presented in the NY Times that gives voice to a wide range of people on the topic, including many relevant experts.
        The first link didn't work for me?<br />
        <br />
        So what I got from that was that the over prescription of anti-depressants is due to the subjectivity of the psychiatric disorder diagnosis criteria which is perhaps in part driven by ethically questionable influence from the pharmaceutical industry.<br />
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        What I was wondering is have you come across any more objective diagnosis methods? I'm currently having a search with not much success but I remember from some of my pharmacology lecturers the mention of autopsy analysis of suicide victims who were thought to have suffered from major depressive disorder having an increased number of 5-HT receptors in the brain indicating low levels of synaptic 5-HT. Also, low levels of 5-HT metabolites in the CSF pointed to the monoamine imbalance theory(<a href=http://www.ncbi.nlm.nih.gov/pubmed/17091615>http://www.ncbi.nlm.nih.gov/pubmed/17091615</a>). Obviously it would be invasive and impractical to try and take these readings from a live patient but it would be interesting to know of any other objective tests to indicate that something like an SSRI would be helpful.
          <blockquote><br />
          What I was wondering is have you come across any more objective diagnosis methods? I'm currently having a search with not much success but I remember from some of my pharmacology lecturers the mention of autopsy analysis of suicide victims who were thought to have suffered from major depressive disorder having an increased number of 5-HT receptors in the brain indicating low levels of synaptic 5-HT. Also, low levels of 5-HT metabolites in the CSF pointed to the monoamine imbalance theory(<a href=http://www.ncbi.nlm.nih.gov/pubmed/17091615>http://www.ncbi.nlm.nih.gov/pubmed/17091615</a>). Obviously it would be invasive and impractical to try and take these readings from a live patient but it would be interesting to know of any other objective tests to indicate that something like an SSRI would be helpful.</blockquote><br />
          <br />
          The studies you're talking about are interesting but represent an incredibly low level of evidence in favour of antidepressant treatment. There are other objective tests, for example PET, SPECT and fMRI, but their relevance to antidepressant treatment is uncertain. It's unfortunate that you get a very skewed view of psychiatry through the study of pharmacology, but it is my opinion, and the opinion of many psychiatrists that the suggestion that depression is the result of a chemical imbalance in the brain is very simplistic and quite possibly just flat out incorrect. <br />
          <br />
          It's a shame, it would be nice to think that we, as people, represent a complex mix of neurotransmitters and that psychiatrists could use their drugs to expertly tinker with a fine balance of neurochemistry.
          My lecturers made it clear that antidepressants were much more effective when used in conjunction with cognitive therapy and the like but as it was a pharmacology course they didn't elaborate. Is there a consensus amongst you and those psychiatrists that don't completely subscribe to the monoamine theory about what a possible alternative cause of depression might be? Genetics? or perhaps the Freudian approach as was previously used and mentioned in the Maria Angell review you linked?
          <blockquote>My lecturers made it clear that antidepressants were much more effective when used in conjunction with cognitive therapy and the like but as it was a pharmacology course they didn't elaborate. Is there a consensus amongst you and those psychiatrists that don't completely subscribe to the monoamine theory about what a possible alternative cause of depression might be? Genetics? or perhaps the Freudian approach as was previously used and mentioned in the Maria Angell review you linked?</blockquote><br />
          <br />
          Hmm, much more effective might be a bit of an exaggeration, or perhaps, a lot of an exaggeration. There is evidence to suggest that but it's not strong. <br />
          <br />
          Depression is a bit like most chronic illness, there's a genetic component and environmental component but the exact aetiology is unknown. It's also a very heterogenous condition, more of a syndrome, really. I think of it in terms of personality traits (which have a big inheritable component) that predispose to depression, upbringing/early life environment that predisposes to a world view compatible with depression and then environmental insults that bring that potential into reality. That doesn't mean that a medical model might not lead to effective treatments for depression, though.<br />
          <br />
          It's worth poining out, however, that there are lots of chronic illness we have no effective treatment for (save a transplantation or something). Similarly we only have three curative drugs - antibiotics, chemotherapy, and immuno-modulators, so it's not like depression is unusual that way.
          I suppose it's all about effective management right? Do you think anti-depressants play much of a role in giving the patient 'breathing space' from the more debilitating manifestations of their depressive disorder so that with therapy and other treatment avenues they can try to negate the destructive personality and environmental factors?<br />
          <br />
          I find mental illness very interesting probably mostly because I know next to nothing about it. Did you think you formed your opinions more as a result of lectures during preclinical med or more on your Psych rotation?
          <blockquote>I suppose it's all about effective management right? Do you think anti-depressants play much of a role in giving the patient 'breathing space' from the more debilitating manifestations of their depressive disorder so that with therapy and other treatment avenues they can try to negate the destructive personality and environmental factors?<br />
          <br />
          I find mental illness very interesting probably mostly because I know next to nothing about it. Did you think you formed your opinions more as a result of lectures during preclinical med or more on your Psych rotation?</blockquote><br />
          <br />
          To be honest, I'm still not sure what I think about anti-depressants. I think they're of very questionable efficacy in mild-moderate depression and severe depression seems to be very persistent despite all treatment modalities, including psychological ones.<br />
          <br />
          My opinions on psych were definitely most well-formed during my psych rotation and, to a lesser extent, in other clinical rotations in which psych will always feature (e.g. vague intolerances in allergy medicine, overdoses in ICU, pain disorders in surgery and gynaecology, behavioural disorders in paediatrics). It's definitely something best appreciated in context.
          <blockquote>To be honest, I'm still not sure what I think about anti-depressants. I think they're of very questionable efficacy in mild-moderate depression and severe depression seems to be very persistent despite all treatment modalities, including psychological ones.</blockquote><br />
          <br />
          Agreed, especially with severe depression.<br />
          Someone I know completely cut out refined, sugary and high fat foods from her diet and it drastically improved her mood.
          <blockquote>To be honest, I'm still not sure what I think about anti-depressants. I think they're of very questionable efficacy in mild-moderate depression and severe depression seems to be very persistent despite all treatment modalities, including psychological ones.</blockquote><br />
          This is reflected in most of the treatment guidelines. In mild/moderate depression, most recommend that guided self help, sleep hygiene, anxiety management techniques and regular exercises all "ought" to come before trialling an antidepressant. Of course what is recommend is not necessarily what is practised. Patients show up to their GP expecting something more than advice, and even though access to psychology services is easier these days, dispensing a script is quick and easy. I suppose in some sense it is similar to situations where someone with a cold presents requesting antibiotics. <br />
          <br />
          However, as Dan Carlat in the second linked book review alludes to, it's more about the money. In the US it isn't financially viable to ignore psychopharmacology given the poor insurance payouts for therapies. It's more or less the same here: Medicare reimburses doctors in Australia is perverse in the sense that clinicians who work with more time consuming, complex patients are rewarded less for their efforts compared to those who churn through high numbers. It's a shame, as part of what makes the discipline of psychiatry unique from other specialities is that it's not really about curing someone, but actually about giving people with mental illness the skills and tools to solve their own problems.
          J
          • J
            JeremiahGreenspoon
          • July 20, 2011
          <blockquote>This is reflected in most of the treatment guidelines. In mild/moderate depression, most recommend that guided self help, sleep hygiene, anxiety management techniques and regular exercises all "ought" to come before trialling an antidepressant. Of course what is recommend is not necessarily what is practised. Patients show up to their GP expecting something more than advice, and even though access to psychology services is easier these days, dispensing a script is quick and easy. I suppose in some sense it is similar to situations where someone with a cold presents requesting antibiotics. <br />
          .</blockquote><br />
          <br />
          For my 2 cents, this is the process I have witnessed in Australia - visit to GP with suspected mild depression during a difficult period, referral to six sessions of (medicare funded) counselling, new visit to GP with potential for another 6 sessions dependent on progress.<br />
          <br />
          In the US, the process was - visit to GP with suspected mild depression during a difficult period, instant script for Prozac. I won't go into the results of it (aside from saying that they were negative), but the point is that anti-depressants weren't ever sought out in either country, and I suspect there is just a different attitude to them in the US medical community to here (or at the very least they are far more normalised).
          They're pretty normalised here. There was a medicare item you could bill as a GP called something like a mental health consultation which reimbursed more than a regular consultation, meaning GPs could take more time with the patient and not feel like they were losing money by doing so but that was scrapped in the last budget, as I understand it. This might mean a time-to-antidepressant-presciption to rival the states.
          J
          • J
            JeremiahGreenspoon
          • July 20, 2011
          I don't know, it's just a feeling, but I feel like there is still some social stigma attached to antidepressants here, whereas in the states it felt as normal as getting a script for antibiotics. There are regular ads on TV, in magazines, and they just seem like the unquestioned best option.
          <blockquote>I don't know, it's just a feeling, but I feel like there is still some social stigma attached to antidepressants here, whereas in the states it felt as normal as getting a script for antibiotics. There are regular ads on TV, in magazines, and they just seem like the unquestioned best option.</blockquote><br />
          <br />
          There's definitely a stigma, and I don't know how it compares in the US, advertising would definitely make a difference so I guess you're right and that is an interesting difference. Very medicalised model.
          <blockquote>They're pretty normalised here. There was a medicare item you could bill as a GP called something like a mental health consultation which reimbursed more than a regular consultation, meaning GPs could take more time with the patient and not feel like they were losing money by doing so but that was scrapped in the last budget, as I understand it. This might mean a time-to-antidepressant-presciption to rival the states.</blockquote><br />
          <br />
          <a href=http://ama.com.au/node/6736>http://ama.com.au/node/6736</a><br />
          More info on the above changes. There's the usual AMA outrage, but some of the comments are telling regarding the standard of these Mental Health Care Plans.<br />
          <br />
          <span style="font-style:italic;">"I have seen numerous examples of 5 to 10 minute Mental Health Plans done by other than the "usual doctor" - often someone seen for a cold at the weekend, or done for patients with very mild distress. The same goes for other care plans."<br />
          <br />
          "Have just spent a prolonged period of time with a patient conscientiously fulfilling in a Mental Health care Plan to have it rejected by Medicare. I then find another GP billed this last week when the mother (visiting for a consultation re her son not even her appointment) mentioned in passing a desire for psychological counselling - he scribbled off a referral letter in a couple of minutes and charged a 2710. She wasn't his regular patient and had no idea whatsoever he had billed a Mental Health Care Plan."<br />
          <br />
          "And the AMA is questioning the PSR role in auditing these rorts! Let's all get real- we can't have it both ways- either do the job properly or risk the item being revamped and downgraded in value which is exactly what has happened."<br />
          <br />
          "I have no problem with a reduction of fees for preparing a mental health plan because honestly many plans are poorly done and do not take any longer than a Level D consult. IF you discuss the quality of plans with the psychologists , you will be surprised by their inadequacy. I often feel I am cheating Medicare to receive $ 163 for under 40 mins work. THis does not mean I do not do a lot of mental health management . To the contrary. THat 's why it doesn't take me long to do a plan because I know most of the history already. Also preparing a Mental Health PLan has only improved access for patients who can afford the gap fees the psychologists charge . The AMA is being too precious about this issue."</span>
          The reimbursement strategy for GPs is so frustrating, I hate how poorly remunerated good GP medicine is and how well remunerated supermarket GP medicine is. I'd be so much more interested in becoming a GP if this weren't the case.<br />
          <br />
          I've discussed exactly this issue with GPs who share the opinion of these comment's author, unfortunately its only one of a number of reimbursement strategies that don't work very well. A shame, because we all know how well placed the GP is to manage community mental health and how well some GPs do in fact manage this issue - but in spite of not because of Medicare.
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