Psychiatry's Dirty Little Secret

When I was in medical school, I learned one of psychiatry's dirty little secrets. That is, that of people prescribed an antidepressant to treat their Major Depression, only about 25% enjoy complete resolution of symptoms, another 50% feel some but not complete relief, and the last unfortunate 25% get no relief at all. This was true 15 years ago and remains true today. As a psychiatrist, I prescribe antidepressants, and I have seen these medications improve and even save lives. There is substantial evidence in the scientific literature that certain individuals are genetically predisposed not only to develop Major Depression, but also to respond to certain types of antidepressants. Thus, there is firm basis to believe that certain individuals have specific deficits in their brain chemistries that can cause Major Depression either "out of the blue" or, more commonly, when stressful situations grow and persist beyond one's capacity to deal with them. It is likely that such people are among those that benefit from antidepressant treatments. But what of those that do not respond to antidepressants? I am happy to say that there is a growing recognition among psychiatrists that mere reduction in symptoms must not be the goal of treatment. Rather, remission of symptoms is what our patients deserve, and this should be what we strive to provide all of our patients.

One approach to bringing full remission of symptoms to patients resistant to antidepressants is augmentation of the antidepressant medication. That is, the addition of another psychoactive medication, with a different mechanism of action, to enhance the effect of the antidepressant and resolve symptoms. Studies have shown that such action can help resolve symptoms in a significant number of patients whose symptoms have resisted the effects of single medication. In fact, I was somewhat startled to see a new commercial on television pitching the use of a drug to add if depression persists while taking an antidepressant. Unfortunately, the costs, side effects, and risks of dangerous drug interactions increase with the addition of a second or even third medication. More importantly, we lack information on the physiological basis and necessity for adding medications.

Prudent psychiatrists look beyond psychoactive medications when a patient presents with Major Depression. Often, despondency is the natural response to adversities of life, and counseling, either alone or in combination with an antidepressant, is the best approach to treating a case of depression. It is also often the case that antidepressants are in order, but inadequacies such as low thyroid hormone, vitamin deficiencies, or substance abuse need to be remedied before the medication can provide all of its benefits.

All psychiatrists in training are exposed to the so-called Bio-Psycho-Social model of mental illness, which states that mental health or illness is the product of complex interactions between the brain, ways of seeing the world, and the way people interact with one another. Unfortunately, there has been a tendency to give short shrift to the role that diet plays in the prevention and treatment of Major depression. A new study in the British Journal of Psychiatry has found that people who eat a diet rich in whole grains, fresh fruit, vegetables and fish, have a 26% less chance of developing Major depression than do those who eat diets loaded with fried food, processed meat, refined grains, sugary desserts and high-fat dairy products. Although the latter diet is likely to be deficient in certain vitamins and minerals, the most concerning effect of a diet loaded with sugar and saturated fat is the development of Metabolic Syndrome.

Metabolic Syndrome is defined by the presence of high levels of fat in the form of triglycerides in the blood; low blood levels of the good cholesterol, HDL; high fasting blood sugar; high blood pressure; and abdominal obesity, which many people refer to as a pot-belly or spare tire. Although Metabolic Syndrome is well known to predispose to heart disease and diabetes, the fact that it also predisposes to Major Depression has been underappreciated. Among the ways that Metabolic Syndrome likely increases the risk of depression is by decreasing the sensitivity of insulin in brain tissue; stimulating liver functions that rob the brain of substrate for important neurotransmitters; increasing levels of the stress hormone, cortisol; and increasing blood levels of potentially detrimental substances called adipocytokines that are released in too high a concentration from abdominal fat cells stretched beyond their capacity to maintain normal function.

The reliance on "comfort foods", substance abuse, unwillingness to exercise, poor sleep, and stress seen in Major Depression is suspected of increasing the risk of metabolic Syndrome. However, there is considerable evidence that having Metabolic Syndrome may significantly increase the risk of developing Major Depression. Insulin resistance, thought to be the underlying basis of Metabolic Syndrome, is four times more likely to be seen in people with Major Depression than in those without this condition. The diagnosis of Major Depression in individuals with Diabetes is roughly three times that seen in the general population. Obesity, particularly the abdominal obesity of metabolic syndrome, is also known to increase the risk of Major Depression.

Although the pathophysiology of Metabolic Syndrome is enormously complicated, the means to treat or prevent the syndrome is astonishingly simple. To minimize the risk of Metabolic Syndrome, we must encourage diets low in sugars and saturated fats, exercise, weight control, stress reduction and adequate sleep. Some individuals are genetically predisposed to Major Depression. However, by reducing the incidence of Metabolic Syndrome, the risk of depression will be substantially reduced and the cases of depression that do arise may be more easily treated. The reliance on expensive and potentially dangerous combinations of psychoactive medications to bring relief to patients with treatment-resistant Major Depression may thus be avoided.

Dr. Mendelson is the author of the new book, Beyond Alzheimer's (http://BeyondAlzheimersBook.com).

 

Comments

[JePense]

This is a good article, but unfortunately, psychiatrists do not treat everyone with depression. Frequently the family doctor quickly prescribes an antidepressant without checking thyroid and other possible contributors. If the first pill doesn't work they just prescribe another another.

[SD Mendelson]

In the comments made in response to my article, several themes are apparent. Some do well on an antidepressant. Others noted that trying a different type of antidepressant did the trick. Some swear by neurontin whereas others dismiss it as useless. I have seen some patients helped enormously by neurontin, whereas others found no relief at all. One individual improved with the combination of buspirone and lamotrigine, which points out the need for proper diagnosis, i.e., depression versus bipolar disorder. Another improved with DHEA. Several noted that the omega-3 fatty acids in fish oil help resolve depression in some people. While true, omega3 fatty acids are not the answer for everyone. Finland, a country whose diet is rich in deep sea fish, has one of the highest suicide rates in the world. The final answer is that mental illness is complicated, without a “one size fits all” solution. We must cast a wide net when looking for the source of the problem, and leave no stone unturned when a suffering patient does not receive the relief they seek. Thanks to all of you!
Scott D. Mendelson, M.D., Ph.D.

[ddanimal]

Read "The Antidepressant Fact Book" by Breggin. It will make you think twice about prescribing these poisons to people.

Why is it that practicing psychiatrists almost never prescribe natural therapies like vitamins and nutritional supplements? The science shows that they work. Could it be that psychiatrists are parroting the drug industry marketing they are bombarded with?

[SD Mendelson]

I have not read Dr. Breggin's book on antidepressants. However, I did read his article about atypical antipsychotics that ran in the Huffington Post piece several days ago. It was absolutely riddled with bias, distortion and hyperbole. Antidepressants don't help everyone, and some people can be driven into mania if the prescribing physician doesn't recognize bipolar disorder. Nonetheless, many lives have been improved or even saved by antidepressants. I have seen it many times. Since the recent scare over antidepressants and suicide in adolescents, prescriptions for antidepressants have gone down and suicide rates have gone up! I use many medications, hormones, vitamins, nutraceuticals, dietary changes and lifestyle improvements in my practice. I intend to keep antidepressants in my armamentarium.

[LOCUTUS13]

"Finland, a country whose diet is rich in deep sea fish, has one of the highest suicide rates in the world" could that be in part because of the extreme northern location of Finland? People in Alaska also have a high rate of depression and suicide, see cabin fever.

[dspencer3491]

Antidepressant do help depression but you won't hear too many people talk about the role that lifestyle plays from any mainstream physician. One interesting line of research is the effect that omega 3 fatty acids play in the development of depression and the fact that taking a fish oil supplement with antidepressant makes them more effective. It's for a reason: Depressed people are often deficient. And this is just one thing

[ddanimal]

There are many nutrients that are effective for treating depression:

EPA/DHA
folate
B12
B6
carnitine
chromium
selenium
magnesium
zinc
SEM-e
trimethylglycine and other methyl donors
lecithin
vitamin D

But the first thing that psychiatrists do when they have a depressed patient is write a prescription for a toxic (and profitable) drug.

read "Optimum Nutrition for the Mind" by Patrick Holford

[saami]

Except there are those of us, Scandinavians, who have taken fish oil all of their lives and still have depression. Depression is a biological illness; it isn't just in someones mind. I am sure there are lots of things that contribute to it, but seratonin and dopamine are chemicals in the brain that moderate depression. I am a lucky one who found my depression completely controlled by Lexapro and then when not so suicidal and depressed found that Cognitive Behavior Therapy made it possible for me to take care of the thoughts that still occasionally came up. You can figure out your own triggers and take action. Please know if you are depressed that it isn't your fault and that you can get better with help. Please seek help.

[LittleMittens]

so what is it you are failing to do or be in your life? Depression always comes from somewhere.

[ddanimal]

CNS Neurosci Ther. 2009 Summer;15(­2):128-33. Omega-3 fatty acids in depression: a review of three studies. The first study examined eicosapentaenoic acid (EPA) versus placebo as an adjunct to antidepressant treatment in 20 unipolar patients with recurrent major depression. The second study used omega-3 fatty acids in childhood major depression; 28 children aged 6-12 were randomized to omega-3 fatty acids or placebo as pharmacologic monotherapy. The third study was an open-label add-on trial of EPA in bipolar depression. Twelve bipolar outpatients with depressive symptoms were treated with 1.5-2.0 g/day of EPA for up to 6 months. In the adult unipolar depression study, highly significant benefits were found by week 3 of EPA treatment compared with placebo. In the child study, an analysis of variance (ANOVA) showed highly significant effects of omega-3 on each of the three rating scales. In the bipolar depression study, 8 of the 10 patients who completed at least 1 month of follow-up achieved a 50% or greater reduction in Hamilton depression (Ham-D) scores within 1 month. No significant side effects were reported in any of the studies. Omega-3 fatty acids were shown to be more effective than placebo for depression in both adults and children in small controlled studies and in an open study of bipolar depression.

[zaneblue]

omega-3 fatty acids are the key to all of this

[JayZee]

Last year, I heard some new about my childhood friend who was put on anti-depressants and became addicted to them.Like Rush, she doctor shopped them.Then one day her husband came home from work and found her in the basement where she had stabbed herself 22 times.She was still alive and was medevaced to the hospital.I didn't believe the "stabbed herself 22 times" number, you know how stories gain numbers as they're repeated...but the number was confirmed to me by her nephew.

Just spoke with the nephew again a year later apparently she is now so drugged up that she barely functions.I guess it's a good thing she survived and I'm sure she is kept drugged to prevent having to deal with the fact that she and her addiction to harmful addictive drugs drove the knife into her heart 22 times.

I just want to tell her IT'S NOT HER FAULT.Not the addiction and not the suicide attempt.The side effect of these addictive drugs is suicidal and homicidal MANIA.

So, if you are taking these drugs i hope you have a babysitter 24/7.

[Norge]

Life styles which are "Chosen" helps people avoid the devestation of depressions. And those who are not able to choose where and how to live due to economic factors can improve their daily enviorments and put more joy into their lives by focusing on activities which they enjoy and give them energy and reduce those activities which drain energy from them.

Those with lives where few dreams have been realized and have reached the borders of hopelessness
are in need of drastic life style changes. At times the best one can do for oneself is simply, walk away and start new and more than likely the awful clouds of depression will dissapate to rains and a new and brighter day will arrive.

[balancedsolution]

Most Dr.'s are sheep and listen only to pharmaceutical reps who aren't trained in science.

They are there to look cute, and dispense the latest and greatest drugs.

Unfortunately those latest and greatest drugs don't have time for being tested, so you are the guinea pig.

Try an older drug, with more history.

Look at what happened with Neurontin.

[Whatevah]

My doctor is a terrific human being. She saved my wife's life and has helped me a great deal.

My impression is that the current generation of doctors are smarter, better trained and more compassionate than ever before. They do not deserve the mindless criticism generated by the anti-science crowd.

I also have a very high regard for the scientists who invent new drugs. My mother was saved from a lifetime in psychiatric centers by the inventors of one of the "miracle drugs" of the 1960s. Every single member of my family benefitted from lifesaving medical advances invented during my lifetime.

I think much of the unfounded criticism comes from peddlers of nutritional supplements and other quackery.

[wrender]

Nutritional supplements do not equal quackery. They are just that, nutritional supplements. Our bodies run on energy and nutrition derived from what we eat. Often times, we don't eat properly so a supplement gives us what our food lacks.

[ddanimal]

Doctors who prescribe pharmies all day, without correcting basic and fundamental nutritional deficiencies are quacks.

Doctors know little more than laypeople about diet and nutrition. They dont learn anything about it, and medicine consistently ignores and attacks science that demonstrates the effectiveness of nutrients and diet therapy.

its all because medical school curriculum is designed by the drug companies. And when doctors are practicing, they dont following the science. They get their continuing education from drug reps. This is why most doctors are know-nothings and are unable to treat chronic health conditions.

[Happyexpat]

My depressive illness continued to torture me fo 20 years, even with anti-depre­ssants--un­til Neurontin was added to the mix. For the first time in my life I am least reasonable stable.

[JayZee]

Most patients call Neurontin - Morontin, a quite expensive and successful snake oil!
IMO, Neurontin is utter quakery and placebo.
ya got to start out with 300 mg and build up to 2400 mg's before the desired effect occurs.
Drooling Morontin ka-ching$.

[balancedsolution]

Some pharmaceuticals work to a limited extent.

Patients need to realize they may only get 50% better.

What is sad is that they don't try and improve on medications all that much they just like to adapt an already made medication so they can sell it as new.

I'm not a huge fan of medications, but for some it does good. After surgeries I don't know what i'd do if i didn't have pain medications.

I'm for a system that integrates both medicine, healthy lifestyles, and other therapies in dealing with depression or for that matter any chronic disease.

Don't let big Pharma fool you though in thinking that medication is the only answer.

If you go into a Psychiatrists office, you are 100% sure of coming out with a prescription. Ok maybe 99% sure. There's always 1% who are sensitive enough to know their problems aren't significant enough for these dangerous liver killers.

[whiterussian]

Paid for by your nation's pharmaceutical industry.

[RevRayGreen]

Got Weed ?

[Cassandrawept]

" To minimize the risk of Metabolic Syndrome, we must encourage diets low in sugars and saturated fats,"

That last is key but most people will think it is "pious" health advice.

Your cell walls are entirely made of fats. If you have too many saturated (or partially hydrogenated polyunsaturated= trans fats) the floppy "legs" of these fats pack too tightly and don't let your cells accept enough sugar and insulin. You have about 2000 "rafts" in each cell, who surface, grab a sugar and insulin molecule and then ferry them down to the mitochondria of your cell. When you have too many floppy fat molecules in your cell wall, only about 1000 rafts can operate. Your cell sends out chemical messages that tell your body to make more insulin and keep more sugar in the blood, to try to make up for the deficit. But, because the problem is in the cell wall, you won't get a cure.

If you want a cure you have to replace trans and saturated fats with healthy polyunsaturated fats.

Which means changing your diet. Try six to eight weeks of virtually no red meat or dairy, no transfats and smallish portions of lean pork, chicken and fish. Drop the sodas. Use soybean, safflower, and corn oils to cook and eat.

The change in diet is proven to work in mice in six weeks.

Read this page, written a few years ago....http://www.transfatdisease.com/changes.html

[ddanimal]

Trans and sat fats are very different. Saturated fats are perfectly heathly.

Excess polyunsaturated omega 6 is the problem.

I dont know of any evidence linking sat fats with metabolic syndrome.

[Dice Klay]

before you try anti-depressants try a healthy diet and exercise. Healthy meaning meat with fat, no flour, no sugar, no processed oils of any kind. Don't forget checking for gluten/casein and/or food allergies.

Most people don't ever do this simple change so there's no way to tell what their optimal health truly would be.

[Elizabeth]

Without big pharma, i'd be dead. 20 years ago dead. my children would also be dead.

[ddanimal]

If you think pharmaceuticals are your only option, then you dont know how to eat properly or select the proper nutritional supplements.

[saami]

If you think nutrition and nutritional supplements are the answer, then never have surgery, don't go to the hospital if you are dying of pneumonia and for god's sake do not take an antibiotic even if your life depends on it. You are so off base it isn't even funny. Good luck with that until you get cancer of have a heart attack.

[Cassandrawept]

Don't blame pharma. Pharma didn't give you the physical defect or the propensity to stay in a depressing situation. One or both of which is causing your depression. Anti-depressants aren't cures, they are supposed to alleviate your symptoms until something changes.

Do you really think you get over TB by the virtue of the drugs you take? No, the drugs knock down the TB and give you time so that your immune system can "learn" to kill cells with TB. Some people don't have an immune system that can learn to kill cells with TB. Those people die.

So, why name them anti-depressants. So your doctor can remember what they are used for. Gee!

But more seriously, these drugs are short or long term "remedies" to get you through the hard times. Trial and error helps. Knowing when to quit helps. Learning to live with a life that is less than completely satisfactory is important. People who are completely satisfied have learned to limit their desire.