Monday, July 18, 2011

Mental Illness in the USA

I have been consistently surprised by the numbers of people in the USA diagnosed with a mental illness. For example, consider this statement from an excellent review on the apparent epidemic of mental illness in the USA:

The number of people treated for depression tripled in the following ten years, and about 10 percent of Americans over age six now take antidepressants. The increased use of drugs to treat psychosis is even more dramatic. The new generation of antipsychotics, such as Risperdal, Zyprexa, and Seroquel, has replaced cholesterol-lowering agents as the top-selling class of drugs in the US. 
The Epidemic of Mental Illness: Why?, Marcia Angell, The New York Review of Books

Read the link to that statement, the author of the review, Marcia Angell, provides some very interesting information concerning this USA trend. Remember when mental illness was believed to be due to a "chemical imbalance" in the brain? The hypothesis was never proved, was very ad hoc in that it was arrived at by noticing that drugs which helped alleviate mental illness typically affected some important neurotransmitters, particularly dopamine and serotonin. Yet when you consider the complexity of the brain, and the varied way in which these neurotransmitters have roles in the brain, the idea of "chemical imbalance" not only seems quaintly naive and simplistic but downright misleading. It was very misleading but that didn't stop a great many mental health professionals proclaiming that mental illness could be understood by reference to the chemical imbalance hypothesis.

There is a strong tendency amongst some to perceive nervous system function as something divorced from the environment. Our nervous systems are in constant contact with the environment. Accordingly we cannot understand our nervous systems work without reference to the environment. To try and do the same is akin to trying to study aerodynamics on the moon. The chemical imbalance hypothesis was very much about perceiving nervous system as processes operating independently of the environment. On that criterion alone the chemical imbalance hypothesis had to be wrong.

There are now a number of studies, including meta analyses, indicating that the efficacy of anti-depressants for mild to moderate depression is no better than placebo. So now we have a large group of people asserting that anti-depressants are a waste of money. I disagree with that. Statistical analyses are very valuable but I'm inclined to the view that if an anti-depressant is helping an individual, and many people will testify how the happy pills have changed their lives for the  better, then, irrespective of whether the effect is placebo driven or not I am prepared to accept that these drugs have a valuable role in treating depression. I consider it very foolish to tell a person that the effect of the drug is "all in their mind" and they would be better off without it. Anti-depressant drugs generally have a very safe profile and have saved many lives. A problem with statistical analyses is the presumption of over riding commonality in our life experience and physiology. We are much more unique than we often give ourselves credit for, so while a statistical analysis may find no "statistically significant" result for a particular drug, for those people for whom a drug does work, and often wonderfully well, are we justified in demanding cessation of the treatment just because the latest paper says the effect must be placebo or there is no benefit at all?

As noted in the review, Kirsch, one of the authors' whose books are reviewed in this article, asserts that principle benefit might be in the placebo effect. Thus he notes research on "active placebos", drugs that emulate the side effects experienced with anti-depressants. It may seem strange but placebo effects do vary. I have addressed this in a previous post. This is not just about emulating side effects, even the size and colour of the pill we are taking can impact on the placebo effect.

A fascinating aspect of many anti-depressants is that they seem to enhance neurogenesis: the creation of new brain cells. This has been well documented in various animal studies. This is a fascinating issue in itself and I can't do it justice in this post. The nutshell goes like this:

A key region implicated in depression is the hippocampus, which receives new neurons from the nearby structure, the dentate gyrus. Longstanding depression can induce sufficient cell death in the hippocampus leading to measurable atrophy of that region. Recovery from depression can induce recovery of hippocampal volume due to increased neurogenesis in the dentate gyrus. This effect is not unique to humans, studies on other mammals also point to the ability of some antidepressants to stimulate neurogenesis irrespective of whether or not depression is present.  

Having gone through all these twists and turns do I think the current rate of antidepressant use is a problem? Yes, and here is why:

  • The emergence of depression as an epidemic is not going to be solved by placing ever increasing numbers of citizens on anti-depressants. "Soma"(Brave New World), is not a solution. If depression truly has become that widespread then it points to a fundamental problem with the structure of society, not our brains. 
  • Particularly in the USA there is a strong trend to medicate at earlier and earlier ages, with far too many children being placed on antidepressants and this in spite of a lack of sufficient empirical evidence to justify such a strategy. We may very well be creating a generation that becomes overly dependent on happy pills and we have no idea of the long term health implications for children taking these medications. 
  • There are many ways to treat depression but there is far too much reliance on happy pills. Exercise, meditation, enhanced social life, sunlight, thyroid function, immunological balance, regular sleep habits, omega 3-omega 6 balance, tryptophan in the diet(tryptophan is an amino acid that is a precursor for serotonin production)can all be very important in keeping us happy. The current emphasis is preventing a thorough examination of all possible approaches to treating depression. We live in a "go fast" culture and want "go fast" solutions when the very problem could be that we are all going too fast. Given that the USA is a "very fast" culture perhaps we should not be surprised that the USA consumes circa 73% of all antidepressants! 
Should we be aiming to reduce reliance on antidepressants? At a societal and treatment level, most definitely. At the individual level though we need to proceed very cautiously. If you are taking an antidepressant don't stop taking it just because someone has told you it is all down to the placebo effect. That might be true at the statistical level but at the individual level it could also be true that the antidepressant is providing benefit that is not through the placebo effect. For each individual case we cannot know if the effect is placebo or otherwise. It is very important to remember that the placebo effect is NOT "all in your head", there are measurable physiological changes occurring. 

Never stop taking an antidepressant "cold turkey". If you are taking an antidepressant and wish to stop being reliant on the drug you must discuss this with your doctor and simultaneously begin other strategies to help manage your condition. Additionally, if possible, advise a partner or close friend that you have stopped taking the drug so they can monitor your behavior. Depression can creep up on us, indeed many people can be mildly depressed and unaware of it. An honest and astute observer can warn you of changes in your behavior that suggest depression is creeping up on you. 

While I don't see any substantive risk for individuals taking antidepressants I have very real concerns about the increasing use of antipsychotics. These drugs can be particularly dangerous with increasing evidence that these drugs can induce cerebral atrophy. The increasing use of these drugs in children and dementia patients is  without empirical support and is placing these groups at serious risk for dangerous side effects and cognitive decline. I am at a loss to understand why so many clinicians are now prescribing these drugs and believe that in the years to come many psychiatrists are going to be fighting legal battles because of their antipsychotic prescribing habits. 

Psychiatrists are caught between a rock and a hard place. They are often called upon to address conditions that are arising from the environment within which individuals must function. If the increasing incidence of mental illness continues we will be overwhelmed and our mental health strategies will be inadequate (already are!) to help all those suffering from mental illness. We need to take a step back and remember that the brain exists in a body and environment. Our ongoing failure to account for general health issues and environmental contingencies in addressing the challenge of mental health will suck our societies into a consuming vortex that will not only make the lives of mental health sufferers much worse but will have wide ranging implications for society. At the end of the day we need to seriously heed the advice of Nancy Andreasen, former Prof. of Psyhiatry at Harvard. At the end of her entertaining text: Brave New Brain, she writes:


"We simply lack the knowledge to cure society as well as individuals.

Confronting this fact seems especially imperative at this time. Psychiatrists are frequently called on to prescribe quick treatments for a variety of social ills, such as the rising rates of crime and violence. Instead of appealing to the speciality of psychiatry to "fix" violence or reduce general unhappiness, all of us, as members of the human community, need to recognize that the sense of "self" in our post-turn-of-the-century worlds may be in need of repair. There has been a widespread move toward materialism, quick fixes, instant gratification, and a superficial sense of success, which is reinforced by the fast-paced cyberworld that we live in. The answer to our many current social problems must come from individual people, who must reappraise their sense of "self" and reach an appropriate perspective on what constitutes a sound moral compass and meaning in life. The need to search for a personal moral compass to guide our individual lives in the twenty-first century is a need that transcends medical intervention, but which has a very real impact on how we choose to employ medical science and what we expect from it. In the era of the genome, fraught as it is with a variety of crucial moral questions, we must all make an agonizing reappraisal of who we are, what life is, what life means, what we must do to help the other human beings who share our world with us, and what we can do to make it a brave new world."


Mercury said...

You are mistaken that anti-depressants do not pose significant dangers. Do a search for "tardive dysphoria" and other tardive conditions. Opponents of Anti-depressants initially speculated that they may cause chronic severe drug-resistant depression, and there are already signs that this is occurring in people who take these drugs. The proper approach should be to use the drugs at low dose briefly and focus more effort on diet and lifestyle change, and reforming the problems in society, such as stress, insecurity (as in food and housing and medical care), inequality, and others that we know are damaging.

John said...

Hey Mercury,

I have previously read about serotonin syndrome. My understanding it is that is irreversible and rare. That is the least of my concerns regarding antidepressants. Over the last 6 months some data pointing to a possible relationship between autism risk and the use of anti-depressants during pregnancy.

The issues you are raising are well known to me and require a great deal of careful work but the essential problem there is that the powers that be want a medical system that keeps the rats running and only happy to the extent it keeps them running. The British psychologist Oliver James does a good job indicating how modern society is being driven by a model of society that is fundamentally and increasingly at odds with the scientific findings regarding human behavior and welfare. This is a problem not for psychology or psychiatry but for society as a whole but until such time as sufficient numbers of people realise that the greater bulk of people in the advanced countries are just peasants doing the beck and call of those calling the shots none of this will change. Anti-depressants are an example of treating a condition as quickly as possible to the person back to work as quickly as possible when in reality some types of mental disorders have been years in the making and will require at least months in the unmaking but what psychologist or psychiatrist can go down that road when the HMO or govt funded facility simply doesn't countenance a treatment regime that will be optimal for the patient but sub-optimal for the economy?

That's the nutshell, I'm sure you know the rest. Good luck in your endeavours.

Mercury said...

Tardive dysphoria and serotonin syndrome are different ailments, AFAIK. According to this paper, a sizable percent develop treatment-resistant depression (TRD) and healthy controls taking anti-depressants they often become depressed. The risk of depression relapse is also high, even if people are switched around to new drugs. Thanks for the mention of Oliver James - can you please cite his books or papers, which you are alluding to? Thanks.

John said...

I had heard about reports of antidepressants increasing the relapse rate. In a way that doesn't surprise me. My attitude is that for some people the drugs really do help them along but the drugs are not a cure only the start of a process. So after the drugs kick in you need a completely different set of strategies to help the patient. People not using the drugs learn strategies to ward off future depression but because the medical profession treats these drugs as cures they are in fact making many people worse.

People can have one off depressions or the occasional bout, that may simply reflect the vicissitudes of life but sustained depression without any obvious causative factors must require us to question the individual's behavior as a primary cause.

As to the neurobiological side of it, we can just do a lot of hand waving and get nowhere. Just like they did with the hypo-glutamatergic or hyper dopaminergic hypotheses for schizophrenia, or the low serotonin or "chemical imbalance" for depression. I don't doubt that the long term use of powerful psycho-active drugs is doing to induce measurable physical changes. That must happen, but just what those changes mean is a very difficult question.

I recently said to a former psychologist: depression is a subtle form of narcissism. It can be that, our culture promotes the idea that there is this "beautiful life" somewhere. Some believe it is possible even when we read repeated accounts of all the beautiful people being bundled off to rehab, or yet another divorce. We may think that depression is something manifest in the individual but it can also reflect some aspects of our culture.

Mercury said...

Have you read "Selfish Capitalist" by Mr. James? It sounds like what you described. Erich Fromm's "Sane Society" has similar views about society, I think. I have not read it yet, though, just some excerpts.

John said...

Read Selfish Capitalist a few weeks ago. His book Affluenza is better. Yes, drawing on ideas from Erich Fromm. Read many of his texts a long time ago now. Interesting, there are others making similiar calls for change, both from within the mental health professions and outside but the issues involve many areas of culture and life. I'm not sure how we can navigate that maze.

John said...


Thanks for prompting me to look at this again. I had heard about these studies but now looking at them well let's just say the psychiatric community is going to have to think very deeply about its drug addiction problems. The use of psychotropic drugs has become reckless and dangerous, the psychiatric profession needs to take stock of what it is doing.

Here is some of the autism data I mentioned. This is disturbing. When I first heard about these reports, only a few months ago, I surmised that we can expect a rash of law suits coming up.
Psychoactive pharmaceuticals induce fish gene expression profiles associated with human idiopathic autism

Our findings suggest a new potential trigger for idiopathic autism in genetically susceptible individuals involving an overlooked source of environmental contamination.

Full text available at link.

Perinatal antidepressant exposure alters cortical network function in rodents.
These findings indicate that 5-HT homeostasis is required for proper brain maturation and that fetal/infant exposure to SSRIs should be examined in humans, particularly those with developmental dysfunction, such as autism.
Full text available at link.

Drug treatment for mood disorders in pregnancy.

The risk of fetal anomalies associated with early in-utero exposure to antidepressants seems to be increased after paroxetine and clorimipramine exposure, whereas prenatal exposure to nearly all antidepressants is linked to the potential onset of the Prenatal Antidepressant Exposure Syndrome. As regards classic mood stabilizers, the teratogenic risk historically reported with lithium should probably be softened, whereas valproate is the medication which shows the strongest association with fetal anomalies. An increased risk of autism-spectrum disorders and infant neurodevelopmental delay is also associated with valproate exposure through the placenta. No significant reproductive safety data are available on atypical antipsychotics, although such medications may indirectly increase the rate of fetal malformation by inducing gestational diabetes.

Avoiding the use of clorimipramine, paroxetine, valproate, and atypical antipsychotics during pregnancy is advisable. However, when starting or continuing pharmacological treatment during pregnancy, clinicians should consider not only the intrinsic iatrogenic risk of birth defects or perinatal complications, but also the general safety profile for the expectant mother. Indeed, specific adverse reactions (such as nausea, vomiting, constipation, and excessive weight gain) may aggravate the classic clinical findings of pregnancy, thus indirectly facilitating the occurrence of pregnancy complications and fetal and neonatal problems.

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