Antidepressants May Be Missing the Mark By Rick Nauert PhD

A new study suggests most antidepressants do not target a key brain protein believed to be of importance in maintaining mood.

The protein is monoamine oxidase A (MAO-A), a substance that is highly elevated during clinical depression. The new study suggests this chemical is unaffected by treatment with commonly used antidepressants.

According to experts, the study has important implications for understanding why antidepressants don’t always work.

Researchers at the Centre for Addiction and Mental Health (CAMH) used an advanced brain imaging method to measure levels of the brain protein MAO-A. MAO-A digests multiple brain chemicals, including serotonin, that help maintain healthy mood.

High MAO-A levels excessively remove these brain chemicals.

Antidepressant medications are the most commonly prescribed treatments in North America, yet 50 percent of people do not respond adequately to antidepressant treatment.

Dr. Jeffrey Meyer, the lead investigator, explains, “Mismatches between treatment and disease are important for understanding why treatments don’t always work. Rather than reversing the problem of MAO-A breaking down several chemicals, most antidepressants only raise serotonin.”

Understanding the Problem of a Persistent Illness

Depression ranks as the fourth leading cause of disability and premature death worldwide, according to the World Health Organization. Recurrent illness is a major problem. Even under the most optimal treatment circumstances, recurrence rates for clinical depression are at least 20 percent over two years.

The new study also focused upon people who had fully recovered from past episodes of clinical depression. Some people who appeared to be in recovery actually had high levels of MAO-A. Those with high levels of MAO-A then had subsequent recurrence of their depressive episodes.

This new idea of high levels of MAO-A lowering brain chemicals (called monoamines), then falling into a clinical depression is consistent with the historical finding that medications which artificially lower monoamines can lead to clinical depression as a side effect.

In the 1950’s some medications to treat high blood pressure also lowered monoamines and people began to experience depressive episodes. When the medications were removed, people recovered.

From Technology to Treatment

VP of Research Dr. Bruce Pollock highlights the study’s use of advanced brain imaging technology. “CAMH has the only positron emission tomography (PET) centre in the world that is dedicated solely to mental health and addiction treatment and research. As a consequence, we were able to develop this new technology to measure MAO-A levels.”

According to Dr. Meyer, “Since most antidepressants miss MAO-A, we are counting on the brain to heal this process of making too much MAO-A, and that doesn’t always happen. The future is to make treatments that tell the brain to make less MAO-A, even after the antidepressant treatment is over, to create better opportunities for sustained recovery.”

Monoamine oxidase inhibitors (MAOIs) are an older class of antidepressants used for the treatment of depression. While more commonly prescribed in Europe and other places, they are not commonly prescribed in the U.S. due to the potential for serious dietary and drug interactions. People who take a MAOI antidepressant must eat a restricted diet to ensure they don’t suffer from serious side effects.

The study is found in the current issue of the Archives of General Psychiatry.

Source: Centre for Addiction and Mental Health

9 Myths of Bipolar Disorder by John M Grohol PsyD

Bipolar disorder has been the focus of attention in recent years, as a new slew of psychiatric medications have been developed to help treat it. Such medications drive pharmaceutical marketing and increased educational efforts surrounding bipolar disorder (for better or worse).

But many myths surround bipolar disorder — what it is, what it means, and how it’s treated. Here’s to busting a few of the most common ones.

1. Bipolar disorder means I’m really “crazy.”

While bipolar disorder is a serious mental disorder, it is no more serious than most other mental disorders. Having a mental disorder doesn’t mean you’re “crazy,” it just means you have a concern that is negatively impacting how you live your life. Left unaddressed, this concern can cause a person significant distress and problems in their relationships and life.

2. Bipolar disorder is a medical disease, just like diabetes.

While some marketing propaganda might simplify bipolar disorder into a medical disease, bipolar disorder is not — according to our knowledge and science at this time — a medical disease. It is a complex disorder (called a mental disorder or mental illness ) that reflects its basis in psychological, social, and biological roots. While it has significant neurobiological and genetic components, it is no more of a pure medical disease than ADHD or any other mental disorder. Treatment of bipolar disorder that focuses solely on its “medical” components often results in failure.

3. Manic depression is different than bipolar disorder.

Manic depression is simply the old name for bipolar disorder. The name was changed to more accurately describe the type of mood disorder it is — someone who experiences swings between two poles of mood (or emotion). Those two poles are mania and depression.

4. I’ll have to be on medications for the rest of my life.

While the default assumption by most mental health professionals is that most people with bipolar disorder will need to be on medications for the rest of your life, nobody can predict how exactly you, as an individual, will react to such medications or what the future holds for your specific needs. So it is a myth to say that all people with bipolar disorder will absolutely be on medications for the rest of their lives. As many people age with this disorder, they find their swings between mania and depression lessen significantly, and the need for medication may decrease, and may even be discontinued without any harmful repercussions.

5. I’m feeling better since taking my medications, which means I probably don’t need them any more, right?

Wrong. Once a person starts feeling better because of the medication, they often discontinue taking the medication, leading to an eventual relapse. This is a common problem in the treatment of bipolar disorder and is something professionals like to call “treatment compliance.” This is just a fancy way of saying that a person needs to continue taking their medication as prescribed, no matter how good they may be feeling. It is perhaps one of the most insidious issues in the treatment of bipolar disorder, and leads many people to greater distress than if they just kept taking their medications.

6. There’s no need for psychotherapy in bipolar disorder.

This varies from person to person (just as the need for taking medications does), but this is a myth insomuch that many people and professionals believe that psychotherapy doesn’t help much in the treatment of bipolar disorder. Psychotherapy can be very helpful and effective in the treatment of bipolar disorder, since medications alone can’t teach a person new coping skills or how to deal with feelings of an impending manic or depressive episode. Psychotherapy can help a person with bipolar disorder learn to live with the disorder in their lives without as much stress or upset. While many people with bipolar disorder forgo psychotherapy, it is usually a helpful treatment to consider when first diagnosed.

7. Atypical antipsychotics are only for schizophrenia.

In the U.S. in 1990, a new class of medications was introduced called “atypical antipsychotics.” These newer medications are not used to treat only psychosis (such as that found in schizophrenia), but also a wider range of psychiatric symptoms. One of their approved uses is in the treatment of bipolar disorder in adults. They may also be approved in short time for use in teenagers and children 10 years and older (although they are already sometimes prescribed by doctors for “off label use” in teens and children). So don’t let the name of the class of medications fool you — they treat far more than just psychosis.

8. Atypical antipsychotics have little to no side effects.

Atypical antipsychotics are often the primary drug doctors use to treat bipolar disorder. In the U.S., the Food and Drug Administration has determined that such drugs are both safe and effective for this use. However, like all medications, atypical antipsychotics have their own set of risks and side effects.

These medications have a different side effect profile than the medications they replace. While initially marketed as a “better” side effect profile, research since 1990 has shown that the side effects they do produce in many people can be just as worrisome as older medications. Chief among the typical side effects are weight gain and metabolism problems, which can be precursors to type 2 diabetes, increased risk of stroke, and heart problems (including an increase in cardiac arrhythmias which can lead to sudden death).

9. I may just have depression.

Many times, bipolar disorder mimics clinical depression, because one of the primary symptoms of bipolar disorder is clinical depression. Up to 25 percent of people who have bipolar disorder are initially misdiagnosed with depression. Why does this occur? Because many people first go to their primary doctor for a diagnosis, and primary doctors do not always ask enough questions to make the proper diagnosis. This can occur with mental health professionals who also fail to probe enough when a person presents with clinical depression in their office.

An incorrect initial diagnosis can lead to incorrect treatment, such as the prescription of antidepressant. Generally, antidepressants are not used in the treatment of bipolar disorder, and in fact, can make the disorder worse in the person. So if you’ve ever had an episode of increased energy for no particular reason (not because you just drank a liter of Coke), make sure you share that information with your mental health professional.

Want to learn more?
Stay up-to-date on the latest bipolar news, research, information and opinions over at our bipolar blog, Bipolar Beat!

Dr. John Grohol is the CEO and founder of Psych Central. He has been writing about online behavior, mental health and psychology issues, and the intersection of technology and psychology since 1992.

Helping Yourself with Depression Help

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If you're currently feeling so out of it, totally out of your normal system and just basically hating and ignoring almost, always everything and anyone that comes along, try to get yourself checked by a psychiatrist because you those little mood swings and erratic Ally McBeal-ish behavior that you're trying to ignore for some long may actually be symptoms of depression. Act fast because if you do, it'll certainly be a lot harder for you to be able to have yourself cured from this illness, especially once self-delusion starts to kick in.

Actually start by hauling your depressed ass into the hospital and get yourself diagnosed by a reputable psychiatrist, one that'll actually help you with your depression concerns, answer all the possible questions that you may have when it comes to depression as well as provide you with the best available to depression treatment that'll make you give yourself some good-old, yet extremly effective depression help. All it needs is the right attitude.

After actually being honest with yourself when it comes to actually being a patient who is suffering from depression, quit turning yourself into a victim and find out from these various types of depression the actual one that you're suffering from: Manic or Bipolar depression - characterized by sudden and extreme changes in one's mood wherein one minute he or she is in an elevated state of euphoria while the next minute (day or week) he or she is feeling to be in a personal hell, Postpartum depression - characterized by a prolonged sadness and a feeling of emptiness by a new mother wherein physical stress during child birth, an uncertain sense of responsibility towards the new born baby can be just some of the possible factors why some new mother go through this, Dysthimia - characterized by a slight similarity with depression, although this time, it's been proven to be a lot less severe, but of course with any case, should be treated immediately, Cyclothemia - characterized by a slight similarity with Manic or Bipolar depression wherein the individual suffering from this mental illness may occasionally suffer from severe changes in one's moods, Seasonal Affective Disorder - characterized by falling in a rut only during specific seasons (i.e. Winter, Spring, Summer or Fall) studies however, prove that more people actually fall in to a rut more during the Winter and Fall seasons and lastly, Mood swings, wherein a person's mood may shift from happy to sad to angry in just a short time. But in spite of how scary or how daunting a task is the road towards a sound mental health is, depression help abounds and is just up to you if you’re willing to take in some of that depression help, may it be from your family, friends, support group and mainly starting from yourself, there really is a lot of depression help to go around.

The old adage, slowly but surely greatly applies in trying to treat depression, as the patient continues taking the prescribed medicines for his/her depression treatment, as well as the corresponding therapy sessions with the cognitive behavior therapist, a patient being treated from depression needs all the support and depression help that he or she can get.

While being treated for depression, the patient as well as his or her family and other loved ones are advised to make realistic goals concerning depression wherein, to not assume that their depression can be easily treated in a snap. Depression help begins with trying to understand the patient’s situation and continue on being patient as well as always extending your help because depression help is never easy nor is the depression treatment itself, which is why both patients and loved ones need to help each other out through every step of the way. Never set goals that are high above your reach, give yourself some depression help by not being too hard on yourself, believe that you are good and strong enough to achieve your goals but only one step at a time.

Timothy Kendrick International

Depression: 5 Steps to Prevent Relaps

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By Elisha Goldstein, Ph.D.

If you’ve struggled with depression in the past, you are likely all-too-familiar with how easy and subtle it might be to slide back into a depressive state. It can sneak up out of nowhere, kick you into auto-pilot and before you know it you feel like you are “back to square one.” When working with depression it is very important to get in touch with our relapse signatures that are the tell tale signs that we are beginning to slide. When I ask people to think of their signatures they say that more negative thoughts begin to visit them, there may be a feeling of wanting to isolate from friends and family, or the phrase “what’s the point” comes up over and over again.

Here is a step-by-step process of increasing awareness of when relapse is happening and what you can do to pre-empt it:

1) Relapse Signatures - Take a moment right now or make a plan to write down some of your relapse signatures just to increase awareness when they’re happening.

2) Breathing Space - When you notice one of these signatures occurring it is going to be important to ground yourself to the present moment so you can increase you chance of making a choice in that moment. Here is where you introduce mindfulness and bring your attention to the breath to anchor yourself to the present moment. Then take a moment to sense into the body to check-in with how you are feeling physically and emotionally.

3) Thoughts are not facts - It is important to remind yourself that thoughts are not facts. We know this because the same event can happen (e.g., a friend walking by us without saying hello) and our interpretation would be different depending on our mood. Therefore, it’s important to remind ourselves that thoughts are not facts, they are mental events in the mind that are temporary and mood dependent. What is a fact is that negative thoughts are circling and however we are feeling physically and emotionally.

4) Take Action - Now that we are grounded to the present moment and have come down from the mental rumination, we want to take action with 2 things that can support us in this moment. That is either an action that brings us pleasure or an action that brings us a sense of mastery or accomplishment. Here you want to make a list with two columns. Column 1 will include actions in your life that you consider to be pleasurable (e.g., having tea with a friend, taking a walk, giving yourself a manicure/pedicure). Column 2 will include those things that give you a sense of accomplishment (e.g., paying the bills, getting exercise, going to the post office). These lists may overlap in some areas, but have the list down so you have access to it and don’t have to think as much when you notice this relapse occurring.

5) A letter of encouragement - Sometimes when relapse is happening, the thought “what’s the point” comes on really fast. When you’re feeling well, write yourself an empathic letter spelling out the importance of engaging in this process. Be kind to yourself in this letter see if you can think of the words that would be supportive and helpful for you to here when in the midst of a slide into relapse.

Remember, this is a process to engage in when you are noticing yourself sliding into relapse and you have not fallen into the depths of depression. See if you can keep your lists and letter in a space that you can remember and have easy access to. Community is also an important aspect of this work, so share this plan with friend so they can gently help point out when they notice relapse signatures. Or look into online communities such as Therese Borchard’s Community at Beyond Blue.

As always, please share your thoughts, stories, and questions below. Your interactions here provide a living wisdom for us all to benefit from.

Elisha Goldstein, Ph.D. is a Clinical Psychologist and conducts a private practice in West Los Angeles. Check out Dr. Goldstein's acclaimed CD's on stress prevention, depression, and addiction -- "They are so relevant, I have marked them as one of my favorites on a handout I give to all new clients" ~ Psychiatrist. If you're wanting an interactive program to find relief from anxiety and stress, check out Dr. Goldstein's progressive online behavioral change program in Aliveworld. If you're wanting to integrate more mindfulness into your daily life, sign up for his Mindful Living Twitter Feed. Dr. Goldstein is also available for private psychotherapy.

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Do Antidepressants Dull Your Emotions? An Interview with Ron Pies, M.D. By Therese J. Borchard

By Therese J. Borchard

Today I have the pleasure of interviewing one of my favorite psychiatrists, Dr. Ron Pies. Dr. Pies is Professor of Psychiatry and Lecturer on Bioethics and Humanities at SUNY Upstate Medical University, Syracuse NY; and Clinical Professor of Psychiatry at Tufts University School of Medicine, Boston. He is the author of “Everything Has Two Handles: The Stoic’s Guide to the Art of Living” and has been a past contributor to the World of Psychology blog.

Question: You’ve written a lot of the topic of grief and depression. How does a person know when grief becomes depression or another mood disorder?

Dr. Pies:

I think it’s important to understand that grief is often a component of clinical depression, so the two are by no means mutually exclusive. For example, a mother may be experiencing intense grief over her recently deceased child, which would be an expectable and quite understandable reaction to such a devastating loss. As I try to explain in my essay on this topic, grief may take one of several “paths”, over longer periods of time. Through a process of mourning; receiving comfort from loved ones; and “working through” the meaning of the loss, most grieving persons are able eventually to move on with their lives. Indeed, many are able to find meaning and spiritual growth in the admittedly painful experience of grieving and mourning. Most such individuals, however, are not crippled or incapacitated by their grief, even when it is very intense.

In contrast, some inviduals who experience what I have called “corrosive” or “unproductive” grief are, in a sense, devoured by their grief, and begin to develop signs and symptoms of a major depressive episode. These individuals may be consumed by guilt or self-loathing–for example, blaming themselves for the death of a loved one, even when there is no logical basis for doing so. They may come to believe that life is not worth living any longer, and contemplate or even attempt suicide. In addition, they may develop bodily signs of a major depression, such as severe weight loss, persistent early morning awakening, and what psychiatrists call “psychomotor slowing”, in which their mental and physical processes become extremely sluggish. Some have likened this to feeling like a “zombie” or like “the living dead.”

Clearly, folks with this kind of picture are no longer in the realm of ordinary or “productive” grief–they are clinically depressed and need professional help. But I would resist the notion that there is always a “bright line” between grief and depression–Nature doesn’t usually provide us with such clear demarcations.

Question: I very much enjoyed your piece on Psych Central, “Having Problems Means Being Alive.” Early in my recovery, I was so afraid to take medication because I thought that it would numb my feelings, keep me from experiencing life’s highs and lows. What would you say to a person who is clinically depressed but afraid to take medication for that very reason?

Dr. Pies: People who are told by a physician that they would benefit from antidepressant medication, or a mood stabilizer, are understandably anxious about possible side effects from these medications. Before addressing the question you raise, though, I think it is important to note–as you may know from your own experience–that depression itself often leads to a blunting of emotional reactivity and an inability to feel the ordinary pleasures and sorrows of life. Many people with severe depression tell their doctors that they feel “nothing”, that they feel “dead” inside, etc. Probably the best description I’ve seen of severe depression is William Styron’s account of his own depression, in his book, “Darkness Visible”:

Death was now a daily presence, blowing over me in cold gusts. Mysteriously and in ways that are totally remote from normal experience, the gray drizzle of horror induced by depression takes on the quality of physical pain…. [the] despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And because no breeze stirs this caldron, because there is no escape from the smothering confinement, it is entirely natural that the victim begins to think ceaselessly of oblivion… In depression the faith in deliverance, in ultimate restoration, is absent…

I present this description to place the question of antidepressant side effects in perspective: how bad could the side effects be, in comparison with severe depression itself?

Nevertheless, you raise a good question. There is, in fact, some clinical evidence that a number of antidepressants that boost the brain chemical serotonin (sometimes referred to as “SSRIs”) may leave some individuals feeling somewhat “flat” emotionally. They may also complain that their sexual energy or drive is reduced, or that their thinking seems a little “fuzzy” or slowed down. These are probably side effects of too much serotonin–perhaps overshooting what would be optimal in the brain. (By the way, in pointing this out, I am not taking the position–sometimes promoted by pharmaceutical companies–that depression is simply a “chemical imbalance”, that can be treated merely by taking a pill! Depression is, of course, much more complicated than that, and has psychological, social, and spiritual dimensions to it).

The sort of emotional “flattening” I have described with SSRIs may occur, in my experience, in perhaps 10-20% of patients who take these medications. Often, they will say something like, “Doctor, I no longer feel that deep, dark gloom I used to feel–but I just feel kind of ‘blah’…like I’m not really reacting much to anything.” When I see this picture, I will sometimes reduce the dose of the SSRI, or change to a different type of antidepressant that affects different brain chemicals–for example, the antidepressant bupropion rarely causes this side effect (though it has other side effects). Occasionally, I may add a medication to compensate for the SSRI’s “blunting” effect.

Incidentally, for individuals with bipolar disorder, antidepressants may sometimes do more harm than good, and a “mood stabilizer” such as lithium is the preferred treatment. Careful diagnosis is needed to make the correct “call”, as my colleague Dr. Nassir Ghaemi has shown [see, for example, Ghaemi et al, J Psychiatr Pract. 2001 Sep;7(5):287-97].

Studies of patients with bipolar disorder who have taken lithium generally suggest that it does not interfere with normal, everyday “ups and downs”, nor does it appear to reduce artistic creativity. On the contrary, many such individuals will affirm that they were able to become more productive and creative after their severe mood swings were brought under control.

I do want to emphasize that most patients who take antidepressant medication under careful medical supervision do not wind up feeling “flat” or unable to experience life’s normal ups and downs. Rather, they find that–in contrast to their periods of severe depression–they are able to enjoy life again, with all its joys and sorrows. (Some good descriptions of this may be found in my colleague, Dr. Richard Berlin’s book, “Poets on Prozac”).

Of course, we have not dealt with the importance of having a strong “therapeutic alliance” with a mental health professional, or the benefits of “talk therapy”, pastoral counseling, and other non-pharmacological approaches. I virtually never recommend that a depressed patient simply take an antidepressant–that is often a recipe for disaster, since it assumes that the person will not require counseling, support, guidance, and wisdom, all of which ought to be part of the recovery process. As I often say, “Medication is just a bridge between feeling awful and feeling better. You still need to move your legs and walk across that bridge!”

Therese J. Borchard writes the daily Beliefnet.com blog Beyond Blue (voted by Psych Central as one of the Top 10 Depression Blogs) and moderates Group Beyond Blue, the Beliefnet Community online support group for depression. Her memoir “Beyond Blue: Surviving Depression & Anxiety and Making the Most of Bad Genes” will be released in January of 2010. Subscribe to Beyond Blue here or visit her at www.ThereseBorchard.com.