Strong Reactions to 'Antidepressants Ineffective' Study
"People are completely missing the point of this paper and all the other recent re-investigations, the true social and clinical consequences of them. For example: they're saying antidepressants are no good. Ok. What do you think doctors are going to use instead? Psychoanalysis? Nothing? They're going to prescribe antipsychotics. Are you listening to me? I'm not even saying this is clinically wrong to do, but do you not see the setup?"
Ben Goldacre at Badscience, meanwhile, like some of the commenters here on PsyBlog, pointed out it didn't tell us much we didn't already know. But the real target of Ben's article is the failure to successfully regulate Big Pharma:
"This new study - published, ironically, in an open access journal - tells a fascinating story of buried data, and of our collective failure, as a society, over half a century, to adequately regulate the colossal $550bn pharmaceutical industry."
He also pointed out several errors in the reporting of the study, one of which I made myself by talking about SSRI antidepressants. In fact two of the drugs included were nefazodone and venlafaxine, neither of which are SSRIs. I made the mistake of trusting the 'editor's summary' that is published with the article in PLoS Medicine.
Finally for an international perspective on this story, Furious Seasons points out the near-silence on this study in the US:
"I am stunned that in Seattle--the most depressed city in America--that neither of the daily newspapers ran so much as an AP wire account of the study--at least as far as I know. That's weird. But then the New York Times has been mum to date as well. That's even weirder."
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Labels: Depression
New Study: SSRI Antidepressants 'Clinically Insignificant' For Most People
A new study published today is sure to set off another storm in the ongoing debate about the widespread prescription of antidepressants. Professor Irving Kirsch at the University of Hull and colleagues in the US and Canada report that new generation 'SSRI' antidepressants like Prozac or Seroxat mostly fall, "below the recommended criteria for clinical significance" (Kirsch et al. 2008). In other words, the most modern drugs prescribed for depression generally don't work.
The study was particularly interested in whether the drugs had different effects on people with different levels of depression. Here is what they found:
- Mild depression: not tested as mild depression is usually treated with a 'talk therapy' rather than antidepressants.
- Moderate depression: antidepressants made "virtually no difference".
- Severe depression: antidepressants had a "small and clinically insignificant" effect.
- Most severe depression: antidepressants had a significant clinical benefit - but see below...
Effectiveness limited even for severe depression
When Professor Kirsch and colleagues looked more closely at the data for those who were most severely depressed they uncovered more bad news for drug manufacturers. The antidepressant effect the drugs appeared to have, though small, was largely due to differences in the effects that the placebo had on the control group rather than better response to the drug.
Let's unpack this a little.
The placebo effect means that even when you give someone a 'fake' antidepressant they still improve a little, simply because they expect to. This effect is so powerful and reliable that to be taken seriously drug studies have to compare depressed people taking an antidepressant to a control group taking a placebo.
What Professor Kirsch and colleagues found was that while the placebo effect was present for moderately depressed people, it disappeared for those who were the most severely depressed. This meant that antidepressants weren't having any more effect on those who were more depressed, it's just that in comparison to the control group that's how it appeared. In reality what was happening was that the control group weren't responding to the placebo.
The authors, therefore, conclude that there's no point prescribing SSRI antidepressants to anyone but the most severely depressed people, unless other treatments have been tried and have failed.
Can we believe this study?
So the question is: can we believe the results? Well, the study used data from 47 clinical trials that had been submitted to the US Food and Drugs Administration (FDA). The FDA already has a rigorous set of criteria for including studies, so this suggests only quality studies were included.
The data from all these studies were then combined using a statistical technique called 'meta-analysis'. This means all the studies were collected together and analysed as though they were all one huge study. By doing this you can increase the power of the study significantly.
Like many statistical techniques, though, there is some debate about the use of meta-analyses. For example it is often argued that they lump together studies with different protocols so that effectively you end up comparing apples with oranges. Whether this sort of criticism is valid depends on the study's nitty-gritty details.
High stakes
More broadly, we have to be careful about drawing conclusions from a single piece of work. There's no doubt how high the stakes are for everyone: Professor Irving Kirsch has built a career on showing the power of the placebo effect, pharmaceutical companies have built their fortunes on studies proclaiming the benefits of SSRI antidepressants, while patients are stuck in the middle.
Despite this, the evidence does seem to be mounting up against SSRI antidepressants. Although previous studies seemed to show SSRIs were effective, recent work has suggested this might be due to a bias in the way research is reported (Turner et al., 2008). Studies which show no effect have a tendency to be 'filed' rather than being submitted for publication. This can result in a much more rosy picture being painted of a drug's effectiveness than is really the case.
Either way, considering the number of people worldwide currently taking SSRI antidepressants, we can be sure this isn't the end of the story.
» Read some of the strong reactions to the antidepressant study.
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[Image credit: selva]
References
Kirsch, I., Deacon, B. J., Huedo-Medina, T. B., Scoboria, A., Moore, T. J., & Johnson, B. T. (2008). Initial severity and antidepressant benefits: a meta-analysis of data submitted to the food and drug administration, PLoS Medicine, 5(2), e45 EP
Turner, E. H., Matthews, A. M., Linardatos, E., Tell, R. A., & Rosenthal, R. (2008). Selective publication of antidepressant trials and its influence on apparent efficacy, New England Journal of Medicine, 358(3), 252-260.
Labels: Depression
6 Self-Help Books for Depression Recommended by Experts
There are many, many self-help books for depression around these days, but which ones do experts recommend and which ones work? Liz Anderson from the University of Bristol and colleagues examined the use of self-help books for treating depression (Anderson et al., 2005). They found six books that were recommended by experts, although only one book had evidence for its effectiveness.
1. Feeling Good
This self-help book for depression has been evaluated in a number of randomised controlled trials, although small ones (Anderson et al., 2005). The book itself is rooted in cognitive-behavioural therapy (CBT), currently one of the most successful methods psychologists have for treating depression. Broadly speaking, CBT tries to identify problematic thought processes, then uses mental activities designed to modify them.
Six studies have evaluated the use of this book in treating mild depression and overall they have showed it can be an effective treatment.
2. Control Your Depression
Like 'Feeling Good', this book is also based on cognitive-behavioural therapy. It has been evaluated in two studies, but neither of these found strong evidence for its effectiveness. This doesn't necessarily mean the book isn't useful, just that these studies failed to find an effect. The fact that it has been used in these two studies, however, underlines the fact that experienced clinicians believe it can be beneficial.
3. Mind Over Mood
While this book hasn't been evaluated in any randomised controlled trials, it is frequently recommended by experienced clinicians. Like the two previous books it is also based on cognitive-behavioural therapy and contains a large number of exercises and worksheets (cognitive-behavioural therapists love to dole out homework!)
4. Overcoming Depression and Low Mood: A Five Areas Approach
Again, this one also uses a cognitive-behavioural approach and is also frequently recommended by clinicians, although studies have yet to be carried out into its effectiveness.
5. Climbing out of Depression
Unlike the previous four books, this one isn't based around CBT. Instead it uses a psychodynamic approach. This focuses on understanding, reflection and contemplation. Again there's currently no evidence from randomised controlled trials, but this book is recommended by organisations like the Mental Health Foundation, MIND and the Depression Alliance.
6. Depression: The Way Out of Your Prison
This book falls into the same category as 'Climbing out of Depression', it is based on a psychodynamic approach, hasn't been formally evaluated but is recommended by depression organisations.
CBT or psychodynamic?
One of the main questions when choosing a self-help book is the psychological theory on which it is based. The six books recommended here fall into two categories: CBT and psychodynamic. Some people prefer the hands-on practical activities used in CBT, others prefer the more reflective techniques used in the psychodynamic approach.
Of course, there are books using many other types of approaches to depression, but CBT and the psychodynamic approach are two theories which have a large evidence base for their effectiveness in conventional face-to-face psychotherapy.
Note
Bear in mind that studies on bibliotherapy are at an early stage. The ones that exist have only examined a few of the books available, and generally these books are only for mild depression.
» Discover more articles in this series on the new science of happiness.
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[Image credit: jillhudgins]
References
Anderson, L., Lewis, G., Araya, R., Elgie, R., Harrison, G., Proudfoot, J., et al. (2005). Self-help books for depression: how can practitioners and patients make the right choice. British Journal of General Practice, 55, 387-392.
Labels: Depression, Self-help
Can You Recommend an Online Support Group?
[Image credit: What What]
For some common mental health problems people are good at helping each other without the need for professionals. Research has shown face-to-face support groups can be effective for people with depression, chronic mental illness and bereavement. But for those who can't get to a face-to-face support group, or don't want to, there's another rapidly growing option: online support groups.
Almost one in five Americans over the age of 18 with internet access have become members of online support groups (Pew Internet Research Institute, 2005). While no figures are available for the UK, there could be as many as 8 million members. There are almost certainly many millions more using online support groups around the world.
The problem is finding decent groups - it's not easy to talk about sensitive personal issues with strangers, even given the anonymity provided by the internet.
Because of this I'd like to compile a list of support groups, especially ones that are largely based in the UK or made up of participants in the UK. Perhaps you know of an online support group or are a member or administrator of one?
What type of online support group?
I'm particularly interested in online support groups with the following characteristics:
- Mostly based in the UK or having a large number of UK participants.
- Reasonably well-established or already with plenty of activity.
- Aimed at those suffering from common mental health problems like anxiety, depression and phobias.
- Providing a warm and supportive atmosphere.
- Mostly involving participants (not mental health professionals) giving and receiving help.
Please remember that you don't need to register or reveal your identity to post a comment to this blog. Simply click 'post a comment' below and then 'anonymous' on the next page. If you prefer to email me directly, my email address is here - I will, of course, thoroughly respect your privacy.
One UK based online support group I'm already aware of is Touching Minds. I also know there are many yahoo groups but I'm not sure which ones meet the criteria above.
Alternatively perhaps you know of a good guide to online support groups? All ideas are welcome...
References
Pew Internet Research Institute (2005). A decade of adoption: How the internet has woven itself into American life.
Labels: Depression
Depression Lifted by Beethoven Piano Sonatas
The gigantic annual meeting of the Society for Neuroscience is currently drawing to a close in San Diego, California with a reported 30,000+ neuroscientists in attendance. One study catching the eye of Scientific American reporters is from researchers at Alzahra University in Tehran:
By all accounts depression is not the only condition Iranian researchers have been targeting with the healing power of music. They have also been investigating its use in substance abuse, Alzheimer's, anxiety and strokes.
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...a group of researchers, noting that music therapy has already been shown to reduce pain, improve sleep quality, and improve mood in cancer patients undergoing therapy and multiple sclerosis patients, wondered if music might alleviate depression as well. It does. They took 56 depressed subjects, had them listen to Beethoven's 3d and 5th piano sonatas for 15 minutes twice a week in a clean, otherwise quiet room -- and saw their depression scores on the standard Beck Depression Scale go up significantly. [I'm sure he means down - otherwise their depression is worsening!]
By all accounts depression is not the only condition Iranian researchers have been targeting with the healing power of music. They have also been investigating its use in substance abuse, Alzheimer's, anxiety and strokes.
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Labels: Depression
Barry Schwartz on Why Too Much Choice is Bad for Us
Thanks to Olenka who pointed me to this great talk by Barry Schwartz on why too much choice is bad for us. Too many choices cause:
- Paralysis rather than liberation - people prefer to make no decision rather than make a complicated choice.
- Less satisfaction with decisions as people have greater reason to regret the decisions they have made.
- Unrealistic expectations.
- Self-blame - when experiences are not perfect, people blame themselves.
Schwartz also argues that in modern affluent societies, too much choice may be a significant contributor to depression. He is the author of 'The Paradox of Choice: Why More Is Less
'.» Also check out Dan Gilbert's talk on why we are poor at predicting our future happiness.
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Labels: Decision-making, Depression, Happiness
Why Attempt Suicide? Evidence from the Poetry of Suicidal Poets
[Photo by acme]
Hollywood actor Owen Wilson's recent suicide attempt once more raises the question of what leads people to take their own life. Research into suicidal poets provides some clues.This week it was confirmed that Owen Wilson, the Hollywood actor, attempted suicide. The question 'why?' naturally arises in these circumstances. While people's specific reasons vary greatly, psychologists are, of course, interested in the general factors that lead to suicidal behaviour. Some fascinating evidence about what these general factors are comes from a study on poets, who appear particularly prone to suicide.
The study by Shannon Wiltsey Stirman and James Pennebaker from the University of Pennsylvania, used a text analysis program to examine poetry written over poets' lifetimes (Stirman & Pennebaker, 2001).
They looked at 300 poems written by 20 different poets, half of whom eventually committed suicide. The linguistic features of these poems were then compared with poets who were not suicidal. Suicidal poets whose poetry was analysed included Sylvia Plath and John Berryman. Non-suicidal poets included Robert Lowell and Denise Levertov.
Poems were analysed to look at the specific features of the language to search for evidence for one of two well-known explanatory models of suicide:
- Hopelessness
The more traditional view of suicide is that people enter an extended period of desperation and sadness which leads to a complete breakdown in hope. Once hope is gone, suicide becomes a real possibility.
If this theory is correct it suggests poets would tend to use more words about death in their poetry, and more references to negative emotional states like anger and sadness. - Social disengagement
Another model of suicide is suggested by the eminent French sociologist, Emile Durkheim. Durkheim argued people become suicidal primarily because they become more obsessed with themselves, detached from social relationships and withdrawn from the social world generally.
Fame can, in some ways, hasten these processes. Poets and actors, for example, are encouraged to focus on themselves and become more detached from social reality.
If this theory is correct, suicidal poets should use more references to the self and fewer references to communication with others.
Self-centred poetry, sex and death
Analysis of the poems did provide some limited support for the social disengagement theory. Suicidal poets were more likely to use the first-person singular (I, me, my) than non-suicidal poets.
On the other hand, no support was found for the hopelessness theory as suicidal poets were no more likely to use negative emotion words or talk about death than were the non-suicidal poets.
Having tested their original theories, the authors found that suicidal poets seemed more preoccupied with sex than non-suicidal poets. Indeed there was stronger evidence for a focus on sexual matters than on death itself in the suicidal poets.
Limitations
The authors of the study are the first to admit their research is exploratory - the main problem with it being the small sample size. They did also look for changes in language use over the poets' career but didn't find any results that provided support for either theory.
Self-centred
Despite these limitation, this study is very creative. It provides a useful way of investigating the factors relevant to suicide and how these are manifested in text. It also highlights the fact that a preoccupation with the self and withdrawal from social contact may well be central components in suicidal behaviour.
Perhaps this was a factor in what happened to Owen Wilson. It is certainly ironic that the film he pulled out of as a result of his suicide attempt is Tropic Thunder in which he was due to play a narcissistic Hollywood actor.
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Reference
Stirman, S. W., & Pennebaker, J. W. (2001). Word use in the poetry of suicidal and nonsuicidal poets. Psychosom Med, 63(4), 517-22. (Full text)
Labels: Depression, Suicide
Effectiveness of Mutual Support Groups
In stressful times we can all do with a little help from our friends. Sometimes, though, our friends cannot provide - or we do not want to ask for - the kind of support required. Mutual support groups based around shared topics such as cancer or addictions have grown rapidly to meet this need. But, can mutual support groups really help people recover from mental health problems? A small but growing body of research suggests they can.
Some of the best evidence comes from a randomised comparison of mutual support group with cognitive-behavioural therapy (CBT) (Bright, Baker & Neimeyer, 1999). This study found that mutual support groups were generally just as effective as trained therapists at alleviating moderate levels of depression.
People with serious mental health problems taking part in a mutual support group were examined by Roberts et al. (1999). They found that participants showed improved psychosocial adjustment over the course of the study. Not only this, but those who helped others were more likely to improve themselves. This is a demonstration of the 'helper therapy' principle - the idea that it is therapeutic for us to help others.
A study by Marmar et al. (1988) looked at women suffering from unresolved grief from the death of their husbands. It compared a mutual support group with brief dynamic psychotherapy. The results showed that both of these treatment were similarly effective.
While this is only a sample of some of the published studies, there is certainly good evidence emerging for the effectiveness of mutual support groups. Why is this important? Mutual support groups are generally much cheaper than one-on-one therapy with a trained professional. The fact that outcomes are equivalent suggests they provide a great alternative.
These types of studies are also particularly important as they tend to show how much helping others can be beneficial. We might assume that the benefits of mutual support are in the receiving, but it does seem that giving support is also a healing activity.
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References
Bright, J.I., Baker, K.D., & Neimeyer, R.A. (1999). Professional and paraprofessional group treatments for depression: a comparison of cognitive-behavioral and mutual support interventions. Journal of Consulting and Clinical Psychology, 67(4), 491-501.
Marmar, C.R., Horowitz, M.J., Weiss, D.S., Wilner, N.R., & Kaltreider, N.B. (1988). A controlled trial of brief psychotherapy and mutual-help group treatment of conjugal bereavement. Am J Psychiatry, 145(2), 203-9.
Roberts, L. J., Salem, D., Rappaport, J., Toro, P. A., Luke, D. A., & Seidman, E. (1999). Giving and Receiving Help: Interpersonal Transactions in Mutual-Help Meetings and Psychosocial Adjustment of Members. American Journal of Community Psychology, 27(6), 841-868.
Depression
Some of the best evidence comes from a randomised comparison of mutual support group with cognitive-behavioural therapy (CBT) (Bright, Baker & Neimeyer, 1999). This study found that mutual support groups were generally just as effective as trained therapists at alleviating moderate levels of depression.
Chronic mental illness
People with serious mental health problems taking part in a mutual support group were examined by Roberts et al. (1999). They found that participants showed improved psychosocial adjustment over the course of the study. Not only this, but those who helped others were more likely to improve themselves. This is a demonstration of the 'helper therapy' principle - the idea that it is therapeutic for us to help others.
Bereavement
A study by Marmar et al. (1988) looked at women suffering from unresolved grief from the death of their husbands. It compared a mutual support group with brief dynamic psychotherapy. The results showed that both of these treatment were similarly effective.
Importance of mutual support
While this is only a sample of some of the published studies, there is certainly good evidence emerging for the effectiveness of mutual support groups. Why is this important? Mutual support groups are generally much cheaper than one-on-one therapy with a trained professional. The fact that outcomes are equivalent suggests they provide a great alternative.
These types of studies are also particularly important as they tend to show how much helping others can be beneficial. We might assume that the benefits of mutual support are in the receiving, but it does seem that giving support is also a healing activity.
» If you enjoyed this post, subscribe to PsyBlog (RSS)
References
Bright, J.I., Baker, K.D., & Neimeyer, R.A. (1999). Professional and paraprofessional group treatments for depression: a comparison of cognitive-behavioral and mutual support interventions. Journal of Consulting and Clinical Psychology, 67(4), 491-501.
Marmar, C.R., Horowitz, M.J., Weiss, D.S., Wilner, N.R., & Kaltreider, N.B. (1988). A controlled trial of brief psychotherapy and mutual-help group treatment of conjugal bereavement. Am J Psychiatry, 145(2), 203-9.
Roberts, L. J., Salem, D., Rappaport, J., Toro, P. A., Luke, D. A., & Seidman, E. (1999). Giving and Receiving Help: Interpersonal Transactions in Mutual-Help Meetings and Psychosocial Adjustment of Members. American Journal of Community Psychology, 27(6), 841-868.
Labels: Depression
Happiness is Right Outside
[Photo by Drawings of Light]
Just having a break from work is not enough suggests new research, it is activities in the open air which have the strongest restorative effects on our mental states.Everyone gets down sometimes - it's only natural. It would be more unusual never to be depressed. The idea that depression is an on-off condition with a purely chemical foundation is a myth no psychologist would endorse. The causes of depression can be many and widespread. But one cause many of us have to cope with is work.
One of the main weapons against stress building up from work is going on vacation. Holidays are a firmly established way of allowing the mind and body to recuperate. In new research, however, published in the Journal of Environmental Psychology, Hartig, Catalano and Ong (2007) find that all holidays are not created equal.
Getting out in the open
The lead author of this paper, Terry Hartig, lives and works in Sweden, a country well known for its long, dark winters. As such, the Swedes know the importance of getting out in the sunshine, when it finally arrives. There is even a law requiring employers to provide four consecutive weeks of holiday in the summer. And it's actually this law that is crucial to Hartig et al's findings.Hartig and colleagues suggest that being stuck indoors on vacation can limit mental recuperation. On the other hand, when able to roam outdoors, we can exert ourselves at a favourite sport or simply linger in the park. Psychologically, beautiful scenery can distract us from our troubles, help us forget our normal stressful environments and reconnect us to nature.
This is a nice theory that is intuitively attractive and plausible. The problem is how to test it scientifically.
Anti-depressant prescriptions and the weather
Hartig et al. decided to use the number of SSRI anti-depressants prescribed between 1991 and 1998 as a proxy for the general level of depression in the population of Sweden. They then looked for correlations between the weather and the amount of anti-depressants prescribed, which they duly found.Wait, though, there's a problem with this. Perhaps people are simply happier when the weather is warmer? It would then follow there would be an association between anti-depressant prescriptions and temperature.
Hartig et al. anticipated this problem. They remove the variation in anti-depressant prescriptions associated with the general change in monthly mean temperature from the equation. Then they get a really interesting finding. Now there's only a correlation between temperature and anti-depressant medications in one month: July. There's no similar effect even for the adjacent months of June or August.
How can that be explained? Why would the relationship only occur in July?
Why July is unusual
Here is the authors' reasoning. In Sweden people take most of their holiday in July at the centre of the period stipulated by law (from 1 June to 31 August). A survey found it is over 90%. This means that during July they have the highest likelihood of being free to enjoy outdoor pursuits. On average, the rest of the year they will be working, so even if the weather is unseasonably warm in May, for example, they won't be able to take advantage of it.The reasoning goes, then, that if the weather is bad in July people are stuck indoors. This means they are unable to fully recuperate mentally before returning to work. Alternately, if the weather is good in July people are, on average, mentally rested and have less need for medication.
Remember that this explanation relies on averaging out many people's behaviour across nine years. Obviously not everyone requires anti-depressants to get through a spell of bad weather. Similarly some people require them whatever the weather. But think about it in terms of the people who are slipping across the boundary of requiring/asking for medication. Then the authors' explanation makes sense.
Happiness is...
I know this study falls into the category of telling us something we already know. But it does so in rather an ingenious way that takes advantage of Swedish vacation patterns. Also, we can't be reminded often enough that we should take every opportunity to get out in the open air.Truly, happiness is looking out across fresh fields, gazing at a distant tree, feeling the sun on your back and the wind brushing your skin.
» Discover more on positive psychology.
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References - Click here to toggle visibilityLabels: Depression, Environment, Happiness
Why It's OK To Be Depressed Sometimes
The modern Western mindset has it that depression is an abnormal state. That when you're a bit down, it means you have a medical problem that requires treatment. Of course, this isn't necessarily true. While depression is clearly a major problem for many people that does require treatment of some type, do we all need to be treated every time we are down? More than this, though, if we become depressed, should we consider ourselves in some way abnormal?
What has been called the 'medicalisation' of mental health issues has long been noted by groups like the anti-psychiatrists. Indeed, Adam Curtis' new documentary provides a stark reminder of how modern mental health is driven by numbers. "Check-lists are nothing more than statistically derived descriptions of what is considered 'abnormal'"In creating the manuals relied on by many, but not all, psychiatrists (and psychologists) for diagnosis, the complexity of human thought and emotion has been reduced to a number of check-lists. These check-lists are nothing more than statistically derived descriptions of what is considered 'abnormal' - and therefore normal - human behaviour. By their very nature they make no attempt to understand the person themselves.
Mental illness may have been exaggerated
One of the major architects of this manual for diagnosing mental disorders is Dr Robert Spitzer. Dr Spitzer is interviewed in Adam Curtis' documentary. When asked what he thinks of his creation he admits, looking rather uncomfortable, that the rates of mental disorders have probably been exaggerated. The rate of exaggeration? Dr Spitzer says no one really knows, but it might be 20, 30, even 40%.
Certainly this is a worrying idea, but what worries me more is the effect it has on the way people view themselves and their personal experience. If doctors, a highly respected group in society, adopt certain yardsticks of mental health, it is only natural that these are going to affect the way we all think about our private emotional lives.
Who benefits?
Those with a Machiavellian bent might ask who the medicalisation of depression benefits. Roger Mulder, a psychiatrist in New Zealand suggests that both researchers and clinicians have something to gain from the increased prevalence of depression (Mulder, 2005). Clinicians make more work for themselves while researchers can attract more money to their research. And there's the pharmaceutical industry, but let's not start with them.
"If you continue to tell someone they have a disorder, they soon come to believe it."One group the increasing medicalisation of depression certainly doesn't benefit is those people who previously thought they were 'a little down', and are now labelled with a 'disorder'. If there's one thing that decades of research in psychology has taught us, it's that human beings are extremely susceptible to suggestion. If you continue to tell someone they have a disorder, they soon come to believe it.
Depression across cultures
Perhaps the clearest way to understand the modern Western attitude to depression is to compare it to that in other cultures. Derek Summerfield, a consultant psychiatrist at the Institute of Psychiatry, points out that Westerners tend to view emotion as internal, unintentional, biological and unrelated to cognition (Summerfield, 2006).
"At least non-Western attitudes to depression acknowledge that a situation can be changed." By contrast, a non-Western viewpoint is often characterised by a focus on situational and moral factors. The Western depression-as-disease model has the hallmarks of a condition inescapable without 'treatment'. How can you change your biology or tame emotions apparently arising unbidden from the deep? At least non-Western attitudes to depression acknowledge that a situation can be changed.
It's OK to be depressed sometimes
Ultimately we don't often hear the simple message that it's OK to be depressed sometimes. It's not pleasant, but it's part of being human. It doesn't necessarily mean professional treatment is required.
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ReferencesSummerfield, D. (2006). Depression: epidemic or pseudo-epidemic? Journal of The Royal Society of Medicine, 99(3), 161-162.
Mulder, R. (2005) An epidemic of depression or the medicalisation of unhappiness. New Zealand Family Physician, 32(3), 161-163.
Labels: Depression
Revolutionary Treatment of Depression
It seems incredible that a successful form of psychological therapy could be based on telling people their thoughts are mistaken. And yet that is partly how cognitive therapy works.
Cognitive therapy was originally developed for the treatment of depression. In his work with patients Beck developed the idea that at the heart of depression lay one or more irrational beliefs (Beck, 1963). Here are a few examples:
For many people he treated, and for the many more subsequently treated with his - and related techniques - his methods have turned out to be remarkably effective. It's no exaggeration to state that the ideas and techniques that have flowed from Beck's study and similar findings brought about a revolution in treatment for many psychological disorders.
Find out more about depressive thinking styles.
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Now Vote!
All the nominations for the top ten studies in psychology are now in. It's time for you to vote for your favourite. Which one most captures your imagination? You can recap the runners and riders here, where you can also vote.
Reference
Beck, A. (1963). Thinking And Depression. Archives of General Psychiatry, 14, 324-33.
"The founding father of cognitive therapy is Aaron T. Beck a psychologist not well known to the lay public, but widely revered amongst psychologists."
This type of therapy has easily overtaking Freudian-style psychotherapy in recent decades to become the most popular form of treatment for depression, phobias and many other common psychological problems. The founding father of cognitive therapy is Aaron T. Beck a psychologist not well known to the lay public, but widely revered amongst psychologists. One of his studies is the third nomination for the Top Ten Psychology Studies.Cognitive therapy was originally developed for the treatment of depression. In his work with patients Beck developed the idea that at the heart of depression lay one or more irrational beliefs (Beck, 1963). Here are a few examples:
- Over-generalisation. Drawing general conclusions from a single (usually negative) event. E.g. thinking that failing to be promoted at work means a promotion will never come.
- Minimalisation and Maximisation. Getting things out of perspective: e.g. either grossly underestimating own performance or overestimating the importance of a negative event.
- Dichotomous thinking - Thinking that everything is either very good or very bad so that there are no gray areas. In reality, of course, life is one big gray area.
"Beck thought depressed patients could be helped if therapists could challenge these irrational beliefs."
These irrational beliefs took the form of 'automatic thoughts' which seemed to be accessible to conscious introspection. Beck thought depressed patients could be helped if therapists could challenge these irrational beliefs. At heart cognitive therapy encourages people to see that some of their thoughts are mistaken. By adjusting these thoughts it has been found that people's emotional distress can be lessened.For many people he treated, and for the many more subsequently treated with his - and related techniques - his methods have turned out to be remarkably effective. It's no exaggeration to state that the ideas and techniques that have flowed from Beck's study and similar findings brought about a revolution in treatment for many psychological disorders.
Find out more about depressive thinking styles.
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Now Vote!
All the nominations for the top ten studies in psychology are now in. It's time for you to vote for your favourite. Which one most captures your imagination? You can recap the runners and riders here, where you can also vote.
ReferenceBeck, A. (1963). Thinking And Depression. Archives of General Psychiatry, 14, 324-33.
Labels: Depression, Top Ten Studies
Depressive Thinking
The causes of depression are many and varied. Occasionally the reasons are there for all to see: a loved one has died, for example, or a job has been lost or an important relationship has broken up. More often the cause is mysterious to the casual observer because it is not events that necessarily cause depression, it is the way in which we interpret events.
Psychologists have found that, despite the variability in the causes of depression, there are some fascinating ways in which the thinking of depressed people often follows particular patterns. These patterns can be seen in people's 'attributions'.
An attribution is when a person attaches a particular cause to a particular effect, for example: "I didn't get the job because I am worthless." It might be clear to other people around me that I am not a worthless person but, in my mind, that is the connection, or attribution, I have made. There are three important components to the type of attribution that are implicated in depressive illness. To continue with this example, they are:
- It is my fault that I didn't get the job. Here I have made an internal attribution.
- I think I am worthless: a thought that is likely to affect all areas of my life. Now I am making this attribution global.
- I see no reason for the fact that I am worthless to ever change. Now the attribution is stable.
This particular type of attribution has been shown to be unusual because people who are not depressed generally do the exact opposite. Most people have what is described as a 'self-serving bias'. Anything good that happens to you is because of your skills, is likely to repeated in the future and will remain the same for you.
So, the theory sounds reasonable, what about the practice? I will take a closer look at some of the research soon.
Labels: Depression
Utility of Categorising Mental Illness
Nevertheless, the categories, flawed as they are, do have practical utility. Indeed, the DSM-IV states that no assumption should be made that there are entirely separate categories of mental illness. Similarly it states no assumption should be made that there is a clear dividing line between the sane and the insane. Despite these disclaimers, what is the practical effect of categorisation?
The three most important uses of a classification system are in aetiology, treatment and prognosis; or where the illness has come from, what can be done about it and, what might happen to you. Perhaps the most important of these for the patient is prognosis: "What will happen to me?".
Bentall points out the difficulty of assessing the outcomes of people with a mental illness because they are often variable across different domains. Clinical outcome attempt to measure the persistence of symptoms, occupational outcomes measure the ability to keep a steady job, while social outcomes measure a patient's network of relationships.
Despite this, Bentall reports 3 general findings from the evidence on the outcomes of those diagnosed as psychotic.
- The course of psychosis is unpredictable. The only fairly solid finding is that the occurrence of psychotic episodes seem to increase the probability that they will occur again in the future. This process is known as kindling.
- There is little predictive power for individual patients from a diagnosis. This conclusion comes from the evidence that there is enormous variability in the outcomes of people with the same diagnosis.
- Patients with a diagnosis of manic depression have a better outcome, on average, than those with a diagnosis of schizophrenia. Despite this, evidence has shown there is no sharp delineation between the two diagnoses. Kendell & Brockington's (1980) study showed the difference manifested itself in a sliding scale. The more a person's symptoms were typical of schizophrenia rather than an affective disorder, the poorer was the outcome.
Moving away from the patient and thinking of the utility of these categories for the academic, though, how do the fuzzy categories affect research? At first sight, it seems that having a number of categories of mental illness is a serious advantage in research. Before the standardisation introduced in the 70s by categorisation, researchers in different places used different definitions so it was difficult to compare results and theories. Categories provide a common language - and that can provide synergy through a common understanding.
The problem is, over time, categories become embedded within the collective consciousness. It becomes accepted, whether explicitly or implicitly, that research can only be conducted with reference to, and with the use of, the official categories. This clearly limits the possibilities for progress. Categories that have, theoretically, been found wanting, persist simply because the effort required to change that many minds is too great.
A related and more sociological idea is the effect of categorisation on the individual. There is an element by which once people receive a label, they then define themselves, and are defined by others, in relation to that label. A person suffering from manic depression becomes less a person than 'a manic depressive'. If this category is theoretically flawed, then what does this mean about how those suffering mental illness are being defined by others and defining themselves?
More to come about aetiology and treatment in further posts.
Acknowledgement: This post is based, to a large degree, on ideas put forward by Richard P. Bentall in his book, 'Madness Explained'.Labels: Depression
Classifying Madness: Criticisms and Alternatives
Richard P. Bentall, a clinical psychologist and Professor of Experimental Clinical Psychology at the University of Manchester, recently published 'Madness Explained', an attempt to wrestle descriptions of madness away from rigid categorisation as well as provide an alternative. In this, the first of a series of posts, I will discuss Bentall's criticisms of the major categories of mental illness.
The Categorisation of Madness
Traditional psychiatric practice has placed madness in a number of different categories. Two well-known examples of these categories are bipolar disorder - what used to be called manic depression - and schizophrenia. These categories, along with a host of others, are used by many mental health professionals as both a shorthand description of mental illness, and a guide to treatment.
Reliability and Validity
There are two simple criteria used by scientists to measure, amongst other things, whether a system of diagnosis is useful: these are its reliability and its validity. Reliability refers to whether different doctors give the same diagnosis to the same person with the same symptoms. The validity of a diagnosis is a measure of whether it describes what it is supposed to describe. In other words, if you were a doctor and I told you someone you are about to meet is schizophrenic, then, broadly, you would not be surprised by the symptoms they exhibited.
Bentall argues psychiatric diagnoses are neither particularly reliable, nor particularly valid. Here is why.
Not Reliable
Reliability studies of different classification systems are many and varied. One typical study is that carried out by, amongst others, Robert Spitzer, a strong proponent of the DSM classification system. This study found only modest agreement between specially trained psychiatrists of the same patients - and these results were obtained under ideal conditions, probably not representative of the average busy clinician.
To pick any single study as representative of the whole is not very scientific. Bentall, however, who has evaluated many of them, argues that, in general, the research has been less than convincing. Many studies even fail to reach the minimum statistical criteria for reliability.
Not Valid
While there are 201 different diagnoses in the DSM-IV, arguably the most established distinction in psychiatric classification systems is between schizophrenia and bipolar disorder. To question this distinction is not merely to attack a straw man - the difference is fundamental. Nevertheless the research has seriously questioned whether there is a clear dividing line between the two diagnoses.
Kendell & Gourlay (1970) examined the symptoms of nearly 300 patients with diagnoses of either schizophrenia or manic depression - now referred to as bipolar disorder. If the prevailing system of classification is correct then we should see two distinct groups of symptoms. What the study actually found was a continuum of symptoms, with most patients falling in the middle. They had some symptoms typical of schizophrenia and some typical of manic depression. Subsequent research has provided similar evidence of the poor validity of current systems of classification.
So What?
Why, then, is it important that classification systems are valid and reliable? What are the alternatives? Can madness be cured? All questions for future posts...
Further related discussion on MindHacks.Labels: Depression
Ecopsychology: Nature is Good for Your Mental Health
Ecopsychology is unapologetically New-Agey. According to http://www.ecopsychology.org:
"At its core, ecopsychology suggests that there is a synergistic relation between planetary and personal well being; that the needs of the one are relevant to the other."It's one of these ideas that's difficult to prove, but who cares? I'm happy to take it on trust as, well, what harm can it do? And, perhaps it can help with all that depression knocking about.
The Belfast Telegraph article on Ecopsychology Labels: Depression
SSRI Anti-Depressants May Increase Suicide Risk In Adults
According to this new analysis the chances that the risk of suicide is increased by taking Seroxat is 90%. This is not the sort of probability level that can be ignored.
Related from PsyBlog:
Treating depression chemically
Curb on the happy pills
St John's wort better than Seroxat
The results of the studies are clear enough to understand without the use of statistics. In the placebo group containing 550 patients, one suicide attempt was made while in the group of 916 patients taking Seroxat, seven suicide attempts were made. No attempts were completed.Treating depression chemically
Curb on the happy pills
St John's wort better than Seroxat
These kinds of results are further blows to the most sophisticated anti-depressants yet developed. A spokesman for GlaxoSmithKine, the manufacturers of Seroxat, executed the standard duck and weave:
- Platitude: "We take the safety of all our medicines extremely seriously."
- Cast doubt: "At this stage, it's not clear what method the researchers have used to arrive at these numbers."
- Head in sand: "...these conclusions in no way reflect the picture that has been built up about the benefits and risks of paroxetine in adults..."
"Seventy per cent of those being treated with the new anti-depressants respond well, and the risks of suicide from untreated depression must be borne in mind in balancing the risks and benefits."The question is, how much risk can be borne?
Suicide attempts in clinical trials with paroxetine randomised against placebo[Research report, PDF] Labels: Depression
Psychosurgery: Lobotomy and Deep Brain Stimulation
Lobotomy and Deep Brain Stimulation (DBS) represent the two bookends of psychosurgery's fall and rise. Since the Nobel Prize was won in 1949 for the findings on which the lobotomy was based, it has been mostly downhill for the procedure.More generally, surgical intervention for mental illness - psychosurgeries - have been shunned for some time. But with the advent of DBS, psychosurgery is making a come-back. DBS involves direct electrical stimulation using electrodes implanted in the brain. The procedure has been shown to be very effective in the treatment of severe depression.
In this article in The Guardian, David Beresford describes his experiences of DBS as a treatment for his advanced Parkinson's - for which it is also effective. A welcome side-effect he describes is a substantial lift in mood to the extent that he has experienced bouts of uncontrolled laughter.
The Guardian Radio 4 programme about psychosurgery
Labels: Depression
Eradicating Depression
There is a half-formed mutant meme knocking around that the psychiatrist, Peter Kramer, wants to destroy. This idea seems to have popped up that perhaps we don't want to completely eradicate depression because some of the greatest artists and leaders have been depressives. Would Van Gogh have been able to knock out those masterpieces if he had been on Prozac? Kramer is determined to fight the battle against those who think that depression is not really a proper disease, but somehow part of the human condition.
NY Times Magazine [Free Reg. Req.]Labels: Depression
St John's wort better than Seroxat
"A specially prepared extract of the herb St John's wort is at least as effective in treating depression as the powerful antidepressant drug Seroxat and has fewer side-effects, a study has indicated."For a little more background on St John's wort (left) have a look at the Netdoctor site.
> From The Independent and Netdoctor
Labels: Depression
Treating depression chemically
One reason that depression is so difficult to treat is that it can have a wide range of causes. If, as in most cases, an anti-depressant is prescribed, it is hard to predict exactly how a patient's condition will interact with the drug.
Recently Seroxat's developers GlaxoSmithKline have received considerable bad publicity about the drug's dangerous side effects. The evidence is mounting that it may not be suitable for treating children. Research has found that after taking Seroxat, children can experience an increase in suicidal thoughts.
There is a growing awareness that psychoactive treatments do not make the best default option for treating depression. Unfortunately they represent the easy option and of course make huge profits for the pharmaceutical industry.
> From The Guardian
> From The Observer
> From The London Times (the most medically informed of these articles by Dr Thomas Stuttaford)
Recently Seroxat's developers GlaxoSmithKline have received considerable bad publicity about the drug's dangerous side effects. The evidence is mounting that it may not be suitable for treating children. Research has found that after taking Seroxat, children can experience an increase in suicidal thoughts.
There is a growing awareness that psychoactive treatments do not make the best default option for treating depression. Unfortunately they represent the easy option and of course make huge profits for the pharmaceutical industry.
> From The Guardian
> From The Observer
> From The London Times (the most medically informed of these articles by Dr Thomas Stuttaford)
Labels: Depression