Sunday, January 31, 2010

In Defense of Antidepressants

Regular readers will know that I have mentioned many times in many prior posts that I have bipolar disorder. Some time ago I reached a conclusion within myself that the best way to counteract the still prominent stigma of mental illness and with it the misinformation based on fear and misunderstanding was to offer myself as a concrete example. I must admit, though, that I never thought I'd need to speak out against anyone or any column that at least concedes that treatment would be necessary, assuming, that is, that it worked. Most resistance I face and most assumptions I refute are mainly a product of people who, as they inevitably put it, don't wish to be a slave to a pill or who think that anyone who has to rely on medication to solve his or her problems must have some deficiency in inner strength, independence, or both.

Begley's article in Newsweek entitled "The Depressing News about Antidepressants" contains much truth, but its underlying assumption that antidepressants aren't worth the risks involved and might be more harm than good only provides more justification for people of such stripes. Fear and unwillingness to seek treatment are the biggest of stumbling blocks to health and the idea that someone whose quality of life is suffering mightily might not reach out and seek a highly available and usually quite effective means of obtaining an otherwise normal life distresses me greatly.

Yes, the drugs are effective, in that they lift depression in most patients. But that benefit is hardly more than what patients get when they, unknowingly and as part of a study, take a dummy pill—a placebo. As more and more scientists who study depression and the drugs that treat it are concluding, that suggests that antidepressants are basically expensive Tic Tacs.

This is an unfair across-the-board characterization of psychotropic medication as a whole. The true problem here is the typically 21st Century liberal sensibility of the back-to-basics, return-to-the earth holistic treatment movement which casts doubts regarding the efficacy of all modern medicine aside from the obviously irrefutable (and sometimes not even then) . A misunderstanding of the basic elements of psychiatry leads many on a series of wild goose chases and frustrating avenues towards health that, in my opinion, could be better resolved through visiting a medical professional. To wit, the brain is a very complex organ, one still frequently beholden to mysteries and theories in place of solid data. Though we might have a good grasp on treating certain diseases, in this instance we only can work with the information and biological advances currently available. This goes for schizophrenia, senile dementia, and migraine headaches.

We have observed recently that though many might clamor for change in the abstract, or as long as it doesn't happen to them personally, the prospect of individual change promises only the unknown. That which we cannot perceive easily is often frightening and distressing, but those who know intuitively that the life they are living is not the one they need while simultaneously recognizing also that they don't have to feel the way that they do, psychotropic medication is a godsend. Sometimes, but rarely, one finds an instant fit with the first drug prescribed, but trial and error is necessary for those who strive for lasting health and stability. I myself have been on twenty-four different meds over the course of roughly fifteen years, and while I take care to note that I have a very severe and very rare case, I am not completely unusual in some respects. I long ago accepted this as the reality of the situation as to all of us who seek to find a balance between illness and health. Finding the proper medication cocktail is a bit like visiting a psychologist. One rarely finds a good fit the first go round, though not always.

Even Kirsch's analysis, however, found that antidepressants are a little more effective than dummy pills—those 1.8 points on the depression scale. Maybe Prozac, Zoloft, Paxil, Celexa, and their cousins do have some non-placebo, chemical benefit. But the small edge of real drugs compared with placebos might not mean what it seems, Kirsch explained to me one evening from his home in Hull. Consider how research on drugs works. Patient volunteers are told they will receive either the drug or a placebo, and that neither they nor the scientists will know who is getting what. Most volunteers hope they get the drug, not the dummy pill. After taking the unknown meds for a while, some volunteers experience side effects. Bingo: a clue they're on the real drug. About 80 percent guess right, and studies show that the worse side effects a patient experiences, the more effective the drug. Patients apparently think, this drug is so strong it's making me vomit and hate sex, so it must be strong enough to lift my depression. In clinical-trial patients who figure out they're receiving the drug and not the inert pill, expectations soar.

As for the clinical trials of varying effectiveness mentioned in the article, I had a much different experience. Beginning in late 2008 into last year I spent nearly six months in-patient at the National Institute of Mental Health (NIMH) in Bethesda, Maryland. I can't say that I ever doubted the antidepressant effect of any or all of the existing trials and protocols that were being performed on site. My reservations mainly were that the process of research was so minutely calibrated and overcautious that psychiatrists and researchers took huge pools of patient data samples before publishing their studies. Individual results were secondary to examining a whole cloud of results and then proceeding warily from there. Often long-term studies ran not just for months, but for years. The focus of each was equally narrow, examining a relatively small number of variables on a very particular desire effect. This makes for safe science and prevents results from being challenged or questioned, but it doesn't exactly advance the discipline and the available scholarship at anything more than a snail's pace.

A particular study I observed as a patient comes to mind. Participants were given the drug ketamine, known to vets as a tranquilizer and anesthetic and a few generations of recreational drug users as Special K. The drug was administered in the form of an IV infusion. The injection was given, mild hallucinatory and/or dissociative side effects subsided after a few minutes, and then almost every patient who underwent the protocol experienced a very pronounced anti-depressant effect. The effect lasted only four or five days in a row, and each day that passed promised less and less of an impact at counteracting depression. Only a single active injection of ketamine was given during the entire study as a whole. The point of the study was to measure how long one treatment achieved its stated purpose, to what degree, and at what point the patient returned to a state of full depression. After the first and only injection that quite clearly wasn't placebo wore off, patients naturally went back to being depressed. Those who felt a pronounced lifting of mood and depressive symptoms knew instantly that the next injection was going to be placebo, regardless of what the nurses or doctors informed them to the contrary.

Those who wish to vent at the pharmaceutical industry for its role in nixing health care reform have a worthy target, but I find more deplorable the means by which it artificially inflates cost of medication, meaning that without insurance, the price of a month's worth of prescription drugs start at the hundreds of dollars and sometimes are priced in the thousands. I myself would have to pay $1000 a month minimum if I didn't have basic coverage and in prior posts I have noted the needless complexities I encountered achieving even that. Certainly it sets prohibitive cost and pushes product, regardless of quality, effectiveness, or grounding in solid research to make money. This is a travesty of the highest order, but I have never in my own life encountered more than a bare minimum of people with mental illness who were not substantially improved by medication, once they found the optimum possible cocktail.

What I have found much more prominently among those with mental illness who have gone off their meds altogether or have only given them a cursory trial is that they couldn't handle the initial side effects or felt discouraged that a single medication either didn't work well, or worked up to a point and then petered out. I am always suspicious of people who push diet regulation or therapy or some combination thereof in place of pills because I can count on one hand the number of people that have adopted that routine and found it wholly sufficient. I have known scores of people who have mental illness over the years because I have been hospitalized at least thirteen times myself, have participated in support groups, and have ended up being curiously inclined to seek company with people who also have mental illness, whether I knew it up front or not. I am a big proponent of therapy in addition to medication because it has helped me out tremendously over the years, but I know that I can never stop taking my meds, ever, for any reason. It is for this reason that when I encounter any article like Ms. Begley's that I feel a compulsion to tell the whole story as I understand it to be.

So, having seen for myself the tedious and sometimes unnecessary safeguards employed, I recognize that much of this delay and frustratingly incremental progress is unavoidable. The existent understanding of brain function and its impact upon mental illness is measured in inches, rather than miles. It is accepted that certain chemicals and neural pathways associated with them determine emotional well-being and mental health, but aside from that, medications have often been developed that use existing treatment regimens to treat disorders, but aim to lessen side effects than try new chemical structures or neurotransmitters. I suppose one could obsess about the unforeseen consequences that daily medication use promises, negative impacts upon the body as a whole that we might not recognize for decades to come, but I'm much more interested in being able to go about my daily tasks unhampered by my disease. Three hundred years ago, after all, the conventional treatment to address physical ailments was bleeding the patient white to release toxins. We laugh now at how primitive and even barbaric a practice that was, but for those who lived in those times, that was all they knew. We can only go with that which we know, and returning to the past or refusing to embrace the newest solutions promises nothing any more or less solid. All of our choices are half-chance, the same as everything else.

1 comment:

PENolan said...

I am also strongly in favor combining talk therapy with medication.

I was only hospitalized once and have been fortunate enough to afford ongoing therapy despite the out of pocket costs. In the hospital I was diagnosed as bi-polar swining from depression to irritability. Through the process, we were able to see that my mood swings were enviromentally triggered (meaning, basically that something or somebody pissed me off) then my neurochemistry changed as opposed to neurochemical changes leading to mood swings.

Without the therapy, we would have never noticed the difference. The meds coated my extreme emotions so that I could look at and deal with them.

Once we figured it out, I could phase off the meds. It's a damn long process and most people cannot afford it - and some folks just don't like to look that closely at their demons.

When the demons come from the chemistry instead of the environment, then you've got to have the meds to function.

I remember when you were in the study. You made a valuable contribution then, and now your experience continues to provide insight.

Well done