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Health News: Depression Special
June 8, 2001
In most developed countries (including Japan) clinical depression affects about 25% of the population and is markedly higher in women than in men. Although much research has been done into the causes and possible cures of depression there are still many myths that, though they have been shown to be false, are still ardently believed both by the public and by many members of the medical and psychotherapeutic professions.
In this special edition we present some of the findings that have been written-up in academic publications. You will read research proving that antidepressants don't work: that it is depression which makes heart disease the number one killer; that day-care may lead to depression and that confusion and stress over women's roles are the real cause of the higher incidence of depression among women.
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Why Women Are More Depressed
Psychiatrists have usually given several reasons for the fact that the rate of depressive illness among women is twice that of men: it's due to hormonal differences between the sexes; it's because depression is under-reported in men, or it's because men develop other problems in reaction to crisis events (e.g. alcoholism).
Dr James Y. Nazroo, of the University College, London, set out to see whether any of these assumptions was, in fact true. His, and his colleagues', findings, published in Psychiatric Times, may well cause the textbooks on depressive illness to be rewritten.
First they looked at the question of reporting. It has been suggested that as women are generally more likely to seek help for emotional problems than men, this would skew the statistics. Further, since the statistics don't take into account the differences between really serious depression and milder forms, women would seek help more frequently for conditions which men would struggle through.
Contrary to the prevailing wisdom, they found that, if anything, the size of the gender difference in depression increased, rather than decreased, with the seriousness of the condition. According to Dr Nazroo, "This suggests that the gender difference was neither a consequence of using too low a threshold of the illness nor of using an average score that emphasized women's hypothesized greater reporting of milder symptom states." In other words there really is more depression among woman than men.
Another common assumption is that gender differences in depression rates may be the result of men developing alternative disorders in response to stress, such as antisocial behavior and alcohol abuse. In particular, women may be more likely to have been socialized to express depression in response to stress and men may be more likely to have been socialized to express anger or other forms of acting out. However the study tended to disprove this assumption as well. The rate of alcoholism was found to be the same in both sexes. Furthermore, it did not appear that the gender differences in depression were the result of men being more likely to externalize their anger. If anything, women reported both feeling and expressing more anger in response to the crises they experienced.
The most important thing that the research uncovered was that women's roles are the deciding factor. Women in the study were 80% more likely to develop depressive symptoms when a crisis occurred in one of the areas of life in which they traditionally play a dominant role than at any other time. Examples of these roles included: child rearing, reproduction and household management. In the areas in which men traditionally dominate, such as finances or work, there was no difference in the rate of depression. In other words, the more stressful it became to adhere to the traditional roles (because of the pressures of work, the lack of support and so forth) the more depressed women became.
They found also that any biological differences which might lead women to be more depressed were heightened by role conflicts within the household. If a woman is enabled to satisfactorily carry out her role, woman's biology is not an issue in depression.
We have said for a long time that, in a large measure, depression is the result of what we call the 'mismatch' between how our society is and the society we evolved to live in (i.e. that of the traditional hunter-gatherer). One of the most important features of a hunter-gatherer society is that the gender roles within it are fixed. In most hunter-gatherer societies clinical depression is unknown. BM
Read more
in the Psychiatric Times
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Official: Childhood Trauma Does Cause Depression
The nature/nurture cause of depression debate has been fought out in academia for a long time. Recently, at least before the publication of the full Human Genome Project results, the biological determinists seemed to be getting the upper hand. Now the other side is having it's say.
The case for nurture was put recently by Professor Charles Nemeroff of the department of psychiatry at Emory University School of Medicine in a lecture called "The Persistent Neurobiological Consequences of Early Untoward Life Events: Treatment Implications." In the world of psychiatry, the very title was controversial.
Professor Nemeroff's thesis is that childhood trauma alters brain chemistry in a very fundamental way. In neurobiological terms he believes that "the hypersecretion of corticotropin-releasing factor (CRF) may be one of the primary causal factors in the pathophysiology of depression. Many, if not most, depressed patients hypersecrete CRF, which, at the pituitary, is responsible for the endocrinopathy of depression and, in the brain, is responsible for many of the signs and symptoms of depression." Most important, Nemeroff is convinced that early childhood neglect and/or abuse, particularly in the presence of a genetic susceptibility, permanently alters CRF neurons, resulting in hyperactivity (ADD/ADHD) and depression.
How does childhood trauma, which many studies have linked to an increased risk for depression later in life, actually result in CRF neuronal abnormalities?
" Our hypothesis is that if you are traumatized early in life, provided that you have a genetic predisposition, there is some kind of plasticity-associated increase in CRF neuronal activity; either you have more neurons expressing CRF than do people who haven't been traumatized or their CRF neurons are more active," explained Nemeroff.
To study the link between early experience and CRF neuronal activity, Nemeroff needed to create an animal model of early childhood neglect and abuse. In collaboration with Paul M. Plotsky, PhD, professor of psychiatry and behavioral sciences and associate professor of biology and psychology at Emory University, and Michael Meaney, PhD, McGill University, Nemeroff chose to work with the hooded rat. " The hooded rat mother is very attentive; she takes very good care of her pups," Nemeroff explained. By interfering even subtly with this caretaking, could the Emory reasearchers simulate dysfunctional human parenting?
Between days 2 and 14 of life, the researchers randomly took some of the rat pups away from their mother at different times of the day. Then, after an accumulated time of three hours of separation, they returned the pups to the mother. The separated pups were kept as a group in a pediatric incubator. When the pups were returned to the mother, both pups and mother hypersecreted cortisol, an indication of stress, and the rat mother treated the separated pups differently. She waited longer before returning a straying pup to the nest; she allowed these pups to nurse only after all of their littermates finished nursing. Occasionally, she would even trample a separated pup in the cage. The separated pups grew in a fashion identical with that of their littermates, entered the colony normally at 21 days, and reached full maturity at 90 days when they were removed for study. The researchers subjected the mature rats to a psychological stressor that rats ordinarily find startling but not noxious: a puff of air blown in the face. When the Emory team compared the hormonal responses of the maternally deprived animals versus the normal controls, they were, according to Nemeroff, "just taken aback." By placing a catheter in the vessels between the brain and the pituitary, Plotsky was able to measure an increase in CRF secretion. In addition, CRF gene expression, measured using an in situ hybridization technique, was increased two-and-a-half-fold in these animals compared to the controls.
"They make more CRF, and there's a marked increase in the amount of CRF in the hypothalamus," said Nemeroff. The locus coeruleus also showed a marked increase in CRF levels. (The locus coeruleus is the site in the brain that provides 70% of the norepinephrine to the forebrain, and norepinephrine is involved in the pathophysiology of mood and affective disorders.) Increases in CRF levels were also found in the central nucleus of the amygdala (a structure known to control affective regulation) and the extended amygdala. CRF concentrations in the rats' CSF were also significantly higher.
How closely does this research carry over to human beings? "In some respects these rats look a lot like depressed people," he said. They were off their food, their reaction times were much slower and so forth. (Maybe the rats' reactions to systematic separation from the mother is a clue to the problems we noted in a previous Health News Archive story,
"Day-care Leads to Agression" concerning the problems children have in day care. AF)
We have been strong advocates of the link between childhood abuse and depression for a long time (see our article on Post Traumatic Stress Disorder: "PTSD& Childhood Trauma"). This research bears out what we have been saying: depression and disorders such as ADHD and post-traumatic stress disorder (PTSD) have their roots in the childhood environment. BM
Read more in the Psychiatric Times
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Depression Runs in Families
A study reported in the Journal of American Psychiatry reports that parents suffering from panic disorder, major depression or both are more likely to have children with certain types of disorders. Lead author Joseph Biederman, a psychiatrist at Massachusetts General Hospital, says that knowing this may help clinicians treating adults identify children at risk for psychiatric and behavioral problems.
Parental depression was linked with increased risks for social phobia, major depression, disruptive behavior disorders and poorer social functioning among children. And parental panic and depressive disorders were associated with increased risks for separation anxiety disorder and multiple anxiety disorders in children. "The presence of depression in families," Biederman concludes, "has quite a major impact in the offspring."
Read more in the Scientific American
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Depression And Loneliness Related To Problem Drinking
Depression, loneliness and coping mechanisms are significantly related to problem drinking for both men and women, according to new research published in Psychology of Addictive Behaviors, published by the American Psychological Association.
The study reviewed data from the Niagara Young Adult Health Study for two groups of people: a younger group, men and women with a mean age of 21.93 years; and an older group, men and women with a mean age of 30.69 years.
The research team looked at the interplay between coping, loneliness and depression and problem drinking behaviors in both groups. Problem drinking behavior was defined as binge drinking, tossing down drinks and frequency of intoxication. Depression and coping style were found to be the strongest predictors of problem drinking behaviors.
The association between coping, loneliness and depression and problem drinking tended to be the same for both genders, with the single exception that in the group of younger study participants, lonely women tended to drink to intoxication more frequently than did lonely men.
While men and women were about equally likely to engage in problem drinking, differences were found in the patterns of problem drinking when comparing the younger study group to the older study group. In the younger group, higher levels of depression were significantly related to increases in the frequency of intoxication and binge drinking, while using an avoidance coping style was predictive of drink tossing.
In contrast, the older study participants did little binge drinking, but among this group, coping by seeking support or avoidance predicted increased frequency of intoxication, while depression was associated with increased drink tossing.
The authors suggest that their findings raise an important question for further research: are the differences in predictors of problem drinking in younger versus older adults a result of different social contexts in which they live, or are there developmental differences between the age groups?
Read more in Uniscience
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Depression and Illness
A couple of years ago a University of Colorado study showed that up to 80% of all people who visit a physician were suffering from depression. At the time the findings were not taken all that seriously by a medical profession (including psychiatrists) more concerned with pushing out drugs and cutting down on patient time than anything else. Things are changing.
An example of how quickly can be seen from an article in Psychiatric Times. The authors say that evidence is accumulating that failure to address depression can impede medical treatment and increase the death rate from medical treatments.
"I'm not sure that people — meaning consumers, mental health professionals and non-mental health professionals — realize what the numbers are," David Kupfer, MD, explained in an interview with Psychiatric Times. "They're epidemic and scary. We're not talking about feeling somewhat down and mildly dysphoric, we're talking about major depression."
Kupfer, chair of the University of Pittsburgh department of psychiatry, recently moderated a conference titled "The Unwanted Co-Traveller: Depression's Toll on Other Illnesses." Sponsored by the National Institute of Mental Health, the conference featured specialists in cardiovascular disease, cancer, diabetes, HIV/AIDS, Parkinson's disease (PD) and other neurological diseases. Psychiatrists and primary care physicians "can learn a lot from each other," Kupfer continued. He believes that depression frequently is undertreated in patients who also have medical illness because of the mistaken belief that depression is a normal response to illness, particularly in the case of elderly patients. In fact, major depression does not occur in the majority of patients with other medical illnesses. However, when it does, neurovegetative symptoms associated with depression (slowing down mentally and physically) can substantially interfere with patients' ability to follow through with treatment recommendations.
Recent studies have shown that one-fifth of all patients with heart problems suffer from depression, and that depression can be a precursor to cardiac illness.
Canadian researchers found that the significantly higher risk of death from cardiac disease at the one-year mark among depressed patients was largely independent of the severity of cardiac disease. Equally, if not more, concerning are recent findings indicating that depression can actually foreshadow the development of heart disease. "Depression is a chronic illness and contributes to chronic stress," says Lawson Wulsin, MD, coordinator of the family medicine and psychiatry residency training program at the University of Cincinnati, "We know that stress is taxing to the cardiovascular system in particular, because it can increase blood pressure, decrease heart rate variability and may suppress immune function in subtle ways that contribute to inflammatory processes, and cardiovascular disease is an inflammatory disease."
"In addition, higher smoking rates among depressed individuals put them at higher risk of developing heart disease," said Wulsin.
Strokes are also strongly linked to depression. An estimated 10% to 27% of American stroke patients experience major depression each year. That translates to between 60,000 and 162,000 people, three-quarters of whom are over the age of 65. An additional 15% to 40% will suffer depressive symptoms within two months of suffering a stroke.
Researchers have discovered that untreated depression in this population can seriously impede patients' chances of recovery. A growing body of research strongly indicates that depression in stroke patients leads to poorer outcomes, both in cognitive functioning and in the recovery of the ability to perform activities of daily living
"Patients tend to report that they're depressed because they've had a stroke," Robert Robinson, MD, head of the psychiatry department at the University of Iowa College of Medicine, explained to PT. "Physicians in those circumstances will often just regard it as an understandable, reactive depression and not realize what a profound effect this depression has on the patients' recovery and survival."
The connection between depression and Parkinson's disease has also been the subject of a lot of recent research. As many as two out of three Americans afflicted with Parkinson's disease (PD) may suffer from depression. While common in this population, depression can be hard to diagnose because some PD symptoms (such as the slowing down of movement and thought, appetite disturbance and lack of emotional expressiveness) can mimic it. Depressed patients with PD have higher rates of anxiety and are more likely to experience sadness without guilt or self-blame than depressed patients who do not have the disease. Looking at phenomena such as sleep disturbance — a chronic problem in PD patients — in conjunction with feelings of hopelessness, worthlessness, and suicidal thoughts is a better way to assess depression in this population, according to William McDonald, MD, professor of psychiatry and behavioral science at Emory University and director of the Fuqua Center for Late-Life Depression.
Other diseases in which depression is a major factor include osteoporosis and various kinds of cancer. For 10 years we have been advising the medical profession to look at depression as a systemic problem affecting the whole body/mind. A recent survey of British doctors (and we assume US and Australian doctors are no different) found that over 50% of them were ignorant of the symptoms of depression — and this included those who were proscribing antidepressants! BM
Read more in the Psychiatric Times
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Myths of Depression Challenged
Several years ago separate studies by researchers at the Universities of Connecticut and London rocked the psychiatric establishment. They showed that most antidepressants were no more effective in treating depression than placebos and that the curative factor in these medicines was the relationship between the prescribing physician and the patient (psychiatrists are notoriously bad at relationships — BM).
Now a small but growing number of members of that psychiatric establishment, at least in the US, are beginning to take notice of the research. To put their present ideas into a nutshell, these investigators propose that:
- Antidepressant drug effects may be far smaller than previously assumed.
- There is no persuasive or consistent evidence that a deficiency of brain serotonin causes depression or that an increase in brain serotonin relieves depression.
- Powerful financial and political interests may bias current research and medical education.
- Psychotherapy appears to be as effective as antidepressants in treating acute episodes of depression, even if severe, and is better at preventing relapse.
This amounts to a revolution in the way we look at depression, and calls into question the standard treatments for it. Starting with antidepressants: although a large body of evidence appears to support the efficacy of antidepressants, new studies indicate that the true antidepressant drug effect in adults may be much smaller than previously believed. Recent studies suggest that inactive placebos (placebos without side effects) are approximately 75% as effective as antidepressant medications in nearly all published outcome studies. In fact, when antidepressants are compared with active placebos, there appears to be no differences in clinical effectiveness. These studies suggest that antidepressants may be better than placebos primarily because the presence or absence of side effects tips off patients as to whether they are receiving drugs or placebos. Patients who realize they are receiving active drugs may feel encouraged, while those who realize they are on inactive medication may feel discouraged. Thus, outcome differences attributed to antidepressant medications may actually result in part from the impact of side effects on patients' feelings of hope.
Dosage levels of the selective serotonin reuptake inhibitors have been minimally related to treatment outcome, if at all. Real drug effects are usually associated with dose-response effects. For example, several alcoholic drinks are far more intoxicating than one.The lack of a dose-response effect raises suspicions that the SSRIs (and other antidepressants as well) may have no true antidepressant effects other than their placebo effects. This is another point that the Connecticut and London studies stressed. Of course many practising psychiatrists strongly disagree with these findings.
Still other studies are confirming the earlier findings that it is the doctor/patient relationship which is the curative agent, and that this is true of psychotherapy as well. In other words it doesn't matter what drug is administered or what form of psychotherapy is used, it is the relationship that is all-important.
Is there evidence that antidepressants correct a serotonin deficiency? Researchers David Antonuccio, PhD, professor of psychiatry and behavioral sciences at the University of Nevada School of Medicine and staff psychologist at the Reno Veterans Affairs Medical Center, David Burns, MD, clinical associate professor of psychiatry and behavioral sciences at the Stanford University School of Medicine, William Danton, PhD, associate professor of psychiatry and behavioral sciences at the University of Nevada School of Medicine and associate chief of staff for mental health at the RenoVA Medical Center and William O'Donohue, PhD, Nicholas Cummings Professor of Organized Behavioral Healthcare Delivery at the University of Nevada Psychology Department are adamant that they do not, and that serotonin deficiency may not be the problem at all.
Depression, they claim, in an article in Psychiatric Times, appears to be a total body disorder, and nearly any chemical measured in the brain or peripheral nervous system (or any body system, for that matter) has a good chance of being abnormally high or low in a severely depressed or manic individual. Of course, correlation is not the same as causality. A hyperactive manic patient will nearly always have a rapid heart rate, but it doesn't follow that a rapid heart rate causes the mania. They claim there is no consistent or persuasive evidence that an abnormality of brain serotonin levels or receptors plays any causal role in depression or any other psychiatric problem.
Antidepressant treatments based on the serotonin deficiency theory have not led to superior treatment (so much for "Listening to Prozac!" BM). The new highly selective antidepressants do not appear to be any more effective than the older tricyclic drugs. Although changes in brain serotonin occur immediately after taking these drugs, improvements in the patient's mood typically do not occur for several weeks. Biological markers specific for depression have been elusive.
Although a physician may tell a patient that a chemical imbalance causes their depression, researchers have pointed out that the physician would be hard-pressed to provide any evidence to support this claim. There is no test available that would demonstrate that any patient has a biological depression, as opposed to any other type, or even that such biological depressions exist.
Antidepressants are used to treat a wide spectrum of psychiatric and nonpsychiatric disorders including depression, anxiety disorders, chronic pain, tobacco dependence, eating disorders, anger and aggression, and so forth. The nonspecificity of clinical effects suggests that these compounds may not really be true antidepressants.
Proponents claim that some of the antidepressants selectively affect only one system of the brain (such as the brain serotonin system), however this does not reflect current understanding of how the brain works. We know that each brain neuron receives input from tens of thousands of other neurons and, in turn, sends output to tens of thousands of other neurons. Therefore, any chemical or electrical perturbation with a strong selective effect on one neuronal system would be expected to have almost instantaneous impact on large numbers of other neuronal and chemical systems throughout the brain.
The authors of this study claim that it is unlikely that the SSRIs only effect the serotonin systems in the brain, even initially. There are hundreds, probably thousands, of chemical systems and transmitter substances throughout the brain. The direct and indirect effects of the current antidepressants on most of these substances have never been examined. They are not arguing that there are no biological factors in depression, just that the biological theories about the causality of depression have not yet been proven. Of course, all thoughts, feelings and behaviors are created by the brain and have a biological underpinning. In their view, physicians do patients a disservice when unproven theories of causation are promoted as facts.
The researchers are none too pleased with the drug companies' claims of clinical success in trials of their drugs. They ask if the current testing methods for antidepressants are scientifically biased. The researchers claim that recent studies raise serious questions about the integrity of the double-blind study protocol. The fact that active drugs have side-effects while placebos do not may allow the blind to be penetrated by patients and their clinicians as well as the researchers who rate their progress. They believe that no study should be called double-blind unless the blind has been tested. Although it is rarely done, they claim that this can be accomplished simply by asking patients and clinicians to guess the treatment method. Studies indicate that the blind appears to be penetrated over 80% of the time. As many as 75% or more of patients are typically able to guess their treatment method accurately.
The researchers' final stab at orthodoxy comes when they claim that all the studies show that psychotherapy is just as effective at dealing with brain chemistry as antidepressants and is less liable to severe relapses that happen when the pharmacological approach is the only one used.
They conclude that "because of it's comparable efficacy and a benign medical profile, psychotherapy may be considered an aggressive first-line treatment for depression."
Most of what the researchers are saying here echos what we Fortinberry-Murray practitioners have been saying for a long time. However current data shows not all psychotherapeutic methods are effective in the long run. A recent University of Toronto study showed that the relapse rate after two years of those who where subject to cognitive behavioral therapy (the most widely-used technique) was as high as 80%. On the other hand the
Uplift Program which we run has been demonstrated by patients' self-reports to have a long-term success rate of up to 94% in dealing with mild to moderate depression and relationship issues. BM
Read more in Psychiatric Times
Details of the earlier Connecticut study about anti-depressants and the placebo effect was reported in the New York Times
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Many PMS Sufferers Consider Suicide
The pain and misery of pre-menstrual syndrome can be so bad that 50% of women who suffer from the problem have considered suicide, research has found. A study for the Women's Nutritional Advisory Service (WNAS) found that more than eight out of 10 PMS sufferers feel violent and aggressive for up to two weeks before their periods.
Most sufferers feel depressed, and eight out of ten said PMS had affected their relationship with their partner. The survey indicates that more women now suffer from PMS than five years ago. (Could this be related to research, described above, showing that the difficulties in fulfilling their roles create depression in women, and that these difficulties are increasing? — AF)
The WNAS says that doctors are failing to treat sufferers effectively. In some cases they are merely offering powerful anti-depressants such as Prozac, or advising women to have a hysterectomy. Up to 40% of women seek medical help for PMS symptoms. However, it is thought that many others simply suffer in silence. Between 2% and 4% are forced to take up to two days off work every month because of the severity of their symptoms.
The new study found:
- 57% of sufferers have contemplated suicide — a rise of 7% on 1996
- 97% have mood swings
- 94% suffer from anxiety
- 92% feel depressed
- 84% feel violent and aggressive
- 73% of women suffer from loss of libido — an increase of 13% from five years ago
Maryon Stewart, founder of the WNAS, said many doctors were simply not providing adequate care. She said: "It seems bizarre in the extreme to think that at a time when we can send women to the moon and clone new organs, the only thing conventional medicine has to offer would result in either a permanent state of zombyism or having a premature menopause and the increased risks of osteoporosis and heart disease accompanying that scenario."
Read more in BBC Online
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