Patients expect the antidepressants to work and to keep working, but that isn't always the case. Why? The science and clinical experience tells us why this is so. And once the reasons become part of standard psychiatric practice, we'll see a dramatic shift in medical treatment of mood disorders. Both clinicians and patients will benefit from a data-driven systems approach to depression, and other mood disorders. Let me outline how we got where we are and where we should be heading.
Introduction of Prozac
In 1988, the western world was taken by storm by Prozac. Patient's were seemingly freed from difficult side effects which plagued them. They had not yet learned that there were other side effects waiting for them around the bend.
Only 30 - 50% Helped
Psychiatrists were inflated with a sense of efficacy with their newfound tool. We didn't know that within ten years we would be layering medication upon medication in an effort to help only 30- 50% of our patients fully recover from mood disorders.
Now, 21 years later, in 2009 we can see more clearly. We don't have to listen to Prozac, we can listen to our patients, and what we are too often hearing is "these new drugs just don't cut it." They help at the rate of placebo. And, they create other problems, such as weight gain, metabolic syndrome, diabetes, and sexual dysfunction.
Am I saying that medications don't work? Absolutely not. Certainly every psychiatrist has seen miracles with medication. Yet, somehow, the miracles have become less and less frequent. What used to be a slam-dunk, now often doesn't work, and so psychopharmacologists have become experts at tweaking the serotonin, the dopamine, the norepinephrine, and now the newest sexy molecule—glutamate. And there are other sexy molecules in the wings: CRF antagonists, cannabinoid receptor modulators, interleukin modulators and more. There are so many molecules involved in the pathophysiology of mood disorders that the parade will never end. And this is not to say that these new medicines will not help some people. But they will not be the answer, they cannot be the answer.
Why? Because of one simple fact: The head is connected to the body by the neck. And you simply can't just ignore the body when treating mood disorders. Each of us exists in the 'soup' of our physical and psychological environment. We can not ignore the fact that we live in a context of people, places, and things that each have an affect on our body and psychology.
Expectations Driven by Pharmaceutical FIrms
On January 17th, 2008 the prestigious New England Journal of Medicine, published a landmark paper by Eric Turner and others:
"Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy"
This paper showed that among 74 FDA registered studies of antidepressants, 31% were not published. 37 studies showing positive results were published, while studies showing negative or questionable results were, with three exceptions, either not published (22 studies) or published in a way that (the authors conclude) erroneously conveyed a positive outcome. This means that if one were to read the literature, one would believe that 94% of the trials conducted were positive. In contrast to the published literature, the study authors, who reviewed all the FDA studies, found a 51% rate of positive trials. And finally, the ‘effect size' (useful for making clinical decisions, effect size is a measure of the strength of the relationship between two variables such as mood improvement and the use of a medication) reported from journal reports were often larger than the data on file with the FDA. The numbers were inflated.
Remedy for Antidepressant 'Failure'
Unbiased science and clinical data has proven that culture, psychology, lifestyle, attachments, diet, hormones, toxicities, immune function, infection, gastrointestinal function are factors in depression, just as they are in most other chronic disorders. There is no single medicine that will remedy or restore each of these factors. Patients' overall health benefits when their mood disorder is treated as part of a large whole body system and not a symptom to eradicate.