Depression Often Misdiagnosed, and Untreated

The New York Times had an interesting article about how depression is often misdiagnosed in the US, and how most people who actually have depression don’t get treatment.  They reference a research study just published in the JAMA Internal Medicine.

This research study performed by Mark Olfson, Carlos Blanco, and Steven C. Marcus, looked at responses from 46,417 people on the Patient Health Questionnaire-2 (PHQ-2) which is a brief screening tool for depression. A score of over 3 indicates depression on this scale.

What did they find? They found that approximately 8.4% of all adults studied had depression, but only 28.7% had received any depression treatment in the previous year! That means 71.3% of the people who suffer depression got no treatment for this depression.

Of those who were being treated for depression, about 30% actually had depression based on the screening, and another 22% had serious psychological distress. That means that of the people in the study who were being treated for depression roughly 48% neither suffered depression nor did they suffer serious psychological distress, indicating inaccurate diagnoses by the treating professionals.

There were some interesting correlates of depression. About eighteen percent of those in the lowest income group suffered depression, while only 3.7% of those in the highest income group suffered depression. It pays to be rich!

Depression was more common in those who were separated, divorced, widowed, or who had less than a high school education. None of this is terribly surprising.

How did depression break down by age?

In the 18 to 34-year-old group 6.6% suffered depression. In the 35 to 49-year-old group 8.8% suffered depression. Ten percent of the 50 to 64-year-old group suffered depression. Of those over 65, only 8.3% suffered depression. So at least in this sample the 50 to 64-year-old group was slightly more likely to suffer depression, and contrary to what many people think, the youngest adults were somewhat less likely to suffer depression.

Of those who were married only 6.3% suffered depression. Of those who were separated, divorced, or widowed, 13.3% suffered depression. Divorce is bad for mental health, with almost a doubling of rates of depression.

Most of the patients who were treated for depression were treated by general practitioners (73%), with roughly 24% receiving treatment by psychiatrists and 13% receiving treatment by other mental health specialists. (There was some overlap, that’s why the numbers add up to more than 100%.)  This may explain the rather poor diagnosis and treatment of depression because general practitioners although competent and intelligent, are very busy and typically only have a few minutes to spend with each patient, not enough to do a good job diagnosing and treating depression.

CONCLUSIONS

What can we conclude from this research?

  1. Almost 10% of the adult population suffers from depression. Of those people who have depression less than 30% of them will get any treatment for depression.
  1. You are more likely to suffer depression if you are in the lowest income group, divorced, separated or widowed, or have no high school education. If you are married you have half the probability of being depressed.
  1. Many adults receive depression treatment even though they don’t really meet the criteria for depression. In this study, almost half of the people receiving treatment for depression were neither depressed nor were they even particularly distressed.
  1. Rates of depression by age groups were relatively equal, with the youngest age group having the least depression and the middle-aged group (50 to 64) suffering somewhat more depression. Married people are suffer half as much depression as divorced, separated, or widowed people.
  1. Most people received depression treatment from their general practitioner or internal medicine doctor, with a smaller number receiving treatment from a psychiatrist, and even a smaller number receiving treatment from psychologists. This also meant that most people who receive depression treatment were treated using medication, and very few people received psychotherapy, even though most studies comparing medication to cognitive behavioral therapy for depression have shown that therapy performs at least as well as medication and probably better over the long term, with less relapse.

Reading between the lines of this study, it suggests that many people who feel depressed would benefit from receiving an accurate diagnosis from a clinical psychologist, and might very well also benefit from receiving cognitive behavioral therapy for depression rather than medication. Even if medication is indicated, a psychologist could recommend it to the patient’s general practitioner, and then monitor more closely the results.

The study also suggests that many people receive antidepressant medication who actually are not depressed, which needlessly exposes them to side effects and also fails to provide the correct treatment for what troubles them.

And finally, since only about 30% of those who suffer depression received any treatment for it, if you feel depressed, be sure to pursue treatment for depression.. Get an accurate diagnosis and then get treatment, ideally with a psychologist or therapist who practices cognitive behavioral therapy.

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Why You Should Never Read Online Illness or Medication Forums, and Why You Should be Skeptical of Google Search Results as Well

The first thing many people seem to do when they get a diagnosis of a physical or a mental illness is to go to the internet and search on that illness. Patients who are prescribed medications do the same. Often the search results lead to internet forums. These forums consist of user-generated content that usually is not moderated or edited by any professional. Anyone can post on these forums. This seems reasonable, right? But in this article I’m going to tell you why, for the most part ,you should avoid reading these forums. And I will also tell you why you should be skeptical of Google search results regarding any illness.

When people read on forums about their illness or medication, they get scared. Many of the forum posts will say that your illness leads to awful and dire outcomes, and that the medications prescribed to you will make you depressed, addicted, or crazy.

For instance, I often treat tinnitus patients. Samplings of the forums that cover tinnitus suggest that most of the people who post on these forums are completely miserable and suffering terribly from their tinnitus.

So what’s the problem here? Isn’t this useful information? Can’t patients learn something interesting and helpful from these forums?

Unfortunately, Internet illness forums often present a distorted, grim, and negative impression of most illnesses and most medications. Why is this? The main reason is because of selection and sampling bias. The groups of people who post on illness forums are not a representative sample of people with a particular illness. Let’s use tinnitus as an example. If you read the tinnitus forums you would assume that everybody with tinnitus is anxious and depressed about it.

But actually, we know from research studies that roughly 20% to 40% of the population experience tinnitus symptoms from time to time. We also know that roughly 2% of people who have tinnitus symptoms suffer psychologically. So the data from research suggests that a small subset (2%) of people who have tinnitus symptoms suffer anxiety and depression as a result of their tinnitus. Most people (98%) with tinnitus symptoms do not suffer significantly or they have adapted over time and gotten over their suffering.

But the forums are full of posts from the people who suffer the most. People who don’t suffer don’t spend their time posting. And people who have overcome their suffering also don’t post. So reading the forums gives a tinnitus patient a distorted and scary view of the experience of tinnitus.

The other problem in reading internet information about illnesses is the way that Google Search ranks and orders search results. When you search on tinnitus, what you might not realize is that Google presents pages in order of popularity, not in order based on how accurate or scientific they are. Sites that are clicked on more frequently will rise up in the Google search results and sites that are clicked on less frequently will fall down. When you do a Google search people typically click on the most shocking and scary links. “Tinnitus caused by alien abduction” will get a lot of clicks even though it may represent a site run by a single person who claims to have been abducted by aliens. Thus the alien abduction tinnitus site will move up in the Google rankings.

Boring scientific sites fall down in the search rankings. That’s because they have scientific names that don’t encourage people to click on the links.

So how can patients get accurate information about their illness or about medication treatments?

One way is to search within scientific and medical sites. For instance, Medscape is an excellent website that offers medical articles about almost every illness. WebMD is another site more designed for lay people, which also offers good information. If you want to search scientific articles you can use the PubMed search engine which searches published research articles.

Let’s do a Google search on tinnitus. Overall, the 1st page of Google results is pretty representative of medical and scientific sites. But the 3rd listing titled “In the news”, is an article “Martin McGuinness tells of misery living with tinnitus,” from the Belfast Telegraph. Pretty grim, you think, misery!

But if you actually clicked through to the article you would get a very different impression because Martin McGuinness actually says that “it had a limited impact on day-to-day life and work and that family, friends and work colleagues were very supportive.… It does not limit me in a professional or personal capacity.” This is a much more positive view than suggested by the title and the Google link.

This is a great example of why the Internet is dangerous. The headline is what’s called click bait, a link that falsely represents the actual page, which is designed to attract people’s clicks.

Forums about medication are also problematic. Many psychiatric medications can have side effects. For most people these side effects are minimal or tolerable and are overbalanced by the benefits of the medications. For a minority of patients, the side effects are not minimal and these are the patients who are over-represented in most Internet medication forums. Also, on an Internet forum you never really know all of the medications the person is taking, the accurate dosages, as well as their underlying illness.

There is one more problem with reading about illnesses on the Internet. It’s one that particularly disturbs me. Many websites, even websites that purport to be objective, actually are selling something. They may be selling a supplement or vitamin, or an e-book or some other kind of program to treat an illness. Obviously, to increase sales, these commercial websites will paint a distorted negative picture of any illness or condition. They may also disparage other more traditional and scientifically validated treatments or drugs. In general, you should be skeptical of any information that comes from a website that sells products or services.

To review:

  1. Take Google search results with many grains of salt. Remember that Google orders search results by popularity not by accuracy.
  2. Beware of Internet illness and medication forums. By and large, they are populated with an unrepresentative sample of illness sufferers, the ones who suffer the most and cope the least well. Reading them will depress you and make you anxious.
  3. If you want to get information about your illness or potential treatments, utilize established and reputable medical and psychological information sites. An exhaustive list of best medical sites can be found at: the Consumer and Patient Health Information Site. Some of the good medical sites include MedscapeWebMD, and MayoClinic. Some of the best sites for mental health information include PsychCentral, NIMH , American Psychiatry Association, American Psychology Association .
  1. Finally, remember that a very large percentage of websites are actually selling something, and be skeptical of information from these sites.

In conclusion, suffering any illness or condition is unpleasant and sometimes scary. Don’t make it worse by consuming information on the Internet in a random way. Be skeptical and selective and remember that Google is not always your friend. Often a good physician or good psychologist can give you clear and balanced information.

 

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Money and Drugs

We hear a lot these days about the drug wars in Mexico and the US. There’s another drug war being waged, the war over drugs and money. That’s the war where drug companies pay influential psychiatrists to recommend the prescriptions of potent and dangerous drugs in children, adolescents and adults. Today the little guy won a small skirmish in that war.

National Public Radio (NPR) reported today that Harvard has punished three well-known psychiatrists over failing to reveal payments from drug companies. These three doctors are accused of accepting more than $4.2 million from drug companies between 2000 and 2007 without reporting the income to Harvard, Massachusetts General Hospital, or the federal government. $4.2 million!  That is $1.4 million per Doctor!

What did they do for this money?  Supposedly they did research, but if that were true then they probably would’ve revealed these payments. One can only guess, but it’s useful to look at their positions on prescribing. Dr. Joseph Biederman is well-known for being a proponent of the off-label use of antipsychotic drugs to treat supposed  “bipolar illness” in young children. Much of his work is seen as encouraging the growth in these kinds of prescriptions, and his funding came from drug companies that make these drugs. Biederman and the other two psychiatrists accused also have published extensively on the use of drugs to treat attention deficit hyperactivity disorder, also a huge growth industry in the Psycho-Pharma business.

All three doctors have been banned from taking any industry money for one year, and will be under probation for two more years after that. Good for Harvard and Massachusetts General Hospital! But it would be better if Harvard and Massachusetts General Hospital were more open themselves about disclosing what these doctors did, who they took money from, and whether they accepted federal grant money while not disclosing industry support which would be a violation of federal guidelines.

(I should add that most psychiatrists that I know and refer to don’t get any money from drug companies. In fact, when I ran some of the data regarding drug company’s payments to psychiatrists by a friend and colleague, he jokingly said, “Wow, I wish I had known, I could be driving a much nicer car!”  It appears that the biggest offenders are psychiatrists in academic settings or large hospital settings. Maybe we should all be asking our doctors to reveal their non-clinical funding so we know their biases.)

Copyright © 2010, 2011 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

New Study Shows Antidepressant Medication Fails to Help Most Depressed Patients

A very interesting study recently published in the Journal of the American Medical Association (JAMA) demonstrated very clearly that when it comes to antidepressant medication, the Emperor is wearing few if any clothes! The researchers did what is called a meta-study or meta-analysis. They searched the research literature for all studies that were placebo-controlled studies of antidepressants when used for depression. That means the studies had to include random assignment to either a medication group or a placebo (sugar pill) group. They eliminated some studies which use a placebo washout condition. (This means the studies first gave patients a placebo, and then eliminated all patients who had a 20% or greater improvement while taking placebo.) When they eliminated all studies that didn’t meet their criteria, they were left with 6 studies of 738 people.

Based on scores on the Hamilton Depression Rating Scale (HDRS), the researchers divided the patients into mild to moderately depressed, severely depressed, and very severely depressed. This is a 17 item scale that is filled out by a psychologist or psychiatrist, and measures various aspects of depression. It is used in most studies of depression. They then analyzed the response to antidepressant medication based on how severe the initial depression was.

The two antidepressants studied were imipramine and paroxetine (Paxil). Imipramine is an older, tricyclic antidepressant, and Paxil is a more modern SSRI antidepressant.

What did they find? They were looking at the size of the difference between the medication groups and the placebo groups. Rather than do the typical thing of just looking at statistical significance, which is simply a measure of whether the difference could be explained by chance, they looked at clinical significance. They used the definition used by NICE (National Institute of Clinical Excellence in England), which was an effect size of 0.50 or a difference of 3 points on the HDRS. This is defined as a medium effect size.

What they found was very disheartening to those who use antidepressant medications in their practices. They divided the patients into three groups based on their initial HDRS scores: mild to moderate depression (HDRS 18 or less), severe depression (HDRS 19 to 22), and very severe depression (HDRS 23 or greater).

For the mild to moderately depressed patients, the effect size was d=0.11, and for severely depressed patients the effect size was d = 0.17. Both of these effect sizes are below the standard description of a small effect which is 0.20. For the patients in the very severe group, the effect size was 0.47 which is just below the accepted value of 0.50 for a medium effect size.

When they did further statistical analysis, they found that in order to meet the NICE criteria of effect size of a 3 points difference, patients had to have an initial HDRS score of 25 or above.  To meet the criteria of an effect size of .50, or medium effect size, they had to have a score of 25 or above, and to have a large effect size, 27 or above.

What does this all mean for patient care? It means that for the vast majority of clinically depressed patients who fall below the very severely depressed range, antidepressant medications most likely won’t help. The sadder news is that even for the very severely depressed, medications have a very modest effect. Looking at the scoring of the HDRS, the normal, undepressed range is 0 to 7. The very severely depressed patients had scores of 25 or above, and a medium effect size was a drop in scores of 3 or more points compared to placebo patients. Looking at the one graph in the paper that show the actual drops in HDRS scores, the medication group had a mean drop of 12 points when their initial score was 25. That means they went from 25 to 13, which is still in the depressed range, although only mildly depressed. Patients who initially were at 38 dropped by roughly 20 points, ending at 18, which is still pretty depressed. And the placebo group had only slightly worse results.

One interesting thing is how strong the placebo effects are in these studies. It seems that for depressions less serious than very severe, placebo pills work as well as antidepressant medication.  Is this because antidepressants don’t work very well, or because placebos work too well? It’s hard to know. Maybe doctors should give their patients sugar pills, and call the new drug Eliftimood!

So in summary, here are the main observations I make from this study.

  • If you are very severely depressed, antidepressants may help, and are worth trying.
  • If you are mildly, moderately, or even severely depressed, there is little evidence that antidepressants will help better than a placebo. You would be better off with CBT (Cognitive Behavioral Therapy), which has a proven track record with less severe depressions, and which has no side effects.
  • Interestingly, CBT is less effective for the most severe depressions, so for these kinds of depressions medication treatment makes a lot of sense.
  • If you are taking antidepressants and having good results, don’t change what you are doing. You may be wired in such a way that you are a good responder to antidepressants.
  • If you have been taking antidepressants for mild to severe (but not very severe) depression, and not getting very good results, this is consistent with the research, and you might want to discuss alternative treatments such as CBT with your doctor. Don’t just stop the medications, as this can produce withdrawal symptoms, work with your doctor to taper off them.
  • Even in very severely depressed patients, for whom antidepressants have some effects, they may only get the patient to a state of moderate depression, but not to “cure”. To get to an undepressed, normal state, behavioral therapy may be necessary in addition to medications.
  • How do you find out how depressed you are? Unfortunately there is no online version of the HDRS for direct comparison. You may want to see a professional psychologist or psychiatrist if you think you might be depressed, and ask them to administer the HDRS to you.  There are also online depression tests, such as here and here. If you score in the highest ranges you might want to consider trying antidepressant medications, if you score lower you might want to first try CBT.
  • The most important thing is not to ignore depression, as it tends to get worse over time. Get some help, talk to a professional.

I’m off to take my Obecalp pills now, as it’s been raining here in Northern California for more than a week, and I need a boost in my mood. (Hint: what does Obecalp spell backwards?)

Copyright © 2010 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

A Better Voicemail Message! (warning, humor!)

Are you tired of all those multiple choice voicemail menus? Press infinity if you’d like more options. I saw this on the web, and had a giggle. Maybe I’ll change my voicemail message to it. (Kidding!)


Welcome to the Psychiatric Hotline.

  • If you are obsessive-compulsive, please press 1 repeatedly.
  • If you are co-dependent, please ask someone to press 2 for you.
  • If you have multiple personalities, please press 3, 4, 5, and 6.
  • If you are paranoid-delusional, we know who you are and what you want. Just stay on the line so we can trace the call.
  • If you are schizophrenic, listen carefully and a little voice will tell you which number to press.If you are depressed, it doesn’t matter which number you press. No one will answer.
  • If you are delusional and occasionally hallucinate, please be aware that the thing you are holding on the side of your head is alive and about to bite off your ear.
  • If you have an anger management problem, please throw the phone against the wall to select an option.

Anyway, I thought it was funny, and hope I haven’t offended anyone by posting it.

In all seriousness, the real messages that many psychiatrists have are almost as funny. You know, the one that says, “If you have a ‘true’ emergency, please go to the nearest emergency room or call 911.” I’ve always thought this is a stupid message, that is insensitive and uncaring. Like patients don’t know about 911 or the emergency room. I believe a better message is to offer a pager number or cell phone number where a patient can reach me, their psychologist, rather than an impersonal 911 operator. It doesn’t happen often, but when it does, I can usually help the client through crisis quickly and effectively.

Copyright © 2009 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Which Anti-depressant Should You Take? Now We Know

Accepted wisdom for a number of years has been that all modern anti-depressants work equally well, and that drug selection depends more on the side effect profile desired. Thus a lethargic patient might benefit from an activating antidepressant like Prozac, and an anxious patient would be better off with Paxil. Often prescribing practices are based on individual doctors’ preferences and biases. But a newly published study suggests that this may be wrong. There may be antidepressants that not only work better, but are easier for patients to tolerate.

A terrific new study was recently published in the Lancet medical journal. A team of international researchers, led by Andrea Cipriani at the University of Verona in Italy, reviewed 117 studies of antidepressants which included 25928 patients, two-thirds of whom were women. These studies, done all around the world, compared various antidepressants to either placebo or other antidepressants.

The researcher compared the results of 12 new generation antidepressants in terms of efficacy and acceptabiltiy. They defined efficacy as the proportion of patients who improved at least 50% on a depression rating scale by 8 weeks of treatment. They defined acceptability as the proportion of patients who did not drop out of the study. They made an attempt to adjust for dosages, and did very sophisticated statistical analyses to compare all of the drugs. They used fluoxetine (Prozac) as the common comparison drug, since it has been on the market for the longest time.

What were the results? The winners in terms of short term effectiveness were: (drum roll) mirtazapine (Remeron), escitalopram (Lexapro), venlafaxine (Effexor), and sertraline (Zoloft). The winners in terms of acceptability were: escitalopram (Lexapro), sertraline (Zoloft), citalopram (Celexa), and bupropion (Wellbutrin) were better tolerated than other new-generation antidepressants. Note that the overall winners for effectiveness combined with tolerability were escitalopram (Lexapro) and sertraline (Zoloft). Two of the best drugs in terms of effectiveness (mirtazapine (Remeron) and venlafaxine (Effexor)) were not among the best tolerated medicines.

The losers in terms of both effectiveness and tolerability were reboxetine (Edronax), fluvoxamine (Luvox), paroxetine (Paxil), and duloxetine (Cymbalta). The worst drug of all was reboxetine (Edronax).

So what about cost? I’ve developed a spreadsheet of all of the drugs’ costs based on a 30 day supply, paying full retail price at Costco pharmacy, and using generic equivalents when available. Of the winners in terms of effectiveness and tolerability, the clear cost winner was sertraline (Zoloft), at $12 a month. The other winner, escitalopram (Lexapro), was a loser in terms of cost at $88 a month! The other winners in terms of effectiveness were quite cost effective too, with mirtazapine (Remeron) at $14 a month, and venlafaxine (Effexor) at $28 a month.

So what should doctors and patients do? For patients, the two best drugs appear to be escitalopram (Lexapro) and sertraline (Zoloft), with sertraline the clear winner if you pay much for prescription drugs. Doctors might want to consider costs as well, as this can help with overall health care inflation. If you can tolerate the side effects, consider trying mirtazapine (Remeron), or venlafaxine (Effexor).

Now there are of course a few caveats about this study. It is possible that another meta-analysis could find different results. One criticism was that the study only looked at effectiveness over 8 weeks of treatment. It is possible that some drugs work more slowly, and at 12 or 16 weeks might have different results. But most patients want results in two months or less, so this is not a major criticism.

Another issue is funding bias. Although none of the authors of this study were paid by drug companies, many of the studies they analyzed were funded by drug companies, and may have reflected some bias. But for now, this is the best information we have in terms of effectiveness and toleration of antidepressant medications.

So who’s the winner? Sertraline (Zoloft) was the clear winner by effectiveness, tolerability, and cost!

Should you change medications if you are not on one of the winners? No, of course not. If your medication is working, don’t change it. But if it’s not working, then talk with your doctor about switching.

And no, I don’t receive any funding or sponsorship from any drug companies…

 

Here’s the table of drug price comparisons.
Comparison of Antidepressant Costs for 30 Day Supply (Costco Pharmacy, Generic Equivalents if possible)
Bolded Drugs were most effective

Drug            Generic Name         Cost          Dose(mg)

Celexa             citalopram                   $3                 40
Prozac             fluoxetine                    $6                  20
Zoloft             sertraline                       $12             100
Remeron     mirtazapine                    $14               30
Luvox              fluvoxamine               $24             100
Effexor         venlafaxine                    $28                75
Welbutrin      bupropion                   $74             200
Lexapro       escitalopram                 $88                10
Paxil                paroxetine                   $91             37.5
Cymbalta       duloxetine                   $128              60

 

Copyright © 2009 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

How to Deal with Teenage Depression: A New Study of Adolescent Depression and its Treatment

A new study reported in the Journal of the American Academy of Child and Adolescent Psychiatry found some interesting results of a study of teenage depression and its treatment.

This study of 439 teenage children with major depression, done at the University of Texas Southwestern Medical Center at Dallas tested anti-depressant medication (fluoxetine or Prozac), cognitive behavioral therapy (CBT), and a combination of both (COMB). They found that only 23% of the patients had their depression cured by 12 weeks of therapy. But 9 months of therapy was much more effective, with 60 percent going into remission.

The bad news though is that this means that almost half of the teenagers (40%) were still depressed after 9 months of therapy.

The good news is in terms of relapse. Of those who responded quickly to treatment, two-thirds retained the benefits of treatment over 9 months. The same was true of those who took longer to respond.

Which treatment was better? That is an interesting picture.

It depends at which time point you are looking at. At 12 weeks, the results for percentage fully remitted (cured) of depression were: combined drug and CBT therapy (37%), drug therapy only (23%), and CBT therapy only (16%). The combined therapy was significantly better than the other therapies. But note that overall, only 23% of the teenagers had recovered at 12 weeks, which means that 77% were still suffering!

But at nine months the outcomes look quite different. The combination therapy is still the best, but by less of a margin. The results for remission at at 9 months were: combination, 60%; drug, 55%; cognitive-behavioral therapy, 64%; and overall, 60%. By 24 weeks all the treatments were working well. But a full 40% of the teenagers were still depressed.

So the right answer to the question of which treatment works better is neither. Both drugs and cognitive behavioral therapy were equally effective, over the long term. But the combination of both was worked more quickly. As the researchers said, “choosing just one therapy might delay many teenagers’ recovery by 2 or 3 months.” As the saying goes, candy is dandy, but liquor is quicker, and we might conclude that drugs or CBT are dandy, but combined therapy is quicker.

So what does this mean to parents of depressed teenagers? Here are my takeaway messages:

  1. Don’t expect treatment for depression to work quickly. It may take more than 9 months of weekly treatment before your teenager responds to therapy. This means at least 40 sessions of therapy.
  2. Be patient, and set reasonable expectations for both yourself and for your child. Tell them that therapy will help, but it may take a while. Let support networks such as school counselors or trusted teachers know to be patient.
  3. Although medications and cognitive behavioral therapy were equally effective in the long run, the combination of both tended to work much more quickly. So if you can afford it, and have access to good practitioners who do cognitive behavioral therapy, use both.
  4. Be aware that in other studies, the relapse rate for medication treatment of depression was significantly higher than for cognitive behavioral therapy, once the medications are discontinued. So choosing medications only may increase the risk that your teenager will relapse into depression.
  5. Be aware that much teenage depression can be a reaction to social environments. This includes the family, the school, and peers. Be sure that your teen’s therapist is attuned to family, school, and peer issues. They should meet with the whole family at least several times.
  6. Take teenage depression seriously. It’s not just a phase. Teenage depression, when serious, can greatly increase the risk of suicide. All suspected depression should be evaluated by a professional and treated if present.

Copyright © 2009 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

SOURCE: Journal of the American Academy of Child and Adolescent Psychiatry, February 2009 . And December 2006 issue too .

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Should the Golden Gate Bridge Have a Suicide Barrier? (Is Suicide an Act of Impulse or an Act of Premeditation?)

One of the consistent and most fascinating facts that arises out of any serious study of psychology research is how much we are influenced by external factors.  So much of our behavior is influenced by seemingly small external factors.  We eat more when served bigger portions.  We spend more when sales are in effect.  Red cars are more likely to get speeding tickets.  We are more likely to marry someone who lives or works nearby.

But what about the truly profound and serious decisions of life?  What about something as serious as suicide?  Can it be that even such a grave decision is affected by seemingly small external factors?

The New York Times Magazine recently published a fascinating article “The Urge to End It All“, which addressed this very issue.  I highly recommend you read the entire article.

First, some numbers.  (I love numbers).  The current suicide rate is 11 victims per 100,000 people, the same as it was in 1965.  In 2005, about 32,000 Americans committed suicide, which is two times the numbers who were killed by homicide.

For many years the traditional view of suicide was that it reflects mental illness — depression, bipolar illness, psychosis, schizophrenia, or other mental illnesses.  This view assumed that the method of suicide was not important; it was the underlying mental illness that mattered.

But something happened in Britain in the 1960s and 1970s that set this model on its head.  It’s called the “British Coal Gas Story” and it goes like this:

For many years people in Britain heated their homes and stoves with coal gas.  This was very cheap, but the unburned gas had very high levels of carbon monoxide, and a leak or an opened valve could kill people in just a few minutes in a closed space.  This made it a popular method of suicide — “sticking one’s head in the oven” killed 2500 Britons a year by the late 1950s — half of all suicides in Britain!

Then the government phased out the use of coal gas, replacing it with natural gas, so that by the early 1970s almost no coal gas was used.  During this time Britain’s suicide rate dropped by a third, and has remained at that level since.

How can we understand this?  If suicide is the act of an ill mind, why didn’t those who could no longer use coal gas find another means? Why did the suicide rate in Britain drop by a third when the option of coal gas was no longer available?
The answer turns conventional wisdom about suicide on its head. Conventional wisdom is that people plan out suicides carefully, and so convenience of method shouldn’t matter. But actually it appears that often suicide is an impulsive act, and when you make it less convenient, people are less likely to complete the act.

Another example of this is found in the Golden Gate Bridge.  For years this gorgeous bridge has been a popular suicide point, where nearly 2000 people have ended their lives.  There have been many debates about erecting suicide barriers on the bridge, but most opponents say “they will just find another way.”

But Richard Seiden, professor at University of California Berkeley, collected data that addresses this issue.  What he did was to get a list of all potential jumpers who were stopped from committing suicide between 1937 in 1971, 515 people in all.  He then pulled their death certificate records to see how many had gone on to kill themselves later.  What would you guess was the percentage of these people who tried to jump off the Golden Gate Bridge and who later killed themselves?  50%?  75%?  25%?

Actually it was only 6%!  Even allowing that some accidents might have been suicides, the number only went up to 10%.  Although higher than the general population, it still means that for 90% of these would-be jumpers, they got past whatever was bothering them, and went on to live full lives.

Richard Seiden got some great stories out of this study.  One of the things he found was that would-be suicides tend to get very fixated on a particular method.  They tend to only have a Plan A, with no Plan B. As he says, “At the risk of stating the obvious,” Seiden said, “people who attempt suicide aren’t thinking clearly. They might have a Plan A, but there’s no Plan B. They get fixated. They don’t say, ‘Well, I can’t jump, so now I’m going to go shoot myself.”

One example he cites was a man who was grabbed on the east side of the bridge after pedestrians noticed him looking upset.  The problem was that he had picked out a spot on the west side of the bridge that he wanted to jump from, but there were six lanes of traffic between the two sides, and he was afraid of getting hit by a car on his way over!

As Seiden said, “Crazy, huh? But he recognized it.  When he told me the story, we both laughed about it.”

Another great example is from two bridges in Northwest Washington.  The Ellington Bridge and the Taft Bridge both span Rock Creek, and both have about a 125 foot drop into the gorge below.  For some reason the Ellington has always been famous as Washington’s “suicide bridge”.  About four people on average jumped from the Ellington Bridge each year as compared to slightly less than two people from the Taft.

In 1985, after a rash of suicides from the Ellington, a suicide barrier was erected on the Ellington Bridge, but not the Taft Bridge.  Opponents countered with the same argument, that if stopped from jumping from the Ellington, people would simply jump from the Taft.

But they were wrong.  Five years after the Ellington suicide barrier went up a study showed that while all suicides were eliminated from the Ellington, the rate at the Taft barely changed, inching up from 1.7 to 2.0 deaths per year.  What’s even more interesting is that the total number of jumping suicides in Washington dropped by 50%, or the exact percentage the Ellington had previously accounted for. So people stopped from jumping from the Ellington did not jump from other locations.

Coming back to our model that small external factors can have large influences on behavior, you might wonder why the Ellington was the suicide bridge instead of the Taft.  It turns out that the height of the railing was what made the difference. The concrete railing on the Taft was chest high, while the concrete railing on the Ellington (before the barrier) was just above the belt line.  One required a bit more effort and a bit more time to get over and this tended to reduce the impulsive action of jumping.

Which brings us to guns. Although guns account for less than 1% of all American suicide attempts, because they are so lethal, they account for 54% of successful suicides.  In 2005 that meant 17,000 deaths.  It turns out there when you compare states with high rates of gun ownership to states with low rates of gun ownership; you find that there is a direct correlation between the rate of gun ownership and the rate of gun suicide.  This is not surprising.

What is more surprising is that in the states with low gun ownership, the rates of non-gun suicide are the same as those states with high gun ownership.  So the lack of availability of guns does not encourage people to find other means of harming themselves.  Studies show that the total suicide rate in high gun ownership states is double that of in low gun ownership states.  So the Supreme Court, in their recent ruling regarding Washington, D.C.’s ban on handguns, may have missed the more important data when they focused on homicide rates.  From these studies scientists conclude that a 10% reduction in firearm ownership would result in a 2.5% reduction in the overall suicide rate.

I am not anti-gun. I like shooting, and if I were a hunter, would probably own a rifle.  But this is why I don’t own a gun, and this is why I don’t recommend that most people own a gun.  All of us are potentially subject to dark moments of the soul, and the research detailed in this New York Times article suggests that the more barriers and impediments there are to impulsively harming ourselves, the less likely we are to try.  If you do own guns, at least try to create barriers and delays such as keeping the guns locked up in a gun safe, keeping ammunition separate from the guns, or even not keeping ammunition in the home where guns reside.  Not only does this protect you from those dark moments of the soul but it may also protect someone you love, your spouse, or your child.

Again, I highly recommend a careful reading of the original article, as it has much other information that is useful and interesting.

In answering the question of the title, I have to say that reading this article convinced me that we should build a suicide barrier for the Golden Gate Bridge. Yes, it would lower the beauty of this gorgeous bridge, at least for pedestrians, but I have to believe that saving another 2000 lives trumps a pretty walk across the Bay.

Copyright © 2008 The Psychology Lounge/TPL Productions

All Rights reserved (Any web links must credit this site, and must include a link back to this site.)

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

More Evidence That Psychiatrists Take “Payments” From Drug Companies

Two new articles from the New York Times confirm my earlier article about psychiatrists taking large amounts of money from drug companies, which tends to influence how they prescribe medicines. The first article documents how psychiatrists in Vermont received more money than any other medical profession. Each psychiatrist received an average of $45,692 in drug company bribes payments. Does this influence how psychiatrists prescribe? You bet! As the Times said, “For instance, the more psychiatrists have earned from drug makers, the more they have prescribed a new class of powerful medicines known as atypical antipsychotics to children, for whom the drugs are especially risky and mostly unapproved.”

Another article, also in the Times, documents that the federal government is starting to look at these practices. The Senate had hearing where they quizzed drug company execs about their practices. My favorite moment in the hearings came when Senator Claire McCaskill was talking about the Senate barring senators from accepting meals from lobbyists. And there should be full disclosure of any gifts or payments to senators. Then she said, “And if it’s good for Congress, it’s good for the medical profession in terms of cleaning up all this lobbying — because that’s what it is.”

You know doctors are in ethical trouble when the closest comparison is the Senate!

Once again, how should we deal with this? First, write to or call your legislators, both state and federal, and ask them to pass legislation to bar the practice of doctors taking money from drug companies. Any payments much be fully and publicly disclosed, and should be limited to a token amount like $100 per year.

Second, ask any psychiatrist you see if they receive money from drug companies and if yes, ask them how much and from what companies. If they refuse to disclose this, consider another psychiatrist. Once you know which companies they took money from, then you can evaluate whether it seems to influence their prescribing practices.

There are many psychiatrists who don’t take money from drug companies, and we should favor these doctors.

Copyright 2007 The Psychology Lounge/TPL  Productions

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Is Your Shrink Being Paid to Give You Drugs? The Secret Link Between Psychiatrists and the Drug Industry

Regular readers of this blog will remember my earlier article on Rebecca Riley, the young girl whose overtreatment with powerful psychiatric drugs may have led to her death.

Now it turns out that some psychiatrists may actually be getting paid by the drug industry to give kids powerful drugs! And this is in spite of an almost complete lack of evidence that these drugs work or are safe for children.

The New York Times has an article called Psychiatrists, Children, and Drug Industry’s Role, and this scary article documents the secretive practice of paying psychiatrists to prescribe certain drugs.

The article documents that more than half a million children are now receiving atypical antipsychotics such as Risperdal, Seroquel, Zyprexa, Abilify, and Geodon. These drugs have never been tested on or approved for use in children!

In Minnesota alone, the only state that requires such reporting, from 2000 to 2005 payments from pharmaceutical companies to psychiatrists soared by six times, to $1.6 million, and the rates of prescribing antipsychotics to children went up by nine times.

And the Times found that the money worked. Those psychiatrists who received more than $5000 from the drug companies wrote 3 times as many prescriptions for atypical antipsychotics than those doctors who got less or no money. Other interesting figures are that the average payment to psychiatrists was $1750, with a maximum of $689,000. (Nice work if you can get it!)

I should point out that atypical antipsychotics are not benign drugs. Side effects can include rapid weight gain that leads to diabetes, and movement disorders such as tics and dystonia, which can lead to a lifelong muscle disorder.

The Times describes one unfortunate girl, Anya Bailey, who was given Risperdal for an eating disorder by her psychiatrist George Realmuto, who had received more than $7000 from Johnson and Johnson, the maker of Risperdal.

Although the drug helped her gain weight, she also developed a painful and permanent dystonia in her neck that now causes her chronic pain and a movement disorder, even after stopping the drug.

And she was never given any counseling for her problems, only drugs!

So what can we learn from this article? First of all, the practice of paying psychiatrists to prescribe certain medications is widespread, but only Minnesota requires full disclosure. We should pressure our legislatures to mandate full disclosure in every state. Write to your state and federal congress and senate and ask them to either ban this practice or to require full disclosure, on the web, by name of doctors, of how much money is given by each drug company.

Secondly, when you take your child to a psychiatrist, you should ask them for a full written disclosure of any money they received in the last few years from drug companies for speaking, or for research. Payments to psychiatrists (and other M.D.’s) are disguised as speaking honorariums or research payments, but when a doctor receives $5000 for giving one or two talks, it is safe to say that they are being paid for something else. If the psychiatrist admits to receiving money, then you should probably find another psychiatrist, as this creates a bias to prescribe that I do not think can be overcome.

Third, you should be dubious about any suggestion to give your child an antipsychotic medication for any diagnosis other than true psychosis. This means that unless your child is actively hallucinating, and delusional, i.e. “crazy” there is no evidence that antipsychotics will help them. For instance, there was only one well controlled study of the use of atypical antipsychotics in bipolar illness in children, and it found little or no difference between using the antipsychotic and not using it. And most of the children in the group receiving the antipsychotic dropped out of the study due to side effects. A second study by the same researchers found no advantage to using antipsychotics.

Fourth, consider taking your child to a psychologist or counselor rather than a psychiatrist. Psychologists don’t receive money to influence their treatment decisions, and use behavioral approaches that don’t have side effects. And there is much more research evidence that supports the use of these behavioral approaches in childhood disorders. Dangerous medications should be reserved as second or third line treatments only. Remember the old saying that to a young boy with a hammer everything becomes a nail, similarly to a doctor whose specialty is giving drugs, all problems become biochemical.

Finally, let’s put pressure on our legislators to outlaw this thinly disguised bribery, which threatens the health of children and adults. Shame on the pharmaceutical industry! And even more shame on psychiatrists, who of all people should be trustworthy and not willing to accept such bribes. I make the perhaps radical suggestion that patients boycott psychiatrists who accept money from drug manufacturers. If doctors can’t earn a decent living without taking payments from drug companies that often have the appearance of bribes, then perhaps they need a new profession. I realize that there are decent, honest psychiatrists who either don’t take drug company money or don’t let it influence them, but I suggest that it may be hard to tell the difference, unless psychiatrists employ full disclosure.


Copyright 2007 The Psychology Lounge/TPL Productions

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

The Mind-Body Connection: Depression and Its Effects On Physical Health

I will return to the theme of happiness in a few more days, but today we will continue with our series about depression, based on Peter Cramer’s book Against Depression, which I heartily recommend to anyone who wants to learn more about depression.

Depression is not just a psychological disease. It impacts the whole body, and especially impacts the cardiovascular system. Depression is one of the strongest predictors of cardiac disease. Even minor depression increase the risk of cardiac disease by 50 percent. Major depression increases risk by 3 to 4 times. For those with pre-existing coronary artery disease, risk is increased 5 times!

You might be thinking that this is no surprise. Perhaps depressed people smoke more, exercise less, eat more bacon, etc. What is surprising is that the numbers in the preceding paragraph are after adjusting for lifestyle and behavior! The raw numbers are even higher!

Why is this? What is the mechanism by which depression reeks havoc with the cardiovascular system?

There are several possible mechanisms. One is through the impact on blood clotting.

Blood clotting is controlled by cells in the blood called platelets. The stickier the platelets are, the more likely you are to develop blood clots, which can lead to stroke or heart attack. Depressed patients have stickier platelets.

Another mechanism is stress. Depressed patients are under constant physiological stress, with excess stress chemicals circulating in their blood. This may raise blood pressure and cause other changes that affect the cardiovascular system.

So what happens if you treat depression? Does this reduce risk of cardiovascular disease?

Studies of antidepressants given after heart attack show a 30 to 40 percent reduction in subsequent heart attacks and deaths.

Antidepressants improve the outcomes after stroke as well. When stroke patients were given either antidepressants or placebo, 66 percent of the antidepressant group survived 2 years, but only 35 percent of placebo group.

Other physical triggers like treatment with interferon for hepatic C and melanoma can also cause depression. In fact, 50 percent of patients who receive interferon will get seriously depressed. Depression in these cases is serious because it can cause the person to stop taking a potentially life-saving treatment.

Antidepressants help even in these cases of drug induced depression. One study found that treatment with Paxil, an antidepressant, reduced depression from 45 percent to 11 percent.

What are the implications of these finding?

  1. All patients who have had a heart attack or a stroke should probably take an antidepressant.
  2. All patients taking long-term interferon treatment should begin taking an antidepressant several weeks before starting the interferon.
  3. Probably most seriously ill cancer patients should take an antidepressant as well.
  4. Counseling that focuses on evaluating and treating depression should be part of any seriously ill medical patient’s treatment regimen.

Copyright 2007 The Psychology Lounge/TPL Productions

All Rights Reserved


——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Your Junk is My Treasure! The Psychology of Compulsive Hoarding


Today I am going to write about a very different type of psychological problem, called compulsive hoarding. The Boston Globe had a very interesting article about hoarding. Researchers Gail Steketee and Randy Carlson have a new book, called “Buried in Treasures,” which documents their new approach to treating this disorder.

First of all, what is compulsive hoarding? It’s when you can’t get rid of anything, and can’t put in order what you have, so much so that you end up having difficulties using the spaces you live or work in.

Are you a hoarder? Of course not! But Steketee and her colleagues developed a simple photo test for hoarding . Take a look at these photos, and pick out the one that looks the most like your bedroom. If it is number 4 or higher, then you probably have a problem with hoarding. (Hoarders, it turns out, are very accurate at identifying the level of chaos in their spaces.)

Your official Lounge Wizard, Dr. Psychology took the test, and scored a 2 or 3, which puts him in the normal range, but right on the borderline of hoarding. So this article is close to his heart.

What causes hoarding? It’s not what most non-hoarders think; laziness, messiness, or even depression. Although many hoarders have some elements of depression or anxiety, the core of hoarding is that they have strong attachments to things. They are sentimental about possessions, and often have very intense feelings about them. They tend to be creative, and can think of many uses for objects.

Most hoarders function fairly well outside their homes. They have jobs, friends, and active involvements. Where hoarding seems to impact them is in romantic relationships. The hoarders I know tend to not have long term romantic relationships, which isn’t surprising, as girlfriends and boyfriends tend to want to come over to your house, and for a hoarder than is a painful experience. “Why do you have all of this stuff? Why don’t you get rid of all this junk? I can’t believe you live this way!” are all typical comments they may hear. Needless to say, there are no more invitations after that. Steketee finds that at least 50% of hoarders are single.

So is there any hope for hoarding? One thing that doesn’t seem to work very well is traditional medicines for depression like antidepressants. Although these medicines work well for regular obsessive compulsive disorder (OCD) they don’t appear to do much for hoarding. Traditional psychotherapy doesn’t work either.

Steketee and colleagues have developed a very nice cognitive behavioral model for treating hoarding. They find that hoarders have similar cognitive models. For instance, hoarders have four common fears: 1) missing important information or opportunities, 2) forgetting something important, 3) experiencing loss, and 4) being wasteful. They tend to focus on lost opportunity, so getting rid of a newspaper entails a possibility of losing some opportunity that was in the newspaper. In general, all of their possessions get elevated in value.

Another common issue is needing to keep things in sight. This is tied into the need to not forget anything. “Out of sight, out of mind,” is the hoarder’s mantra. This causes the visual chaos that creates many of the problems of hoarding, since if one just had many possessions, but they were well organized and stored, hoarding would not be a big problem.

So it is not surprising that Steketee’s treatment plan focuses on helping hoarders learn to organize their space, rather than focusing on getting rid of stuff. This is more palatable goal for most hoarders, who know that their space is poorly organized.

The treatment also focuses on helping hoarders overcome the need to acquire things. The rules for acquisition are: 1) immediate need for the object (this week), 2) time enough to acquire and use the object, 3) money to buy it, and 4) an appropriate space for the object. This nips the problem in the bud.

The treatment works, but it’s not a miracle. According to Steketee, it’s not unusual for someone to move from 7 to 3 on a 9 point scale where 1 is neat and organized, and 9 is total mess. But relapse is always a danger, as there is something very compelling about hoarding.

So what is the core of hoarding? Even Steketee and her colleagues are a little baffled about this. As a borderline hoarder who closest friends include some hoarders, I can give some intriguing answers.

Hoarding is about possibility. The thought “I could use this item someday,” is central to the decision to hold onto something. For instance, I have a box of scrap pieces of wood and plastic, which I keep because I might have a use someday. Every once in a while, I use a piece from my scrap box. And that reinforces keeping it.

Or papers. I used to clip articles from papers, thinking I would write about the topic someday. I had many files of articles on travel, psychology, and technology. The technology innovation that has changed that is computers, and more specifically, the email program Gmail. Instead of printing out articles, now I email them to myself. Since Gmail can hold thousands of articles, and with a simple search I can find any of them, I’ve tossed out my article files.

One of the beauties of computers is that even massive hoarding of articles or writing takes very little space on a hard drive. I can hold every email I’ve ever written in my life on a single USB memory stick. So if you are a hoarder of articles, or papers, consider buying a scanner, and using computer technology to hoard more effectively.

Another aspect of hoarding is sentiment. I hate throwing out something that reminds me of a good time in my life, or almost anything that has significant meaning. So I’d never throw away a photograph or a letter from someone I care about. I will throw out cards, though, unless they have a significant written message inside.

And some of hoarding is simply about difficulty in making decisions. For instance, I have too many books. But it is hard to figure out which books to toss. Some rules are easy. A bad paperback novel is easy to toss. But a good novel is tougher; maybe I will want to reread it sometime.

And reference books are still arder. Will I need the information in this book sometime? I try to ask myself realistically if the info is something I’ll need in the foreseeable future, and especially if the information is still even relevant. Thus old computer books are easy to toss, since in the computer world things date quickly.

One trick I’ve used successfully in de-hoarding is to remind myself that one of the advantages of getting rid of things is that you can get new things! For instance, if you go through one’s clothes closet and toss all the clothing that doesn’t fit and doesn’t look good, then you get to buy some cool new threads! The same is true with books. The key is to replace less than you toss.

Conquering hoarding is about psychological growth. Central to the process of growth is letting go of the old in order to make room for the new. New things, new people, and new experiences. Another aspect of de-hoarding is traveling through life less encumbered. That gives you more flexibility to move, and change. The irony of hoarding is that the biggest hoarders I know love to travel. And when they travel, they leave almost all of their stuff behind. And they are perfectly happy living out of a suitcase or backpack, and don’t miss their stuff at all.

Maybe this is really a metaphor for our psychological baggage. Travel light, and leave the junk behind. Throw out old stuff, and organize what you keep. Let go of things, and make room for new things.

Copyright 2007 The Psychology Lounge/TPL Productions

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Forbes Magazine Endorses Cognitive Behavioral Therapy! In a Faceoff between Cognitive Behavioral Therapy and Antidepressant drugs, Therapy Wins!


As regular readers know, your editor is a big fan of a type of psychotherapy called Cognitive Behavioral Therapy (CBT). Cognitive therapy is a modern non-drug therapy that teaches clients new ways of thinking and feeling. The basic concept is that it is our distorted thinking that creates psychological problems of anxiety, depression, panic, etc. The cognitive therapist combines teaching cognitive skills with behavioral techniques that allow the client to overcome their difficulties.

And much to his surprise, this week Forbes Magazine put CBT on their cover! The Forbes article about Cognitive Behavioral Therapy was very positive. They summarize 30 years of research, including studies that show that CBT works well for insomnia, hypochondria, anxiety, depression, bulimia, obsessive compulsive disorder, preventing suicide, and even matches surgery for low back pain. Here is a video demonstration of exposure treatment for an elevator phobia.

They also compare the effectiveness of CBT to antidepressant medication. Although both work, in the long run CBT is more cost effective, and leads to less relapse. In one study comparing Paxil to CBT, only 31% of the CBT group relapsed within one year of completing treatment, compared to 76% of the Paxil group! This is a very big difference. The skills that clients learn seem to have a lasting impact on preventing future depressions.

Even in terms of cost, CBT beats antidepressant medications, at least with the assumptions the Forbes editors made. After three months of treatment, they estimate the costs of cognitive therapy at $1200 and the costs of medication treatment with Effexor at $502, which includes one psychiatrist visit at $200, and $302 in drug costs. At one year, they estimate the costs of cognitive therapy at $2000, and drug treatment at $2009, which includes $800 for four psychiatrist visits at $200 each, and $1209 for the Effexor.

As much as I like the comparison, it is based on faulty assumptions. First of all, it’s not clear how many sessions of cognitive therapy they are estimating. The $2000 would pay for 20 sessions at $100, but only 13 at $150. It’s probably optimistic to believe that a good outcome would come out of only 13 sessions. And because the primary group of professionals who perform cognitive therapy are psychologists, who typically charge more than masters level therapists, $100 is probably too low.

So let’s fix the numbers. Let’s assume 25 sessions of cognitive therapy, at $150 per session, which comes out to $3750. That’s probably a fairer assumption.

Now let’s look at the other assumptions. Effexor is an expensive, non-generic anti-depressant, which costs $100 a month, or even more. But the generic version of Prozac, called fluoxetine, can cost as little as $10 a month. And four psychiatrist visits in a year is also too optimistic. In my experience, patients need every two week visits initially to get the medication adjusted, and after 6 or 8 weeks, can graduate to once a month, and after another 3 visits, can be seen every three months. Also, psychiatrists typically charge at least $300 for the initial evaluation, and less than $200 for the follow-up visits which tend to be shorter visits.

So by these assumptions, the psychiatrist visits would cost $1380 at least. This brings the total cost of one year of treatment with Effexor to $2589. Of course, if fluoxetine was substituted then the total costs would only come to $1500!

So drug treatment costs less than cognitive therapy, right? It either costs a lot less ($1500 compared to $3750) or somewhat less ($2589 compared to $3750).

But there is still a glitch in the assumptions. We are only looking at the first year costs. Remember the statistics mentioned above, that up to 76% of patients who stop taking antidepressants relapse back into depression. Those are pretty bad odds. If a patient stayed on Effexor for 5 more years, their total cost of treatment would skyrocket to $6756, assuming psychiatrist visits 4 times a year. Compared to this cognitive therapy looks good!

There is another, unmentioned advantage to cognitive therapy, which is incredibly important, and which too often is left out of this debate. Here’s the dirty little secret the drug companies don’t want you to know—most antidepressants ruin your sex life! With really just a few exceptions (Wellbutrin, and Emsam) almost all of the major antidepressants make it much harder to have an orgasm for both men and women, and for men may make it difficult or impossible to get or maintain an erection. Antidepressants should really be called anti-sex drugs! (Caveat: not everyone will have the sexual side effects, but most will.) Here is a good article about the sexual side effects of antidepressants.

And this leaves out all of the other side effects of antidepressants. Here’s a link to common side effects of antidepressant medication Dry mouth, dry eyes, blurred vision, nausea, insomnia, headaches, the list goes on and on. How do you place a value on the costs of side effects?

Cognitive therapy obviously has no sexual side effects, or any other side effects. So for this reason, and for the advantage in preventing relapse, I believe cognitive therapy should be the first choice therapy for those patients suffering depression, providing they can afford therapy or have good insurance coverage for therapy. If not, then having your regular doctor prescribe and monitor a generic antidepressant such as fluoxetine (Prozac), sertraline (Zoloft), or bupropion (Wellbutrin) is the best option, with the downside being that you will most likely need to take the medications long-term to avoid relapse, and that you will most likely have physical side effects. Thus it may be worth taking a loan from your credit card in the form of a cash advance, or simply using a credit card to pay for cognitive therapy. After all, that’s how most people pay for their next car, or flat screen television set.

So here’s the executive summary. Cognitive therapy works for a large variety of common psychological problems, and even a few physical problems. Although initially it costs a little more, the effects are longer lasting than medication treatment. And in the long run, it can end up saving money. Best of all, other than working a little bit on therapy homework, there are no side effects of therapy! Conclusion: If you are depressed, anxious, having insomnia, obsessive compulsive disorder, hypochondriasis, phobias, or relationship problems, your first move should be to find a psychologist who specializes in cognitive therapy. Borrow the money if you don’t have it, or put it onto your credit card, but don’t miss out on this effective treatment out of some false sense of economizing.

Copyright 2007 The Psychology Lounge/TPL Productions

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Let’s Not Kill Any More Rebecca Riley’s! Debate Over the Use of Psychiatric Drugs for Young Children

 

The New York Times reported that Rebecca Riley, a four year old girl from near Boston, was found dead on the morning of December 13, a victim of an apparent overdose of the psychiatric drugs Seroquel, an antipsychotic drug; Depakote, a powerful anti-seizure medicine used for mood control, and Clonidine, a blood pressure drug often prescribed to calm children. Rebecca had been diagnosed at having bipolar disorder at the age of two! So some overzealous psychiatrist had diagnosed her as been manic depressive at age 2.

Now this is pretty crazy. A child at two is a work in progress, and if is virtually impossible to diagnose anything at that age. The only exceptions are the developmental disorders, such as autism. Probably Rebecca was a difficult child, prone to moodiness and maybe even tantrums. So her parents, with a willing psychiatrist, gave her mind-numbing drugs to calm her, rather than learning better parenting skills. From the article: “A relative of her mother, Carolyn Riley, 32, told the police that Rebecca seemed “sleepy and drugged” most days, according to the charging documents. One preschool teacher said that at about 2 p.m. every day the girl came to life, “as if the medication Rebecca was on was wearing off,” according to the documents.”

This is more than sad, it is pitiful. How many other, nondrug interventions were tried before using medication? Was there parenting training? Was there a home visit, to see how Rebecca and her parents were interacting? The article does not say, but I’m guessing that none of these things were done. There’s an old saying, “Give a young boy a hammer, and everything becomes a nail.” In much the same way, bringing a child to a psychiatrist means that they are likely to get drugs. That’s why the first stop for children, especially young children, should be to a child psychologist, a psychologist who specializes in treating children and their families.

It should also be noted that most psychiatric medications are not and have never been approved for use in young children. There are no studies of using these drugs on toddlers. Although it might be occasionally reasonable to use drugs meant for adults on older teenagers, who are at least biologically similar to adults, it is irresponsible at best to use these drugs with young children.

The problem is that giving kids drugs is too easy. From the New York Times article, “Paraphrasing H. L. Mencken, Dr. Carlson added, ‘Every serious problem has an easy solution that is usually wrong.’” Behavioral problems in children can be very serious, and the behavioral interventions take time and commitment. Learning good parenting techniques, such as the proper use of time-outs and other interventions, takes dedication and a competent psychologist’s help.

As with adults, medications should always be reserved for after all other interventions have failed. And with children, only medications that have been tested on children, and used for years should be tried. If psychiatrists want to prescribe these medications for children, let them first run the research trials required by the FDA to test safety and effectiveness. Let’s not kill anymore Rebecca Riley’s!

PermaLink to article

Copyright 2007 The Psychology Lounge/TPL Productions

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Mild Depression, A Mild Problem?

 

More from Peter Cramer’s book Against Depression, which I heartily recommend to anyone who wants to learn more about depression.

We talked about the full blown diagnosis of depression. For a diagnosis of major depression you need 5 or more symptoms for at least 2 weeks. What if a patient has only 2 or 3 symptoms for 2 weeks? Is that a problem?

First of all these mild depressions can be the precursor or follow-up to major depression. So they are important for that reason.

But even if there is no major depression, mild depression looks like major depression. Mild depression runs in families where major depression is prevalent. Low level depression causes disability, absenteeism, more medical visits.

Another type of mild depression is dysthymia. Dysthymia means being sad at least 50% of the time, for 2 years or more. And dysthymia is not the same as unhappiness. Dysthymics suffer the same relentless internal stress, the hopelessness, sadness, and low self-esteem of the depressed. The fact that they may function well, or eat and sleep well, is of small comfort to them.

The problem with dysthymia and mild depression is that medications may be less effective with these conditions, and some types of psychotherapy, more effective. Although no one exactly knows, the general consensus is that dysthymia is less responsive to antidepressants than is major depression. But it may be more responsive to cognitive behavioral therapy.

In summary, even mild depression has serious impacts on people. Mild depression can be effectively treated with cognitive behavioral therapy, and responds well to it.


Copyright 2006 The Psychology Lounge/TPL Productions

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

The Natural History of Depression

I’m still reading Peter Cramer’s book Against Depression, which is his follow-up to Listening to Prozac, his groundbreaking book about depression and Prozac. This is a fascinating book, as good as Listening to Prozac. I continue to be impressed by his scholarship and ability to pull interesting research together. If you have any interest at all in learning more about depression, I would strongly recommend this book, which is a philosophical and scientific exploration of depression.

What is the natural history of depression? That is, what happens later in life if you get depressed now? Do you recover, or do you have more depressions?

We have good data on this issue from some studies funded by the National Institute of Mental Health. These studies followed depressed patients over many years. The findings are astounding, at least to me.

They show that if you are diagnosed as being depressed today, there is a 20 percent chance you will still be depressed 2 years later, and a 7 percent chance you will still be depressed ten years later, and a 6 percent chance you will be depressed 15 years later!

Even if you recovered, your probability of relapse is high. In these studies, most patients had subsequent depressions: 40 percent at two years, 60 percent at five years, 75 percent at ten years, and 87 percent at 15 years.

And with each episode of depression the prognosis worsens. After the second episode of depression, the 2 year recurrence rate soars to 75 percent!

One likely explanation for this effect is called kindling. The kindling model was first developed to explain how epilepsy works. In epilepsy, each seizure you have makes you more likely to have more seizures. This is because the seizure damages the brain.

We now think that each major depression may alter the brain as well. Particularly it may cause a shrinking of cells in several important areas of the brain. One of these is the hippocampus, which governs the formation of short term memory. Another is the prefrontal cortex, which has many functions in reasoning.

And how many patients got treatment? Only 3 percent of the patients who were diagnosed with depression had ever received even a single one month trial of anti-depressant medication! This is shameful in a country that claims to have good health care.

So what do we learn from these studies?

  1. Depression is a chronic disease, and relapse is very high.
  2. Each relapse makes you more susceptible to future depressions. Each depression erodes the resilience of the brain.
  3. A small but substantial percentage of depressed patients remain depressed for years on end.
  4. Prevention of initial depressions, early treatment of major depression, and prevention of future depressions can change the natural history of depression, and prevent a lifetime of depression.


The other important thing to realize about these studies is that they only looked at major depression. That is, at depression with many serious symptoms. Later studies that have looked at milder versions of depression have found that even mild depressions predict future major depressions. A future post will talk about minor depression, or dysthymia.

Copyright 2006 The Psychology Lounge/TPL Productions

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Depression: No Big Problem? Right? Wrong!

Here is some more good stuff from Peter Cramer’s book Against Depression, which is his follow-up to Listening to Prozac, his groundbreaking book about depression and Prozac. This is a fascinating book, as good as Listening to Prozac. If you have any interest at all in learning more about depression, I would strongly recommend this book, which is a philosophical and scientific exploration of depression. Much of what follows is inspired by this book.

How big a problem is depression compared to other illnesses? Other health problems such as AIDS, arthritis, heart disease, diabetes, and cancer are much bigger problems, right?

Wrong. If you look at the impact of depression on disability, very interesting facts emerge. Let me explain how these figures are calculated. Imagine a 20 year old woman develops chronic depression that causes her to be 1/3 disabled for the next 60 years. That means she loses the equivalent of 20 years of life, which is the same as if a healthy woman died at age 60 instead of the normal lifespan of 80.

When disability from depression is calculated this way, the figures are astounding. The World Health Organization looked at this data from around the world. They found that by the year 2020 depression will be the largest cause of disability with the sole exception of heart disease. Even in 1990, depression was already the number one cause of disability within the major chronic diseases of midlife. Major depression accounted for almost 20 percent of disability-adjusted life years lost for women in the developed countries. This was more than three times the amount caused by the next illness.

Other studies looked at the impact of depression in the workplace. In the United States this cost is estimated at over 40 billion dollars, which is almost 3% of the total economy. Being depressed on the job is estimated as the equivalent of calling in sick half a day per week.

Just how common is depression? There are many studies and they often disagree, but the best studies suggest that about 16 percent of Americans will suffer a major depression over their lifetime. That is almost 1 in 6 Americans. Look around at your friends and family and co-workers, 1 in 6 of them will suffer a major depression. In any given year, between 6-7 percent suffer major depression.

And depression has major health implications. Studies that look at elderly people find that depression increases the risk of death very significantly, independent of suicide. One study found that elderly people who were depressed were 40 percent more likely to die than those who were undepressed. When they analyzed the data to see what the cause was, they found that even when you controlled for all other health behaviors and other factors, depression still accounted for 24 percent increase in deaths. This was the equivalent of high blood pressure, smoking, stroke, or congestive heart failure.

So depression is no big deal? Not unless you consider major disability, huge workplace effects, and shortened life a big deal. In reality, depression is one of the most devastating diseases that human beings suffer.

Copyright 2006 The Psychology Lounge/TPL Productions

——————————————————————————————————————

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.