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

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

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

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 .

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.)

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

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

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

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

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