Dr Carolyn Kaufman Guest Blogs 21st Century Treatments for Depression

Hi everyone! On Monday I talked about how The Writer's Guide to Psychology is useful and generally fabulous. Today, the author, Dr. Carolyn Kaufman, is here to tell you about cutting edge treatments for depression.

I don't know if you folks know this, but Dr. Kaufman is an assistant professor at Columbus State Community College and also teaches classes at Otterbein College. She'll stop by later to answer any questions you have, but as a result of her teaching schedule, it will probably be in the afternoon and evening.

In addition, she's giving away one signed copy of The Writer's Guide to Psychology to one of my commenters today! I'll be announcing the winner Friday. And without further ado ...

If your character has a serious problem with depression, you probably think she has two options for treatment: psychotherapy or medications.  And you’d be right – sort of.  Those are the first two things a good therapist will try. But what happens if neither approach works?  Are there cool new 21^st-century alternatives?

You bet there are.

Now, in most cases, your character will start with psychotherapy, and in many cases, psychotherapy alone is sufficient.  Sometimes, however,  medications warrant serious consideration; here are a couple of examples of situations when your therapist will want to consider referring to a psychiatrist:

1. The client is so depressed that she’s unable to really get much out of therapy – she needs additional help.
2. The client has numerous close family members who are taking medication for the same condition – and they’re benefitting from that medication or medications.

Once in a while, however, an individual has what we call Treatment-Resistant Depression (TRD), which means that various psychotherapeutic approaches and medications have been inadequate to help the person.  Research suggests that for these people, Treatment as Usual (TAU) may only be successful in about 7% of cases.

The Old Standard

Traditionally, electroconvulsive therapy (ECT) has been used as a last-ditch effort in these situations.  The good news is that ECT is not the brutal, barbaric thing portrayed in most movies, where the wide-awake patient is strapped down and subjected to painful, terrifying shocks that cause convulsions.  Rather, the person is both asleep (thanks to a general anesthesia) and still (thanks to a muscle relaxant). Miraculously, some people feel significantly better after a single treatment, but for most people, several weeks’ worth of treatments are necessary.  After that, medications and psychotherapy are usually effective.

 The biggest downside of ECT is that it interferes with what we call the “consolidation” of memory.  In other words, over the few weeks that you’re doing ECT, you may have trouble storing information in long-term memory. That can certainly make it hard to remember your next appointment if you don’t have it written down!

Though most people say they would do ECT again if they needed it, and though it has been called “no more unpleasant” than going to the dentist (?!), some people have really bad experiences with it. For example, once in a while people who have undergone ECT say that they have problems with anterograde memory loss (which means they have trouble remembering things even after the ECT is done). Others say they have retrograde amnesia, which means they have forgotten chunks of their past.  The hard thing about these situations is that normally ECT is only done when the doctors don’t know what else to do to keep someone alive.  So which is worse – being dead, or having some memory loss?  The answer genuinely depends on the person. 

But scientists have been working on new, drug-free biological treatments for people with TRD.  Here are three.

Transcranial Magnetic Stimulation (TMS)

Transcranial Magnetic Stimulation is the least invasive of the three new treatments I want to discuss.  Unlike the other two, there is no surgery and no implantation of a device.

During TMS, the client sits in a chair that resembles a dentist’s chair (I know, what’s with the recurring dentist theme?), and an electromagnetic coil is placed near the left front of the head. The coil turns on and off rapidly, creating a magnetic field that stimulates the brain’s cells (called “neurons”) to release brain chemicals like serotonin and norepinephrine. (In people who are depressed, serotonin and norepinephrine levels are too low.)

The machine makes a very loud (and unpleasant) tap-tap-tap-tap sound as the electromagnetic coil is turned on and off, so both client and doctor wear earplugs. Many people experience prickling or discomfort of the scalp under the coil, and some experience twitching of facial muscles or headaches afterward. Research suggests, however, that about half of the people who undergo TMS experience some relief of their depression symptoms.

Vagus Nerve Stimulation (VNS)

Both Vagus Nerve Stimulation and the next treatment we talk about, Deep Brain Stimulation, involve a bigger commitment than TMS.  Both involve the surgical implantation of an expensive pacemaker-like device under the collarbone. 

With VNS, wires run from the main device up into the neck  and are wrapped around the vagus nerve, which travels up into the brain and down into the body.  Every five minutes, the VNS unit emits a mild electrical pulse.  At first, this pulse is noticeable: it feels like a very mild shock accompanied by the requisite prickle of electricity on the left side of the voice box.  Over time, however, the body adjusts and the individual is no longer aware of the pulses unless she’s paying close attention, exercising heavily, or speaking loudly (the pulse makes some people’s voices a little bit husky or hoarse). The prickling sensation goes away, and the pulse itself feels like a finger laid very lightly against the left side of the voice box.

The effects of VNS take time, and patients may take up to a year to get the full effects.  The battery in the unit is said to last up to 7 years in some patients; when it runs out, a whole new pacemaker-like device has to be implanted.

Research argues that significantly more people with TRD respond to VNS therapy than treatment as usual (ie therapy and medication alone), with about a third of patients getting significant relief and up to 80% of patients getting some relief.

Deep Brain Stimulation (DBS)

Still in the experimental stages, Deep Brain Stimulation also involves the implantation of a pacemaker-like device under the collarbone.  Rather than wrapping around the vagus nerve, however, the electrodes are placed directly into the brain.  Patients are awake when the electrode is actually inserted, and many, fascinatingly, report an immediate lifting of their depression.  Early research has shown that patients have remained in remission while the current is left on, but experience a return of symptoms when the current is switched off.

What makes DBS unique is that it may help people for whom electroconvulsive therapy has not been effective.  TMS and VNS are not usually helpful for this group.

Since DBS has not been proven in large groups of people, it has not yet been approved for depression in North America.

Particularly with the last two treatments, you may think that you wouldn’t want someone implanting anything in your body – and especially in your brain – for any reason! But for people for whom depression is an unrelenting specter, these treatments offer new hope.  Unfortunately, although both TMS and VNS  have been FDA-approved for depression in the US, insurance companies aren’t usually willing to pay for them, forcing individuals to find ways to pay for them out of pocket.

For more information on TMS:

NAMI: http://www.nami.org/Content/ContentGroups/Helpline1/Transcranial_Magnetic_Stimulation_(rTMS).htm

Neurostar (company that makes the TMS machine): http://www.neurostartms.com/Home.aspx

For more information on VNS:

VNS and Me: Wordpress Blog of someone who was implanted with the VNS device: http://vnsandme.wordpress.com/

Cyberonics (company that makes the VNS device): http://us.cyberonics.com/en/vns-therapy/

For more information on DBS:

Time Magazine article: http://www.time.com/time/magazine/article/0,9171,1214939,00.html

What do you think? Had you heard of these treatments? What questions do you have for Dr. Kaufman (they don't have to be limited to these treatments--feel free to ask general questions or anything about The Writer's Guide)? Remember--one commenter will win a signed copy of The Writer's Guide to Psychology, so ask (or just comment) away! She'll stop by after 3pm (EST) to answer!

And finally, on the Sisterhood of the Traveling Blog front, Deb Salisbury is posting today about what she does when she loses her writing mojo. Please check it out!

Depression Anger Sherrys Testimony

Everyone who suffers from depression struggles with anger to some degree. It may be focused or unfocused, or be primarily directed at depression’s symptoms as well as towards our own mind and body for ruining our life by never ceasing to manufacture those symptoms month after month. Focused anger can be towards whatever or whoever caused the depression, towards God for allowing this thing to befall us, or even towards the enemy.

My sister in Christ, Sherry Castellucio, has kindly granted me permission to reprint here an article she wrote called, ‘Fighting Depression.’ She shares her testimony of her life long battle with depression and its accompanying anger.


FIGHTING DEPRESSION, by Sherry Castelluccio

The best way I’ve heard depression described is “anger turned inward”. It can be a real vicious anger, depending on the week. It’s a debilitating, mean-spirited, cruel monster with little regard for the rest of the world. It doesn’t matter if you’re a stay at home mom or if you’re a teenager just trying to survive. You could be an old lady, living at home by yourself with all of your family away in other parts of the country, or you could be a widower who just lost the love of your life. It’s no respecter of persons and doesn’t care about age, race, or religion. If you are human, you are susceptible. If you’ve had it before you’re even more of a target.

Over the years, I’ve found the simplest way to fight it is just to accept it. Yes, I have depression but no, I’m not going to allow it to rule my life. The biggest help I’ve ever given myself was to figure out what parts of it I can control and what parts I need help with. I can’t control the fact that it’s genetic and sometimes appears, regardless of how hard I fight to contain it. After the birth of my child, it buried me. Suddenly I was enmeshed in things I had no control over and my body literally shut down like a computer hard drive. There was simply too much information to process.

I remember feeling so incredibly angry but had not the foggiest idea why. Surrounded by in-laws, an intrusive mother, and a newborn became too much to handle all at once. I had to learn how to function as a person and learn how to keep the voices at bay, and eventually disappear. I had to accept that for a while the only elixir was medication.

The parts I can control are a bit trickier. I know what I have to do to make this better, but I have to decide what I’m going to do about it. I have to choose within myself how I’m going to live today, being bitter and angry or choosing to come out of it, albeit ever so slowly. I have to know what makes me feel good and even if I have no desire to participate in those things, I know I must if I am to make it out alive and able to be the person my family needs me to be. It’s much easier to admit I can’t live this way when there are people at home that need me.

Still, there are those days when I would much rather curl myself up into the foetal position and sleep the day away, forgetting everything and everyone in my life. Shirking my responsibilities and ignoring my needs are tempting, but not realistic. It’s my responsibility to make this home run smoothly and raise my child the best way I know how. It’s impossible to be productive when I’m zonked out in bed.

The Lord has been so faithful in pulling me out. He never fails to reveal himself in those dark times when I feel so empty, so lifeless. He is there reminding me that if I just give a little bit, try just a tiny fraction, He’ll bless me for it. It is work but I give in to Him because I know that He is right. It isn’t worth it to indulge in myself because I get nothing out of it. Giving in to myself is the last great mistake.

What words of comfort can I give to someone who struggles as I do? Remember that the devil is a liar, you are loved and it is possible to go on today. Recognize your anger for what it is and do something constructive about it.

Are you bored at home? Pick up that hobby you put down. Are you lonely? Call that friend you haven’t spoken to in months. You will both be glad you did. Is your body physically sick? Go sit outside in the sun for a few minutes. Find the one thing that makes you smile and drink it up.

Surround yourself with children, rent a comedy, finger paint. You are here because God put you here with a purpose. Find out what it is, make it your ambition to find out what you can do to bless others. I have found that the fastest way to bust Satan in the teeth is to do something for someone else. It puts a stop to the feelings of sadness and makes you feel alive and full of purpose, all at the same time. Make yourself laugh. It’s the simplest, most inexpensive cure there is and the most readily available. It changes your whole outlook.

“I praise you because I am fearfully and wonderfully made; your works are wonderful, I know that full well”. (Psalm 139:14) Allow this truth to embrace you and accept you. You are His child and he loves you as if you were the only one on this earth.

I have suffered from depression my whole life but I refuse to allow it to consume me and to dictate how I will live. My master is my Saviour Jesus Christ. I submit to his laws, not the laws of depression. There are some days that I am happy simply because I am alive and loved. There are other days when I must decide that I’m going to be happy, regardless of what my body or mind is telling me. It’s those days, when I have to make the most effort to really choose to smile that I know God is with me. Those are the days when I know I’m winning.

Fighting depression is no easy thing. Half the battle is won when you can stand back and decide that your life is good, even if Satan is trying to convince you otherwise. And in the end, the joke’s on him. He can’t be happy because he can’t be in the presence of the Lord. Now that is a depressing thought.

© 2005 Sherry Castelluccio

Download an ebook on depression, ie, this blog's articles

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Latuda and Bipolar Depression

Have you seen them? The brand new, direct to consumer (DTC), ads touting the drug Latuda for bipolar depression? The drug company just received the indication for this purpose from the FDA a very short time ago, but the drug company, Sunovion Pharmaceuticals Inc., was ready to roll.

Latuda is a dopamine blocking drug, which makes it an antipsychotic medication and not an antidepressant.  We have known since the 1950’s that all antipsychotic medications have some effectiveness in bipolar disorder, although primarily for the prevention of the manic phase of the illness. We have known that they also may augment an antidepressant for those who only get a partial response to the antidepressant in both unipolar and bipolar depression. A colleague of mine routinely used the antipsychotic Navane to augment the old tricyclic antidepressants in the 1970's.

Only two other antipsychotic medications have official FDA indications for bipolar depression, probably because the other drug companies did not spend the money to get it.  If doctors know one member of a class works, they’ll know that the others probably will too, so why bother?  One of these two drugs that has the bipolar indication is actually a combination drug containing an antipsychotic medication (Olanzepine [Zyprexa]) AND the antidepressant Prozac. The other is Quetiapine [Seroquel].

The main problem with using an antipsychotic instead of an antidepressant in this condition – aside from the unequivocal fact that antidepressants are way more effective – is that antipsychotics have much more potential toxicity. Latuda is probably one of the safer ones in this regard, having a low incidence of the two biggest concerns, metabolic syndrome (weight gain, higher cholesterol, diabetes - horrible and very common problems with Zyprexa and Seroquel) and the long-term neurological side effect, tardive dyskinesia.  Interestingly, the FDA won’t let Sunovion make that claim despite the fact that it’s true!  Go figure.

Almost simultaneously with the start of Latuda's DTC ad campaign, two research studies of the drug’s use in bipolar depression were published in the February 2014 issue of the flagship psychiatry journal, the American Journal of Psychiatry (AJP). The studies showed that the drug was effective by itself for the disorder, and also effective as an adjunct treatment when combined with either of the two major anti-manic drugs, lithium and valproate.  Weirdly, the  “effect size” of the improvement in patients, a measure of how much better patients got, was less (0.34) with combination therapy than it was in the case of the drug by itself (0.51). Both of these effect sizes are moderate at best, btw.

That difference is particularly odd in the case of valproate, since there is zero evidence that it is effective for the depressed stage of bipolar disorder (lithium sometimes is, but not usually). Does valproate somehow make Latuda less effective than it would be otherwise?

There is a big issue here:  the question of whether antidepressants alone are the better choice for treatment of bipolar depression.

The last author of the first AJP Latuda  study is Gary Sachs, someone I have discussed previously in this blog [ 10/31/11].  He is the author of a major study that claimed to show that antidepressants were completely ineffective – worse than placebo – in the treatment of the depressed phase of bipolar disorder.  

He conveniently neglected to point out in the earlier paper that the sample of patients he used in this study had already proved to be resistant to antidepressant medication in the first place, and continued to dissemble about this omission when I had the opportunity to confront him about it. Some subjects of his had even failed a trial of a combined antidepressant and antipsychotic. The conclusion of the study as presented in the study was bogus as hell.

A defender of Dr. Sachs made this point: Dr Sachs and colleagues in the abstract did not say that they had proven that antidepressants were ineffective in bipolar depression. They reported their finding and immediately called for additional long-term well designed studies - what I have called plausible deniability.

The more recent Latuda article which Sachs co-authored did in fact state the following: “There is limited evidence of the use of standard antidepressants for the treatment of bipolar depression.”  I guess that isn’t exactlythe same as saying they don’t work, is it?  Might as well be, though! It's not what you say, it's what people hear.

Furthermore, I learned from the article that Dr. Sachs is a paid consultant for Sunovion pharmaceuticals!  

The article’s reference for the statement about antidepressants not being effective was one study that was a meta-analysis of existing studies of antidepressants in bipolar depression (a study which combines the statistics from several other studies). In an editorial in the same AJP issue publishing the Latuda studies, one R.H. Belmaker restates the opinion that “the evidence that antidepressants can be useful seems less and less convincing.”  

His reference for this statement? It is an editorial he himself wrote in the same journal as the original bogus Sachs article appeared [New England Journal of Medicine 356 (17), 4/26/07 (NEJM)]!  I went and got a copy of it.  These folks seem to all run in the same circles, as well as in the same circular reasoning.

In that editorial, he mentions the same meta-analysis that was mentioned in the AJP Sachs article.  But he also mentions that there are two other meta-analytic studies, both totally ignored in the AJP Latuda articles, that showed that antidepressants could be “highly beneficial” in bipolar depression.

There is fairly subtle obfuscation of the evidence going on here, since the other two meta-analyses never seem to be mentioned in articles touting antipsychotics for bipolar depression any more.  I wonder why that is?

In Belmaker’s original NEJM editorial, he opines that maybe the condition is heterogeneous and that subjects in studies outside of the United States may be different than they are here. The two positive metastudies were by authors from outside the USA.

Aside from the fact that there is absolutely no clinical evidence for that whatsoever, Belmaker neglects to mention that at least one of the two meta-analyses showing that antidepressants were effective did not limit itself to studies done overseas, but included studies done in the States! (I could not get a hold of the second, but this is probably also true of that one as well).

Of course, the issue of antidepressants causing bipolar patients to switch into mania is also brought up again and again ad nauseum all over the place, even though everyone agrees – even the original Sachs article in NEJM - that the anti-manic drugs like lithium and divalproate prevent this.  Since true bipolar patients should be on one of those drugs to begin with, this is a superfluous issue.

I also have my doubts that all of the subjects in the Latuda studies were even diagnosed correctly, since one of the diagnostic tools used wasthe Bipolarity Index, which includes the items, “Episodes with characteristic symptoms of hypomania, but symptoms, duration or intensity are subthreshold for hypomania or cyclothymia” and “baseline hyperthymic personality when not manic or depressed. " 

For a discussion of the significance of that nonsense, see my posts about treatment resistant depression and bipolar disease mongering.

These folks are doing nothing but trying to sell expensive and potentially toxic drugs to both doctors and the public when more effective and safer alternatives already exist.