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!

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Cognitive Behaviorists and Big Pharma Demonize Tranquilizers for PTSD

A medical society called the International Society for Traumatic Stress Studies (ISTSS) publishes a set of guidelines for treating those people suffering from post traumatic stress disorder (PTSD), such as soldiers returning from war zones or victims of natural disasters.

Treatments for PTSD generally involve both psychotherapy and psychiatric medications. No psychiatric medication controls two of the primary symptoms of post traumatic stress disorder:  re-experiencing the trauma as flashbacks, and becoming episodically numb or zoned out.  We do, however,  have a medicine that effectively controls the nightmares, believe it or not – an old blood pressure medication called prazocin. I will talk more about medication a little later in the post, but first let me discuss the psychotheray of PTSD. 

Many types of psychotherapy have been employed for PTSD, with widely varying results. 

In my clinical experience, many chronic PTSD patients have been given group therapy, in which they meet with other PTSD sufferers who have had similar experiences. I have found that this sort of treatment has been next to worthless for a significant percentage of such patients, particularly those patients who have been severely disabled by their disorder and who have been unable to work for years or even decades.

In patients with chronic PTSD (who do not also have severe personality disorders or majorly dysfunctional families), it is generally believed that the most effective type of psychotherapy is something called prolonged exposure therapy (PE), which is an intense form of what cognitive behavioral therapists (CBT) refer to as systematic  desensitization.  

It is a difficult process in which - and I am grossly simplifying it in order to be brief (and since I do not do this sort of work myself) -  the traumatic experiences suffered by the patient are relived under controlled conditions so that the anxiety and other symptoms generated by the memories can gradually be extinguished.  I have read that doctors have even experimented with recreating the traumatic events using virtual reality through computers, projected images, and earphones, to enhance the desensitization process.

In a PTSD treatment facility I know of, I was told that if a patient were taking a benzodiazepine tranquilizer like Klonopin or Xanax, then they would not be a candidate for PE and would therefore be referred to the aforementioned group therapy.  I was told this was the case because, CBT folks believed, that tranquilizers somehow affect the learning process so that the PE therapy was not effective if the patient were on the meds.  I had heard this idea before from other CBT therapists. 

However, since people who take benzodiazepines are almost never intoxicated, I had always thought this idea a bit strange. So I asked the head of the clinic for a reference. He did not know of one.  Interesting, I thought.  So I did my own literature search. 

Well guess what?  I found exactly one study that showed that benzodiazepines might affect learning in rats.  But in people?  All of the studies showed they had absolutely no effect whatsoever. 

Yet another urban CBT psychotherapy myth.

But then things got even stranger. I was also told that I should check out the treatment guidelines from ISSTS, which said that benzo’s were not indicated for the treatment of PTSD, and that  this clinic followed ISSTS guidelines.  On advice from the clinic leader, I looked up said treatment guidelines, which turned out to be pretty amazing.

Here’s what they said:

 “Although [benzos] are effective anxiolytics [anti-anxiety] and anti-panic agents, they are contraindicated [italics mine] for PTSD treatment.  They don’t reduce re-experiencing or avoiding/numbing behavior.  They should not be prescribed in patients with past or present alcohol/drug abuse or dependence.  Finally, they may produce psychomotor slowing or exacerbate depression. [Benzo’s] do not have any advantage over other classes of medications; therefore they cannot be recommended as monotherapy[again, my italics] in PTSD at this time.”

Being the cynical critic that I am, I should not have been shocked how a supposedly scientific document could be filled with so many half truths. (I’ll enumerate them shortly). But I was. And then I remembered that the pharmaceutical companies had been demonizing benzo’s ever since they all went generic and therefore became far less profitable for the companies (See my earlier post). 

The Cognitive Behavioral Mafia folks also has a vested interest in demonizing benzodiazepines, it seems to me, since the drugs are so effective for some symptoms. This leads to a situation in which  patients would rather just take drugs than go to a CBT therapist to go through systematic desensitization, which can be a long, involved process that is sometimes itself quite traumatic in the short run. 

This preference is unfortunately common even though it is probably better to treat chronic anxiety with psychotherapy than with medication alone, because when the therapy is successful, the patient might be  more or less cured. Not so with the medication.  If you stop them, the symptoms often return.  (And no, not because the medications cause the symptoms, but because they stop but do not cure the symptoms).

Of course, it is also a perfectly good idea to treat anxiety issues with medicine for the quick relief andtherapy for the eventual cure. You might then be able to stop the drugs after therapy is completed.  Remember, there is no evidence that medications interfere with systematic desensitization. Still, the CBT folks (and many psychiatrists as well) seem to think of drugs versus therapy as some sort of competition or zero sum game, so their prejudices just happen to coincide with the interests of drug companies: demonizing benzodiazepines. 

It is well documented by several news organizations that drug companies have insinuated themselves into scientific committees that draw up treatment  guidelines to make sure that their interest in making higher profits from their brand-named medication is advanced.  I do not have any proof, of course, but might this have been what happened with the ISSTS treatment guidelines for PTSD?

So let us return to the subject of the half truths in the ISSTS guidelines.  Most of the misleading ideas in the paragraph reproduced above have to do with the misconception implied in the guidelines that PTSD generally exists in some sort of psychiatric vacuum in which PTSD patients show no other symptoms of any other psychiatric disorders as well (Comorbid conditions). In fact, comorbidity is the rule rather than the exception.

For patients suffering from PTSD, I find clinically that the most important common co-morbid condition is panic disorder. In this disorder, sufferers experience severe anxiety attacks with physical symptoms that mimic those of a heart attack.  People who have been traumatized are especially vulnerable to developing panic attacks. 

I found it difficult to find information about exactly what percentage of chronic PTSD sufferers also have panic attacks, but in one study it was 35% and in those patients who sought treatment, 49%! (Cougle et. al., Anxiety Disorders 24(2), p. 183, 2010.)  In another study  (Falsetti & Resnick, Journal of Traumatic Stress 10, p. 683, 1997) the percentage was 69%. More than two thirds!

Yet another study (MacFarlane and Papay, Journal of Nervous and Mental Disorders 180 (8)p.498, 1992) showed that comorbid panic disorder is an important predictor of PTSD turning in to a chronic disorder.

People who have panic disorder also often develop agoraphobia - the fear of being out in crowded places.  Agorophobia is particularly likely to develop in combat veterans who have comorbid PTSD and panic disorder because of another symptom of PTSD: hyper-vigilence. It is as if these veterans have to remain constantly on guard for enemy soldiers, rocket propelled grenades, and improvised explosive devices – even though they are now back home in a safe environment. Being hyperalert in a crowd will often bring on panic attacks. 

This is probably one reason why patients with chronic PTSD and panic disorder may do not do well in group therapy. They are deathly afraid of groups.

Supposedly the first line treatment for panic disorder is an SSRI antidepressants like Paxil or Zoloft, but in my clinical experience benzodiazepines tend to be far more effective. The SSRI’s often only decrease the frequency and severity of panic attacks, but do not stop them completely as certain benzo’s often do. In fact, many victims of PTSD are already on SSRI’s when I first see them, and their panic symptoms and agoraphobia are not under any semblance of control whatsoever. 

So I add a benzo. The combination of an SSRI and a benzo is probably the most effective pharmacologic treatment of panic attacks of all, but you will never find a study that shows that.  In fact, you will never find a study using them in combination for the treatment of any disorder. The drug companies won’t fund such studies, because they don’t want doctors to think that benzo’s are good drugs.

Interestingly, the clinic I have been discussing allows patients who are on SSRI’s to get PE, whereas not so for those on benzo’s or the combination.

Back to the ISSTS guidelines.  They correctly point out that benzo’s do not help the PTSD symptoms of flashbacks and numbing - but no one has said that they do.  I agree that they should not be used as monotherapy for PTSD, as the guidelines say, for that very reason. But why would they be contraindicated (which means they should never ever be used under any condition)? The guidelines themselves start out by admitting that they are very effective for panic disorder, which as I have shown is highly comorbid with PTSD.

Well, maybe it’s because, “They should not be prescribed in patients with past or present alcohol/drug abuse or dependence. Finally, they may produce psychomotor slowing or exacerbate depression.” 

Well first of all, the first statement is not at all true for all patients, particularly those patients who have been sober for a significant period of time. Two different studies have shown that ex-alcoholics do not abuse benzo’s at a higher rate than anyone else. Also, some alcoholics are drinking only because they are, in fact, medicating themselves with alcohol for their panic attacks. They often STOP drinking when put on a benzo.

And even if a chronic PTSD sufferer becomes dependent on benzo’s, so what?  Is that somehow worse that being nearly housebound and completely disabled from work because of panic disorder with agoraphobia?  I think not. And the drugs have almost no side effects. The worst thing about being addicted to a benzo is that you are addicted to a benzo.

Ironically, a lot of the PTSD patients I see are never taken off SSRI’s. Essentially, they are dependent on them. But somehow that’s different. How?  Beats me.

What about benzo’s causing depression?  They sometimes do.  Rarely. The studies that led to FDA approval of the various benzo’s show that this happens in the range of 2-6% of cases. Not much different than placebo!  Sometimes one benzo will have this side effect on a given patient, while another will not. And if they all do in a given patient, they can be discontinued. Or an SSRI can be added for the very effective combination therapy, which prevents this side effect as well as the panic attacks.

The treatment guidelines do not say that SSRI’s are contraindicated because some people might develop side effects, so why should benzo’s be? This is particularly nonsensical in light of the fact that one common side effect of SSRI medication is increased agitation. PTSD is an anxiety disorder!!  (This side effect can also be treated with – you guessed it – a benzo).

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