Too stoic for antidepressants

Should people who are depressed take antidepressant medication, or should they just tough it out?

There’s often a stigma surrounding the use of antidepressants, and it may be preventing people from getting the treatment they need, college student Leah Lancaster wrote this week in an insightful opinion piece for the Minnesota Daily.

Lancaster writes that she has been taking antidepressants since she was 15 years old – and that without them, she most likely would not have gone to college. “Yet, when the topic comes up, I often find myself defending my decision against accusations that I’m ‘numbing myself’ or ‘taking the easy way out,’” she writes. “Supposedly, if I did yoga, ate healthier and took a more ‘natural’ approach, I wouldn’t need to contaminate my mind and body with toxic pills.”

Some of the stigma surrounding depression itself seems to have eased in the last couple of decades. But when it comes to antidepressants, it can still be hard for the public to accept that for many people, medication may be necessary to help them feel better.

It’s hard to measure how widespread this attitude might be. It clearly exists, however, and one of the consequences is untreated depression. A study that appeared last year in the Annals of Family Medicine found that patients often don’t tell their primary care doctor that they’re experiencing depression. The No. 1 reason for this lack of disclosure? They feared being prescribed an antidepressant.

Even in the medical setting, patients often are reluctant to report that they take prescription medication for depression or anxiety, writes Mag Inzire, a physician assistant at a community hospital in New York.

The patients she encounters rarely worry about disclosing a history of diabetes or high blood pressure, she wrote. “Yet when it comes to depression or anxiety, there is some uncertainty in their response. And it always seems to follow by some long, drawn-out explanation as if to justify the diagnosis.”

Depression in fact is relatively common. In any given year, about 6.5 percent of the
American population will experience depression. Across a lifetime, about 16.2 percent of the population will have depression at some point. Stigma or not, antidepressants are one of the most frequently prescribed drug categories in the United States.

How antidepressants work in the brain, and whether they’re truly effective, is a matter for some debate. At one time it was thought that low levels of serotonin, a mood-enhancing chemical, were a trigger for depression, and that drugs such as Prozac, which raise the level of serotonin in the brain, would correct this. This theory has been called into question, though, and if continuing neuroscience study is any indication, the role of antidepressants is considerably more complex than this.

Why, for instance, does medication seem to be more effective for severe depression but less so for mild or moderate depression? Why do some antidepressant medications cause a worsening of depression in some people?

Studies have found that people with mild depression often do well with talk therapy alone. Other studies have found that a combination of medication and talk therapy is often most effective for mild to moderate depression. What does this mean for the role of talk therapy in treating some forms of depression?

Of the millions of antidepressant pills dispensed in the U.S. each year, some likely have been overprescribed to those who don’t really need them. “The reality is that many psychiatrists do give out pills too freely, and many patients start taking medications without properly researching them beforehand,” Lancaster writes.

But in her own case, antidepressant medication has made the difference between being able to function vs. withdrawing from life, she wrote.

Medication hasn’t been a cure for her. “No pills can do that,” she wrote. “What they can do is give you some energy and focus so you can make it through the day without feeling lethargic, irritable or just downright horrible.”

And she notes a double standard, at least in college-campus culture, of peers who view binge drinking, smoking, unprotected sex and “study drugs” as socially acceptable but believe antidepressants are “dangerous and mind numbing.”

“Like any medicine, antidepressants aren’t perfect,” she wrote. “But to make the sweeping generalization that all of them are bad is dangerous and prevents many from getting the help they need.”

Will the mental health stigma ever end?

My calendar today says it’s Aug. 8, 2012. That’s more than a decade into the 21st century. So why does it still often feel we’re back in the Dark Ages when it comes to mental health?

The latest evidence that the stigma surrounding depression and substance use remains alive and well was demonstrated this week in the petty politicking of Sen. Mike Parry of Waseca, Minn., who portrayed Minnesota Gov. Mark Dayton as a pill popper and “scary.”

You can say this for the critics: They were immediately all over Parry like glue on a cheap campaign bumper sticker. Maybe there’s more enlightenment out there than I think.

But would that this were about politics alone.

I don’t know Sen. Parry, I wasn’t at the Brown County Republican fundraiser where the remarks were made, and I wouldn’t presume to guess what he was thinking. But given that Gov. Dayton has been open about his depression and alcoholism, both of which have been treated, it’s hard to see this as anything other than a barb aimed squarely at the “weakness” implied by taking medication for a mental health issue.

And it’s shameful, because the last thing we need is to perpetuate the negative attitudes and judgments that often make it so hard for people to get help.

I had the opportunity last week to visit with some folks at Chippewa County Montevideo Hospital and Medical Clinics, here in west central Minnesota, about a community survey they’re launching this month to learn more about local attitudes regarding mental health and substance use.

The health providers in Montevideo have been working hard in the past few years to get better at identifying people who may have issues with depression and unhealthy substance use and connecting them with sources of help. What they’ve discovered, however, is that it’s often difficult to even begin the conversation. Patients are uncomfortable talking about it; sometimes doctors are uncomfortable too.

It’s hoped that the survey will give Montevideo health providers a better understanding of how their community feels about depression and substance abuse and lead to some strategies that will help.

People don’t get better when these issues stay in the closet. But to admit to being depressed, or to having a problem with alcohol, is to risk opening up oneself to negative judgments by the misinformed. The fact that a public figure would even go there – and on the record, no less – makes it painfully clear that the fear of being stigmatized is well founded.

Consider a poll conducted in 2004 in Tarrant County and Fort Worth, Texas, that found two out of five of those surveyed believed anyone with a history of mental illness should be barred from public office, more than 40 percent believed major depression was the result of a lack of willpower, and fully 60 percent thought “pulling yourself together” was an effective treatment for depression. Or a 2009 study in the Medical Care journal that concluded fear of stigma and how their parents would react was a major reason why adolescents didn’t seek treatment for depression. Or recent research suggesting that one in three U.S. soldiers with post-traumatic stress syndrome doesn’t seek treatment because of the stigma.

Really, the Parry incident shouldn’t be worth the ink being spent on it, except for one thing: the message that is sent by looking the other way.

Untreated depression and substance abuse take a toll on people’s lives, on their quality of life and their human potential. They take a toll on society. The consequences are serious indeed: Of the thousands of Americans who die by suicide each year, the vast majority have an untreated or ineffectively treated mental illness, most commonly depression.

Can we afford to allow the misinformation and stigma to continue? I don’t think so. Please get the facts and get educated. If you can’t or won’t, then at least have the grace to just keep quiet.

The medicalization of grief

Is grief part of the normal human experience, or is it a “problem” in need of fixing?

When the fifth edition of the Diagnostic and Statistical Manual, the so-called Bible of mental health disorders, is published next year, it more than likely will contain major revisions in how some conditions – personality disorder, for instance – are defined and diagnosed.

Of all the revisions that are under review, few have been more intensely debated than the one that would add complicated grief to the list of major depressive disorders and that would allow depression to be diagnosed within two weeks of a loss.

Will it mean that millions of bereaved individuals will be labeled with a mental disorder simply because they’re grieving? Many say this could be exactly what happens.

The discussion boiled over this month with a blog entry by Dr. Joanne Cacciatore, a researcher at Arizona State University and founder of a nonprofit group for grieving parents. The proposed revision – especially the two-week time frame – would have the effect of “further pathologizing the authentic human experience of sorrow,” Dr. Cacciatore wrote. “So, a person may, at the discretion of a psychiatrist, social worker, or psychologist, be categorized as ‘mentally ill’ as soon as two weeks following the death of a loved one.”

Bereavement isn’t a state that can be healed with pills or therapy, she writes. “If we wish, as a society, to truly help those suffering in the aftermath of loss, then we must make the move toward collective compassionate and open hearts. Systems of ‘care,’ HMOs, hospitals, and evidence-based practice manuals will not help heal others.”

There isn’t always a clear line between grief and depression. Often they resemble each other, and at times they may overlap. But how much of this is normal and how much should be considered “disordered”?

In a statement issued in response to the uproar over the DSM-V’s proposed handling of grief, Dr. Kenneth Kendler, a member of the work group on mood disorders, offers a perspective on where the dividing line might lie:

… The vast majority of individuals exposed to grief and to these other terrible misfortunes do not develop major depression. That does not mean, and here is the source of much confusion, that they do not grieve. They do. It does not mean that they do not feel terrible pain and loneliness. They do. Depression is a slippery word and we are so used to using it to mean “sad”, “blue”, “upset” or, in this specific case, “grieving.” Major depression – the diagnostic term – is something quite different.

How much of this debate is rooted in a broader cultural aversion to grief, loss and suffering and a belief that it’s somehow better for bereaved individuals to blunt their pain with medication or therapy? A mother who lost her firstborn son to stillbirth had this to say in response to Dr. Cacciatore’s blog:

“there are some things in life we just need to FEEL with every nerve ending (physical and emotional), no matter how much it hurts. that’s the only way to get through it, come to terms with it, and learn to live with it.”

For some people, grief can indeed become so prolonged or intense that it interferes with their ability to function. These individuals may need help but it doesn’t necessarily mean they’re clinically depressed – or, more to the point, that they should be treated the same way as someone with depression, argue Dr. Allen Frances, a professor emeritus at Duke University who chaired the DSM-IV task force, and Dr. Holly Prigerson, a Harvard psychologist who specializes in grief.

Although it’s possible for someone with prolonged grief to also have major depression, the two conditions aren’t interchangeable, Dr. Prigerson explains. “In the context of bereavement, survivors are likely to experience symptoms of both depression and grief. But the characteristics that define an orange, or grief, are not the same as those that define an apple, or depression.”

Dr. Frances concludes: “It is important to respect the legitimacy of all forms of grief, but also to provide a helping hand to those who need it.”

What do readers think about the DSM-V proposal? Does it medicalize normal grief? Will it help bereaved individuals experiencing prolonged or severe grief?

Talking about depression

Depression doesn’t care if you’re well off or struggling on the lower rungs of the economic ladder. For better or worse, though, it often goes hand in hand with poverty – a fact that’s taking on increased significance as the global ranks of the poor continue to swell.

Here are some sobering findings from some of the data collected for STAR-D (Sequenced Treatment Alternatives to Relieve Depression), one of the largest studies in the U.S. on depression and the treatment of depression: Chronic depression is associated with unemployment, lower income, less education, lack of health insurance, lower quality of life and poorer overall health.

One of the big questions is which comes first. Do people develop depression because they’re poor, or do they become poor because of the toll depression often takes on human potential?

The burden of depression is no small matter. It’s one of the most prevalent mental health conditions in the U.S., affecting approximately one in every 10 Americans.

You’d think this would make the public more aware of depression and more likely to be able to recognize it and have it effectively treated. All too often, though, this isn’t the case.

Several years ago I visited with local mental health professionals for a story about a new initiative on depression and older adults. I learned a number of things – for instance, that here in the rural Midwest there’s a tendency to believe depression is a character weakness that can be fixed with a dose of stoicism and/or positive thinking. I also learned that when older adults develop depression, it’s frequently shrugged off as normal. Similar misconceptions apply to age and demographic groups across the board.

Given all of this, it was therefore both dismaying and enlightening to come across a recent study in the Annals of Family Medicine that explores some of the reasons why patients often don’t tell their primary care doctor that they’re struggling with depression.

The study, which involved about 1,000 adults in California, came up with some interesting findings:

- More than 40 percent of the respondents reported at least one barrier to asking their doctor for help with their depression. The most common reason: worries about being put on medication.

- Stigma appeared to be an issue for at least some of the survey participants. Fifteen percent didn’t trust the confidentiality of the medical record. Others feared being referred to a counselor or psychiatrist, or being labeled as a psychiatric patient.

- Those who reported the most barriers also were the most likely to have moderate to severe depression - in other words, they had the most to lose by not speaking up about their depression. People who are depressed may not be able to speak up, however – often because their capabilities are diminished or they don’t perceive themselves as competent, the study’s authors point out.

- Here’s one of the clinchers: Lower income and less education were associated with more, rather than fewer, barriers to disclosing depression to a primary care doctor.

The relationship between socioeconomic status and depression is no doubt complex and not fully understood. It’s pretty clear, though, that it exerts a significant undertow on society when it goes unrecognized and unaddressed.

You can learn more about depression by checking out the many links on the National Institute for Mental Health’s online resource center for information on depression or by visiting the Screening for Mental Health website, where you can complete an online assessment for depression.

Photo: Wikimedia Commons

Facebook for grownups

It appears to be the top health news story of the week already: The American Academy of Pediatrics published new guidelines Monday to help pediatricians be on the lookout for depression, cyberbullying and other concerns associated with use of the social media.

It’s about time. There’s been considerable debate over whether Facebook, chat rooms and other online activities are good or bad for kids’ health. The AAP’s clinical report, which appears in the latest issue of the Pediatrics journal, cites a Common Sense Media poll indicating 22 percent of adolescents log on to their favorite social media site more than 10 times a day and more than half visit one of the social sites, such as Facebook, at least once a day.

The risks include harassment, indiscreet behavior, potential exposure to inappropriate photos and information, and “Facebook depression,” the feeling that all your friends are more popular and having more fun than you are.

These are all very real concerns. The cut-and-thrust of the social scene among pre-teens and adolescents can be quite ferocious, with plenty of potential for kids to get into trouble. But what I want to know is: Should there be guidelines for adults too?

Adults are presumably more mature, more experienced and better equipped to navigate the social media. Or are they?

Unwise behavior knows no age limit. Adults can be stalked or bullied on the Internet too, or captured in a moment of indiscretion with possible repercussions for their career and/or personal and professional relationships. (Consider a study published last year in the Journal of the American Medical Association, which polled medical students anonymously about their online experiences and found episodes of profanity, sexually suggestive comments, discriminatory language, depictions of drunkenness and illegal drug use, and violations of patient confidentiality.)

Depression and low self-esteem know no age limit either. Although social sites such as Facebook can be a wonderful way for depressed adults to connect with the rest of the world, they sometimes end up feeling worse if they perceive they’re not measuring up to everyone else’s page on Facebook. And let’s not even get into the emotional intricacies of friending. If you’re the competitive sort, you might feel like a loser if other people have way more friends than you. Even well-adjusted adults can feel a slight pang of rejection if someone doesn’t respond to their friend request or, worse yet, decides to unfriend them. (Been there.)

Nuances such as tone and facial expression can be lost online, creating misunderstandings and hurt feelings. When people have a significant emotional investment in online friendships, it can be upsetting when there are disagreements or when a debate gets personal. In one of the online communities I belong to, I’ve seen several instances of people becoming deeply offended or getting angry and storming offline after a discussion got too intense.

Even without these psychological minefields, the Internet and the social media sites have another unfortunate effect: They can easily become a vast sinkhole into which the minutes and hours disappear without a trace. Adults are just as prone as kids to frittering away their time on Facebook and chat sites, parked in a chair, not getting enough physical activity and staying up late into the night.

There’s also the potential for spreading inaccurate and possibly harmful health advice through Facebook discussions and other online interaction.

The social media aren’t just for kids. In fact, a study last year by the Pew Research Group found that social networking is growing the fastest among the older demographic. From April 2009 to May 2010, social networking among adults age 50 and older grew from 22 percent to 42 percent. An estimated one-fourth of people over age 65 are now online.

Should physicians be formulating guidelines for adult use of the Internet? Perhaps not. But they’d be smart to recognize what a force it can be, for both good and ill, in the lives of grownups as well as kids.

HealthBeat photo by Anne Polta

Mental health: still a stigma

When former Minnesota senator Mark Dayton recently disclosed his treatment for alcoholism and mild depression, I can’t say I was surprised by the reaction. Many people were understanding and felt Dayton’s issues make no difference in his qualifications as a potential future governor of Minnesota. Others, not so much.

“With all these problems, he’s not up for the job,” one person commented after reading the Minneapolis Star Tribune’s exclusive interview last month with Dayton. Someone else, referring to Dayton’s upbringing in one of Minnesota’s wealthiest families, wondered, “What does he have to be depressed about?”

You have to wonder: Would the reaction have been the same if Dayton had revealed a history of, say, asthma? Or cancer?

When it comes to mental health, there’s still a fair amount of stigma. Or, at the very least, a lot of misinformation about mental illness, the people who have it, the causes of mental illness and how to treat it. (For instance, the inaccurate notion that wealthy people should somehow be immune from clinical depression.)

More than a few experts believe it’s the stigma, not the mental health issues themselves, that’s most likely to derail Dayton’s latest political aspirations. The Star Tribune explains:

Mental illness is not the political kiss of death it once was, partly because it’s now more widely recognized as a treatable brain disease. Depression is now regarded as one of the most common medical conditions, affecting as many as one in five people at some point in their lives, by some estimates. But there is still enough stigma that many people commended Dayton for disclosing his history with both depression and alcoholism.

If this is the case, then I really don’t know what to think about the latest chapter in the story: that the Star Tribune is querying other candidates to find out whether any of them have ever received treatment for drug or alcohol use, depression or anxiety. (Politics in Minnesota broke this development late last week.)

Granted, we’re talking about a group of individuals from among whom Minnesota’s next governor likely will be elected. Perhaps some higher standards of disclosure ought to apply here – and candidates who are uncomfortable with this level of public exposure should rethink whether they truly want to be in public office.

Nevertheless, I’m uneasy with the underlying tone of “gotcha!”, the implication being that mental health issues are the damaging equivalent of a skeleton in the closet that should be dragged forth and revealed. And where, I wonder, do we draw the medical privacy line for candidates for public office?

I’ve been following the discussion at David Brauer’s media blog at MinnPost, where the issue has ripened into a contentious brew of politics, mental health, media ethics and privacy rights. Brauer asks: “Why should mental health questions be off limits if we wouldn’t bat an eye when candidates are asked for their traditional health histories?”

A sample of some of the comments:

- “Politicians are human beings with faults and frailties. It would help society in the long run to realize this, and not to demand some superhuman strength as a precondition of public service.”

- “As someone who feels most of the public can’t adequately understand the most primary of issues, it gives me pause to think we are going to let people make their own judgment about phenomena which aren’t even deeply understood by clinicians.”

- “The stigma doesn’t come from not talking about it. It doesn’t come from talking about it. It comes from treating that element of health as different from… you know… the health of ‘normal’ people.”

- “What do you think, every elected official currently serving is the picture of perfect physical and mental health? Medical records are confidential for a reason; keeping them that way doesn’t stigmatize anyone. The invasion of privacy will not promote human dignity. If we’re all gonna start voting based on our ‘medical’ evaluations of candidates, seriously, stick a fork in us… we’re done.”

- “If a candidate ingests potentially mood-altering drugs on a daily basis, does it really matter whether the candidate is self-medicating (alcohol or some illict drug), had been prescribed Vicodin or methadone for chronic pain, or takes a combination of antidepressants to correct a biochemical imbalance? I don’t think so. What does matter, it seems, is the moral judgment which still attaches to mental health conditions in the minds of many.”

While most of us would like to think we in the United States are understanding and caring when it comes to mental illness, the evidence all too often points to the contrary. Heiress Casey Johnson, for instance, who died last week at the age of 30, captured tabloid headlines for her outrageous lifestyle when in fact she may have been suffering from an undiagnosed – and untreated – psychiatric illness, Dr. Harold Koplewicz, a child and adolescent psychiatrist, writes in a commentary for the Huffington Post. “Regardless of the family’s income or celebrity, the stigma associated with mental illness encourages denial and inhibits the actions of those who care desperately and sincerely want to help,” he wrote.

In Britain, you can’t serve on a jury if you have a history of mental illness. Stigma also has been an issue in the U.S. military, where many service members are unwilling to seek help, even when they need it, because they fear being perceived as weak.

For what it’s worth, I think it was courageous of Mark Dayton to go public. It has put the issue squarely on the table for open discussion. Whether we’re ready to have a constructive discussion about it, especially in the highly charged political arena, is another question altogether. It’s true that we’ve made some progress; 25 or 30 years ago, an admission like Dayton’s could easily have spelled the end of his political career. But we clearly have a considerable way to go yet.

For more information on how to reduce the stigma surrounding mental illness and mental health, visit these online resources provided by the Minnesota affiliate of the National Alliance on Mental Illness.