Mindfulness

By Steven ReinbergHealthDay Reporter

TUESDAY, April 21, 2015 (HealthDay News) — Mindfulness-based cognitive therapy might offer an alternative for people with depression who don’t want to take antidepressants long-term, British researchers say.

Their study, published April 21 online in The Lancet, found this new therapy was as effective as antidepressant drugs in preventing a recurrence of depression over a two-year period.

“Depression frequently is a recurring and relapsing disorder. People suffering from it are wise to look at ways of maintaining wellness after their depressive symptoms have resolved,” said Dr. Roger Mulder, head of psychological medicine at the University of Otago in New Zealand. “Mindfulness-based cognitive therapy appears to offer one way of doing this.”

“There are alternatives to remaining well after being depressed besides being on long-term medication,” added Mulder, who wrote an editorial accompanying the study. The mindfulness therapy appears to cost no more than medication and has no side effects, he noted.

Mindfulness-based cognitive therapy brings together two treatment approaches. Guided mindfulness practices, which aim to increase awareness of negative spirals, are combined with aspects of cognitive behavioral training, a short-term therapy that teaches skills to help resist or counter damaging thoughts or moods.

The program is intended to train the mind and body to respond more constructively to experiences in hopes of preventing another slide into depression, said the researchers, led by Willem Kuyken, a professor of clinical psychology at the University of Oxford in England.

Mindfulness cognitive therapy is catching on in the United States, said Simon Rego, director of psychology training at Montefiore Medical Center/Albert Einstein College of Medicine in New York City.

“Much like with cognitive behavioral therapy, people being treated with mindfulness therapy initially see their therapist on a weekly basis and then taper off to less frequent sessions as skills are built before ending the treatment,” he said.

In the new study, 424 people with major depression were assigned to either mindfulness-based cognitive therapy or to antidepressants. Over two years, the relapse rates were similar — 44 percent in the therapy group and 47 percent in the medication group.

The therapy participants attended eight group sessions each lasting two and a quarter hours. They were also given techniques to practice at home. Therapy sessions included guided mindfulness practices, group discussion and other behavioral exercises. After the sessions ended, they had the option of attending four more sessions over a year.

Those assigned to antidepressants continued their medication for two years, the researchers said.

Tony Tang, an adjunct professor in the department of psychology at the University of Pennsylvania, is skeptical about the need for mindfulness therapy to prevent relapses of depression.

“Nobody really knows how mindfulness cognitive therapy works,” he said.

“We understand cognitive therapy a great deal by now. It works by teaching patients how to examine and refute their unrealistically negative thoughts. Mindfulness training comes from an Eastern meditation tradition. How it prevents depression is still a mystery,” Tang said.

Cognitive therapy alone can help prevent depression relapses, Tang said. “So, I am not convinced yet that the addition of mindfulness training is absolutely necessary,” he said.

But some patients might find standard cognitive therapy too logical and dry, Tang said.

“Adding the mindfulness training might make the package more appealing to many clients,” he said. “It also fits in better with the current fashion for New Age alternative care. When working with real-world patients, these are actually important considerations.”

More information

For more about depression, visit the U.S. National Institute of Mental Health.


Zelda Williams on Depression: 'Hold on to the Possibility of Hope'

Just over a year after Robin William’s death, the beloved comedian’s daughter Zelda Williams has opened up about coping with grief and depression in a touching new Instagram post.

“Avoiding fear, sadness, or anger is not the same thing as being happy. I live my sadness every day, but I don’t resent it anymore,” she wrote, accompanying a photo of a moon reflecting upon a lake. “Instead, I do it now so that the wonderful moments of joy I do find are not in order to forget, but to inhabit and enjoy for their own sake.”

She continued, “And for those suffering from depression, I know how dark and endless that tunnel can feel, but if happiness seems impossible to find, please hold on to the possibility of hope, faint though it may be.”

RELATED: 20 Celebrities Who Battled Depression

Her famous father was battling depression, anxiety, and dealing with a Parkinson’s Disease diagnosis before he died by suicide. Zelda Williams has since been an advocate for open discussion about mental health issues.

On World Mental Health Day last year, she tweeted: “Let’s stop the misconceptions & support those who need our help. Healing the whole starts with healing minds. No matter what the misinformed say, you can’t simply CHOOSE to make mental illness go away. It is NOT cowardly to suffer or seek help. Lastly, my dad openly fought depression his whole life, both in general and his own. No matter what anyone says, it is a FIGHT. Fight on.”

Read her latest post below.

RELATED: 10 Signs You Should See a Doctor for Depression

New Study: Are Antidepressant Users Bad Drivers?

SUNDAY, August 17, 2008 (Health.com) — Are antidepressant users worse drivers than those who don’t take the drugs? A new study suggests this could be the case, although it’s not entirely clear if it’s the use of the medication or the underlying depression that’s to blame.

In the study, psychologist Holly Dannewitz, PhD, and a colleague recruited 60 people who were mostly in their 20s to take a simulated driving test. Half of the subjects were taking an antidepressant and the other half were on no medications at all, aside from oral contraceptives.

The test wasn’t a Sunday drive. The subjects had to steer smoothly around a track; follow a car in front of them; hit a “brake pedal” when they saw taillights; and click a paddle or hit a button when they saw a red light, traffic hazard, or stop sign.

Overall, antidepressant users performed worse on the test than those not taking the drugs, according to the study, which will be presented at the American Psychological Association meeting in Boston this weekend. But it wasn’t clear if it was depression or the medication used to treat depression that may have affected their driving skills.

So the researchers measured the mood of the antidepressant users, and then divided them into two groups: medication users who were still depressed and medication users who were not.

When they looked at all three groups, depressed medication users performed worse on tests of concentration and scanning than people not on any medication at all. Nondepressed medication users scored somewhere in between.

“It’s still a little bit murky,” says Dannewitz, who performed the study as a graduate student at the University of North Dakota. “My bottom line is that those taking antidepressants with highly depressed mood do perform significantly worse than a control group.”

Her research does have some caveats. The study subjects were taking a variety of different antidepressants—from Prozac, a selective serotonin-reuptake inhibitor, to Wellbutrin, an atypical antidepressant.

They also could have been taking other medication in addition to antidepressants, and a couple of the study subjects were taking up to 10-12 medications, says Dannewitz.

Dannewitz declined to speculate whether the behind-the-wheel behavior she witnessed could lead to more accidents in the real world; she says that previous research into the effect of antidepressant use on cognitive function has been mixed.

Some studies indicate that taking an antidepressant improves cognitive function in the moderately depressed. Others suggest that when people who aren’t depressed take such a medication, they do worse on tests of mental ability.

Investigating the effects of antidepressants and depressed mood on mental performance is important—and not just for driver safety, Dannewitz says.

“Would you really want to have brain surgery [done by] someone who is really depressed, or would you rather have them on an antidepressant, or no medication at all?”

For now, Dannewitz believes the research is too conflicting and preliminary to conclude that not taking antidepressants would be a safer alternative.

“I think my general assumption is, if you have significant depression, then an antidepressant is probably going to help you in your performance,” she says.  “It seems to be a mishmash of mood and medication, and that’s what we need to tease out for future studies.”

By Theresa Tamkins

(PHOTO: CORBIS)


Related Links:

12 No-Cost Ways to Treat Depression Yourself

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Despair, Denial: How You May Feel During Therapy

How to Care for Someone Who Is Suicidal

Should You Stop or Switch Antidepressants?

5 Questions to Ask Your Doctor About Antidepressants


Acupuncture Relieves Breast Cancer Hot Flashes

Jenna Glazer was diagnosed with breast cancer in 2004 at age 34. And then she experienced one of the most intense and disturbing side effects of cancer treatment for young women, enduring up to 50 hot flashes a day and night sweats that constantly disturbed her sleep.

“I was having several hot flashes an hour, which was absolutely brutal,” Glazer said of her therapy-triggered menopausal symptoms. “I would be sitting in the living room in the middle of winter with the windows open and the air conditioning on in boxer shorts and a tank top.”

Now a new study suggests that acupuncture can help such symptoms. Indeed, it seems to be just as effective as Effexor, an antidepressant commonly used to treat treatment-related hot flashes, but without side effects such as insomnia, constipation, dizziness, or a lag in sex drive.

In fact, the study, which will be presented at the American Society for Therapeutic Radiation and Oncology meeting in Boston on Monday, suggests that women might get more than just symptom relief.

“It had benefits in terms of increased energy [and] increased clarity of thinking,” said study author Eleanor Walker, MD, a radiation oncologist at the Henry Ford Hospital in Detroit. “Overall, patients felt better and, in some patients, they had an increase in their sex drive.”

Next page: What the study found

What the study foundDr. Walker and her colleagues randomly assigned 47 patients who were taking tamoxifen or Arimidex (two breast cancer drugs that can cause menopausal symptoms) to a 12-week course of either acupuncture or Effexor.

On average, the women had 6 to 10 moderate-to-intense hot flashes a day and woke 2 to 3 times a night due to night sweats.

They found that the response was about the same for both treatments—65% of women received a benefit. However, when patients stopped Effexor, they started having hot flashes again in two weeks, while it took 15 weeks for symptoms to return in the acupuncture group.

Although some patients didn’t respond at all to the acupuncture, many reported significant relief. One woman in the study started with 27 hot flashes a day, said Dr. Walker, and “within two treatments, her [symptoms] dropped to half that.”

Dr. Walker said it was unlikely that the response was due to a placebo effect.

A previous study of women with breast cancer–related hot flashes compared acupuncture to sham acupuncture, in which needles are inserted in the wrong places at insufficient depth.

In that study, the real acupuncture reduced daytime hot flashes by 50% compared to the control treatment.

Next page: Why breast cancer patients have hot flashes

Why breast cancer patients have hot flashesSuch menopausal symptoms are common because the drugs used to fight cancer do so by blocking estrogen. About 80% of breast cancers are sensitive to estrogen, and will grow more rapidly in its presence.

Glazer said her symptoms started after she underwent chemotherapy but became much worse after she had surgery to remove her ovaries (which produce estrogen).

Typically, severe menopausal symptoms in women without cancer might respond to a short course of hormone therapy, but that’s not a safe option for breast cancer patients.

Sometimes doctors use inflammation-fighting corticosteroids instead, but those aren’t a great choice because “you gain weight and there are long-term side effects to steroids also in terms of your bones and joints,” said. Dr. Walker.

That’s why so many women take the antidepressant Effexor, which can alleviate hot flashes and depression.

Glazer tried both acupuncture and Effexor for her symptoms and found some relief with both. However, going off the antidepressant was harder than she thought, even though she tapered the dose.

“I gradually came off of it, it was not a cold turkey thing at all,” she said. “It almost felt like when I took a step…my brain was rattling around in my head—I felt dizzy and disoriented.”

Each time Glazer dropped her dosage, she had those symptoms for one to three days. When she finally stopped, it took a week before she felt normal again.

Next page: Will your insurance company pay for acupuncture?

Will your insurance company pay for acupuncture?Although insurance companies do pay for Effexor, they don’t always pay for acupuncture.

“Here in the Midwest, insurance does not pay for [acupuncture] at all,” said Dr. Walker. “In the East Coast and on the West Coast, insurance will pay at least 50% for acupuncture treatment.”

Glazer had to pay $90 out of pocket for each one of her acupuncture sessions.

However, she notes that one nonprofit organization in New York, called You Can Thrive, provides acupuncture, massage, and reflexology to breast cancer patients at no cost.

“I always think it’s just penny wise and pound foolish because these drugs that they put you on to control side effects are expensive, they’re intense, and they cause other problems—then maybe you need to go on more drugs,” says Glazer. “If some of these things can be controlled with acupuncture, these insurance companies should wise up and realize it’s to their benefit to open their minds a little bit.”

Dr. Walker hopes that insurance companies “will recognize the importance of this study, and this option for women, and at least pay 50% of the cost, if not 100% of the cost.”

The Susan G. Komen Foundation funded the study.

By Theresa Tamkins

(PHOTO: ISTOCKPHOTO)


Related Links:Slideshow: My Breast Cancer Diary in PicturesBreast Cancer Myths7 Women With Breast Cancer Who Lost Their Hair3 Ways Breast Cancer Can Screw Up Your Sex Life

Cheap Prozac and Free Therapy From the Bailout Package? For Millions, It's Still a Dream

By Walter Armstrong

WEDNESDAY, Oct. 7 (Health.com) — By the time the gargantuan $700 billion Wall Street bailout bill was passed and signed last Friday, it contained a landmark piece of legislation that just might improve—surprise!—the quality of our lives. Dubbed the Mental Health Parity and Addiction Equity Act, the law forces most insurance plans to offer the same coverage for mental problems as they do for physical ailments.

No longer can insurers discriminate against people with bipolar disorder, say, or alcoholism, by providing fewer benefits than they do for broken bones and breast cancer. Longstanding restrictions on mental health and substance-abuse treatment will be lifted, ranging from higher deductibles, co-pays, and out-of-pocket expenses to the automatic cutoffs (typically at 30) for hospital days and therapy sessions.

Hard times, good timingThe timing couldn’t be better, of course, with our moods growing darker daily along with the economic outlook. But while the financial rescue was passed in a single week, mental health parity took 18 years to gain critical mass.

“There’s been a revolution in the science and treatment of mental health in the past two decades,” says Andrew Sperling, the director of federal legislative advocacy at the National Alliance on Mental Illness (NAMI), who helped push the bill through Congress starting with its first draft. As evidence accumulated of the biological basis for diseases ranging from schizophrenia to obsessive-compulsive disorder to addiction, yielding targets for the development of effective drugs, the managed-care industry could no longer justify controlling costs by relegating mental health issues to second-class status.

Next page: Why depression isn’t cheap

Depressed people cost moneyThey also did the math. “Employers and insurance companies came around to seeing it as cost-effective,” Sperling says. “Expenditures are much less than was feared, and the increase in productivity is substantial.” Originally estimated as a 10% cost hike, the parity price tag attached to federal and state programs is calculated to be anywhere from 0.4% (Congressional Budget Office) to 2% or 3% (World Health Organization).

The rise of so-called managed behavioral health companies, which large insurers pay to deal with their plan’s mental health and substance-abuse items, also upped industry acceptance, according to an official at Blue Cross/Blue Shield, who asked not to be named. “Under managed behavioral health, the cost-sharing for these benefits can be managed, and that’s why we didn’t scream bloody murder over the bill,” he says.

While the bill may be a boost for the dying art of long-term psychotherapy, eager analysands should take note: The law is not a mandate and therefore leaves employers free to offer no mental health or substance-abuse benefits at all. And it doesn’t apply to businesses with fewer than 50 employees or to individual health plans. That leaves 31 million Americans out in the cold.

Relief in 2010, if you’re luckyStill, it’s progress. Increased benefits should start kicking in around January 2010, according to Sperling. But some consumers will be left twiddling their thumbs a lot longer than that. “The new law will not interrupt an existing contract,” he says, “and some extend all the way out to 2013 or so.”

And don’t expect your health plan to become your new best friend. Expect push-back on big-ticket items like inpatient substance-abuse treatment. Whether insurers will bankroll detox programs with extensive follow-up care or boutique mental health facilities, such as those for teenage drug abuse or alcohol treatment, remains to be seen. Prior authorization is key, so check with your plan manager before emergency strikes.

Finally, one problem the new law leaves untouched is the generally lousy treatment that managed-care plans offer their members. Customer service will continue to deny or delay reimbursements, especially for out-of-network care, driving us crazy with their claims that our claims were never received or are missing information or are under review (still). But that’s payback.

(PHOTO: ISTOCKPHOTO)

 


Related Links:Economic Crisis Takes Toll on Emotional Health‘Fear of Losing’ Key Emotion in Economic DecisionsHow the Financial Crisis Could Break Your Heart, LiterallyThe Best and Worst Habits for Controlling Nighttime Anxiety

News Roundup: Sunshine May Improve Male Fertility

Male fertility may get a boost from sunshineA smidgen of sunshine could be beneficial for men’s sperm. Australian researchers found that one-third of 794 men visiting an infertility clinic had a vitamin D deficiency. Since getting only 10–15 minutes of sunshine a day can boost vitamin D levels, 123 men tried to do just that—along with taking vitamins and living a healthier lifestyle in general. The payoff? A 75% drop in sperm fragmentation, a measure of damage. Overall, 31 men had partners who conceived after making the changes.

More than half of U.S. doctors use placebo treatmentAs many as 58% of U.S. doctors use placebo treatments on their patients, a study suggests. They’re not passing out sugar pills, however. Instead, doctors are prescribing painkillers, vitamins, or antibiotics that they think will make their patients feel better, rather than get better. The study, published in BMJ, largely confirms findings in a smaller study in Chicago from earlier this year. Coauthor Franklin G. Miller, director of the research ethics program at the National Institutes of Health (NIH), described the new findings as “disturbing.” However, the doctors surveyed had a more cavalier attitude toward placebo use: 62% believed the practice was ethical.

Woman never sees doctor in 19-hour ER visit, but still gets billJust when you think you’ve heard every U.S. health-care horror story, here’s one more. MSNBC reports that a Dallas woman with a leg fracture waited 19 hours in Parkland Memorial Hospital’s emergency room before giving up and going home without seeing a doctor. Sounds bad, but it gets worse. Two weeks later, she received a bill for $162 for the nurse’s assessment (she refused to pay). The woman, who doesn’t have insurance, rested her leg, put on a brace, and is letting it heal on its own. If only our health-care system could do the same. (Read our tips on how to save money on health-care costs.)

FDA approves magnetic beam therapy for depressionThe Food and Drug Administration (FDA) approved the first noninvasive brain stimulator to treat depression in patients who do not respond well to antidepressant medications, reports the AP. In each 40-minute session, the NeuroStar TMS (transcranial magnetic stimulation) system beams roughly 3,000 magnetic pulses per minute through the left front of the skull into the prefrontal cortex, which stimulates deeper brain regions involved with mood. Magnetic therapy appears to be safe, but expensive: At $6,000 to $10,000 for five weekly sessions during a six-week period, TMS is pricier than pills but cheaper than invasive treatments such as surgically implanted electrodes or electroconvulsive therapy. The NIH currently has a study underway to corroborate the FDA’s efficacy and safety findings. (Learn more about depression and ways to treat it.)

Extreme caffeine products flood the market—and your showerApparently it’s no longer enough to sip your caffeine in a cup at breakfast time. Now you can get a jolt while soaping up in the shower or lathering lotion on your face, according to Time.com. A trend that started with energy drinks is steamrolling ahead, and 126 new caffeine-containing products have been introduced in the last five years. Some of them are quirky choices that don’t fit the late-night-cram-session profile—such as caffeinated oatmeal, sunflower seeds, potato chips, and jelly beans. Others are caffeine-containing soaps and lotions. Experts fear that absorbing caffeine from multiple sources may lead to an overdose, which can result in nervousness, insomnia, a racing heartbeat, and agitation.

(PHOTO: FOTOLIA)

U.S. Suicide on Rise: Middle

By Theresa TamkinsTUESDAY, Oct. 21 (Health.com) — After a decade-long decrease, U.S. suicide rates have started to rise, largely due to an increase in suicides among middle-aged white men and women.

Whites age 40 to 64 have “recently emerged as a new high-risk group for suicide,” according to the study in the American Journal of Preventive Medicine.

Suicides increased between 1999 and 2005 by about 3% annually in white men and 4% in white women age 40 to 64, according to Susan Baker, MPH, of the Johns Hopkins Bloomberg School of Public Health in Baltimore, and her colleagues. Suicide rates remained the same in Asians and Native Americans, and declined in blacks.

Overall, the suicide rate rose in the early 1980s, then dropped each year from 1986 to 1999. From 1999 to 2005, however, the rates have increased 0.7% annually.

In all, 32,637 people killed themselves in the United States in 2005, a rate of 11 per 100,000 people.

Guns are the most common method of suicide, but their use has declined over time. Suicide by hanging or suffocation has increased among both men and women.

The reason for the increase is unknown. But if economic conditions continue to decline, suicides could go up. “This is a concern, especially when one looks at the high rates during the Great Depression,” says Baker.

Seetal Dodd, PhD, a senior fellow at the University of Melbourne in Australia, has found that suicide rates tend to fluctuate with the economic trends—at least in men.

The study is cause for concern, Dodd says, because it identifies middle-aged white men as the new high-risk group for suicide—the same section of the population at risk for suicide during an economic downturn.

“There is a considerable risk that the current economic situation may result in a further spike in the suicide rate for men of working age, especially if we start to see an increase in unemployment and a decrease in housing affordability and consumer sentiment,” Dodd says.

Robert Bossarte, PhD, assistant professor of psychiatry at the University of Rochester in New York, says that people have traditionally focused on suicide prevention in the very young and the old—but not necessarily the middle-aged. Historically, people over 65 have had the highest suicide rates, but this study suggests that trend is changing.

“The most important take-home message is try to understand what’s unique about the [middle-aged] population and what message would be most effective at preventing this,” he says.

A number of factors could be affecting the middle-aged, including taking care of aging baby-boomer parents, or coping with substance abuse or unemployment.

Bossarte also notes that while rates are rising in women, men are at greater risk overall.

“There’s something unique about the life circumstances of white, middle-aged males that is contributing to this risk,” he says. “The key is getting people into treatment and getting people to use the resources that are available to them.”

(PHOTO: FOTOLIA)

Depression During Pregnancy Doubles Risk of Preterm Birth

By Anne Harding

THURSDAY, Oct. 23 (Health.com) — Depressed moms-to-be are more likely than nondepressed women to have a preterm birth—and the worse their mood, the greater their risk, says a new study published in Human Reproduction. In fact, women in the study who were severely depressed during early pregnancy more than doubled their risk of giving birth to premature babies.

The reasons why aren’t entirely clear, but the researchers don’t think antidepressants are to blame. Only 1.5% of women were taking the drugs during pregnancy, and excluding them from the study didn’t change the results.

Depressed women who are pregnant, or planning to become pregnant, should get help, says De-Kun Li, MD, PhD, the lead study author and a reproductive and perinatal epidemiologist at Kaiser Permanente’s Division of Research in Oakland, Calif.

“Don’t think, ‘This is just part of being pregnant, this is my hormones doing something,’” he says, adding that depression relief doesn’t always have to include medication. “Getting the emotional and physical support of your family members can significantly alleviate symptoms of depression.”

About 12.5% of babies born in the United States each year are preterm, which means that they are delivered within the first 37 weeks of pregnancy, according to the March of Dimes. (A typical pregnancy is 40 weeks.)

These tiny babies can have a host of medical and learning problems. But despite decades of research, doctors still have no surefire way to determine who’s at risk of preterm delivery; nor do they understand why it happens or how to prevent it.

Treating depression might be one way to help prevent these premature births, according to Dr. Li.

“Depression during pregnancy really has not been paid attention to,” Dr. Li says. “It’s definitely underdiagnosed, undertreated, and frequently dismissed and ignored.”

In the study, Dr. Li and his team interviewed 791 women between 6 and 18 weeks of pregnancy. All were members of the Kaiser Permanente Medical Care Program, a managed-care plan. About 41.2% were at least “significantly” depressed, and 21.7% had severe depression.

After taking other risk factors into account (such as a mother’s age, education level, and whether she had a preterm baby in the past), the study found that women who were depressed were 1.6 times more likely to give birth prematurely than women with so-called normal moods. Women who were severely depressed were at 2.2 times the risk for preterm delivery.

Women with less education, past fertility problems, at least two previous pregnancies, or a history of stressful life events were most at risk for a depression-related preterm birth.

Dr. Li and his team don’t know why depression might influence preterm birth risk. However, past research has linked stress to poor pregnancy outcomes through effects on hormones, the immune system, and other factors.

“Women who are depressed also have a lot of other factors that can put them at risk for preterm birth,” notes Diane Ashton, MD, deputy medical director of the March of Dimes in White Plains, N.Y. For example, she explains, they tend to eat poorly and are more likely to smoke.

“What I tell my patients is that they need to be well during pregnancy,” says Diana L. Dell, MD, an assistant professor in obstetrics and gynecology as well as psychiatry at Duke University in Durham, N.C. “That’s what the study is basically showing us.”

Pregnancy itself doesn’t seem to increase the chance of depression. About 15% to 16% of women are depressed during pregnancy—no more than the general population, Dr. Dell says.

“Women are willing to make incredible sacrifices for their children, and they endure all sorts of discomforts during pregnancy,” she adds. But because depression and anxiety can have health consequences for both a mother and her child, Dr. Dell says, they should not be endured, but treated.

For women with mild to moderate depression, therapy is often enough, according to Dr. Dell. But medication might be necessary for women with more severe depression.

(PHOTO: ISTOCKPHOTO)

 


Related Links:CNN.com: New dads can get postpartum depression, tooYou’re Pregnant. Why Aren’t You Happy?How Support Can Prevent Postpartum Depression9 Symptoms of Postpartum Depression


New Antidepressant Guidelines: All Work the Same, But Some Pricier Than Others

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By Ray HainerMONDAY, Nov. 17, 2008 (Health.com) — If you are feeling depressed and your physician says she knows just the medication to help you, don’t take her word for it.

There is no evidence to suggest that one antidepressant is more effective than another at making you feel better, according to new guidelines released Monday by the American College of Physicians (ACP). Cost and side effects do vary, however, and should play a role when choosing a medication.

The guidelines were based on an analysis—the largest of its kind to date—of more than 200 clinical trials of antidepressants that have flooded the market since the release of fluoxetine (Prozac) more than 20 years ago.

Antidepressants are among the most widely prescribed drugs in the United States and include selective serotonin-reuptake inhibitors (SSRIs) like fluoxetine, sertraline (Zoloft), and paroxetine (Paxil), as well as other drugs, such as bupropion (Wellbutrin) and citalopram (Celexa).

“The available evidence shows no clinical difference in the efficacy of these second-generation antidepressants,” says Amir Qaseem, MD, PhD, the lead author of the guidelines and a senior medical associate with the ACP. “Medication A is the same as Medication B. You can’t really say that one is better than the other.”

The most common side effects of each medication do vary significantly, however, as do the cost of the drugs.

Venlafaxine (also known by its brand name, Effexor) appears more likely to cause nausea than SSRIs, for instance, while paroxetine tends to result in more weight gain than other drugs. Doctors should forgo predicting which medication is most likely to work for any given patient, and should instead discuss the side effects that patients are able (and willing) to tolerate and what their budgets will allow, the guidelines say.

In addition to factoring in cost and side effects, the guidelines also recommend that doctors:

Change or modify treatment if a patient doesn’t respond within six to eight weeks.

Monitor patients regularly beginning one to two weeks after they start a drug, to make sure it’s working and to check for side effects. The U.S. Food and Drug Administration recommends close monitoring for suicidal thoughts and attempts, as the risk is higher in the first couple of months.

Treat first-time depression patients (those experiencing their first episode) for four to nine months after they respond to treatment. Patients who have had two or more bouts of depression may need longer treatment.

About 1 in 5 adults in the United States experience depression at some point in their lifetime, and the economic burden of such depressive disorders is $83 billion, according to the ACP.

Next: Some monthly medications cost $200 more than others

Dr. Qaseem says the message that doctors should take away from the guidelines is, “Talk to your patients, and make them aware that these medications are all the same. Then, tell them that these medications have different side effects—some more serious than others—and that the costs will vary depending on their health plan.”

The new guidelines run counter to the conventional wisdom that prevails, even among some experts.

Dr. Qaseem and his colleagues, for instance, compared the effectiveness of second-generation antidepressants among several subgroups of patients, including men and women, the young and old, and people who experience symptoms of anxiety or insomnia in addition to depression. They found no significant differences in efficacy, even among these patients; it’s a finding that some psychiatrists would dispute on the basis of their experience, according to Gregory Simon, MD, a psychiatrist and researcher at the Group Health Center for Health Studies, in Seattle.

“There is a lot of clinical lore out there. People who have anxiety symptoms, say, are supposed to do better with this kind of medicine than that kind of medicine,” says Dr. Simon. “But that lore has never been supported by research. There’s no good way to predict who will do better with which medicine.”

The cost implications of this fact are important to consider, according to Dr. Simon, especially since individuals are increasingly responsible for a greater share of their health-care costs.

Although the efficacy of antidepressants is very similar, the price is not. A monthly supply of duloxetine (Cymbalta)—a drug that is still patent protected—runs about $240, according to figures compiled by Consumer Reports; an equivalent supply of fluoxetine (Prozac) costs just $30 a month, on average.

Both patients and doctors tend to labor under the misconception that newer (and more expensive) medications must be better, says Dr. Simon, and patients are often skeptical when a doctor explains that he is prescribing the cheapest available medication. But, he adds, “I can say with 100% certainty: The more expensive one is no better.”

The guidelines were published this week in the journal Annals of Internal Medicine.


Related Links:12 No-Cost Ways to Treat Depression YourselfYup, Therapy Is Expensive. Here’s HelpHow Exercise May Boost Your MoodShould You Stop or Switch Antidepressants?

Lack of Exercise Is Key to Heart Disease–Depression Link

Istockphoto

By Anne HardingTUESDAY, Nov. 25, 2008 (Health.com) — It’s long been known that heart patients who are depressed are at greater risk of heart attack, stroke, and death than their happier peers, and now a new study sheds light on the reasons why.

The risk seems to be due to a patient’s behavior, rather than some mysterious biological factor or other problem, as some have theorized. Depressed people who have heart disease are more likely to smoke, less likely to take their medicine, and—the biggest problem—are less likely to exercise than nondepressed heart patients, according to the report in the Journal of the American Medical Association.

“The good news for patients is that it’s all about behavior,” says Mary A. Whooley, MD, of the Veterans Affairs Medical Center in San Francisco. Dr. Whooley was the lead researcher on the study, which followed 1,017 people with stable heart disease for nearly five years.

“That means that the link is modifiable and there’s something they can do about it,” she says.

The bad news? It’s all about behavior. “It’s so hard for people to change their behavior, and especially for depressed patients because they have so much less motivation to take care of themselves,” Dr. Whooley explains.

And it seems to be a vicious cycle. People who are depressed are more likely to develop heart disease in the first place, and people who have a heart attack are (not surprisingly) at risk for depression. Depression can also hamper recovery from heart surgery or heart failure.

Researchers have proposed numerous factors to explain the complex interplay between mood, stress, and cardiovascular health: Examples include behavior and biological factors such as inflammation; some experts even think that antidepressants are bad for the heart.

To dig deeper, Dr. Whooley and her team looked at people—mostly older men—with confirmed, stable heart disease, and assessed various measures of heart disease severity as well as hormones, inflammation markers, and even levels of omega-3 fatty acids.

“We spent a lot of time and effort and money measuring all sorts of fancy biomarkers,” Dr. Whooley says. “We thought for sure one of those was going to explain the link. We were really surprised that it was such a simple answer.”

Next: One in five people in the study were depressed

In all, 19.6% of patients had symptoms of depression and they were indeed at greater risk of having a cardiac event, defined as a heart attack, stroke, a mini-stroke (known as a transient ischemic attack), heart failure, or death due to cardiovascular causes.

Annually, 1 in every 10 depressed patients had a cardiac event, compared to 1 in 15 nondepressed patients. After the researchers accounted for the severity of a patient’s heart disease, as well as the presence of other illnesses such as diabetes, depression still boosted cardiac event risk by 31%.

But when the researchers threw physical activity into the equation, they found the depression–cardiac event link nearly disappeared, suggesting that most of the increased risk seen in the depressed people was due to their lack of exercise. Skipping medication and smoking also helped account for the link.

“Yes, they’re at higher risk, but their risk seems to be driven by these other unhealthy activities [and] behaviors, rather than depression per se,” says Gregg Fonarow, MD, a professor of medicine at the University of California–Los Angeles and codirector of UCLA’s Preventative Cardiology Program. The findings help explain why studies investigating antidepressants or social support to help ease depression in people with heart disease have had disappointing results, he adds: “Treating depression may not in and of itself lower cardiovascular risk in these patients.”

Next: What you should do if you’re depressed

So what can be done to help depressed heart patients take their pills, quit smoking, and become more active? Cardiac rehabilitation programs, which include counseling on exercise, nutrition, medication use, and coping with stress, are one strategy that has been shown to help people change their behavior. But while national guidelines recommend cardiac rehab for anyone who’s had a heart attack, and Medicare covers it, use of such programs is far from universal among the people who could benefit from them. (Medicare also pays for cardiac rehab for heart disease patients with angina or people who have had bypass surgery.)

“The problem is many patients don’t adhere to the recommendations, or the prescription isn’t provided by the physician,” Dr. Fonarow says.

Patients should go to cardiac rehab three times a week, a frequency which goes a long way toward helping them build healthier habits, according to Janet S. Wright, MD, senior vice president for science and quality at the American College of Cardiology in Washington, D.C. “It’s definitely underutilized and it’s one of the most effective programs we have,” she says.

The first step a depressed person with heart disease should take is to recognize that they are under stress and get help, Dr. Wright says. Becoming more active can start with just heading out the door for a brisk walk around the block. Intensity and quantity of exercise aren’t as important as consistency, Dr. Wright points out.

Getting more exercise is a well-known antidote for depression, if you can muster the will to get moving.

“You literally treat depression with exercise the same way you would with an antidepressant. It has to be taken daily,” says Dr. Wright.


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