Thursday, 1 October 2015

The Recalcitrance of Depression

In previous posts I’ve expressed some concerns over the effectiveness of SSRI medications such as prozac and I’ve pointed to recent research by Fournier and colleagues that indicates antidepressant medication mostly benefits very severe depression. I highlight such things because antidepressant medication is the dominant method of treatment and more and more people appear to suffer depression. It’s important therefore to put such treatments under the spotlight in order to test their true effectiveness and to encourage more and better treatments.

The Star*D treatment trial for depression was one of the most extensive studies undertaken into the treatment of clinical depression. Nearly 3,000 patients across 41 treatment sites across the United States were involved. After 14 weeks of treatment for depression some 72 per cent of patients still had significant residual treatments. From what we know of depression even those patients who initially responded well stand a fairly high chance of it returning at a later stage.

The vast majority of people with depression fall into the mild to moderate category. One of the most worrying things to emerge from the analysis of six large clinical trials was the fact that only the most severely depressed people appear to benefit from antidepressant medication. As Dr. Jonathan Rottenberg, Associate Professor of Psychology at the University of South Florida, recently stated in his blog:

            “Undertreatment of depression is not the real story; the real story is the recalcitrance of depression, even to state-of-the-art treatments. That’s the hard truth we should be telling the public.”

He’s right. While antidepressant medications are better than nothing they can hardly be said to constitute a cure for depression and the sad reality is that their therapeutic credentials are suspect except for the most severely depressed individuals.

It’s a worrying trend that more and more people are becoming depressed. Encouraging people into treatment is fine but it presupposes that the treatments currently on offer actually work. People with depression actually have precious little to turn to in the way of effective therapy. One day they might, if we continue to push for greater investment, research, and creative thinking.


Fournier et al. (2010). Antidepressant Drug Effects and Depression Severity: A Patient-Level Meta-analysis JAMA, 303: 47-53.

Rottenberg, J (2010) Charting the Depths. Depression Treatment: We Need Better Not Simply More. Psychology Today. Jan 5th.

Sunday, 30 August 2015

The Anxiety and Depression Blur

Let me begin by throwing out a few statistics. It is estimated that the vast majority, over 85 per cent, of people with depression also have an anxiety disorder and over 30 per cent of these have panic attacks. It is further estimated that over 50 per cent of people with an anxiety disorder have major depression but many more have symptoms of depression but that don’t fit within the major depression category. The treatment of people with depression and/or anxiety often involves the use of selective serotonin reuptake inhibitors (SSRIs), the best known of which is fluoxetine (Prozac). In other words, not only do there appear to be more similarities than differences between anxiety and depression, but some of the major treatments are also the same. No wonder it’s confusing.

Given the overlap in symptoms you might now be sharing the same thoughts as some other esteemed health professionals - which is, are anxiety and depression actually symptoms of a mental illness yet to be ‘discovered’? Interesting thoughts, but for the moment at least we’re still in a situation where the two are regarded as distinct, but frequently appear together, known as comorbidity.

The next logical step is to take a look at the similarities and differences. In terms of the similarities between anxiety and depression there are lots. Just a handful of these serve to illustrate the point. Psychological and emotional symptoms of the two include feelings of fatigue, lowering of self-esteem and confidence, guilt, loss of interest in normal activities and difficulties in concentration. There are also similarities relating to sleep disturbances, appetite changes, physical symptoms such as headache, muscular pains and tensions and a general sense of feeling unwell.

With all these similarities, and more besides, it falls on the differences to explain why anxiety and
depression are considered as separate entities. In many ways these are explained by degree of focus and extremes of thinking. For example, negative thinking is a feature of both anxiety and depression, but someone with depression tends to have a bleaker and all-encompassing outlook, whereas an anxious person without depression will focus negatively on specific issues but can often see light at the end of the tunnel.

Failure is expected in people with depression but tends to be feared in people who are anxious. Perceived shortcomings are seen as evidence of something deeper and defective in people who are depressed whereas anxious people strive to correct or avoid shortcomings either through avoidance or striving harder. Physically, a depressed person has heavy, slumped, slow moving and energy-lacking features, whereas someone with anxiety tends to be more tense, more alert, agitated, and with an excess of energy. Suicidal thoughts are a feature of deep depression. The fear of death may feature in some cases of anxiety but this is not the same as contemplating suicide.

So, where the symptoms of anxiety are different to those of depression it starts to become clear what those differences are. Unfortunately the picture is frequently more blurred and this makes attempts at distinguishing one from the other both more difficult and perhaps less significant.  Today we have a situation where someone is frequently deemed to present with a dominant and secondary set of symptoms such as depression with anxiety or vice versa. It opens up a whole debate about the role of cause and effect and even whether people have been diagnosed correctly.