Shrink Rap (Psychology Books) discussion
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PBS program Depression: Out of the Shadows
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I just watched this the other day. It was really eye opening. I saw myself and my clients in a lot of what they talked about. I watched with my boyfriend and couldn't stop talking about the "cocktail". I have seen one or two of those meds completely knock people out and can't even begin to imagine what all of those combined would do.
The PBS doc seemed interesting, at least the 5 minutes I was able to catch before having deal to other matters. However, I noticed the website has an option to watch the episode online, which I plan on doing so in the next couple of days. I am starting to have some shifts in my own thinking around my own practice when dealing with depression (e.g. the need/benefit of medication). Since I haven’t watched the doc yet, perhaps this post is premature but I am wondering where on the depression spectrum was the use of “cocktails” discussed, was a distinction made between for example MDD v.s. Dsthymia? I did catch the part on Area 25 brain stimulation and agree that it is quite fascinating.
interestingly, i actually know richard freidman, solomon's psychopharmacologist, and so i wasn't that surprised by the cocktail. part of his method is to fight side-effects with other meds, because he doesn't want to lose the strength of the positive aspects - so you heard him say that he took an alzheimer's drug to help with the cognitive functions, etc. wellbutrin with zoloft is a fairly common combo i've seen, and what really surprised me was that he didn't have a different atypical from zyprexa, since he was taking at least two additional meds to combat the side effects of that med, and there are plenty of atypicals to choose from - abilify has had great results with less side effects, for example.different drugs affect people differently - my aunt, for example, can take .25 mg of xanax and fall asleep happy and relaxed. i have taken 2 mg of xanax (i'm a terrified flyer) and it didn't affect me at all. only clonazapam really works on my anxiety, and it doesn't affect drowsiness at all. i also have chronic and insomnia, and none of the prescription meds work for me. i just lie there, totally awake, even on really high doses. turns out, though, that 7.5 mg of remeron knocks me out. go figure, right? so that's another case of using a med for its side effect, and not it's first intent.
what i appreciated was that they talked about how it's wrong that "depression" is the only word we have for so many feelings, and yes, they were specifically talking about MDD, as they mentioned depressive episodes, etc. (i haven't wanted the whole thing yet, so.)
Not having seen the program, I'm curious - what therapeutic tools did they examine beyond meds, if any? I was trained with the approach that meds must be an adjunct to psychotherapy, preferably cognitive-behavioral with a strong emphasis on self-monitoring and correcting distorted beliefs; the rationale is that meds may be needed to help someone climb out of a major depressive episode, but for MDD the typical antidepressants become less effective after several months to a year or so, and unless they're using CBT or something like it, they are likely to relapse into more depressive episodes. The "cocktail" of continuing to take one or more antidepressants, along with other meds like anxiolytics or mood stabilizers, is more suited to bipolar disorder than to MDD.
i know that the adolescents did not use medication successfully at all, and that solomon also incorporates his diet, talk therapy and exercise with his cocktail. i believe it was hart, one of the adolescents featured, who had bipolar . . . but the girl went into an inpatient unit, and eventually was sent out of state to a residential facility (but i haven't watched that segment yet). so yes, other treatments were looked at, definitely - in fact, from the beginning, i thought it was going to be a relatively negative-toward-medication program. i agree that meds only provide a "band-aid" for the situation, which is why i think GPs shouldn't be allowed to prescribe psychiatric meds, but that's another story. I do know, however, that some meds have continued to work with individuals with MDD for years, in combination with their CBT/DBT/psychodynamic therapy. i know someone who has been on prozac for years now, and continues to see her therapist, although in much diminished capacity, because she is feeling so much better. my understanding is that she continues on the prozac as a kind of safety net if she has another MD episode - that it won't allow her to fall as far down. i could be wrong though, and she might just be taking it and it has basically a placebo effect at this point.
however, i'd hate to think that even with CBT a MDD's cocktail would have to change so frequently - even shifting from say, prozac to paxil has effects, and i've known people who responded horribly to effexor that are great on cymbalta, etc. it's the weird individual side effects that i think make people want to stay with "something good" when they find it.
It's true that changing meds is not something to be done lightly, also that even a med that has worked well for someone may not work again if he/she has stopped using it and then starts again. The metabolic side of things can be strange and baffling. It does often happen that even when an antidepressant has initially worked very well for someone, he/she can develop what seems to be a tolerance so that its effectiveness drops off, and if not using CBT, that person is quite vulnerable to a depressive relapse.Beyond the CBT, it's best to try to put in place a whole set of protective measures - outdoor activity, diet, sleep hygiene, social support system, and if possible, avoidance of possible depressive triggers.
It helps a lot to use fish oil as a supplement - the data has found it to be as effective as first-line antidepressants for preventing depressive episodes, though not for getting out of one if you're already down; and it's good for cardiac health too, and cheaper than dirt. Seems to be important to have about a 1:1 balance between omega-3 and omega-6 fatty acids, and most Americans' diets are way out of balance, often with a omega-6/omega-3 ratio of 10:1 or worse.
I can see why they chose to interview Andrew Soloman (author of Noonday Demon), but I thought his pharma "cocktail" was excessive. I'd love to discuss with other viewers.