Saturday, April 11, 2015

Apprehending Depression & The Neurobiology Model

The Human Mind

Societal Alienation & the Human Brain: Begun writes: “The larger concern is that in our eagerness to resort to brain-based explanations, we sacrifice an interpersonal form of understanding. While social neuroscience appears capable of illuminating myriad connections between social and biological phenomena, and therefore of uncovering the ways in which social conditions mediate mental illnesses like depression, our enthusiasm for it may turn us away from the kinds of contemplation and action through which we relate to other human beings. As Benjamin Y. Fong, a scholar of philosophy and religion, put it in a blog post on the New York Times website, ‘neuroscientists unconsciously repress all that we know about the alienating, unequal, and dissatisfying world in which we live and the harmful effects it has on the psyche, thus unwittingly foreclosing the kind of communicative work that could alleviate mental disorder.’ ”
Image Credit & Source: The New Atlantis

Sometimes you read an article, and you know it rings true; this is the case with an exceptionally written and argued article, by Michael W. Begun, in The New Atlantis on depression. Major depression is a debilitating illness, which affects about 8 per cent of Canadians; it is important to add that 20 per cent of Canadians will suffer some form of mental illness in their lifetime. How brain scientists have viewed and treated depression has changed over the last few decades, which is an important point to make, given that how medical science views depression generally informs clinicians on how to treat it.

Today, “the model” is governed by the science of neurobiology, a discipline of neuroscience, which is the study of how complex neural circuits are shaped and developed during the formation of the adult brain. Depression, simply put, is viewed as something gone wrong (sometimes drastically so) with the normal functioning of the brain's neural network. The move away from understanding depression, since 1980, as emanating from social and psychological roots to originating in human biology, that is, in changes or abnormalities in brain chemistry (e.g. neurotransmitters) has lead to the treatment of depression with a class of drugs that are supposed to stabilize the brain, and thus one’s mood.

Yet, in “The Neuroscience of Despair,” (Summer/Fall 2014), the article questions rather strongly on whether these drugs are really that effective in relieving individuals of feelings of despair; Begun writes:
Many patients find that antidepressants do not alleviate their depression, and some find that the drugs have no impact on their moods at all. A 2002 meta-analysis published in the journal Prevention and Treatment found that for six of the most prescribed antidepressants, placebo control groups matched 82 percent of the medication response. This situation led a 2014 article in Nature to claim that “five decades of work on antidepressant drugs have not made them more likely to lift people out of depression.” It has also led pharmaceutical companies to develop secondary drugs intended to enhance the effectiveness of antidepressants, with multi-drug treatment becoming more common.
Despite the limited effectiveness of antidepressants and the theoretical gaps in understanding how they work, they have immensely shaped the theory and practice of psychiatry. The drugs provided clues to chemical processes involved in depression, which fueled attempts to formulate hypotheses for neurobiological causes of depression. These hypotheses were first formulated by looking at the biochemical effects of antidepressant drugs and attempting to infer the neurobiological abnormalities they were thought to fix.

But antidepressants were much more than an example of new technology changing the course of scientific research; they also helped widen the range of symptoms thought to be caused by depression. The Food and Drug Administration loosened restrictions on direct-to-consumer advertisements in the late 1990s, allowing pharmaceutical companies to run ads for antidepressants in national magazines, television shows, and elsewhere. Many of these advertisements limned the most general and benign symptoms included in the DSM’s criteria for depression (like irritability and fatigue) and their role in interpersonal problems and workplace difficulties, implicitly pushing the idea that drugs could relieve everyday human troubles.

Before these changes in FDA regulations, pharmaceutical companies advertised mostly to physicians and psychiatrists in specialized medical journals rather than mainstream outlets. The change in regulations allowed for “educational” advertising that focused on the disorder instead of the drug itself. As Horwitz writes, Prozac advertisements showed women happily performing work and family roles, using slogans like “better than well.” Pharmaceutical companies sold the idea of depression as much as the drugs themselves, promoting the belief that depression stems from a chemical imbalance in the brain, with a marketing apparatus rival in scope to national political campaigns. (By 2000, pharmaceutical companies were spending over $2 billion in direct-to-consumer advertising. By comparison, spending by candidates in the 2000 presidential election totaled a mere $343 million.) This marketing effort played no small part in shaping the public’s understanding of depression.
And it is likely a misinformed understanding on the effectiveness of such “antidepressants.” Yet the narrative remains, even among clinicians, who want to help their patients. This explains to some degree, why doctors prescribe anti-depressants; an article, by Sharon Kirkey, in The National Post (“Psychiatrist warns against trying to cure ordinary sadness as Canadians among top users of antidepressants; January 19, 2014) points out that Canadians are the third highest users of such drugs among the 23 member-nations of the OECD.

Kirkey writes, citing Dr. Joel Paris, professor and past chair of the department of psychiatry at Montreal’s McGill University:
The OECD figures, contained in its recently released “Health at a Glance” report, shows Canadians consumed 86 daily doses of antidepressants for every 1,000 people per day in 2011, more than the United Kingdom (71 doses per day), Spain (64) and Norway (58). Canada was behind only Iceland (106 doses per 1,000 people per day) and Australia (89 doses) among the countries surveyed.
(The data are expressed as “defined daily doses,” which means the average daily maintenance dose for the condition for which the drug was prescribed.)

In Canada 42.6 million prescriptions for antidepressants were filled by retail drugstores in 2012, up from 32.2 million in 2008, according to figures provided to Postmedia News by prescription-drug tracking firm IMS Brogan. Citalopram (sold under the brand name Celexa), venlafaxine, (Effexor) and the generic drug, trazodone, make up the three top-selling antidepressants in Canada.

Paris and others stress that antidepressants are essential in cases of severe, debilitating and life-threatening depression.

But the pills, including Prozac and its cousins that were held out to be miraculous when they hit the market in the late 1980s, are being swallowed by millions of Canadians every day, even while studies suggest that, in cases of mild depression, where “you’re still working, you’re still functioning,” Paris says, the drugs often don’t work, or they produce a temporary placebo effect, which doesn’t last.
Many other articles and studies confirm this well-informed view. We know that drugs like pain relievers, chemo drugs and drugs to regulate the heart, blood pressure and other body function work, because we can measure the effects. This is not the case with drugs that regulate brain chemistry.

Moreover, there are many problems with looking at an individual's brain state as an indicator of how well a person is from a mental or emotional point of view, Begun writes: “Another problem for neurobiological explanations of depression is that a mere correlation between a particular brain state and symptoms of depression in some people does not prove that other people with that brain state have a disorder.” And there are many problems distinguishing causation from correlation; there is no test or brain scan that can definitively show a person is depressed. There is no scientific evidence that depression results from a faulty neural mechanism, a neurotransmitter gone awry, etc.

Yet, not only is this model lauded, it continues to play a large part in how depression is viewed and treated.  While it is true that such drugs are necessary and quite effective to treat serious psychiatric disorders such as schizophrenia and other delusional disorders of the mind (and these are indeed life-savers), there is really no proof that such drugs are effective in treating mild to moderate cases of depression, which forms the largest cohort of persons clinically diagnosed with depression. In many cases, these same people are anxious and unable to fully function in doing tasks they once enjoyed doing; in many cases the reasons are normal and expected, a result of loss, of sadness, of grief, of bereavement.

Antidepressants might help in the short-term, but these drugs will not help such people in the long-term; they might actually make things worse. Everyday sadness is not depression; it is a human response to a real-life situation. Sadness is difficult, but depression is a magnitude of order greater.

Psychological counseling can often bring about a better result, because the problem is human, and this requires a human remedy. This takes time. So do solutions centred on building  friendships, communities and societies that view people as important. Social media is a poor substitute for genuine relationships, but for many it is the only source of relationships. It might well be that societal alienation might be one of the largest causes of depression, and this forms a large cohort of individuals today. This will not be cured or made better or ameliorated by the use of antidepressants.

Let’s speak about sadness, which is more common than many would like to admit. Sadness, which we all feel, informs us about a loss, and the greatest losses centre on those human qualities that cannot be reduced to neurobiology: human relationships, human understanding and human intimacy.

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