Do Anti-Depressants Work?

 Anti-depressants are the most prescribed medications in the history of mankind. Doctors have issued hundreds of millions of prescriptions over the last two decades. But how effective are they? It appears that much of the benefit that some people perceive is a kind of generalized treatment effect that has nothing to do with molecules in the brain. Instead, it seems that people often feel better from just being in treatment. In clinical trials, antidepressants don’t work much better than a placebo pill. 

The File Drawer Phenomenon

If that’s the case, why does the ‘science’ seem to suggest that antidepressants are highly effective? One major reason is that pharmaceutical companies conduct the research—and this really matters. If a drug is equally as effective as a placebo, then about half of trials will show that the drug outperformed the placebo, while the other half will show that the placebo outperformed the drug. If a drug company puts their ‘failed trials’ into a file drawer and sends their ‘successful,’ trials out for publication, the published literature will seem to suggest that the drugs work. Research over the past ten years has shown that pharmaceutical companies are indeed building up huge file drawer repositories of failed trials—research they hope will never see the light of day. 

Junk food and depression--is there a connection?

Tons of studies have found that there is a relationship between diet quality and junk food. If you go online to the world of medical journals, via Medscape, you’ll find studies that show that junk food is associated with depressive symptoms. But one of the first things a person learns in a graduate statistics course is that ‘associations are not causation.’ So, for example, if junk food and depression are related, which came first?  Or, could there be a third cause (sometimes called a ‘confounder’) that might be causing both?

I looked into this last month and found some studies that examined this important relationship. Turns out, many of the studies that find a relationship between depression and diet are ‘cross sectional.’ That means, that the data is collected at one time point. There’s no way to figure out which came first—the depression or the junk food. And even more importantly, many of the studies are small—under 1000 patients. What does that mean for our analysis? It means that important confounders—outside factors that might be causing both depression and poor diet—can’t be measured accurately. What is needed is a big study, that is longitudinal (takes place over time) and can show the direction of causality—and has enough participants so that the accurate measurement of confounders is possible.

A study like this came out in 2017. It publishes results from the ALSPAC study in the UK, a huge cohort study that has been following thousands of British children and their families for years. In this study, researchers looked at about 11000 parents over time, measuring both their diet and their depressive symptoms.

What they found is important. The quality of diet was associated with depressive symptoms. People who ate a ‘healthy’ diet with lots of vegetables and whole grains were less depressed. People who ate a lot of junk food and processed foods were more depressed.

 But, the problem was this: wealthier, more educated people ate much healthier diets. Poorer, less educated people ate a lot more junk food. As the researchers note: In brief, increasing scores on the ‘health-conscious’ components were associated with higher educational attainment, being white, owner-occupied housing and older age. “ Processed, high sugar and high fat food patterns showed associations that were the reverse of these.

What this tells us is that depression and poverty are also related.  Being poorer makes people more depressed. Being poorer also leads people to consume a poor diet. When ALSPAC researchers entered socio-economic factors entered into the equation, the relationship between diet and depression went away. Gone!

Why do lower income people eat worse quality diets? Maybe because high sugar and high fat food is comforting or delicious—probably for evolutionary reasons, it relieves our stress in the short term. Maybe it’s because of food deserts—neighborhoods where there isn’t enough good food at affordable prices available for low income people to consume. Maybe because of a time crunch—working hard at long hours means less time to shop and cook. For whatever reason, low income people get stuck with poorer diets as well as more depressive symptoms.  This has implications for food justice policy. But, there’s no good science showing us that reducing junk food in the diet will do anything for their depression.

What’s the take home here?

A diet heavy in junk food is not good for you. And if you are one of the many people who are finding that eating has become a compulsion, you should consider seeking help. But that doesn’t mean that your diet is responsible for your depression. People struggling with depression often feel highly self critical. The last thing they need is one more thing to feel they fall short on.

If you are depressed, don’t blame the donut you ate for breakfast. Maybe you need to give yourself a break. Grabbing junk food is understandable when you feel low, and it may relieve your low mood for a little while. Try finding other ‘quick fixes,’—more on that later.

If you can tolerate the jargon, here’s a link to the ALPAC article. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5848748/pdf/S1368980017002324a.pdf

Science vs Scientism: Why Does it Matter? (Copy)

To a lot of people, even to a lot of scientists, science is a subject matter. “Science” is numbers. Science is molecules. Science is ‘scientific experts,’ white coats, stethoscopes, medicine bottles, brain images. When we think about science in this way, it’s easy to get sucked into a phenomenon I called scientism. Scientism is a cultural phenomenon unique to modern culture. “Scientism” is like the child’s joke about washing a diaper. As a seven-year-old, I rolled on the ground with laughter at this one.

(pretending to scrub a diaper in the sink): “Wishy washy wishy washy wishy washy!

(Holds up the diaper to inspect) “Looks clean, feels clean. . .

(Smells the diaper) “Smells. . .  (pause).

(Scrubs vigorously) “Wishy washy wishy washy wishy washy!”

The fact is that scientism isn’t a subject matter, like a class at school. When I teach research methods at my medical school, I define science as “systematic inquiry.” The question of how to treat mental disorders requires systematic scientific inquiry to painstakingly uncover the truth.

When you understand science as a subject and not a method, you start to confuse something that looks like science…sounds like science…smells like science?

But isn’t science.

I did a post-doctoral fellowship at a prestigious mental health services institute. In the 1990s, the big question for mental health researchers was the question of why so many depressed patients, especially low income patients, were not getting effective medications for depression. And the goal of a lot of the research at the institute focused on how to get more medication into these patients. At the same time, there was a lot of emerging data regarding the effectiveness of these medications that suggested that getting more poor people on antidepressants might not solve the public health crisis of depression. When it comes to treatment, both for medication and psychotherapy, evidence suggests that a lot of the healing comes from the relationship between the healer and the patient. Something like caring, empathy, support, guidance…

One of my colleagues had designed a program that used a complicated algorithm to identify depressed patients and offer them antidepressants. When I asked her about the issue of therapeutic relationship, she scoffed: “Sounds like you think that the way to treat depressed people is to be nice. But being nice is not science!”

That’s scientism in a nutshell. The fact is, if being ‘nice’ helps patients, we need a science of ‘niceness.’ What is it about empathy, warmth, and support that makes people better? How do individuals differ in terms of what they need? How do we develop effective therapeutic relationships?  How do we design institutions like schools, hospitals, workplaces, so that individuals are supported and cared for? The jury is still out…

Public Health Minute: My interview with Dr. William Latimer (Copy)

Public Health Minute

Public Health Minute (PHM) is a one-minute segment in which Dr. William Latimer, interviews researchers, medical and other professionals about a wide variety of public health topics. The Institute of Medicine estimates it takes 20+ years for health researchers to get scientifically proven findings that inform best practices into communities. Public Health Minute gets practical health advice informed by cutting edge research to the public today. I was interviewed last year on PHM. I spoke with Dr. Latimer about the importance of context and environment in depression and other mental disorders.

https://soundcloud.com/publichealthminute/social-and-environmental-causes-of-depression-dr-karasz

Why Exercise? The Role of Pleasure (Copy)

People who exercise live longer, healthier lives, and are less vulnerable to a host of poor health conditions, including Alzheimer’s disease. If you can find a way to work exercise into your daily routine, it’s a good idea to start. Unfortunately, even though most people believe they should exercise more, more than 50% of those starting exercise programs drop out in the first year. https://pubmed.ncbi.nlm.nih.gov/8153498/

One of the ways to increase the amount you exercise in your life is to make sure that the exercise you do is pleasurable. Research shows that if you actually enjoy exercise while you are doing it (as opposed to feeling satisfied after you are finished) you are going to be much more likely to stick to an exercise routine. https://pubmed.ncbi.nlm.nih.gov/25921307/

Not to mention the fact that pleasurable activities, in themselves, make you feel better!

So, find some kind of exercise that really is pleasurable for you. For many people, outdoor activities may be a lot more pleasurable than going to the gym. Do you like to bike? Hike? Ski? Kayak? Walk? These are highly pleasurable activities for some people, and may be good activities to incorporate into your life if you can. Do you like group activities, like dancing? Join a dance group or take a class.

 On the other hand, if you don’t really enjoy exercise, think of ways to trick yourself into enjoying your exercise routine. Find a fantastic podcast or a book on tape—and listen to it ONLY when you are exercising. Make sure it’s really good—so you can’t wait to get to it!

Finally, try to reduce the un-pleasurable aspects of exercise. For example, research shows that in the long run, very vigorous exercise may provide more benefit. However, vigorous exercise is often much more unpleasant! And it is very hard to stick to a habit that involves a behavior that is no fun. So, keep your exercise to a level that feels pleasurable. Don’t bike so fast you can’t take in the scenery. Don’t run so hard it hurts. As you exercise more, you’ll build strength, and will be able exercise harder while still enjoying it.

What works in psychotherapy?

Training programs for psychologists are often focused on technical proficiency—and the focus on skills and techniques has become intense in recent years with the roll out of ‘manualized’ therapies, high structured protocols that control the interactions between therapists and patients. But overall, research continues to show that it is the quality of the therapist, and the quality of the therapeutic relationship, that drives change and healing. I love Scott Miller’s blog post about this. It’s written for therapists, but I think it’s interesting for patients too. Take home point: if you don’t feel your therapy is working, trust your judgement. Patient’s perceptions are sometimes more accurate than therapists’.

https://www.scottdmiller.com/what-works-in-psychotherapy-valuing-what-works-rather-than-working-with-what-we-value/

Depression and productivity

One of the most common reasons that clients in my Fort Greene practice seek therapy is work and productivity issues. Many of my clients have problems with procrastination. They feel like they can’t ‘get going.’ Blocks to action—whether work, socializing, exercising, planning—are a common consequences of strong negative emotion. Sometimes, procrastination and the anguish that it generates becomes its own problem, and may be easier to experience than the original emotions themselves. Procrastination is an especially severe problem among people in the creative professions—artists, entrepreneurs, etc—but it can affect anyone. Treatment of procrastination and its variants, such as writers’ block, is two pronged. First, I work with my client to understand and experience the strong emotions—sadness, feelings of failure, anxiety—that are preventing you from doing what you really want to do. Next, we work to understand how procrastination creates a vicious circle of shame and depression—as you blame yourself and your lack of productivity. As we try to normalize and forgive doing ‘nothing,’ it becomes easier to take small action steps, and can lead you to return to your normal state.

Some of my strategies for treating procrastination come from my cross cultural research. I’ve come to realize the very cultural component that contributes to these problems in my own practice. Our society values productivity above almost anything else. Paradoxically, this has led to an epidemic of depressive procrastination. People, naturally, are highly creative. We want to work, to act, and to make things. But when the stakes become too high, we can get paralyzed.

 My paper (link below) examines how culture affects the ways that European American women and a comparison group of South Asian immigrants, understood their health and daily symptoms. A key finding from this paper is that European Americans conceptualize health in terms of productivity, energy, creativity, and output. Maybe that is why American Depression takes its peculiar form—as sluggish, slow, and unproductive. I think the research can help us think more creatively about depression and anxiety. To what degree is our suffering caused by cultural values insisting on endless innovation, creativity and get up and go—all part of the culture of late capitalism.

 https://journals.sagepub.com/doi/pdf/10.1177/1363461508094674

American Motherhood

I’m interested in mothering—as a cultural phenomenon, as an influence on child health, and as a risk factor for depression and anxiety. I’m carrying out a randomized controlled trial on child feeding among South Asian immigrant mothers in the New York area. As we move forward with this study, larger issues of motherhood, and how we define it, are becoming more and more salient. Our team is realizing that problems in child feeding have a lot to do with how motherhood is defined and the obligations that are imposed on South Asian moms.

More on the clinical trial some other time. In the meantime, I have been looking into what other people are writing about mothering in the US. In the 1940s and 50s—mothers were often blamed for society’s problems. Smothering, hostile, envious, indulgent…mothers were even blamed for schizophrenia and other severe mental disorders. Despite the advances in women’s equality over the past forty years, some things never change. The twenty first century is is a difficult time to be a Mom. Standards for childrearing are incredibly high. Today’s mothers are not only expected to provide top quality physical care for their children, to love and nurture them, but also to make a huge investment in children’s cognitive, emotional, and play lives.

Read this super review by Judith Warner to get a sense of the major ant-feminist themes in a lot of our modern assumption about parenting.

https://www.nytimes.com/2012/05/13/books/review/the-conflict-and-the-new-feminist-agenda.html?pagewanted=all

Antidepressants over the long term

Over a quarter of people currently on these medications have been taking them for a decade or longer. Some people feel a significant benefit and would not dream of cutting back or stopping. Increasingly, though, many people are wondering about the road ahead. How long should a person stay on antidepressants?

The problem is that we don’t know very much about the effectiveness, or the impact, of these drugs over the long term. Since most studies track patients for only a year or two, we just don’t know enough about their long term effects. A recent ‘meta-analysis’—which combines data from many different studies and analyzes these data using a uniform method—shows that in the general population, anti-depressant use significantly increases the risk of mortality. See a link to the paper here: https://pubmed.ncbi.nlm.nih.gov/28903117/

Yet, for many patients, going off an antidepressant is a scary prospect. Relapses can occur. On the other hand, over 30% of people on antidepressants report that they experience occasional relapses even while taking the medications. Furthermore, the ‘discontinuation’ effects of anti-depressants—the symptoms some people get when they go off the drugs—can mimic an attack of depression and anxiety.

If you are considering going off anti-depressants, have a serious talk with your doctor. Many general practitioners and psychiatrists will be supportive if it seems an appropriate step. The process should be slow and gentle. It should only be undertaken under the care of a physician.

One of the most ‘famous’ advocates of anti-depressants, Lauren Slater, is a psychologist and an amazing, gifted writer. She was an influential in the creation of the 1980s cultural movement sometimes called the Prozac Generation—in which we became the biggest consumers of mood altering drugs in the history of the world. Now 30 years later, she is wondering about her legacy:

https://www.theguardian.com/books/2018/apr/01/the-drugs-that-changed-our-minds-lauren-slater-review

Understanding post partum depression

Over the past three years, I’ve been carrying out an intervention for South Asian immigrant mothers (from Bangladesh, Pakistani and India). We’re trying to address feeding problems in South Asian families that may increase children’s risks of obesity and diabetes. One factor that really affects the quality of children’s feeding is the mother’s mood. When mothers are depressed, children’s nutrition suffers. In societies where food is scarce and expensive, children of depressed mothers tend to be malnourished. In societies like ours, where food is overly plentiful and not very nutritious, depressed moms have overweight kids. See a link to my study here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5984363/.

We’ve been learning a lot about distress and depression in the post-partum period while conducting this study. One thing we’ve noticed: A lot of our immigrant Moms feel distressed. They may not call it depression. In fact, they may feel a lot of different symptoms, especially irritability and exhaustion. But one symptom that that all most all distressed Moms report is loneliness.

When the media talks about postpartum depression, there’s always a lot of focus on hormones. But actually, there is no consistent evidence that fluctuations in hormones cause post-partum distress and depression. To the contrary, there is plenty of evidence that a lack of support, lack of companionship, and simple loneliness are a major cause of this problem.

Our immigrant moms miss their own mothers very much, along with the extended family network of siblings, cousins, and aunts and uncles. Mothers who are caring for their second child, alone in a small apartment, often talk about what it was like to have their first baby back home, surrounded by caring relatives, and never having to lift a finger.

For immigrants and non-immigrant mothers alike, companionship and support may be the very best treatment for postpartum depression. That may be one reasons why more and more women are working with doulas, or birth attendants, in the post-partum period. https://www.wbur.org/commonhealth/2014/06/20/best-kept-secret-for-postpartum-depression-help-at-home.

If you are feeling post-partum distress—sadness, anxiety, or excessive guilt—you may also want to consider psychotherapy. Working with a skilled therapist can help you navigate this challenging period. Reach out to me at 718-858-7968 to schedule a consultation.

Psychotherapy and the sense of flow

Personally I am fascinated by ideas about flow—that state of mind in which you lose self-awareness and become completely immersed in something. This seems like it is easier for children than for adults. It’s kind of the opposite of being distracted. And it’s definitely the opposite of burnout. Flow can help explain the calming, therapeutic effects of certain repetitive experiences. Even knitting can produce flow…

When I am with a patient in the consultation room, sometimes we both become aware that flow is happening. Researchers and clinicians have started writing about the experience of ‘flow’ in psychotherapy. It includes a feeling of intense connectedness, engagement, and sometimes joy—even if the emotions that are emerging in the moment are not all positive. When I experience this with a patient, I often find that both of us seem to be able to read the other person’s thoughts much more easily than usual. Freud’s disciple Sandor Ferenczi believed that he had telepathic experiences in the consultation room. I don’t personally believe in telepathy. None the less, the ‘peak’ experiences of flow lead to a heightened empathy that help connect the therapist and patient.

http://positivepsychology.org.uk/living-in-flow/

Goats and Depression in Rural Bangladesh

Common mental health problems such as depression and anxiety are at epidemic levels in low and middle income countries. Over the past 25 years, mental health researchers have implemented hundreds of clinical trials investigating whether standard, structured manualized psychotherapies such as cognitive behavioral therapy, problem solving therapy, and similar treatments, can be effective in treating depression among low income individuals struggling with poverty and everything that goes with it—hunger, marginalization, exclusion, and despair. Yet, recently, emerging evidence suggests that psychotherapy in these circumstances has weak effects. Even when it helps with depression in the short term, it’s impact is temporary. Some have proposed that while psychotherapy can be a powerful treatment, it is not powerful enough in the context of severe social and economic problems.

With a grant from the National Institute of Mental Health, I am working with researchers at the ICDDR,B Research Institute in Dhaka to implement a ground breaking clinical trial in a rural area of northern Bangladesh. We will be selecting rural women with depressive symptoms and assigning them to one of two treatment groups. The first group will receive a standardized depression treatment. The second will receive depression treatment plus an agricultural asset—most likely a small herd of Black Bengal goats that you see in the picture above. Women will also receive agricultural skill training, veterinary and feed costs, and other supports. Our goal is to determine whether women in the experimental group (receiving both depression treatment and poverty alleviation support) will experience more benefit, and more lasting benefit, than those receiving psychotherapy alone. Two papers about our preparatory studies may be found here:

https://pubmed.ncbi.nlm.nih.gov/26639376/

https://pubmed.ncbi.nlm.nih.gov/33401489/

Check back here for updates on the project. In another post, I’ll be talking about how my work with economic empowerment in Bangladesh has shaped my approach to practice in Fort Greene, Brooklyn.

Science vs Scientism: Why Does it Matter?

To a lot of people, even to a lot of scientists, science is a subject matter. “Science” is numbers. Science is molecules. Science is ‘scientific experts,’ white coats, stethoscopes, medicine bottles, brain images. When we think about science in this way, it’s easy to get sucked into a phenomenon I called scientism. Scientism is a cultural phenomenon unique to modern culture. “Scientism” is like the child’s joke about washing a diaper. As a seven-year-old, I rolled on the ground with laughter at this one.

(pretending to scrub a diaper in the sink): “Wishy washy wishy washy wishy washy!

(Holds up the diaper to inspect) “Looks clean, feels clean. . .

(Smells the diaper) “Smells. . .  (pause).

(Scrubs vigorously) “Wishy washy wishy washy wishy washy!”

The fact is that scientism isn’t a subject matter, like a class at school. When I teach research methods at my medical school, I define science as “systematic inquiry.” The question of how to treat mental disorders requires systematic scientific inquiry to painstakingly uncover the truth.

When you understand science as a subject and not a method, you start to confuse something that looks like science…sounds like science…smells like science?

But isn’t science.

I did a post-doctoral fellowship at a prestigious mental health services institute. In the 1990s, the big question for mental health researchers was the question of why so many depressed patients, especially low income patients, were not getting effective medications for depression. And the goal of a lot of the research at the institute focused on how to get more medication into these patients. At the same time, there was a lot of emerging data regarding the effectiveness of these medications that suggested that getting more poor people on antidepressants might not solve the public health crisis of depression. When it comes to treatment, both for medication and psychotherapy, evidence suggests that a lot of the healing comes from the relationship between the healer and the patient. Something like caring, empathy, support, guidance…

One of my colleagues had designed a program that used a complicated algorithm to identify depressed patients and offer them antidepressants. When I asked her about the issue of therapeutic relationship, she scoffed: “Sounds like you think that the way to treat depressed people is to be nice. But being nice is not science!”

That’s scientism in a nutshell. The fact is, if being ‘nice’ helps patients, we need a science of ‘niceness.’ What is it about empathy, warmth, and support that makes people better? How do individuals differ in terms of what they need? How do we develop effective therapeutic relationships?  How do we design institutions like schools, hospitals, workplaces, so that individuals are supported and cared for? The jury is still out…

Could boredom be good for you?

It’s obvious that in a society like ours, obsessed with productivity, doing nothing at all feels like it can’t be good. But interesting new research suggests that boredom can sometimes be good for you. Paradoxically, it may even help you be more productive.

https://www.theatlantic.com/magazine/archive/2017/06/make-time-for-boredom/524514/

Sleep problems in teenagers

Sleep problems in kids

As a psychologist, one of the most common concerns that I hear about from parents of young children is sleep problems. I’ll write more about this in another blog, but this week I want to talk about sleep problems in teenagers. By the time kids reach adolescence, their parents often give up trying to influence their sleep patterns. But poor sleep is a huge health issue for adolescents. Poor sleep affects kids’ mental health, their school work, relationships, and emotional lives. Here is an article about it, with some helpful tips for parents:

https://www.psychologytoday.com/us/blog/healthier-minds-happier-world/201806/what-poor-sleep-could-be-doing-your-child-or-teen