CBT: a questionable form of therapy for depression

CBT is a therapy based on the belief that one’s negative illogical thoughts can cause depression and correcting them can CBT_Cycletreat the depression. CBT therapy is usually performed with a therapist however now computer programs are being created to help depressed individuals. While CBT therapy is endorsed by psychiatry it has a number of problems.

Depression is known to cause distorted thinking so what comes first the depression or the distorted thinking? CBT doesn’t clarify this issue. It just says that correcting illogical thinking treats the disorder.

CBT therapy has been shown to be as effective as antidepressant therapy and prevents relapses better than drugs. The problem with this is that antidepressant therapy isn’t all that effective. Antidepressants are, in reality, only slightly more effective than a placebo. Additionally, since major depression is cyclical how does one know for sure if the treatment was actually helping. Many experiments are performed over rather short periods of time and a certain percentage of people will have spontaneous remissions. This of course could be the same issue for antidepressant trials.

Experiments involving CBT vs antidepressants are not double blind which is considered essential for the highest level of objectivity. If the researchers and the patients know what type of therapy is being performed objectivity is diminished.

A major criticism has been that clinical studies of CBT efficacy (or any psychotherapy) are not double-blind (i.e., neither subjects nor therapists in psychotherapy studies are blind to the type of treatment). They may be single-blinded, i.e. the rater may not know the treatment the patient received, but neither the patients nor the therapists are blinded to the type of therapy given (two out of three of the persons involved in the trial, i.e., all of the persons involved in the treatment, are unblinded). The patient is an active participant in correcting negative distorted thoughts, thus quite aware of the treatment group they are in

Researchers say that brain scans show that CBT “works” and yet brain scans are not considered a reliable way to diagnose mental illness. People with mental illness often have more than problem such as depression and ADD. This confounds diagnosing a mental disorder or saying confidently that an individual is in remission. This excerpt from Scientific American explains the problem.

During testing, the system analyzed the shapes of brain regions in each test scan and assigned it to the group it most resembled. The scientists checked its work by comparing the new labels on the test scans with the original clinical diagnoses. They repeated the procedure several times with different randomly generated sets. When the system chose between two disorders or one ailment and a clean bill of health, its accuracy was nearly perfect. When deciding among three alternatives, it did much worse.

The basis of CBT doesn’t explain how people with a rapid cycling form of bipolar disorder cycle between depression and mania. Do they start off having negative thoughts during a depressive episode which eventually cycles with mania  and the mania consequently produces delusional thinking? CBT has not been shown to be effective for preventing depressive episodes in bipolar disorder.

CBT has given no biological explanation for how it works and yet implies that possibly negative thoughts might exacerbate stress which in turn precipitates a depressive episode. Even though stress has long been thought to cause depression stress(HPA activation) is not distinctive to just depression. Stress is implicated in numerous health problems in a rather vague manner. To further complicated matters what is stressful to one person isn’t stressful to another. Consequently it is complicated to study stress.

In the end CBT emphasizes that depressed people are responsible for their depression which is still questionable in the eyes of science.

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Do antidepressants cause weight gain?

Antidepressants have been associated with weight gain however a new study refutes that idea.

Yet according to a study published a few days ago in the online issue of JAMA Psychiatry, this should not have antidepressant-weight-gain-thinkstock-72919774-617x4161happened. Using electronic medical records to gather information on weight change among more than 19,000 patients on antidepressants, Dr. Roy Perlis and colleagues of the this hospital in Boston found only minimal changes in weight. Using electronic medical records to gather information on weight change among more than 19,000 patients on antidepressants, Dr. Roy Perlis and colleagues of the this hospital in Boston found only minimal changes in weight. ….. Conclusion: The researchers said that patients should not be scared of taking antidepressants because they think they will gain weight. [1]

Weight was gained among those who had depression, but according to the author, only among those who had what she described as atypical depression, a depression characterized by increased appetite.

The majority of my 50 pound weight gain started 4 years ago after I stopped taking Wellbutrin. Ten of the 50 pound weight gain could be due to taking Risperdone in the last year. I doubt the author’s speculation about an increase in appetite. My calorie intake was about the same over that four year period since I am rather rigid/consistent when it comes to eating. The fact that the weight gain could be related to atypical depression could be supported in my case however I didn’t gain much weight while on Wellbutrin. Atypical depressives can also gain weight independent of calorie intake.

Antidepressant discontinuation syndrome

In the fall of 2010 I experienced psychotic depression at the age of 39. What is odd is that it was the first psychotic episode that I have been diagnosed with.  In the past my psychiatrist mentioned that I tested on the MMPI as slightly paranoid but not psychotic.  The episode in 2010 was dramatically different with voices, paranoia and delusions.

Prior to the fall of 2010 I had experienced much stress; I lost a job, my father had a heart attack and I was in conflict with a 14ef18e6fb92ddc1388dab6060f8d1f6neighbor. The neighbor seemed rather sadistic and during the the winter I hid for most of the three months in the medical library. Many people didn’t believe the neighbor was threatening but I perceived it that way. Then during the spring I moved to another apartment in order to get away from my neighbor. In the summer I tried to taper off of Wellbutrin and started valproate for migraines.

One day during August or so I started to hear voices and and experience delusions. Looking back I wonder if tapering of Wellbutrin might have played a role in that episode. There are a few case studies where individuals experienced psychosis when they started the drug and some who experienced difficulty discontinuing the drug.

According to several case reports, stopping bupropion abruptly may result in a “discontinuation syndrome” expressed as dystonia, irritability, anxiety, mania, headache, aches and pains.[51]

Recently I came across an article by Joanna Moncrieff where she mentioned that some individuals experience psychosis when coming off of antipsychotics. She also stated that various drugs could cause symptoms which could be confused with mental disorders. Wellbutrin has a weak effect on dopamine but it is not blocking it like antipsychotics. According to Moncrieff there is something called super sensitivity psychosis which can develop when coming off antipsychotics. Super sensitivity psychosis is attributed to a reaction regarding dopamine. On antipsychotics dopamine is blocked so when it is stopped abruptly dopamine acivity increases in reaction. Similar to the law in physics, for every reaction, there is an equal and opposite reaction. Here is a quote from her paper.

Adverse effects induced by discontinuation of psychiatric medication include: (1) a somatic
discontinuation syndrome that includes psychological symptoms which may be mistaken for relapse, (2) a rapid onset psychotic reaction after withdrawal of both conventional neuroleptic drugs and some atypicals, notably clozapine(sometimes referred to as supersensitivity psychosis), (3) a psychological reaction to withdrawal, which may be mistaken for relapse or may itself precipitate relapse, (4) a genuine relapse of the underlying condition precipitated by the process of withdrawal

A second researcher by the name of Giovanni Fava found that over time antidepressants can worsen depression and cause hypersensitivity of the HPA axis which is primarily involved in stress regulation. A hypersensitive HPA could potentially cause psychosis since psychotic depression often manifests with abnormally high cortisol levels.

By facilitating 5-HT receptor mediated neurotransmission, 5-HT post synaptic down regulation, a putative  final common pathway of the actions of different antidepressants may induce an activation of the HPA axis.

SSRIs have the potential to disrupt the dopamine balance as well since as seorotonin levels increases dopamine is said to decrease. Consequently SSRIs have the potential to cause psychosis as well when tapering.

When I brought the possibility of Wellbutrin precipitating my episode my pdoc dismissed the idea entirely. Perhaps doctors don’t want to acknowledge that there is anything wrong with the drugs that they prescribe, with potential lawsuits and all.

 

This person had a similar experience tapering off of Effexor. 

 

Presence of ‘activation syndrome’ suggests bipolarity

KraepelinWavesWhen younger(in my twenties) I noticed that SSRIs initially gave me panic attacks and akathisia. I always had a suspicion that my depression had a degree of bipolarity about it and this study confirms it a little. Activation syndrome is more common among bipolar patients and it consists of the following symptoms:

The components of activation syndrome, as stated by the US Food and Drug Administration, are anxiety, agitation, panic attack, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, and mania/hypomania. The syndrome is believed to flag suicidality risk in patients taking antidepressants.

If an individual has these symptoms it increases the chance of being bipolar by 3.27 fold.

On multivariate analysis, a bipolar diagnosis was one of only two variables independently associated with activation syndrome, increasing the likelihood 3.27-fold.

The other variable was experiencing a mixed depressed state which like a bipolar diagnosis, increases suicidality. In the past another mood researcher Benazzi, a proponent of ‘mixed depression’, believed that individuals with a few hypomanic traits such as irritability, insomnia and agitation while depressed were more likely to have bipolar disorder.

The other significant variable was being in a depressive mixed state, which raised the likelihood for activation syndrome 4.13-fold. The researchers note that a depressive mixed state is reportedly almost as common in patients with MDD who attempt suicide while on antidepressive treatment as it is in patients with bipolar disorder.

Given the small size of the study and the naturalistic/retrospective nature, further studies are needed to confirm the connection between activation syndrome and bipolarity.

Not all fish supplements created equal

I have been taking a variety of fish oil supplements( Twinlab, Now) since 2003 and I believe, for the most part, that they were helpful, howevergel capsules I couldn’t say for certain. Recently I came across some information that is new to me. A website PsychEducation mentioned that if you purchase fish oil the amount of EPA should be 60 percent of the total amount of Omega-3 fatty acids per/pill.  A fish oil pill with less than that percentage acts more or less like a placebo. I found it difficult to discern this from some of the brands since some don’t give you much detail.

big review of all these studies and more suggests that the ratio of EPA to DHA (the two omega-3 fatty acids) really matters. Their analysis shows that of these two omega-3’s in each pill, at least 60%  must be EPA. Less than that and it does not work better than a placebo; in fact in several studies, less than 60% EPA was worse than a placebo.

The Mayo Clinic gives fish oil a grade of C due to the fact that results of various studies have been mixed. I’m not sure if the information from this latest review has been taken into account?