Of the handful of studies that have used a waiting-list arm (mostly psychotherapy studies), the typical rate of spontaneous remission of major depression (many studies allow waiting-list patients to receive naturalistic treatment) is approximately 10% per month, with a mean episode duration of 6 months [ Posternak, M. A. & Miller, I. (2001) Untreated short-term course of major depression: a meta-analysis of outcomes from studies using wait-list control groups. Journal of Affective Disorders, 66, 139 –146 ]
. This indicates that although both drug and placebo arms offer substantial benefit, some early remission would have occurred without intervention, particularly if patients were recruited at peak depression severity.
Two things have to be stated first; first in importance. 1.
What has worked before will work again.
That is very reassuring.
Switching to something else may lead to extra disappointment and be the last straw in failure.
2.
The illness always
[ mmmmh.. but see below for the rare exceptions : Mayberg } ]
gets better, although it may be months - maybe at the extreme, two years or so - so that even if all else fails, normality returns.
Treatments are there to neutralise current illness until it mends itself - as it always does. Treatment is offered because of the distress during the illness, the effect of the illness on the position of the individual in society - jobs, reputation, financial mismanagement, and family disruption from the strain of living with someone who has unrelieved hypomania [euphoria and assertiveness, plus plus ] or depression: the consequnces of that may do lasting damage.
In order of historic success
Electro-convulsive treatment ( ECT ) was statistically and historically the most successful in removing mood illnesses - given in twice weekly applications somewhere around a course of eight treatments.
It was the earliest and the only success story for a long while.
The fact that it could be given as out-patient treatment well away from the mental hospital, meant it was extensively used. Perhaps it's success led to it being overused.
The procedure itself brings anxiety. The immediate memory loss effect usually soon fading, but uncommonly lasting troublingly in a very few people.
The discovery was based upon hospital observation that some with 'epilepsy' saw their illness relieved after natural 'fits'. That applied to people suffering with excitement in schizophrenia but it was then applied to the agitation in disturbed depression - successfully.
The 'fit' - the muscle jerk - is now suppressed by anesthesia- an injection before each treatment.
Before ECT , people had to wait for recovery, treated outside hospital in the meanwhile by sedatives, hypnotics, and more with hope than success by amphetamine type drugs - sometimes combined with a sedative ( drinamyl ... two on rising one before lunch ... amphetamine plus sodium amytal ).
The most important outcome of the long stay in hospital before ECT was the observation that others in the same condition, recovered in due course , and went home, confirming with encouraging assurance that this condition always recovers in due course, returning the person to their previous selves.
That continual reassurance given repeatedly by someone in whom confidence can be placed - who would know that from their experience - and perhaps can recall that previous attacks in the person - or similar attacks in relatives or friends always recovered completely - this remains the basic, never to be missed out, plank of treatment. A determined confidence given by the significant companions; never uncertain, and never demanding; but persistently there in quiet nearby company.Leave raising any difficult matters till the least depression in the day - usually evening time.
Kraepelin the pioneer hospital psychiatrist watched the natural course of mood illnesses in hospitals, and his advice about release from his hospital was ... when normal sleep pattern is restored, and appetite and weight regained. He anticipated that after release there might be further phases of a lesser degree and of shorter duration, followed by clear years.
A duration of sleep disturbance was the best indicator of 'illness'. Normal sleep means normal moods.
The return to normal refreshing sleep, and normal weight, remains the best criterion that the mood illness has gone.
The second most successful line of treatment began with the discovery of an incidental finding whilst looking for something similar to chlorpromazine - for schizophrenia and agitation.
The tricyclic anti-depressant tablet - the first to be tries out was imipramine (Tofranil-Geigy) - when it was given given to some agutated people from prolonged endogenous depression in hospital , they saw their illness disappear, after a waiting out of two to four weeks on the preparation.
Next it was found that stopping the tablets, when well for a short time, often was followed within days by a return to the porevious illness. The medication had to continue to be taken for a number of months.
Eventually it is accepted that these tri-cyclic medications did not end the depression; they neutralised it so long as they were being taken - until the illness recovered in its own way.
If the preparations were stopped before that happened - this was the case in the earlier trials - then the depression might return within two to three days - and the preparation had to be restarted as before.
Of significance was that these preparations only worked with endogenous mood - they had no lifting or stimulating effect on ordinary people. The side effects are a nuisance - and they turn up before any benefit - dry mouth, a bitter taste that sometimes which sticks around, lowering of blood pressure initially - faintness - which wears off, sweating, constipation, maybe initial bladder hesitation, increased pulse rate. Most - except the dry mouth and bitter taste - are there only in the initial days - 'it means the tablets are working' .
A valuable asset was that if successful it always would be in the future. Any future susceptibility could be managed, either by holding to a maintenance dosage, or by the immediate re-introduction upon early signs of return of illness.
If the medication is withheld or forgotten, it loses its effective presence in 2-3 days so that it is always wise to have some ready for resumption at once.
The next category of medication was the mono-amine oxidase inhibitor chemicals - noticed to be of some efficacy when one of its class - isoniazid - was used to treat tuberculosis - some were moved into elation by the drug.
The successor MAOI drugs were never as effective as the tri-cyclic drugs, but in a minority did neutralise depression, and were successful when the tri-cyclic drugs did not work. The side-effects were rather similar without the taste. Their biggest drawback is that they interfere with the downgrading of some foods so that elements are left which can catastrophically heighten the blood pressure: cheeses, are the most prohibited. They are dangerous when taken with some other medications, and when combined, or overlapping with the tricyclic group of drugs. They take three weeks to leave the body after they are stopped, and in that time length the contra-indications mentioned above still apply.
Often where one member of the family kin found an MAOI drug efficacious in their depression, it would suit any other member. That was also the case with the tri-cyclic range. The opposite was also true; failure in one of a family meant failure in others in that family if they had the condition.
Some people found that this MAOI class of drug had a general euphoriant effect on them.
The last preparations to be introduced remain controversial.
The group - particularly Prozac and Seroxat, but the category as a whole - have been accused of having a tendency to bring people to suicide in the early days of treatment, before the benefits from them are obtained. As though there was a rush of energy which enabled people to put through a depressive thoughts, before any benefits against that depression could have 'kicked in'. The issue is not yet resolved. The Prozac group of drugs ..seroxat ...- serotonin boosting in the brain - remain a puzzle. They seem to have success in removing endogenous moods in some people, but not others.
There are far too many people being prescribed the drug, and declaring effective help, that it must be doing something for people who do not have endogenous mood , but have 'reactive' depression circumstances or depressive gloomy personalities.
In these people it may be having a boosting effect, which is not like that due to amphetamne type drug stimulation, but it leaves some dependent upon continuing with the medication, for benefit. Seemingly, many have difficulty coming off the medications, with a downside following.
That is quite different from the tri-cyclic group of drugs, which have no advantage for other than the endogenous mood group, and if the underlying neutralised phase of mood has passed, the tricyclic group can be withdrawn without any reaction.
The serotonin modifying group have less pronounced side-effects largely 'stomach upset'.They are marketed to family doctors as being safer in overdosage, and being lesser in side effects than the older drugs are therefore more acceptable at the family doctor surgery. This has been disastrous in some cases, where a previous success with the tri-cyclic drugs was over-looked or replaced with optimism by Prozac or its 'look-alikes'; failure and subsequent disappointment has led to suicide leaving a feeling that if the previously succesful class had been tried again - that previous success would be reassuringly remembered despite the side -effects that came with them, then the outcome would have been the same relief as before.
There does seem to be a 'buzz' effect - not the same as the euphoria with amphetamines - with this serotonin altering class of drug which makes it appealing to all manner of 'psychiatric appeals' in the family doctor surgery. It may be that altered serotonin alters the neurosteroid function, and therefore modifies gaba amino butyric acid, the natural brain inhibitor, and allows more 'excitability'. In normal male volunteers a few people noted a wound up aggressive inner feelong.
Some ssri drug experience has felt their wsas anissue in an earlier /push/ before depression could be relieved so that suicide beahviour might come first before relief. Something to be watched out for, and by carer companions.
But reports of complications continue to accumulate whilst a satisfactory protocol for the class has not been decided.
It's very widespread usage cannot mean that it is just being prescribed for psychiatric mood illness of the kind that ECT and the tri-cyclic treatments are used in successful practice.
It must be being used for some effect, that touches a generality of people.
The tri-cyclic success is that there is a return to the a recognisably natural previous mood flexibility.
Whereas the tricyclic medications were regularly introduced when this illness was recognised, nowadays family doctors are first prescribing the SSRI drugs- they carry no risk of overdose -are promoted highly as 'safe drugs'. The trouble is that this will lead to efficacious tri-cyclic medication being put off till the previous try with ssri medication has failed - allowing depression to have gone on longer, adding to the despair after no success and raisng doubts about successor medications - the first drug which must have been the best now I am being given a second choice preparation leading to areluctance to take medication - especially as the tri-cyclic medications even when effective, carry early side-effects before the good benefit kicks in two to four weeks. = feeling worse before better.
Good explanation to carer and patient is essential to dissipate reluctance. The SSRI drugs seem to carry an unnnatural lift or drive so that they have come to be prescribed in nummbers of people far above what is considerd to be the number thought to have the 'medical illness' of depression.???
The story of Prozac and its cousins has yet to unfold.
NEW .... There are very rare cases of persistent depression resistant to current medications, and not getting a satisfactory result from one or two eight session, twice weekly, courses of ECT.
A new line of treatment is being pioneered on a very few cases. [ Mayberg ]
Electrodes , of material which does not upset the brain are inserted accurately by imaging into an area of the brain, under local anaesthesia, so that the patients can respond when the right area is found .. ..., for confirmation ( the subgenual cingulate region - the lowest part of a deep band of brain tissue that runs along the midline of the brain,front to back. This area the neurosurgeons found was overactive when there was depression, and it changed back when there was a remission,or when the depression yielded to medications.)
a small 'exciting' current is applied to the white matter that is the 'nerve fibre links' leading into the area.
Four out of six cases - where all else failed, were cleared of their depression, back to normal feelings, The success persisted into a second year. Early days, but it seems ther was no change to the other abnormal mood shift - hypomania.
The electrodes remain implanted.
The patient carries a connected pacemaker which can repeat the procedure.
[ Helen Mayberg ]
What a sufferer and carers can do for themselves.
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