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November 27, 2013

Myths and Depression

The Canadian Charger

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In a lecture about depression delivered on November 23 at Ottawa's Royal Ottawa Hospital, Dr. Pierre Blier addressed the issue first by tackling certain myths. Blier is the Director of Mood Research at the University of Ottawa and Canadian Research Chair of Psychopharmacology.

His myth #1: The Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association’s classifications proliferate to sell more drugs.

On the contrary, the DSM criteria for depression remain virtually unchanged over 30 years.  (The fifth edition has appeared this year.)  Blier thinks that more change may well be needed, as he believes that the wide range of the criteria covers more than a single condition.

Myth #2: Depression is not very important compared to other illnesses.

On the contrary, it is the condition in moderate and high income nations casing the greatest losses.  Around the world, it is number three, and he says that by 2030 it will be number one there as well.  And when a person with depression suffers from some other medical problem, there is a synergistic effect, where one and one no longer equal two but instead equal three or four or more. 

Myth #3: Anti-depressants are overprescribed. 

In fact, they may be under-prescribed.  Sometimes they are prescribed for anxiety and phobias rather than for depression, but often prescriptions for depression are prescribed at inadequate strength. 

Myth #4: Anti-depressants are addictive.

He might wish it were so.  If they were addictive, people would not stop taking them.  Half who do take them quit, and they usually relapse.  When a person relapses and goes back to the medication, the medication may no longer work.  Lack of maintenance of the medication leads to a weakening of efficacy. 

With a first episode of depression, the person needs to take medication for at least six months.  If there are further episodes, such treatment may require many years.

Myth #5:  Depression has little effect on the body.

Depression can have substantial impact on physical health.  Sufferers are apt to lose bone density, especially women.  They may also suffer neurodegenerative disorder, especially if they have a number of depressed episodes.  Among the elderly, current and past depression increases the risk of dementia.

Depression may affect the heart, leading to arrhythmia and increasing the likelihood of infarction, and of death caused by infarction. 

In pregnancy, depressed women have smaller fetuses.  Blier favors treating depressed pregnant women aggressively, using medications.  “There has been no evidence of harm to the fetus,” he assured us.

Myth #6:  We are born with a set number of brain cells. 

No, new cells are constantly being produced, even in people older than 70.  Brain cell production is increased by use of anti-depressants, reduction of stress, and electro-convulsive therapy (ECT), otherwise known as shock treatment.

There are different chemicals in the brain implicated in mood, and medications mirroring them are used in treatment.  Broadly, serotonin is involved in impulse control, norepinepherine in energy, and dopamine in drive, though there are overlapping effects.  Combining medications is therefore not unusual, but it is a balancing act.  While it is important to avoid too many drugs, called polypharmacy, it is also important to avoid not addressing the problem fully.

Fear of polypharmacy should not deter the physician from treating depression aggressively, as it worsens all other medical problems and shrinks the brain.  “In most cases, depression does not take months to lead to remission because of effective treatments.”  And there are new treatments on the horizon. 

Blier commented on a couple other matters that are not directly related to depression—on generic drugs and on the shortage of specialists to treat depression.  He reported that generic drugs can vary from the original, with potency 20% less or 25% greater.  In Canada, the situation can be worse.  “There are no spot checks in Canada.”

He pointed to a lack of professionals to treat depression, noting that it is often dealt with by family physicians.  When asked about using psychiatrists in a consultative role to assist family practitioners, he said that that is being done in distance medicine for service to remote areas.  When pressed about providing the same kind of help in urban areas, he was reluctant to take psychiatrists away from direct practice.  This observer sees that reluctance as a preference among professionals for providing the service directly rather than a way of maximizing benefit to the community and to patients.

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