Treat the Individual - Not the Diagnosis
We live in a society of “medicating where it hurts”. We have encouraged this trend by neatly packaging our illnesses with a scientific name. We hoped in doing so, the illness magically becomes more manageable, more treatable, and that everything can be under control. Then we can go back to what we were doing before we were “so rudely interrupted” in our heads.
How do we tell “normal depression” from “chemical depression”? Stressful situations can induce a depressive state as a normal response. In time, with support and lifestyle adjustment, we may recover and be “mentally robust” again. However, we are now quick to seek medication, doctors have less time to diagnose (correctly), managed care organizations are keen on money-sparing “treatment algorithms”. We no longer treat complex individuals with complex problems. We have come to a state of reduction, a state of “take this once a day and come back in 4 weeks.” (IF your insurance covered the visit, that is!)
Mental health professionals may be pressured to prescribe the conventional, because they are liable if something goes wrong under a “non standard of care”. Insurance companies know this, thus “experts” design “algorithms” to ensure that most patients are treated “appropriately”. The current healthcare milieu makes alternative therapies risky business for many health care professionals.
Even therapy has become a game. If you recover too quickly, your therapy sessions will no longer be covered under insurance, because you are”well”. If you recover too slowly, your therapy sessions will be terminated and replaced with something “that works”, because the insurance company does not want to lose too much money on lost causes.
Many psychotropics available on market are useful. I have personally benefited from medication therapy for severe depression. I may never know whether my depression would be alleviated just as well if I had intense psychotherapy accompanied by lifestyle changes including exercise, adequate sleep, balanced nutrition, and meditation (all foreign concepts to a typical graduate student). Would all this worked just as well for my depression as a 20-milligram-per-day dose of Prozac?
I subscribe my own recovery from depression to a combination of medication therapy and psychotherapy. Did my unhealthy life situations contribute to my depression? I have no doubt of it. I wonder what would happen if we treated depression like diabetes - aggressively intervene with lifestyle changes first, before we start prescribing medications. Eat well, exercise, get enough sleep. For even better results, identify external or internal triggers and learn coping skills or eliminate those triggers altogether. Just like diabetes, if you’re in the ER because your illness has landed you in a dangerous predicament - medications are immediately used - with careful follow up and lifestyle intervention close behind, but the goal is to prevent that train wreck in the first place.
Do psychotropic drugs have value? Absolutely. Do psychotropic drugs need ten different indications? I doubt it. I believe in proactive self-education and patients taking responsibility for their own mental health management. I don’t believe we should leaving it solely to healthcare professionals to make decisions for us. We can’t expect others to help us if they can’t access inside information on our overall health and mental state of mind. We must communicate this to our physicians, and be accountable for restoring our health as well.
Many illnesses - not just mental illness - are becoming more complex, because we live in a world of accelerating paces and increasing socioeconomic complexity. Unfortunately, as a society, we have become lazy. We often allow others to decide for us rather than remain an active partner in decision making that intimately affects our lives. After all, can’t we simply sue if someone did us wrong? We’ll let money take care of our pains.
My prescription - and one that gives the consumer the greatest chance of success at finding the right treatment for their mental illness - is for the consumer (and the loved ones/friends/family) to be as involved as they expect the doctors to be in their own mental health care. We all have to take responsibility and not give up our rights to that responsibility. But it is our burden to communicate this to the physician, who is doing the best he or she can.
Talk therapy
I believe in combination therapy for the treatment of depression: combining medication therapy with psychotherapy. Depression is a vicious cycle of a biochemical imbalance and destructive or unproductive behavior/thought patterns. Many experts agree that psychotherapy is a powerful tool for helping depressed patients explore core thought processes and behaviors that can exacerbate the depression.
Medication is often necessary to overcome the chemical imbalances in depression. Managing psychological reactions to external triggers that occur through the day can only help with the recovery process. Even the most analytical individual may not always step back from the situation and look at what is happening objectively. I went through the phase of “if I were so smart, I can talk myself through it.” Then, I meet a mental “wall” in the face of an emotional or environmental trigger. Even as I consciously knew that I was repeating a pattern, I felt powerless to overcome the reactionary behavior. Psychotherapy helps trip my old behavioral wires so I can establish new, productive coping skills.
Cry. it’s good for you!I see the medication therapy as giving me a window of opportunity so that what I have learned from talk therapy can “sink in and take lasting effect”. Medication had gotten me out of bed to be functional (this is especially critical for severely depressed patients who could not imagine life beyond the next minute). Psychotherapy helped me gain insight into conditioned patterns of thinking. This helped me manage unproductive emotional reactions before I became overwhelmed.
Finally, it is helpful to look at therapy as Dr. Alan Siegel at Cambridge Hospital in Boston puts it: “It is hard to resolve depression without tears.”
I need a new wardrobe with my medication
Aside from sexual dysfunction, weight gain is another side effect that becomes problematic for patients who need long-term antidepressant therapy. Many patients stop antidepressant therapy on their own, without notifying the physician (”noncompliance”) due to undesirable side effects that further impact their self image or normal daily functioning.
Most Psychotropics Cause Weight Gain
The effects of antidepressant therapy on weight, particularly those within the SSRI (selective serotonin reuptake inhibitors, such as fluoxetine, sertraline, paroxetine, or citalopram) class, have been often debated. Often, early during treatment, SSRI’s have been associated with weight loss due to increased agitation in some patients. However, in the long run, the patient may gain weight due to mechanisms that are still not well understood. Atypical antidepressants such as nefazodone (brand name Serzone) and bupropion (brand name Wellbutrin) are not associated with weight gain, although bupropion appeared to be linked with weight loss. The atypical antidepressant mirtazapine (brand name Remeron) is associated with significant weight gain, which may be an advantage for elderly patients who are often dangerously underweight.
Weight gain may also be a “natural” part of recovering from depression. If a patient loses appetite due to depression and stops eating, recovery will include a desire to eat and therefore regaining of lost weight. Some antidepressants may change appetites or metabolism, and these mechanisms warrant further study.
Many have complained of cravings certain foods (such as carbohydrates) while on antidepressant therapy or mood stabilizers. While patients may not stop therapy due to weight gain, clinicians are beginning to realize that weight gain is not simply a cosmetic issue. Patients who gain a large amount of weight may be less likely to keep complying with therapy (keep taking medication as directed) and their self image will not improve. Recently, weight gain associated with medication therapy had taken on a more insidious nature - accompanied by increased risk for heart disease or diabetes.
Although new drugs in the pipeline for treating depression and mood disorders may have improved side effect profiles and minimize weight gain, for the time being, physicians do not have a many options for treating weight gain cause by medication therapy, other than changing medications or stopping the medication therapy.
Psychological v. Physiological Craving
With my own treatment-induced weight gain experience, my cravings weren’t due to hunger. I would often be full, and still crave sweets. Gorging on sweets was comforting. It was easy to lose control with a gallon of ice cream or a whole pizza pie. I saw this as a psychological side effect rather than being hungry. Since people react to medications differently, what made me gain weight may easily make someone else lose too much weight. Therefore, even testing medications that will help your symptoms improve without too many side effects remains an individual trial and error.
I have been free of antidepressant therapy for many years. I was able to take off most of the extra weight through good old fashioned “eating smaller portions” and exercise. I still have carbohydrate cravings - these seemed to not go away. However, a high protein, low carbohydrate diet seemed to help take the edge off the cravings.
In addition, I also get adequate sleep. Studies have shown that lacking sleep can actually contribute to weight gain and obesity, plus other health problems associated with sleep deprivation.
Drinking water and keeping yourself hydrated throughout the day is a simple yet important way to keep your body working properly.
Incorporating weight- or resistance training with regular aerobic exercise is an excellent method to increase metabolism. Muscles require energy and you are able to burn fat even while not aerobically exercising. For women, please do not worry about “buffing up” too much. Unless you were genetically programmed for bulk, regular weight training will tone muscle, not build bulk.
Finally, when the cravings are clearly psychological - when you’re bored, when you’re stressed - keep a list of things to do to distract you from your cravings, or simply remove yourself with a walk down the block or in the park.
I know these aren’t clear-cut solutions, especially if you are still on an antidepressant for managing your depression. Trying many different methods - especially non-medication methods - can maximize your chances of controlling treatment-related weight gain.