The tide of prescribing for depression is turning
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7505.1450-c (Published 16 June 2005) Cite this as: BMJ 2005;330:1450All rapid responses
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NO ABSOLUTE CAUSE FOR DEPRESSION
22nd June, 2005
Nancy E. Hokkanen has highlighted the chemical cause for depression. A
classical example is riserpine induced depression. There is no doubt that
chemicals alone can cause depression but chemical- induced depression
clears when the causative chemical is identified and eliminated. The
belief that a chemical imbalance cause depression rather than reflect it
continues to be debated.
Long standing disputes between biologically and analytically oriented
psychiatrists have made the topic of depression highly controversial in
the psychiatric world. Psychoanalysts have been attempting to find and
treat past traumatic memories in the grail-like search for the causes of
depression. Recurring memories grow in strength and, as a result, become
more emphatic. Patients would surely benefit more by opening the “jewel
box of the past” as opposed to “the skeleton-filled closet”. Theologians
and medical professionals have always held differing opinions on the
causation and treatment of this illness and indeed each school of thought
has its own unique insight into this subject and so currently, it is not
advisable to hold strong views on the universal and transcultural
depression phenomenon.
Most experienced psychiatrists would admit that we know only about
“the arm of the mind body.” Medical scientists who adhere to a strict
biological model of the mind tend to ignore the non-biological aspects of
depression. Recently, however, hypnotherapeutically oriented researchers
have postulated that the depressive experience is a network of different
negative trance states and whilst hypnotherapy may not have a place in the
treatment of depression, it can certainly play a highly relevant role in
the comprehension thereof 1, 2. Clinical parapsychologists even believe
that if we were to understand that the mind contained a non-physical
element, and that such an element were capable of interaction with other
minds and discarnate spirits, then, where the causation of depression is
concerned, the spiritual realm would simply become another facet of the
social realm 3. Parapsychological research is now beginning to validate
scientifically some of the intuitive truths of primitive cultures 4.
Sceptics of the survival hypothesis could argue that it is too early to
bring depression under the domain of clinical parapsychology, however,
research involves forming hypothesis, proving or disproving them, and
modifying them accordingly.
There is no one absolute cause for depression and so it is impossible
to find one absolute cure which will be effective in all cases. A
multidimensional approach is far more desirable and logical. Nonetheless,
when patients are suffering from psychic pain, what they most urgently
need is relief of that pain, which can only be achieved through
psychotropic drugs. Finding the right antidepressant is sometimes a matter
of life and death issue in psychiatry. A psychiatrist should have his
footing in biological psychiatry, but holding a belief that depression is
a neurotransmitter disease is equivalent to thinking that British Telecom
determines the foreign policy!
No funding and no conflicts of interests
References:
1.Yapko, M.D (1992). Hypnosis and the treatment of Depressions.
Brunner/Mazel. New York
2.Pandarakalam J.P, (2005) Are the hypnotherapeutic views of depression
Valuable? Modern Medicine, Volume 35, Number 5, p21-26,Eireann
publications
3.Ehrenwald, J. (1974). Telepathy and Medical parapsychology. Gordon
Press, New York
4.Greyson Bruce (1977) Telepathy in mental illness : deluge or
delusion? J. Nervous Mental illness. 165:3, 184-199
Dr James Paul Pandarakalam,
Consultant Psychiatrist,
St Helens North Community Mental Health Team,
Peasley Cross Resource Centre,
Marshells Cross Road,
St Helens,
Merseyside WA 9 3DA.
United Kingdom
Email address: jpandarak@hotmail.com
Competing interests:
None declared
Competing interests: No competing interests
Neither talk therapy nor medications treat the root cause of mercury-
induced depression. Anyone with a mouthful of mercury amalgam tooth
fillings should investigate them as the causal agent of biochemical
imbalance that manifests as mental and physical illnesses.
Tacit assurances by trade organizations such as the American Dental
Association gloss the fact that these fillings outgas into surrounding
tissue that is highly vascular.
Other sources of mercury injected and ingested include Thimerosal in
flu vaccines and, of course, many species of predator fish.
The U.S. president Abraham Lincoln suffered mood swings while taking
mercury-laced "Blue Mass" pills.
http://www.biomed.lib.umn.edu/hmed/2001/07/20010717_lin.html
http://faculty.washington.edu/chudler/linc.html
Unfortunately anecdotal experiences like my own are too often
dismissed rather than studied, as if reality were limited strictly to lab
work.
Competing interests:
Parent of child recovering from mercury-induced autism
Competing interests: No competing interests
If my involvement in Nofreelunch is a competing interest then I am
very willing to achknowledge this. The reason that I do not normally quote
this connection is that these are my personal views and not those of the
nofreelunch organisation. I hope that this clarifies the point.I have no
finicial conflicts of interest.
Competing interests:
memeber of nofreelunch
Competing interests: No competing interests
Editor
Readers may be unaware that Des Spence is the UK spokesperson for No
Free Lunch, an international organisation that believes health
professionals should distance themselves from the pharmaceutical industry
and pledge to be free of drug company money and influence in their
clinical practice, teaching, and research.
I was therefore surprised to note that he had not declared this
competing interest in his letter(1).
Dr Spence states his clear contempt for a “greedy pharmaceutical
industry” that he believes are propagating a depression myth. His rallying
call is to halt widespread antidepressant use. Surely his remarks must be
seen in light of this blatant conflict of interest.
Your guidelines(2) suggest that you ask all authors to declare any
competing interest but that you restrict yourselves to asking directly
about financial interests only. A previous editorial(3) explains that this
policy was intended to increase the number of authors declaring their
interests. Though this is an honourable intention, I suspect some doctors
are still not declaring all relevant competing interests.
Dr Spence may receive no financial backing from No Free Lunch.
However his involvement in an organisation that denigrates pharmaceutical
industry promotion must be made known to ensure what he calls a “myopic
medical profession” have the benefit of transparency when reading the BMJ.
(1) Spence D. The tide of prescribing for depression is turning. BMJ
2005;330:1450.(18 June).
(2)http://bmj.bmjjournals.com/cgi/content/full/317/7154/291/DC1
(3) Smith R. Beyond conflict of interest. BMJ 1998;317:291-292(1 August).
Competing interests:
None declared
Competing interests: No competing interests
DISTINGUISHING DEPRESSION AND SADNESS
Sir,
The paper of Hollinghurst S, Koestler D, Peter T.J, Gunnell D. 2005.
Opportunity cost of antidepressant prescribing in England: analysis of
routine data( 2005.B.M.J.330:999-1000 ) and the response of Des Spence (
The tide of prescribing for depression is turning. Des Spence B.M.J. 2005:
1450,DOI 10. 1136/BMJ 330.7505, 1450-C have been timely [1,2].
Psychiatrists and general
practitioners are often met with people presenting their personal and
social difficulties as causing low moods trying to convince themselves and
others that their problems are resulting from an underlying mental illness
thereby avoiding the personal responsibility of their decisions and
actions. Sometimes depressive feelings are mistaken for depressive illness
but it does not respond to antidepressant medication and can get worse if
they are used [3]. One of the reasons for the uncertainty involved in the
detection and management of depression in primary care is due to the fact
that depression carries different meaning to different professionals even
though international criteria have been set out for its assessment.
General practoners perceive depression differently from hospital
psychiatrists. Because there are no objective indicators, depression is
interpreted differently and the concept of depression has been so much
stretched that it has nearly lost it’s meaning.
If depression can be considered as a psycho-bio-social condition,
while antidepressants correct the neurotransmitter disease involved in
this illness, cognitive depression is demystified by psychotherapeutic
methods. The rationale behind giving psychotherapy for personal and social
difficulties is the belief that negative life experiences lead to
cognitive depression in individuals with cognitive vulnerability to
depression and if not nipped in the bud, can promote the development of
biological correlates. The controversy
whether biological depression precipitates cognitive depression or vice
versa, still remains unresolved [4]. Also, the use of cognitive therapy is
not restricted to
clinical depression alone as cognitive and behavioural factors are
relevant to all human experiences [5]. Depression should be ideally healed
with positive life events but they are not always easily available.
The suggestion that instead of non-specific application of
antidepressants, C.B.T and counselling should go in primary care
deserves serious attention, even though a few other reasons that have also
contributed to the prevailing uncertainty in distinguishing and treating
mental illness in the primary care remains unclarified. The belief
that anxiety or panic attack could sometimes be a heralding symptom of
depressive illness is thought to justify premature introduction of
antidepressant medication. The recent media propaganda against minor
tranquillisers has also contributed to the excessive usage of
antidepressants in primary care so as to take advantage of the anxiolytic
properties of such drugs. Many general practioners prescribe anti
depressants for cognitive depression along with counselling hoping it has
some prophylactic value against biological depression and this has not
been proved. When antidepressants are used as anti-stress agents;
patients are running the risk of getting over diagnosed as suffering from
depressive illness, which can lead to disabling abnormal illness behaviour
as time goes by. The same view can be held against psychotherapeutic
techniques when applied in the medical setting of primary care. Ideally
antidepressants are indicated only when there are biological symptoms.
Competing interests: None declared.
Dr James Paul Pandarakalam,
Consultant Psychiatrist,
5 Boroughs Partnership NHS Trust,
St Helens North Community Mental Health Team,
Peasley Cross Resource Centre,
St Helens, Merseyside WA 9 3DA ,U.K.
References.
(1) Hollinghurst S, Koestler D, Peter T.J, Gunnell D. Opportunity
cost of antidepressant prescribing in England: analysis of routine data
2005.B.M.J.330:999-1000 .
(2) Spence Des The tide of prescribing for depression is turning.
B.M.J. 2005: 1450,DOI 10. 1136/BMJ 330.7505, 1450-C
(3) Cookson. J, Crammer J. Heine B. The use of drugs in psychiatry
1993 p133 Gaskell. London.
(4) Teasdle JD Cognitive vulnerability to persistent depression.
Cogn. Emotion 1988; 2; 247.7
(5) Simon Jenright Cognitive behavioural therapy—clinical
applications. 1997.BMJ V314, P, 1811-1813.
Competing interests:
None declared
Competing interests: No competing interests
Hurrah for the voice of good old-fashioned common sense and reason!
Dr Des Spence welcomes the report of Hollinghurst et al and goes on to
regret the rising trends in the diagnosis of clinical depression and the
prescribing of antidepressants.
Those of us who have tried to resist this trend and who have
questioned the validity of depression rating scores have been accused of
missing clinical depression and consequently of the underprescribing of
antidepressants.
My own view, deeply held after 32 years in general practice, is that
this is not the case. However, we certainly have been resisting a
medicalisation of the ups and downs of normal life. In particular I
believe we have been refusing to recognise unhappiness as an automatic
pathological entity. The medicalisation of unhappiness, stress and mild
anxiety must surely encourage in our patients not only a lack of self-
awareness and responsibility, but also the creation of an inappropriate
expectation of, and dependence on, medical services.
By encouraging our unhappy, stressed and anxious patients to use
talking therapies and all the other opportunities described by Dr Spence,
we can help them to develop strategies with which to ride life’s
difficulties and to do so against a background of acceptance of their own
personalities.
The tide is indeed turning. Doctors must encourage and support their
patients for whom life is less than ideal in seeking answers, sometimes
with the help of talking therapies, within the community and within
themselves. Those patients who are truly clinically depressed will as a
result benefit all the more from the concentrated and appropriate time,
attention and prescribing of their doctors.
Competing interests:
None declared
Competing interests: No competing interests
Biochemical imbalance causes depression
Does talking replete zinc, copper, magnesium, manganese, B vitamins,
folic acid and essential fatty acid (EFA) deficiencies or lower levels of
neurone impairing toxic metals? Mental instability does indeed reflect
biochemical imbalances, which is easily proved if the relevant tests are
used. The tragedy of modern medicine is that most psychiatrists and
doctors do not have free access to high quality nutritional analyses to
diagnose the biochemical reasons for depression in their patients.1,2
Normal brain function and development and growth depend on an
adequate zinc status.3,4 Intracellular zinc levels can be measured at
parts per billion by using passive sweat collected for an hour. Zinc
deficiency is the commonest biochemical abnormality if a sweat test is
used for the diagnosis. Cadmium from smoking lowers zinc levels. Mercury
from dental amalgams is more toxic when zinc, selenium and glutathione are
deficient.
Too high serum copper levels have long been associated with
schizophrenia. Copper deficiency and low copper stores can be diagnosed by
a red blood cell superoxide dismutase function test. Restoration of a
normal zinc/copper ratio can result in extremely dramatic improvements in
mental and neuronal function.
Abnormalities in minerals and B vitamins can relate to mental
symptoms and can also block essential fatty acid (EFAs) pathways.
Repletion of omega-3 EFAs have given significant improvements in adverse
mental symptoms in randomised trials.
Mental illness and zinc brings up 876 references in Pub Med
Mental illness and copper - 583 references
Mental illness and polyunsaturated fatty acids - 1642 references
Surely correcting biochemical deficiencies and advising avoidance of
common social poisons, such as depressive progesterone-dominant
contraceptives or HRT, smoking, alcohol and drugs, should be the first
priority before talk-therapy or antidepressants?
1 Grant ECG. Psychiatrists ignore science.
http://bmj.com/cgi/eletters/330/7485/260#94858, 30 Jan 2005
2 Grant ECG. Deficient NICE guidelines on depression.
http://bmj.com/cgi/eletters/330/7486/267#95750, 6 Feb 2005
3 Grant ECG. Children with psychiatric disorders and learning
disabilities have biochemical abnormalities.
http://bmj.com/cgi/eletters/330/7494/742#102754
4 Grant ECG. Nutritional deficiencies cause mental illnesses in
adolescents.
http://bmj.com/cgi/eletters/330/7495/835#103064, 8 Apr 2005
Competing interests:
None declared
Competing interests: No competing interests