Archive for the ‘Depression’ Category

Depression, religion and the atheist bus.

Wednesday, October 22nd, 2008

Over £50 000 has been raised for an advertisement campaign on London buses intended to spread the word of unbelievers. The slogan, ‘There’s probably no God, now stop worrying and enjoy your life’, whist not being particularly catchy, is interesting.

In dissecting it, there’s a connection implied between religion and anxiety, a plea made to end introspection concerning speculation of the existence of a supreme being - as if this enquiry was somehow reprehensible - and an implication made that religion is the root of all our problems, as if the only thing standing between mortals and earthly contentment is religious belief.

This small campaign, whether your agree with it or not, or whether like me you consider it only marginally less prescriptive than the religious advertisements it seeks to combat, at least feels like a levelling. The campaign, funded mostly by small contributions, represents a rare right to reply. As during so much of our day, we are assaulted with large advertisements, and beyond graffiti, there is scant ability to register our dissent or disapproval.

But what part does a religion belief play in mental well-being?

The best insight I’ve found on this is a 1999 literature review of 80 studies concerning the association of depression and religion. This suggests that people who are involved frequently in organized religion and who highly value their religious faith for ‘intrinsic reasons’ are at substantially reduced risk of depressive disorder and depressive symptoms. They also appear to recover more quickly from depressive episodes and are less likely to become depressed over time. On the other hand the authors say that people who are involved in religion for reasons of ‘self-interest’ are at a higher risk for depressive symptoms.

Two groups – Jews and people who are not affiliated with a religion – are at an elevated risk of depression and depressive symptoms and the authors speculate that these effects are ‘a result of trade-offs in how latent predispositions for psychopathology are expressed in certain religious cultures’.*

Private religious activity and particular religious beliefs, which probably equates to people saying that they are ‘spiritual but not religious’ (we’ve all met them), appear to bear no reliable relationship with depression.

The review states that these associations are modest, but consistent, and does flag up weaknesses in the evidence base. In terms of validity it concerns me that the difference between religious believers who have intrinsic and extrinsic beliefs and their relative vulnerabilities may essentially be a proxy for the personality types amassing under these banners.

* I’ve thought about this last sentence and I’m not entirely sure what it means. Can you help?

Links

The origin of the campaign:

Comment is free: Atheists- gimme five

All aboard the atheist bus campaign

Donate to the campaign: Just giving

Research/reviews:

Religion and depression, a review of literature

Religion and spirituality, linkages to physical health

Religious involvement and depressive symptoms in primary care elders.

Religion, spirituality and medicine: Psychiatrists’ and other physicians’ differing observations, interpretations and clinical approaches

Related Books:

No Logo - Naomi Klein
Essential reading on corporate intrusion via branding

The God Delusion - Richard Dawkins God is Not Great - Christopher Hitchens
Current atheist calls to arms

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More reading material: Beating stress, anxiety and depression

Sunday, July 27th, 2008

theguardian online today has a story on its main page which is titled ‘Why smiles are better than Prozac’

On closer inspection, it’s less an article, more an advertorial for a book called ‘Beating stress, anxiety and depression’ by Jane Plant and Janet Stephenson.  The  article says that the book is ‘new’ but the amazon.co.uk page says that it came out at the beginning of May this year.  I can only imagine that they were short of copy and rehashed a press release that they found knocking around the office.

Be this as it may, this is the sort of thing that catches my eye.  The introduction is available for perusal online, and Plant and Stephenson say some sensible things - like advising us to ignore celebrity culture - but I am concerned about some of the things they say particularly when they assert that levels of neurotransmitters should be assessed in patients suffering from depression.  The neurotransmitter hypothesis is problematic, as discussed by Badscience.net and Mindhacks.com, and this sort of test are likely to be more expensive than meaningful.

Daily Mail article on the same book title: ‘How the wrong drugs could be causing your depression’.

Best read it before I comment further.  If anyone has read it and would like leave a comment below I would be most grateful.

Also in the paper today Rachel Cooke has this to say about reality TV and meeting Jodie Marsh

What strikes you most about Marsh when you meet her is not her pleasure at the unexpected turn her life has taken, but her implacable anger…..(about four paragraphs)….I’ve lost count of the number of times youth workers and criminologists alike have made the connection, as they discuss knife crime, between low self-esteem and anger. Well, there is an awful lot of anger among those who participate in reality TV, the majority of which, it seems to me, is the result of low self-esteem, and Marsh is no exception.

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How Burgers Saved my Life.

Wednesday, March 5th, 2008

This is a story that I wrote during idle moments during the MMC/MTAS debacle last year when I was wondering if I should get another career. 

 

In those first weeks without a job I felt shifty and aimless.  Despite waking early, in the mornings I could not get out of bed.  The flat was very cold; I had been forced to economise by switching off the heating. To keep warm I would lie with my head under the covers and my knees folded up into my chest. For lunch I’d eat soft white cheese on semi-stale bread and afterwards spend the hours browsing the shelves of libraries, sometimes visiting several over the course of an afternoon.  I almost never cleaned my teeth.

In time I grew restless such that only the longest walks taken during the brief winter sunshine would exhaust me enough to sleep that evening without ruminating on my situation.  Despite residing in distant Dalston, I would walk into central London, taking in Oxford street, a hateful place, Regent Street, where you could surf the internet for free in the Apple Store, and Piccadilly Circus, where I would try and kick pigeons by luring them toward my foot on which I had placed bird feed.  I walked home in the dark my arms folded tightly across my chest my eyes focused on the ground.

Then as time passed I ceased to sleep at all.

At first I put this down to the number of cigarettes I was smoking throughout the day.   They provided entertainment for my hands and I reasoned it was justification enough in my smoking them that at least one part of me was occupied.  But I cut down and this made no difference.  Late night television hurt my eyes and my head and the neighbours politely complained about the floorboards creaking as I, in sleepless desperation, paced up and down on the bare wooden floor in the early hours of the morning.  Having once been sued by the residents committee as a result of unenthusiastic recycling, I knew that for my own safety I should spend at home as little time as possible.

Central London after dark is different to during the day. As my evenings progressed I would pass the same people night after night, as if all of us were involved in a sponsored walk.  With this over the weeks an embarrassed and unenthusiastic ‘hi’ evolved into a cadged cigarette and then eventually something resembling friendship.  It was difficult at first; if you don’t talk all day, sounds do not pass easily from your mouth; your tongue cannot make the words.  Of the people I met, an unusually high number introduced themselves as ‘Dave’.  I cannot say whether such a name predisposes to either misfortune causing insomnia, insomnia de novo, or whether in losing the structure in their lives my fellow street walkers also lost their ability to create interesting pseudonyms.  Whatever the reason, my name was soon ‘Dave’ too; it seemed to make things easier. 

On coldest nights we ‘Daves’ would gravitate towards places of warmth.  These were provided by some of the larger buildings that had hot air outlets that discharged onto the street.  We kept these havens scrupulously clean.  For example one night we discovered a drunk Arsenal supporter vomiting liberally across our favourite spot.  Chasing him off, we all clubbed together to purchase a 65p bottle of thick bleach and some jay cloths from Tesco Metro; then only after some furious cleaning did we settle down as usual to our habitual positions, standing as close to the hot air as possible, completing discarded cryptic crossword puzzles and swapping stories concerning the origins of our various gradations of misery.

Another place of warmth was the hot dog stands.  There were several that dotted around the area, drawn to the financial opportunities presented by thousands of tourists, drunks, clubbers, lovers and assorted street life hungered by sight-seeing, lager, ecstasy, lust and chronic malnutrition.  At four in the morning, my feet cold and hurting, I’d stop and have one with onions and mustard, or a burger in an unsavoury bun.  Sometimes I’d buy a tomato and add it in, cutting it with my scouting penknife now blunt and worn.

When they weren’t too busy, the men at the burger stalls were eager to talk, most of them happy to take the opportunity to brush up their English with a conversation beyond simply the desire of their customers for brightly coloured condiments.  They would show me pictures of their families - most often very geographically distant  - and I was often offered a place to stay should I ever find myself in Bagdad or Kabul.  Their trade was fugitive, their carts illegal and liable to be seized, and so it was not unusual to find my conversations curtailed by a customer who was actually a council official, with a stall requisitioning van in close pursuit.

So the turnover of vendors was swift, and with the passage of time I found myself on the other side of the fence; a user-turned-dealer, if you will.

Despite its illegality, the dog burger trade is run rather like a private company.  There’s an interview, a period of assessment, payment by the hour.  That is where the similarities end of course, as I am sure that stealing from McDonalds results in disciplinary process, rather than repeated kicks in the face.  Not that I would have considered jeopardising my new job in any way as I wheeled my cart into Soho at 9pm for my first shift. 

It was on this night with my new career, and every subsequent, that I witnessed with paternal consternation, the bacchanalian drinking of today’s youth.  Although it was by then a year since the NHS had no longer needed my services I couldn’t help looking on my customers as future patients, such was their disregard for their health.  And alcohol distils out idiots; one such fool made this painfully obvious.  I had turned my back on my cart, its sausages sizzling gently and their smell far too enticing to be anything other than chemically synthesised, to talk to some plump girls in short skirts.  I was feeling the best I had done in months, not actually good, but for the first time in a long time I thought that perhaps there might be, for me, a future ahead.  My intoxication by this rare positivity would not last long as I heard a loud yell from close vicinity.  It seemed that the girls were flirting with me simply to distract a lonely man.  Meanwhile, behind my back one of their friends was gaily relieving himself only my hotplate; I had wondered why the girls seemed to be laughing so keenly as I spoke.  Alas his heroic turn in front of the ladies was to be short lived.  His no doubt substantial alcohol intake had given him an advanced sway and this to his penis sustaining gave a nasty looking burn.  I was too astonished to be cross, and for reasons of economy was unable to discard the twenty or so sausages he had soiled, serving them without discount to a batch of gurning clubbers ten minutes later. 

The nights passed quickly: I’d sometimes set myself challenges – one night to talk only in Shakespeare quotes, another I would invite every third customer to a party on a road that didn’t exist.  Over time I grew to have an established clientele, who were becoming the closest things I had to friends.  Unfortunately this was at the expense of my previous buddies.  There had been some friction between us as I had neither the permission nor inclination to give away free produce.  It didn’t bother me much; I was happier now and could remember more than one name. 

Three months on and I had begun to sleep again.  At first not much, perhaps 45 minutes during woman’s hour, but soon I was able to sleep from half way through ‘In Our Time’ until the closing minutes of ‘You and Yours’.  My ‘manager’ – although I am sure that the title would amuse him – a Pole called Rudolf, had moved from a position of initial distrust and suspicion to regularly reminding me that I was his most trusted employee.  Although I was pleased with this accolade I found his hearty back-slaps disabling.  They were however an accurate indicator of his gratitude as I was making him money, and not just from the burgers:  the probity of his staff meant much to him as it afforded him more time to deal drugs to wealthy Kings Road kids during the day. 

I have one last tale to tell: with my job there’s always was a lot of standing around and not always all that much to do.  I would wonder about stuff, like how radio waves travel through walls and how long it takes for every cell in your body to change.  It was during one such reverie when I turned to serve a customer who happened to be one of my old colleagues, who had treated me so carelessly. 

’£3.50’ I said, adding an extra 50p on the price.  It was a hotdog that he wanted

He looked at me in a puzzled way.  ‘Do I know you?’ he said.

‘Don’t worry’ I replied.  ‘I have one of those faces that looks just like other peoples.  Perhaps I’ve sold you one of these before?’ I handed him the hot dog. 

He still looked disturbed.  ‘I don’t think so’, his face relaxed and he handed me a five pound note.  ‘You must meet a lot of people out here’ he said conversationally.

‘Yes’ I said.

Do you know the way to ‘Soho House?’

‘Yes’ I said and provided him with instructions that would send him in entirely the wrong direction.  I even drew him a map. 

‘Enjoy your day’.  I called after him as he left.  These special moments come all too infrequently. 

 

 

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SSRIs in the doghouse

Tuesday, February 26th, 2008

It’s a bad time to be an SSRI antidepressant.

Strike one:

In January a paper in the NEJM found that the evidence base for the use of these drugs was incomplete, with a large publication bias towards positive results.  When negative results had been published, it was in such a way as to give these results a positive skew.  This publication bias in itself does not mean that a drug is ineffective, but hardly instills confidence.  There have been rumblings about this sort of thing going on for a long time….

Strike two:

A paper published today in the Public Library of Science Medicine Journal entitled Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration collected (via the freedom of information act) what it believes to be all the trial data available before their licence was granted (published and unpublished, positive and negative) on Fluoxetine, Paroxetine, Venlafaxine and Nefazodone, and found via meta-analysis their effects for mild and moderate depression to have no clinical improvement over placebo. 

This raises a number of concerns for psychiatrists and the population at large, several million of whom were taking these medications at the last count.

  • Already not especially convincing, where does this leave the monoamine theory of depression?
  • Have pharmaceutical companies deliberately mislead the doctors and patients as to the effectiveness of their product, thereby costing health providers billions of pounds and subjecting millions to ineffective medication and unnecessary side effects?  If so, shouldn’t we take them to court or something?
  • What should we tell our patients?  There are plenty of people out there on the above medications for mild/moderate symptoms of depression.  See end of piece for a quick summary of how depression is categorized.  Doctors who prescribe antidepressants in these circumstances will be aware that it’s not the best treatment, but wouldn’t wish to give somethings that really doesn’t work at all.  If these antidepressants were working because of a placebo effect then, with all this publicity, they won’t be working now.
  • What are we going to do instead?  NICE already recommends that counselling/therapy is the most appropriate intervention in mild/moderate depression.  However waiting lists are very long and many people crave a quick fix to their problems, which in any case are more ingrained than that which is amenable to a course of cognitive behavioural therapy.

Classification of depression

Depression as an illness is somethings that’s talked about a lot these days.  The first thing to say is that the difference between ‘depression’ as an illness and simply feeling ‘gloomy’ is not qualitiative but quantitative.  There is also no test for depression, but rather a line in the sand that when (methaphroically) overstepped people say that you are depressed.  The diagnosis of depression is made on clinical grounds rather than via a test.  This is not unusual in medicine, epilepsy for instance is diagnosed in the same way.

When we as psychiatrists, (but also as lay people, but in a less formalised way) say that someone is depressed, what me mean is that they are displaying a number of symptoms that suggest to us that their main problem is of low mood.  In order to make diagnoses more consistent and also to aid in professional communication psychiatrists use diagnositic guidelines for their diagnoses.  In America these guidelines are called the Diagnostic and Statistical Manual edition IV and in Europe we mostly use the International Classification of Diseases edition 10. 

(I’m almost there.)

Although mood and hence depression exists on a dimension, i.e. there is a continum from ‘not depressed’ to ‘very depressed indeed’ with no breaks in between, we choose to draw further lines in the sand and make categorical diagnoses - this is where the mild/moderate/severe depression diagnoses come from. 

So, when the above study talks of ‘mild depression’ it’s saying that a person meets the criteria for either the DSM-IV or ICD-10 criteria for depression.  The ICD-10 criteria are:

F32.0 Mild Depressive Episode: Diagnostic Guidelines
Depressed mood, loss of interest and enjoyment, and increased fatiguability are usually regarded as the most typical symptoms of depression, and at least two of these, plus at least two of the other symptoms described above should usually be present for a definite diagnosis. None of the symptoms should be present to an intense degree. Minimum duration of the whole episode is about 2 weeks.
An individual with a mild depressive episode is usually distressed by the symptoms and has some difficulty in continuing with ordinary work and social activities, but will probably not cease to function completely.

If you’re interested in classification of depression then try this site

Roundup

Bad Science on SSRIs and criticism of media response to PLOS paper

Guardian articles on PloS paper: Ann Robinson - If the drugs don’t work; Allegra Stratton - A bitter pill; Sarah Boseley Prozac, used by 40m people does not work, say scientists; Mark Lawson Something for Nothing

 

 

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