Researchers were looking at how BD progresses through a person's life, how related it is to other psychiatric disorders, and how related it is to suicidality.

It found that few treatments alone were successful in treating BD, however psycho-social interventions (such as Cognitive Behaviour Therapy) and psycho-education interventions combined with mood stabilizers showed the most positive results.

BD was also shown to be strongly related to substance abuse and smoking, both of which affected the success or otherwise of chemical and psychological treatments.

Interestingly, paroxetine or bupropion were shown to be no more effective than a placebo in achieving sustained recovery (in this instance, determined as eight weeks of 'stable' behavior). So, too, were lamotrigine, risperidone, and inositol found to deliver minimal positive effects.

To the vexed, 'hidden', taboo subject of suicide -- the 'S' word not spoken of by the media (although thankfully that is slowly changing, at least in Australia). Suicidality persists with BD, even when treatment outcomes are good. The biggest predictor of suicidality being previous attempts.

The authors' conclusions
The authors of this review paper note seven contributions of the STEP-BD program:

1. Antidepressants remain poorly effective in treating BD;

2. BD is particularly disabling (tell me about it), and frequently doesn't respond to medications;

3. BD does respond modestly to intensive psycho-social interventions;

4. Other psychiatric disorders are common and destabilizing, yet anxiety disorders and smoking are able to be treated and when treated positively impact on BD;

5. An early age on onset of BD usually results in a more severe course of the illness, but rapid-cycling usually diminishes;

6. The sub-syndrome of Depression may be so strong as to mask the manic pole of BD, therefore careful symptom appraisal by psychiatrists is essential;

7. Suicidal thoughts persist in BD sufferers, and a previous attempt is a good indicator of a future event. However, by reducing feelings of 'hopelessness' in particular, there is the possibility of reducing the risk of suicide.

Source: Parikh, S.V., LeBlanc, S.R., & Ovanessian, M.M. 2010. Advancing Bipolar Disorder: Key Lessons From the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). The Canadian Journal of Psychiatry, Vol. 55, No 3, p.p. 136-143.

Please see our medical disclaimer.

[That sounds/reads bizarre, doesn’t it? Surely ‘major’ means that it’s flown past being a ‘mild’ or ‘moderate’ depression… but I digress.]

The study by Fournier et al reduced 2,164 studies to just six worth analysis (by their standards) and found that medication only helps those with severe depression.

There are, of course, limitations with the study – the low number of studies in their meta-analysis being just one, but it does allow the HMHL an opportunity to remind us that exercise, psychotherapy and relaxation are powerful aids in the fight against the black dog for those suffering mild to moderate depression.

----------

Source:

Fournier JC, et al. “Antidepressant Drug Effects and Depression Severity: A Patient-Level Meta-Analysis,” Journal of the American Medical Association (Jan. 6, 2010): Vol. 303,
No. 1, pp. 47–53.

Harvard Mental Health Letter, April 2010 – www.health.harvard.edu

Please see our medical disclaimer.

The Harvard Mental Health Letter is reporting that the US Preventive Services Task Force is recommending that 12-19 year olds get screened for depression.

BUT, they stress, ONLY if there are adequate systems in place for treatment and follow up care. Which I am sure is comforting for those who live in rural and remote, or extremely poor, areas where such services and systems are lacking.

According to the Harvard Mental Health Letter, major depression affects nearly 3% of children younger than 13, and 5.6% of those ages 13 to 18.

They also note that major depression is so disabling, with long-term consequences, and yet most youngsters who are depressed go undiagnosed and untreated. I am sure I am not alone amongst us all in knowing from personal experience how true that is.

It's also interesting to note that the US Task Force recommended NOT screening pre-teens for depression, on the very sound grounds that there is not enough research into how effective screening tools are, nor is there enough research into how effective therapeutic and psychopharmacological treatment programmes are and what longer-term side effects medicines in particular may generate.

Source: U.S. Preventive Services Task Force. "Screening and Treatment for Major Depressive Disorder in Children and Adolescents: U.S. Preventive Services Task Force Recommendation Statement," Pediatrics(April 2009): Vol. 123, No. 4, pp. 1223-28.; cited in Depression screening in adolescents, Harvard Mental Health Letter, September 2009, p.7

Technorati : adolescent, cbt, depression, follow up, interpersonal therapy, screening
Del.icio.us : adolescent, cbt, depression, follow up, interpersonal therapy, screening
Ice Rocket : adolescent, cbt, depression, follow up, interpersonal therapy, screening

In the last few weeks I have been drinking a lot of fresh coffee (I can't stand the instant stuff) and I've found that my medication hasn't been as effective as normal.

Normally, I could take my medication in the morning and it would last 24 hours; over the last few weeks and coinciding with my increased coffee intake my meds only seem to last until early evening. Certainly my night-time dreaming has been wacko-weird as a result of the medication not 'protecting' me as long as it normally does; and whilst the dreams are certainly entertaining and vivid, the headaches that I am suffering before and after sleep are equally as vivid and definitely not welcome.

So last week I reduced my caffeine intake. Result: 24 hour cover and a lot less headaches. The dreaming is no longer vividly technicolour, alas, but that is a price I am prepared to pay. Perhaps when I come to write the 'Great Australian Novel' I may revisit that decision... [smile]

Technorati : anxiety, caffeine, dream, mental health, protection, sleep
Del.icio.us : anxiety, caffeine, dream, mental health, protection, sleep
Ice Rocket : anxiety, caffeine, dream, mental health, protection, sleep

The Harvard Mental Health Letter for August 2009 reports on a ten-year history of research that noticed a disturbing correlation (a seeming relationship between two sets of data): depressed patients had lower bone strength and a greater risk of fractures.

Although the earlier studies left the door open to a pharmaceutical reason for increased risk of fracture (as in, the medications used may have caused dizziness, resulting in falls and fractured bones), later studies have been better-designed and seem to implicate SSRIs are causing bone erosion.

Two recent significant studies appear to conflict. One finds that inhibiting 5-HTT, which SSRIs do better than any other antidepressants, slows bone formation and accelerates bone resorption (which is when calcium and other minerals are released into the bloodstream, leaving trenches behind in the bones); the other finds that inhibiting 5-HTT actually increases bone mass.

5-HTT is the transporter mechanism for 5-HT, which you might know as serotonin; SSRIs enhance serotonin activity.

Despite the conflict between the two aforementioned studies, the Canadian Multicentre Osteoporosis Study Research Group followed 5,008 men and women who were aged 50 and over for five years, finding that the patients who were taking SSRIs everyday had lowered bone mineral density measurements, particularly in the hip. They were also twice as likely as non-SSRI-taking patients to suffer a bone fracture.

Ways to overcome any risk of bone erosion include increasing the intake of calcium, increasing the intake of vitamin D, reducing the amount of caffeine and alcohol taken, and exercising in a way that bears weight on bones (such as walking, weight lifting, stair climbing). It also seems that some medications help slow bone resorption: alendronate (Fosamax), risedronate (Actonel) and ibandronate (Boniva) are mentioned positively.

Of equal significance is that no one has yet taken a look at how SSRIs might affect the bones of children or teenagers.

Source: Harvard Mental Health Letter, August 2009 - www.health.harvard.edu.

Technorati : beverage, bone, calcium, depression, exercise, fracture, osteoporosis, ssri, vitamin d
Del.icio.us : beverage, bone, calcium, depression, exercise, fracture, osteoporosis, ssri, vitamin d
Ice Rocket : beverage, bone, calcium, depression, exercise, fracture, osteoporosis, ssri, vitamin d

For example, sufferers of cardiovascular disease, falls and fractures, multiple sclerosis, Crohn disease, pain, autism (possibly), and diabetes mellitus have been shown to have benefitted from higher than recommended doses of vitamin D supplementation.

Of interest to me is the finding that above-recommendation dosage of vitamin D can also assist in the treatment and management of depression and Seasonal Affective Disorder (SAD).

A study in Australia apparently found that 4,000 IU per day for 2 months of vitamin D3 improved mood significantly more than 600IU per day, with no ill effects.

Even though sunlight is the most natural way to top up one's vitamin D levels, the risk of skin cancer (particularly in Australia) counters the idea of spending hours in the sun. The ingrained Aussie habit of slipping on a shirt, slapping a hat and slopping on sunscreen means that exposure to vitamin D is reduced.

Vitamin D levels can also be depleted by drugs, including barbiturates, carbamazepine, cholestyramine, cimetidine, colestipol, corticosteroids, famotidine, fosphenytoin, isoniazid, mineral oil, nizatidine, phenobarbital, phenytoin, ranitidine, and rifampin. Kauffman additionally notes that cholestyramine and colestipol also deplete cholesterol.

"Sodium valproate is one of the few [ ] drugs that lower vitamin D levels and one of the few gestational drugs that lead to autism," states Cannell [Cannell JJ, Autism and vitaminD. MedHypotheses 2008;70:750-759.]

Kaffman also suggests that there is a potential cancer link between vitamin D depletion and the use of prevastatin [Shepherd J, Blauw GJ, Murphy MB, et al. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet 2002;360:1623-1630.]

Good sources of vitamin D (apart from the sun) include fish, cod liver oil, and shiitake mushrooms. A more complete list is available from Holick, MF. Vitamin D deficiency. NEngl JMed 2007;357:266-281.

But if you ARE going to bask under the sun's golden rays, apparently a mere 15 minutes of summer noonday sun on both sides of the body will generate the equivalent of 10,000 IU of D3 in most light-skinned adults. Apparently a repeat top-up once or twice a week is all that's needed to keep one's levels up. Glass, plastic and clothing will seemingly absorb nearly all UV-B from sunlight.

Even safer (for us Australians, anyway) is grabbing just 5-10 minutes of direct sun on the arms and legs; it generates around 3,000 IU. That's easy to accomplish by the simple act of driving to pick up the kids from school, walking to the shops, walking around the park for exercise, and so on.

Conclusion
We know that exercise is beneficial in the treatment and management of depression; it looks like getting some sunshine is an additional help.

~~~~~~

Source: Kauffman, Joel M.(2009) Benefits of Vitamin D Supplementation, Journal of American Physicians & Surgeons; Summer2009, Vol. 14 Issue 2, p38-45

Joel Kauffman, PhD., is professor of chemistry emeritus at University of the Sciences in Philadelphia and a freelance writer on medical topics.

Technorati : Crohn disease, SAD, Seasonal Affective Disorder, autism, cardiovascular disease, diabetes mellitus, falls, fractures, multiple sclerosis, pain, supplementation, vitamin D
Del.icio.us : Crohn disease, SAD, Seasonal Affective Disorder, autism, cardiovascular disease, diabetes mellitus, falls, fractures, multiple sclerosis, pain, supplementation, vitamin D
Ice Rocket : Crohn disease, SAD, Seasonal Affective Disorder, autism, cardiovascular disease, diabetes mellitus, falls, fractures, multiple sclerosis, pain, supplementation, vitamin D

But the research community is divided as to whether one of the extremely unwanted side-effects of second-generation antidepressants is an actual increase the likelihood of suicide, especially in the initial phases of medication, or not.

And it makes no difference whether the medication is a selective serotonin reuptake inhibitor (SSRI) or a serotonin and norepinephrine reuptake inhibitor (SNRI).

The best advice seems to be this: monitor yourself or the person taking the medication. If behaviour significantly changes, if there are displays of increased anger or irritability, or if thoughts of suicide play a larger role than usual in thought processes, seek urgent advice from the treating physician and consider whether the treatment plan needs to be modified.

Please see our medical disclaimer.

Recognising that each different type of antidepressant carries with it different types of possible side-effects, the Letter reports on a large meta-analysis which shows two antidepressants having a slight (emphasis on ’slight’) edge of the rest in terms of efficacy and tolerability.

But that is not to say that side-effects are not to be considered when thinking about which drug with which to start treatment.

The study showed that escitalopram (Lexapro, Cipralex) and sertraline (Zoloft) demonstrated a very slight overall edge over other second-generation antidepressants, in terms of efficacy and least amount of side-effects.

Here’s the list of side-effects most likely to be encountered, and the drugs most likely to induce them:

Nausea and vomiting:
venlafaxine (Effexor)

Diarrhoea:
sertraline (Zoloft)

Weight gain:
mirtazapine (Remeron) and paroxetine (Paxil)

Sexual side effects:
paroxetine (Paxil), fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), with bupropion (Wellbutrin) the least likely of those drugs that did report a sexual side effect to do damage. But bear in mind that dosage can also play a part; my own high dosage of Effexor certainly doesn’t make for wonderful bedroom happiness and a libido like a rugby player!

Conclusion

I know from personal experience that over a course of treatment, or lifetime in my case, a person is likely to move from one to the other as the positive effects of one type start to wane due to tolerance and your practitioner and yourself try a different drug to see if that can kick-start the recovery process again. But keep a watch on the side effects and report anything to your GP or treating physician.