Antidepressants have a role in clinical practice but they are grossly over-utilized.  As a certified psychopharmacologist, practitioner of Whole Psychiatry (Functional Medicine and traditional psychiatry) and Clinical Professor of Psychiatry at Georgetown School of Medicine, I prescribe antidepressants, but  only after a thorough multi-faceted  evaluation of the patient.

We rely on drugs as a solution rather than deal with root causes of illness, and the pills generally are not as effective as we would be led to believe by the pharmaceutical companies (publically acknowledged as distorted in peer reviewed journals such as New England Journal of Medicine, Eric Turner, 2008). Nor are these drugs without financial costs and side effects.  I suggest that the solution is to develop better assessments of the metabolic factors leading to the syndrome of depression. The psycho-social-spiritual risk factors are reasonably well spelled out, and we have excellent targeted psychotherapeutic techniques available now.

The fact that the head and brain are connected to the body by something called the neck may be relevant.  In fact, there is a great deal of basic science and a good deal of clinical science indicating the very significant role played in subjective and objective mental health by at least six metabolic systems: nutrition, gastrointestinal physiology, immune/inflammatory/infectious processes, methylation processes, oxidative stress, and all hormonal systems.  This list excludes other factors such as circulatory problems, physical-structural problems, age, gender, and lifestyle factors.

Assessing these metabolic systems, and their mediators in a careful comprehensive manner, and re-establishing multi-system reserves not only helps depression with less medication, but at the same time reduces the side effect burden imposed by medication, and reduces the incidence of known co-morbidities such as diabetes, cardiovascular disease, osteoporosis, sexual dysfunction.  Psychopharmacology is only one small tool in our toolbox.  As Confucius once said, “To do good work, one must first have good tools.”  Anti-depressants are somewhat useful tools; they are just not the best or the only ones.  We have other tools at our disposal.  Why not use them?

According to a new study discussed on Health.com "about 2.4% of people around the world have had a diagnosis of bipolar disorder at some point in their lifetime, according to the first comprehensive international figures on the topic.The United States has the highest lifetime rate of bipolar disorder at 4.4%, and India the lowest, with 0.1%". 

Bipolar disorder has a strong genetic component. Depending on which studies you look at, the  gentics acount for anywhere from 40-60% of the vulnerability. While that seems like a high number it also means 40-60% of the risk of developing the disorder  despite having the same genes comes from the environment. Only 40-60% of  every set of identical twins will develop the disorder. So what is it that could be triggering this high rate of bipolar disorder in the US?

Let's look at this problem from the 'macro' to the micro' levels. On a socio-economic macro level, the US, as the largest and most industrialized Western society, has a somewhat exagerated culture. First, we have the largest gap between rich and poor, so the economic stresses on a large part of thepopulation are greater than in other western societies. This translates into psychological stress, more substance abuse, poorer quality nutrition, and fragmentation of the family. Early child hood rearing is more likely to be by a day care center -which is inherently unstable (people change centers or caregivers change in a center) and impersonal. There is a higher likelihood of bullying and reduced supervision.

The result of all this is impaired social bonding in those who are particularly vulnerable. The poor nutrition results in imparied metabolic functioning (now we are into the micro level), trouble making or breaking down neurotransmitters, more likely infection and inflammation (which change brain chemistry). This is a simple overview, and many books could easily be written about this subject (in fact I have written three books myself on these factors). Suffice it to say that the most vulnerable amoung us pay the price for our imbalanced society. Included in that group are the young, the ill, the genetically vulnerable, and the elderly.

In a previous blog, I talked about how many doctors and patients do not know the full story about their drugs or medical treatments because of a widespread problem involving unpublished or biased clinical trials. Here is an update on what is happening.

As I mentioned, frequently, medical journals or pharmaceutical companies that sponsor research will report only positive results, leaving out the non-findings or negative findings where a new drug or procedure may have proved more harmful than helpful.

“A new review of research about this problem points to hidden or misleading studies for all sorts of conditions, including depression, Alzheimer's disease, type 2 diabetes, menopausal symptoms and cancer”, said Beate Wieseler, deputy head of the Institute for Quality and Efficiency in Health Care (IQWiG) Drug Assessment Departmentresearchers at in Germany.

Much of that problem arises from financial conflicts of interest when pharmaceutical or medical device companies fund the studies, according to Wieseler and her colleagues.  They pointed to past research showing an association between industry sponsorship and positive outcomes or conclusions in studies.  The FDA currently does not disclose much of the information it receives from companies when deciding what drugs or devices to approve for market. Now Wieseler and her colleagues want a global system to register trials and make public all research results for drugs or other medical interventions.  They detailed their findings in the April issue of the journal Trials.

"It's been shown that reporting bias is associated with all sorts of funding – government funding, department funding, industry funding – but the worst source of bias is industry-funded," said Kay Dickersin, an epidemiologist at Johns Hopkins University in Baltimore.

The FDA's European counterpart, the European Medicines Agency, has also considered its own steps toward more disclosure. "The agencies understand that there's a need for more transparency," Wieseler said. "There is increasing understanding that the public should have access [to clinical trial data]."
But regulatory agencies still have not decided how to balance the need for public access against the desire by companies to keep commercial information or trade secrets confidential, Wieseler noted.

As a post script…

In the above we see the overlapping territory of medicine, government, and politics. I encourage people to be proactive in improving and protecting their health. Here is an opportunity to do so.