December 17, 2009

When Therapy Won't Work, Try Cymbalta. When Cymbalta Doesn't Work, You're Dead Meat

this should work as well as placebo


A patient describes being told by her psychiatrist that her depression was too severe for therapy or  behavioral techniques.  Only medication would work.  The patient says that the doc was right:

Her advice was grounded in neuroscience.

One research study... used high-definition brain imaging to reveal a breakdown in the emotional processing that impairs the depressive's ability to suppress negative emotions. In fact, the more effort that depressives put into reframing thoughts-the harder they tried to think positive-the more activation there was in the amygdala, regarded by neurobiologists as a person's "fear center." ... Healthy individuals putting more cognitive effort into [reframing the content] decreas[e] activity in the brain's emotional response centers. In the depressed individuals, you find the exact opposite.
Well, that's one interpretation.  Another among the other fifty possible would be that  depressive patients don't have an opposite response to cognitive framing, but that they are unable at that time to do it-- and so they end up using an emotional reframing, hence the amygdala effect.  See?  All depends what century you want to live in.

It's an easy criticism to make-- and I've made it-- that this kind of advice damages society, because it makes it acceptable, normalizes, that idea depression is primarily a biological illness that requires meds; and, in a  more general way, that "health," emotional and physical, is just as much other people's problem as it is yours.

The title of that article is: Note To the Severely Depressed: Don't Try So Hard.


"So you think that doctor sucks?"

No, actually she's a good doctor, and this is why robots will never be able to be (good) psychiatrists, though that they will become psychiatrists is inevitable.  She (the doctor) looked at her, understood her, where she was in her life, and did what the Oracle did:

Neo: But the Oracle told me--

Morpheus:  --she told you exactly what you needed to hear.

She tailors the advice to the whole patient, their perspective, their life, their situation.  That's gold, that's the only reason the psychiatrist is there.  The psychiatrist did the cognitive reframing for her.  The post doesn't describe how awesome the Pristiq or Cymbalta was, it describes how awesome the advice was.  Hearing the advice got her better, not taking the advice.  Said another way: had she not internalized this advice, would the Cymbalta have worked?


Before you ask me: no, I'm not advocating lying to patients.  She wasn't lying, she was saying what was true at that moment for her patient.

"Until you feel stronger, I suggest you stay away from the type of self-help literature you have brought it because those texts can do further damage if read in a very depressed state." [said the psychiatrist]
The psychiatrist's advice to this patient was perfect; this advice to anyone in general with depression would be disastrous-- beyond it not even being accurate-- for them and for society.

Example: what if the medication doesn't work?  You've already told them that CBT and yoga are no good for severe depression, so if the meds fail, does a person have any hope left?  One might reasonably argue that the type of person who fails medications should try CBT or yoga.

Some people derive strength from knowing their symptoms aren't their "fault" and out of their hands; others derive strength from believing that it's entirely up to them, that they can overcome anything if they apply themselves.  Each patient has to be evaluated separately, and their advice individualized.  And, of course, all of this is in flux: in a month, they may have a different worldview.  In psychiatry, if you burn a bridge, you're trapping the both of you on one side.


We can ask one last important question about the utility of advice in medical treatment.  "Said another way: had she not internalized this advice, would the Cymbalta have worked?"

Everyone knows that with every efficacious treatment, some proportion of it is related to a "placebo effect."  For example, being told you are being given a strong pain killer (but it is a placebo) reduces pain by some amount.  Similarly, while antidepressants reduce symptoms by 30%, placebo does it by 20%.  So we atttribute some of the antidepressant's efficacy to the "placebo effect."

This is based on the patient knowing they are getting a medication or a placebo.

What happens when you are given a medication covertly?  Not that they think it's a placebo but it's actually Valium, but rather that they are not aware they are injesting a chemical at all?  Would taking valium but not knowing you are taking anything at all reduce the anxiety?

covert valium.JPG
Not very reliably

This doesn't imply you feel nothing; it means that your symptoms remain unchanged.  e.g. "I suddenly feel more tired, but still anxious."

We tend to downplay the effect of words.  An antidepressant has a chemical effect that is real (even if it might not be efficacious) but words are thought to be incidental.  That's backwards.   Someone can make you cry with words, someone can make you sad forever with words.  How a doctor frames your chances for improvement matters.  And how, by the pitch of his voice and the choice of words, he conceptualizes your problems also matters a great deal.  Ask David Foster Wallace.


(part 2, sort of)

Also see: Is Prayer Worse Than Cymbalta?