Medication helps some with mild depression

By Genevra Pittman

NEW YORK (Reuters Health) - People with mild depression may benefit from taking antidepressants, suggests a new analysis of past studies that compared symptoms in people on the drugs to those given drug-free placebo pills.

Some earlier reports had suggested that antidepressants generally only improve mood in people with severe depression.

But that might be because those studies weren't precise enough to pick up on smaller changes in symptoms that can still make a difference for people with milder forms of the disease, researchers said.

"I think there's a valid concern... that if someone has not-that-severe depression that hasn't lasted that long, maybe it will get better itself or with therapy," said Dr. David Hellerstein, from the New York State Psychiatric Institute and Columbia University, who worked on the study.

Still, he said the question of whether or not to prescribe medication shouldn't necessarily come down to how severe the depression is, but how long symptoms have lasted.

People with "transient depression" that will improve with diet or exercise or after a few weeks of therapy "shouldn't be taking the risk of being on meds," he told Reuters Health.

"But people who have more persistent depression should be evaluated for treatment and medicine should be one of the options," even when the depression is more modest.

Hellerstein and his colleagues collected data from six studies done at the state's psychiatric institute between 1985 and 2000. Those included 825 people with non-severe, long-lasting depression enrolled in trials that compared symptoms with antidepressant treatment versus a placebo.

In three of the six studies, patients taking an antidepressant improved more on a widely-used scale of depression symptoms and severity than those taking a placebo, and in four studies, a higher percentage of patients taking antidepressants went into remission, meaning they were no longer considered to have clinically-significant depression.

Depending on the particular drug and study, the researchers calculated that between three and eight people with non-severe depression would have to be treated with an antidepressant for one to benefit substantially from it.

That, they wrote in the Journal of Clinical Psychiatry, is "a range considered by researchers as sufficiently robust to recommend treatment."

The drugs tested in those studies included Prozac, as well as older and now less-popular medications known as monoamine oxidase inhibitors and tricyclic and tetracyclic antidepressants. It's hard to know how well the findings would apply for newer antidepressants, the researchers said.

The results don't mean that everyone with mild depression should be on an antidepressant, a psychiatrist not involved in the study pointed out.

"People with these milder depressions also respond well to counseling and psychotherapy and can respond well to exercise," said Dr. Michael Thase, from the University of Pennsylvania School of Medicine in Philadelphia.

"This is basically saying, these antidepressants aren't that good, and you should also consider other treatment options and don't just focus on the thing that's the easiest," he told Reuters Health.

The researchers said that some combination of antidepressants and talk therapy is considered most effective in depression treatment -- but getting therapy is often more expensive and time-consuming than medication.

Talk therapy can run $100 or more per session, while generic brands of antidepressants usually cost about $20 per month. Drugs may come with side effects, including insomnia and stomach aches, but they're usually minor, according to Hellerstein.

Still, people on antidepressants should be followed closely by a doctor to see how they're responding to treatment, he said.

Several of the authors of the current study reported having received funding for other research projects from drug companies that make antidepressants.

One recent study found that some depressed people on the antidepressant Cymbalta did worse than the comparison placebo group -- but the majority got some benefit (see Reuters Health story of December 9, 2011).

"I believe the basic finding that drugs are more effective than placebo," Thase said.

But, "The benefits of antidepressants may not be that dramatic in patients with milder depressions for whom many other (non-drug) strategies can also be considered."

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Ending Nightmares Caused By PTSD

by

Amy Standen, KQED

Everyone has nightmares sometimes. But for people with PTSD, it's different.

Sam Brace doesn't want to talk about what he saw when he was a soldier in Iraq eight years ago. In fact, it's something he's actively trying not to dwell on. But what he can't control are his dreams.

They're almost always about the same explosion. "When I was overseas, we'd hit an IED," Brace says. "When I have a nightmare, normally it's something related to that."

Healthy dreams seem kind of random, according to Steven Woodward, a psychologist with the National Center for PTSD at the VA Medical Center in Menlo Park, Calif. "They're wacky," he says. "They associate lots of things that are not normally associated."

PTSD dreams are the same real-life event played over and over again like a broken record. "Replicative nightmares of traumatic events ... repeat for years," Woodward says. "Sometimes 20 years."

Scientists wanted to find out the reason why people with PTSD can't sleep and dream normally. One theory comes from Matthew Walker, a psychology researcher at the University of California, Berkeley. His particular interest lies in rapid eye movement, or REM. It's the time during sleep when a lot of dreaming occurs.

It's also a time when the chemistry of the brain actually changes. Levels of norepinephrine — a kind of adrenaline — drop out completely. REM sleep is the only time of day when this happens. That struck Walker as a mystery. "Why would rapid eye movement sleep suppress this neurochemical?" he asks. "Is there any function to that?"

Walker found that in healthy people, REM sleep is kind of like therapy. It's an adrenaline-free environment where the brain can process its memories while sort of stripping off their sharp, emotional edges. "You come back the next day, and it doesn't trigger that same visceral reaction that you had at the time of learning."

Emotions are useful, he says. They show us what really matters to us. "But I don't think it's adaptive to hold onto that emotional blanket around those memories forever," he says. "They've done their job at the time of learning, then it's time to hold on to the information of that memory, but let go of the emotion."

Walker's theory suggests that in people with PTSD, REM sleep is broken. The adrenaline doesn't go away like it's supposed to. The brain can't process tough memories, so it just cycles through them, again and again.

So, what if you could make the adrenaline just go away? Enter prazosin.

Pfizer Inc. introduced the drug under the brand name Minipress in the 1970s to treat high blood pressure. Dr. Murray Raskind, a VA psychiatrist in Seattle, says the drug, now generic, can cost anywhere between 5 and 15 cents. And, actually, it's not terribly effective as a blood pressure medication, he says.

But what prazosin does do is make people less sensitive to adrenaline. About a decade ago, Raskind starting giving prazosin to some of his PTSD patients, including one Vietnam War veteran.

"He had this recurrent nightmare of being trapped by the Vietcong forces in a landing zone and having his best friend killed in front of his eyes by a mortar round," Raskind says.

After a few weeks of treatment with prazosin, the veteran came in for a follow-up appointment. Raskind says the veteran told him that he wasn't sure the medication was working. He was still having the same dream over and over — just about something else. He told Raskind that in the new dream he was in his fifth grade classroom and there was a test. If he didn't pass the test, he wasn't going to be promoted to the next grade. But he never even got the assignment.

"I said, 'That's my nightmare!' " Raskind says.

Indeed, the veteran's new dream was the stress dream of a healthy brain trying to work things out, Raskind says.

This year, the VA is expected to finish up its trial for prazosin. It's already prescribing the drug to about 15 percent of its PTSD patients. Raskind, of course, would like to see that number rise.

"To us, it's a simple thing that works," he says.

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How to Train Your Brain to Alleviate Anxiety

By Margarita Tartakovsky, M.S.

Our thoughts affect our brains. More specifically, “… what you pay attention to, what you think and feel and want, and how you work with your reactions to things sculpt your brain in multiple ways,” according to neuropsychologist Rick Hanson, Ph.D, in his newest book Just One Thing: Developing A Buddha Brain One Simple Practice at a Time. In other words, how you use your mind can change your brain.

According to Canadian scientist Donald Hebb, “Neurons that fire together, wire together.” If your thoughts focus on worrying and self-criticism, you’ll develop neural structures of anxiety and a negative sense of self, says Hanson.

For instance, individuals who are constantly stressed (such as acute or traumatic stress) release cortisol, which in another article Hanson says eats away at the memory-focused hippocampus. People with a history of stress have lost up to 25 percent of the volume of their hippocampus and have more difficulty forming new memories.

The opposite also is true. Engaging in relaxing activities regularly can wire your brain for calm. Research has shown that people who routinely relax have “improved expression of genes that calm down stress reactions, making them more resilient,” Hanson writes.

Also, over time, people who engage in mindfulness meditation develop thicker layers of neurons in the attention-focused parts of the prefrontal cortex and in the insula, an area that’s triggered when we tune into our feelings and bodies.

Other research has shown that being mindful boosts activation of the left prefrontal cortex, which suppresses negative emotions, and minimizes the activation of the amygdala, which Hanson refers to as the “alarm bell of the brain.”

Hanson’s book gives readers a variety of exercises to cultivate calm and self-confidence and to enjoy life. Here are three anxiety-alleviating practices to try.

1. “Notice you’re all right right now.” For many of us sitting still is a joke — as in, it’s impossible. According to Hanson, “To keep our ancestors alive, the brain evolved an ongoing internal trickle of unease. This little whisper of worry keeps you scanning your inner and outer world for signs of trouble.”

Being on high alert is adaptive. It’s meant to protect us. But this isn’t so helpful when we’re trying to soothe our stress and keep calm. Some of us — me included — even worry that if we relax for a few minutes, something bad will happen. (Of course, this isn’t true.)

Hanson encourages readers to focus on the present and to realize that right now in this moment, you’re probably OK. He says that focusing on the future forces us to worry and focusing on the past leads to regret. Whatever activity you’re engaged in, whether it’s driving, cooking dinner or replying to email, Hanson suggests saying, “I’m all right right now.”

Of course, there will be moments when you won’t be all right. In these times, Hanson suggests that after you ride out the storm, “… as soon as possible, notice that the core of your being is okay, like the quiet place fifty feet underwater, beneath a hurricane howling above the sea.”

2. “Feel safer.” “Evolution has given us an anxious brain,” Hanson writes. So, whether there’s a tiger in the bushes doesn’t matter, because staying away in both cases keeps us alive. But, again, this also keeps us hyper-focused on avoiding danger day to day. And depending on our temperaments and life experiences, we might be even more anxious.

Most people overestimate threats. This leads to excessive worrying, anxiety, stress-related aliments, less patience and generosity with others and a shorter fuse, according to Hanson.

Are you more guarded or anxious than you need to be? If so, Hanson suggests the following for feeling safer:

• Think of how it feels to be with a person who cares about you and connect to those feelings and sensations.
• Remember a time when you felt strong.
• List some of the resources at your disposal to cope with life’s curveballs.
• Take several long, deep breaths.
• Become more in tune with what it feels like to feel safer. “Let those good feelings sink in, so you can remember them in your body and find your way back to them in the future.”

3. “Let go.” Letting go is hard. Even though clinging to clutter, regrets, resentment, unrealistic expectations or unfulfilling relationships is painful, we might be afraid that letting go makes us weak, shows we don’t care or lets someone off the hook. What holds you back in letting go?

Letting go is liberating. Hanson says that letting go might mean releasing pain or damaging thoughts or deeds or yielding instead of breaking. He offers a great analogy:

“When you let go, you’re like a supple and resilient willow tree that bends before the storm, still here in the morning — rather than a stiff oak that ends up broken and toppled over.”

Here are some of Hanson’s suggestions for letting go:

• Be aware of how you let go naturally every day, whether it’s sending an email, taking out the trash, going from one thought or feeling to another or saying goodbye to a friend.
• Let go of tension in your body. Take long and slow exhalations, and relax your shoulders, jaw and eyes.
• Let go of things you don’t need or use.
• Resolve to let go of a certain grudge or resentment. “This does not necessarily mean letting other people off the moral hook, just that you are letting yourself off the hotplate of staying upset about whatever happened,” Hanson writes. If you still feel hurt, he suggests recognizing your feelings, being kind to yourself and gently releasing them.
• Let go of painful emotions. Hanson recommends several books on this topic: Focusing by Eugene Gendlin and What We May Be by Piero Ferrucci. In his book, Hanson summarizes his favorite methods: “relax your body;” “imagine that the feelings are flowing out of you like water’” express your feelings in a letter that you won’t send or vent aloud; talk to a good friend; and be open to positive feelings and let them replace the negative ones.

Margarita Tartakovsky, M.S. is an Associate Editor at Psych Central and blogs regularly about eating and self-image issues on her own blog, Weightless.

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