![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 24 of 24. This is the beginning of the thread.
Posted by wcfrench on October 14, 2002, at 14:56:04
I feel pretty good, but I feel a little detached. Not like I'm separated from my body, but more like a "couple of beers" feeling. It worries me though because I wonder if now I've just escaped my issues or if I'm just over them and can now not think about them. I think about my ex-girlfriend (one of my issues) a lot less than before, but I don't feel like I'm really past it, I just feel like I'm ignoring it. I'm wondering if anyone else is experiencing this feeling. I definitely feel more calm though, and am enjoying things a little more. But mainly I want to be happy, not drunk. Thanks for any response.
-Charlie
Posted by tai on October 14, 2002, at 16:46:19
In reply to Drunk on Zoloft?, posted by wcfrench on October 14, 2002, at 14:56:04
Charlie-
Dont worry about that detached feeling. When I was taking zoloft I went through the same stuff on the road to recovery. I think I still had instances where I felt like I was tripping or something up to 3 months after I started on the zoloft.
My only advice is just try to go with it, if at all possible try to have some fun with this wierd state of mind that you are in. But in my experience, it will eventually pass and you will forget all about it.
IN the meantime, happy voyages space cadet.
Posted by wcfrench on October 14, 2002, at 18:42:54
In reply to Re: Drunk on Zoloft?, posted by tai on October 14, 2002, at 16:46:19
Hey Tai
Thanks for responding to my post. Sometimes these threads go unresponded so I'm glad you told me about your experience on it. I do like the "drunk" feeling I have a little, but I feel like the crux of my depression is still there. Kind of like if you drink to get rid of your depression, you know? It's like, you don't feel it actively because you are intoxicated, but when you think about it, it's still very there. It seemed, at least with Remeron, that it takes several weeks before the main depressive symptoms start going away, which for me are discomfort when talking eye to eye with someone, positive outlook, getting rid of the bleakness, etc. Anyway it's only been a few days so I definitely have to give it more time, but I'm tapering Remeron concurrently and I can feel the effects that I established with the Remeron starting to fade. It was as if the Remeron corrected only a few things, such as anxiety, concentration, and feeling like I was over my last relationship, which ended very painfully. It didn't seem to help with adhedonia (lack of pleasure), positive outlook, motivation, or feeling generally good. I felt really dry most of the time, as I wrote in your thread, and I didn't enjoy doing the things I liked doing, so that was a big factor in the med change. With the Zoloft, I immediately noticed most of those things change that the Remeron wasn't hitting, but the other stuff isn't there. I think I just have to wait it out and give it the full time to kick in before it matches the efficacy of the Remeron. I agree with you, I hate waiting.
Anyhow, sorry for that long explanation. Thanks for responding.
-Charlie
Posted by tai on October 15, 2002, at 11:46:46
In reply to Re: Drunk on Zoloft?, posted by wcfrench on October 14, 2002, at 18:42:54
hey charlie,
zoloft seems to be my one area of expertise, so I think I can probably kind of "walk alongside" you as you go through the different stages. Now obviously, our paths won't be completely similar, but right now it sure sounds like you are in a familiar spot.
Thats good that you are starting to slightly feel the effects of the zoloft so quickly. I think that may be due to the fact that you were already on the remeron. It took me months before I felt truly secure and confident. And every small step forward was followed by a big leap back. So hopefully you are already ahead of this, and in a position to simply start reaping the benefits. Well not really that easy, but the eventual outcome is something to really look forward to. so, as hard as it may be you have to have patience, and give yourself 2-3 months on this, so you can really measure how well its working for you. I know that seems like a hell of a long experimentation period, but what you are already saying sounds so familiar, so feel confident that zoloft will work out for you.
When I first started taking zoloft I was in a bad, bad state; massive anxiety attacks, severe deppression...so I didnt start feeling a little better for at least 3-4 weeks or so. And I remember I had worked my way into a functioning state, and even got the nerve up to get a job. My sleep was still all out of wac, but I toughed through those shitty mornings at work, because it was all I could do. And then there would be these random days where I would feel good, I mean really good, where the same shit on the radio sounded good, and the same day to day people that I could barely look in the eye, were now having interesting conversations with me. Instead of the outside world being a sponge, soaking the life out of me, I was the sponge, soaking up life from the world. But like I said, those highs were also followed by regression. The zoloft doesnt work as a steady ascent upwards, but kind of like steps, where you will move up a little, and then kind of flatten out, and then back up a little, and then flatten out. I would also constantly be analyzing how I felt, like a constant dialogue within me. And even though some things were feeling better, I could always think myself back into a depressed state, like wait a second, nothing has changed, I should still be depressed, so I guess I am.
Eventually, feeling good about yourself and life, will become a regular state of mind. And the doubts will slowly fade from your mind, although I don't think they will ever completely go away, you are always going to think about where you have been. It used to scare me at night, I was so afraid to wake up and be back in that place again.
But listen, keep me updated on your progress. I think things can work out really well for you. Maybe I am just being overly optimistic...I should take some of your optimism and use it on myself.
good luck.
Posted by wcfrench on October 15, 2002, at 16:13:52
In reply to Re: Drunk on Zoloft?, posted by tai on October 15, 2002, at 11:46:46
Hey man
Thanks for writing, I am glad you are optimistic and I'm glad you can help me a bit with your experience. I want to keep up with you as well so feel free to write on your post and I'll be watching over it.
I'm wondering a couple of things. When I was on the Remeron I could feel music, like I would get chills or sometimes cry, and it was nice. I'm not sure if that's because I was depressed or because it was working, because since I've started tapering Remeron and brought on the Zoloft, that has kind of gone away. Also some things don't seem as funny as before; it's like an emotional zone-out. So I guess I'm wondering what your experiences were in this respect? Did you feel music, laugh at things? I think that these are things that start correcting themselves for me after the medicine has really had time to onset its benefits. I think they are the symptoms that take some time on an antidepressant to help. Does that make sense? I guess I'm writing this because I'm worried that I will lose some of the positives from the Remeron for good. But if I do the math, I guess I'm losing the positives of the Remeron because I'm tapering.. I am lower than where I started, and from what I've heard, antidepressants have a sort of level where they kick in for your chemistry and you don't reap many of the benefits at a lower dosage. Well, I know I need to give it time since I'm still early on Zoloft, but I just hate these transitions as you do because I'm scared of these symptoms... it's like they say in the Effexor pamphlets: "Your life is waiting!"
Anyway, Did you feel music, laugh at things, etc? BTW, I already know what you mean about socializing. I feel that working already.. it was something the Remeron did not to anything for, and that's one of the reasons I stopped it. Everything was dry, conversations on the phone were pointless, and I didn't take any pictures because life wasn't special. But my concentration and memory are now going fuzzy and I'm about to start waiting tables. I met with the owner of the place and couldn't remember his name or when he told me to come in. Thank God for pen and paper. Life always happens this way!
Take care,
CharlieLater,
Charlie
Posted by tai on October 15, 2002, at 17:19:52
In reply to Re: Drunk on Zoloft?, posted by wcfrench on October 15, 2002, at 16:13:52
Charlie,
haha, deja vu for me. Got up around noon, had some breakfast, sent some messages, then started feeling really tired and nauseous. Went to bed. Now its 6pm, wake up, making some dinner and posting some more messages. Im feeling all kinds of out of wac now. Guess my little happy vacation is over.
But don't worry man, I was getting a little laugh trying to picture you as a waiter running around taking orders with your lazy memory. Good thing they give you pen and paper for that job.
I think you are still in a delicate situation with yourself. By no means in the clear. Sounds like the remeron kind of stabalized things for you, but did not really light that spark that everyone needs inside. I know what you mean about the music. I love music, I play music...well I spin records. Alot of people find comfort in music during thier bad times, but I couldnt. I would play stuff that always seemed to save me in the past, and move me, inside and outside, but it was as if even the records had no life. I would listen to them, but they just didnt do anything for me which of course further fueled my deppression and anger. But over time, I started getting pleasure in the little things again, first music, and then people. I consider myself an extrovert, but in my worst times I could illicit no joy from others. I had no interest in people and went out of my way to avoid engaging people. This was of course doubly hard since my job was very people oriented. But it all comes back. You will notice one day, you are smiling, and you really mean it. No more of those forced half smiles.
As for your time schedule on things, I am not sure. you know its a long and sloooowwww path to recovery. When you are not feeling well, time can stand still. And of course you are going to go through different phases as your body not only adjusts to the zoloft, but also to the withdrawing of remeron from your system. It may temporarily disrupt your sleep, eating, excercise habits...hell, you may not even be able to squeeze a pebble out your bum for days...everybodys body will react differently to the introduction of a new drug into thier system. I think you need to give yourself a good 6 weeks to see what you have gained from the zoloft and what you have lost from the remeron.
You know how the game works, always waiting. In the meantime try and go about your daily life, it will be uncomfortable for awhile, but things will eventually come back to you.
You know, I think I just convinced myself to get back on the zoloft. Guess good sex is gonna have to be put on the shelf for a couple of years.
Posted by Simon Sobo MD on December 12, 2002, at 6:44:03
In reply to Drunk on Zoloft?, posted by wcfrench on October 14, 2002, at 14:56:04
See my article regarding this "well whatever feeling" http://ourworld.cs.com/ssobo2/myhomepage/index.html
Posted by Dinah on December 12, 2002, at 8:07:56
In reply to Re: Drunk on Zoloft?, posted by Simon Sobo MD on December 12, 2002, at 6:44:03
I read the article with interest. You brought up two points that I have long felt to be true.
First of all that the DSM categories only describe symptoms and that it is foolish to think that many of the Axis I disorders and all of the Axis II disorders could possibly come from the same cause. There are probably many ways to come to "borderline personality disorder" which really just describes a cluster of coping mechanisms that often come together. Other than underlying emotional reactivity, why would any one physical cause be behind all cases? Moreover there is so much comorbidity within the DSM diagnoses that someone ought to be skeptical just because of that. DSM is not equipped to diagnose an organ as complex as the brain, in my opinion.
More importantly, I have long been questioning whether "side effects" of psychotropic medications (especially SSRI's) weren't really the primary effects, leading to their usefulness in so many conditions. For example, I used Luvox for OCD and I've always felt it worked through a combination of memory loss and apathy. If you forget what you've done that day, you're not as likely to worry that you've caused disaster, and the apathy takes care of what you do remember.
Which is not to say that the drugs aren't useful, and if I needed them to function I'd go back on them. I just agree that the drugs should perhaps be explained something along the lines of "SSRI's cause apathy and a reduction in stimulation. These effects are useful in treating a number of disorders."
What do you think of the current practice of prescribing antipsychotics as adjuncts to treatment for those who are not psychotic? How do you think that *really* works? Is it just a tranquilizing effect?
Thanks for the link.
Dinah
Posted by Simon Sobo MD on December 12, 2002, at 9:44:50
In reply to Re: Well, whatever.... » Simon Sobo MD, posted by Dinah on December 12, 2002, at 8:07:56
Dinah, I'm not sure I would describe SSRI's as always causing apathy. That is pretty extreme, but I do think they cause emotional blunting (a term used in an earlier thread) The key point I was trying to make is that meds would be best used if they would be considered in terms of the psychological effect they have (which cuts across DSM IV diagnoses). Indeed like alcohol, Ritaline, morphine etc, SSRIs, for better or worse, cause a similar effect with or without a DSM IV diagnosis. Please see my article regarding my use for "thin-skinned" teen-agers and the like.
My main arguments is with the belief that the various disorders described in DSM IV are due to a "chemical imbalance" specific to them in the same way that say, tuberculosis is caused by a specific germ. Despite the impression of most people no chemical imbalance has been found for any disorder. The isn't to say that we don't have different genetic dispositions, possibly even differences in our brain chemicals and wiring. But we are centuries away from making sense of all of this, and we have no way of measuring it
As for your question about "anti-psychotics" Their actual history is that they began as a pre-anesthetic sedating agent and were tried out on Schizophrenics. They worked quite well. They also worked for anxiety and panic and all kinds of conditions. When I was in training they were called "major tranquilizers" and benzodiazepines (like Xanax and Valium and Ativan) were called "minor tranquilizers" The problem with drugs like Thorazine was that they had many side effects and finally when it was discovered that tardive dyskinesia was a common result they were pretty much reserved for psychotic conditions. Pretty soon they were being called "anti-psychotics" as if they were only effective in psychosis. Atypical neuroleptics, the new generation of anti-psychotics have been found to not be as likely to cause tardive dyskinesia so now they are being used for all kind of syndromes. They are also being touted as "mood stabilzers" a confusing, lousy term. You can find a link to at article about that whole mess at bipolarworld.net. Or it is linked to my article.
Hope this hasn't been too confusing. The fact is that we have a lot of great new effective drugs, which is reason for optimism. We also have a lot of gaps in our knowledge and I am not sure the current official wisdom is the best way to arrange what we know and don't know.
Posted by wcfrench on December 12, 2002, at 14:00:34
In reply to Re: Well, whatever...., posted by Simon Sobo MD on December 12, 2002, at 9:44:50
You have good theories. The zoloft "drunk" effect wore off long ago, and I'm not sure how much it helped or is still helping, but I am doing just fine. Of course, I still get anxious and occasionally depressed but who doesn't? I think we should all hope to achieve a happy life without the use of medication, but this may not necessarily be an option for some people. I think psychotherapy is a much more powerful tool than medicine, in some cases, and in others, a combination is always more helpful than just medicine alone. However, the fact remains that the reason people take these medicines, however inaccurate or unspecific they are, is because they help, in some way, somehow. Whether it is a placebo effect, chemical imbalance, neurotransmitters... whatever the case, they help, and people who go through such "misery" look to anything for reprieve, and when you're in that state, you'll do anything. For me, it took almost two years to be feeling back to "normal" (whatever that is) and only now am I able to say that I want to be off medicine one day, and be happy without being dependent on it... But I think for most people going through serious depression (or anxiety) it can take a lot of work, and sometimes a lot of trying different medications (with different, and sometimes inaccurate methods of action) before finding something that provides relief from their despair.
We still have much researching to be done, and new things are coming out so fast, we're bound to become more educated as the years go by. I think eventually we'll have a very direct grasp on it, as these illnesses affect so many people in the world. Yes, I believe antidepressants are overprescribed, and many patients are misdiagnosed, but I also stand firm that medicine has done far more good than it has done bad, and always will.
Take care,
Charlie
Posted by Dinah on December 12, 2002, at 15:15:51
In reply to Re: Well, whatever...., posted by wcfrench on December 12, 2002, at 14:00:34
I think that SSRI's can be life savers. I just wish that they would be de-mystified. By describing them solely in terms of neurochemicals, it makes it sound as if depression, OCD, and a host of other problems are caused by a deficiency in seratonin, and it probably isn't that simple.
If on the other hand we admit that just as benzos have a nonspecific way of acting no matter what your diagnosis, that SSRI's do too, it takes the mystery out of it. SSRI's may well work on so many disorders through their nonspecific way of acting, probably through emotional blunting, or reduction in sensitivity to stimuli. SSRI's aren't necessarily "correcting" an imbalance. They are just acting as SSRI's work. It doesn't matter what your diagnosis is. Either the effects of SSRI's will help you or they won't.
In addition, patients wouldn't be so surprised by sexual side effects or emotional blunting side effects.
And Paxil could stop disclaiming on their advertisements that they don't know how Paxil works on depression or anxiety. :)
Posted by BrittPark on December 12, 2002, at 15:23:53
In reply to Re: Drunk on Zoloft?, posted by Simon Sobo MD on December 12, 2002, at 6:44:03
I enjoyed reading your article, but must say that I don't entirely agree with you. First there are few psychiatrists who believe that simple chemical imbalances like too much or too little of specific neurotransmitters explain mental illnesses. They know that nobody knows how ADs work. Good psychiatrists work phenomenologically, using their experience and data from colleagues and the scientific literature. I don't see anything wrong with this approach. In fact I don't think there is any other rational approach.
Scientifically I don't think you'd find any researcher who believes he/she understands the mechanisms of mental illness and its treatment.
There is in fact much promissing research. In particular tomagraphic imaging of the brain, though in its infancy, has usually found that there are significant chemical and anatomical differences between "normal" and "mentally ill" people. In the future we can hope that such imaging will be used clinically as a diagnostic tool.Finally psychodynamic and cognitive behavioral approaches to therapy can be very useful. However for people who are severely ill (let's say depressed to the point of suicidality) talk therapy isn't possible until some kind of pharmacological intervention works well enough for the patient to work with a talk therapist.
If I were a psychiatrist (I'm a biologist by training) I would use as my model: medication first and talk therapy as soon as the patient can reason clearly enough. If the patient is cogent enough (perhaps mild depression following loss) drugs might be unnecessary.
<irelevant>
Let me just say that the drug companies are doing a terrible job of finding new and better treatments for mental illness. Since the discovery of antidepressants in the 50s there has not been a single new antidepressant shown to be more effective than any other. The opioid system and the dopamine system, to a lesser degree, are ignored in drug research even though they may well be excellent targets for ADs. I could go on but I've babbled too much already.
</irelevant>Regards,
Britt (Piled higher and Deeper)
P.S. Please continue to post. It's very helpful to have bona fide physicians post to this board.
Posted by wcfrench on December 12, 2002, at 15:44:10
In reply to Re: Drunk on Zoloft? » Simon Sobo MD, posted by BrittPark on December 12, 2002, at 15:23:53
Sometimes the most interesting stuff is the babbling... After all, look at the name of the website.
-Charlie
Posted by Simon Sobo MD on December 12, 2002, at 21:22:51
In reply to Re: Drunk on Zoloft? » Simon Sobo MD, posted by BrittPark on December 12, 2002, at 15:23:53
You comment "In particular tomagraphic imaging of the brain, though in its infancy, has usually found that there are significant chemical and anatomical differences between "normal" and "mentally ill" people."
Most of these studies are almost comical.
If you raise your right arm one part of the brain will show activity. If you raise your left leg another part of the brain will be busy.
Thus, for example, it is shown that when confronting an attention requiring task ADHD kids don't use the part of the brain that normal kids use to process information.
DAHWe already know they are not using this part of the brain from their behavior. Documenting that this is taking place does not mean the problem is necessarily biological. It merely demonstrates what would be expected given what can be observed. They are now using the thinking delaying parts of the brain.
I do agree with you that many patients will not be helped by psychotherapy alone. I also think some patients are not helped by psychotherapy even with medication.
My article was not an attack on meds, merely an attempt to understand what they might be doing on a psychological level. As I noted in the article there is value in viewing the meds likelihood of success on the basis of an accurate diagnosis but there is also a weakness in relying on diagnosis alone under the false impression that a particular diagnosis points to a particular chemcial imbalance. I was suggesting that understanding the psychological effects of these drugs might be valuable in deciding when and how they might be used with particular patients and particular situations. But that requires knowing the patient a lot better than 15 minute med checks once a month allow and evaluations based solely on diagnosis and side effects. Emotional problems are not the same thing as a strept throat. Strept throat points to penicillin regardless of other details of the patient's life. A given psych diagnosis does should not automatically lead to a specific med.
Posted by BrittPark on December 12, 2002, at 23:29:30
In reply to Re: Drunk on Zoloft?, posted by Simon Sobo MD on December 12, 2002, at 21:22:51
First, please be civil.
I seem to value MRI and PET scan studies more than you. When the results are obvious they are important because they validate the methodology. They are simply positive controls. However considerably more is being done with brain imaging than simple glucose metabolism tracing (which is valuable in and of itself because some illnesses seem to have characteristic signatures). Researchers are using and trying to find other effective PET tracer molecules to measure receptor density, and activity. Given 5-10 years, brain imaging techniques will be an integral part of psychiatric practice and will result in significantly better outcomes.
My apologies for lack of references. I'm tired now but will hunt them up on medline tomorrow.
One point that I didn't make and should have in my first post is that I believe it's a mistake to dichotomize mental illness into psychological and physiological spheres. Psychological phenomena are physiological phenomena. Drugs can effect physiology which in turn is reflected in changed psychology. Talk therapy changes psychology by changing physiology.
With great hopes for the future of psychiatry,
Britt
Posted by BrittPark on December 13, 2002, at 12:01:53
In reply to Re: Drunk on Zoloft?, posted by Simon Sobo MD on December 12, 2002, at 21:22:51
Here are some recent SPECT references. I just picked a handful from the first page of a medline search.
Britt
A patient with Cotard syndrome who showed an improvement in single photon emission computed tomography findings after successful treatment with antidepressants.Hashioka S, Monji A, Sasaki M, Yoshida I, Baba K, Tashiro N.
Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. hashioka@f2.dion.ne.jp
We report the case of a presenile woman with Cotard syndrome, in the context of major depression, who showed an improvement in bilateral frontal hypoperfusion in a SPECT study using 99mTc-HMPAO after undergoing successful treatment with antidepressant therapy. We also retrospectively evaluated her clinical course based on the clinical stages. The symptoms of Cotard syndrome have been reported to change dramatically according to the stages. This peculiarity made it difficult for us to rapidly diagnose Cotard syndrome in the context of major depression, and not dementia, and thereby adequately treat the patient in our case. Differences in the reduced blood flow regions and a time lag from psychiatric remission were observed before the improvement in the SPECT findings when comparing our case with a previously reported case of Cotard syndrome. These differences suggest that the mechanism of Cotard syndrome is still not well understood at the present time.
Clinical impacts of single transcranial magnetic stimulation (sTMS) as an add-on therapy in severely depressed patients under SSRI treatment.
Conca A, Swoboda E, Konig P, Koppi S, Beraus W, Kunz A, Fritzsche H, Weiss P.
Department of Psychiatry I, Regional Hospital Rankweil, 6830 Rankweil, Austria.
Research on single and rapid transcranial magnetic stimulation (sTMS/rTMS) indicates an antidepressive efficacy of these methods. In our 4 week study of sTMS, 12 patients affected by severe non-psychotic major depression (DSM-III-R) were enrolled and put on standardized combined antidepressant medication with the serotonin re-uptake inhibitor citalopram, and the serotonin modulating drug, trazodone. They underwent sTMS in a specific method as an add-on therapy. Age, gender, illness and episode duration, episode number, Hamilton Rating Depression Scale-24 (HRDS), Mini-Mental State (MMS), drug levels assessed by HPLC, magnesium and thyroid stimulating hormone (TSH) were recorded. For each patient functional brain imaging was performed by (18)FDG and (99m)Tc HMPAO SPECT at the beginning of the study, as were EEG tracings which also were recorded at the end. Lorazepam was allowed as co-medication. Of the patients, 66.7 per cent (N=8) could be identified as sTMS responders. Possible predictors for sTMS response as add-on therapy may be duration, pattern of improvement in global and in specific single items of the HRDS, lorazepam dosage, functional involvement of basal ganglia and cortical temporal lobe and the initially lower mean frequency and lability of the alpha-activity of EEG. These variables possibly predict the clinical outcome of depressed patients treated by sTMS as an add-on therapy. Copyright 2000 John Wiley & Sons, Ltd.
PMID: 12404305 [PubMed - as supplied by publisher]
Left dorso-lateral repetitive transcranial magnetic stimulation affects cortical excitability and functional connectivity, but does not impair cognition in major depression.
Shajahan PM, Glabus MF, Steele JD, Doris AB, Anderson K, Jenkins JA, Gooding PA, Ebmeier KP.
MRC Brain Metabolism Unit, University of Edinburgh, Edinburgh, UK.
PURPOSE: Transcranial magnetic stimulation (TMS) has been used for over a decade to investigate cortical function. More recently, it has been employed to treat conditions such as major depression. This study was designed to explore the effects of differential treatment parameters, such as stimulation frequency. In addition, the data were examined to determine whether a change in connectivity occurred following TMS. METHOD: Fifteen patients with major depression were entered into a combined imaging and treatment experiment with single photon emission computed tomography (SPECT) and repetitive transcranial magnetic stimulation (rTMS) over left dorso-lateral prefrontal cortex (DLPFC). Brain perfusion during a verbal fluency task was compared between pre- and poststimulation conditions. Patients were then treated with 80% of motor threshold for a total of 10 days, using 5000 stimuli at 5, 10 or 20 Hz. Tests of cortical excitability and neuropsychological tests were done throughout the trial. FINDINGS: Patients generally improved with treatment. There was no perceptible difference between stimulation frequencies, which may have reflected low study power. An increase in rostral anterior cingulate activation after the treatment day was associated with increased functional connectivity in the dorso-lateral frontal loop on the left and the limbic loop on both sides. No noticeable deterioration in neuropsychological function was observed. CONCLUSION: TMS at the stimulation frequencies used seems to be safe over a course of 5000 stimuli. It appears to have an activating effect in anterior limbic structures and increase functional connectivity in the neuroanatomical networks under the stimulation coil within an hour of stimulation.
PMID: 12369271 [PubMed - in process]
Cerebral blood flow changes in depressed patients after treatment with repetitive transcranial magnetic stimulation: evidence of individual variability.Nadeau SE, McCoy KJ, Crucian GP, Greer RA, Rossi F, Bowers D, Goodman WK, Heilman KM, Triggs WJ.
Geriatric Research, Education and Clinical Center, Malcolm Randall Department of Veteran Affairs Medical Center, Gainseville, Florida 32608-1197, USA. snadeau@ufl.edu
OBJECTIVE: To elucidate the neural mechanisms of depression. BACKGROUND: Despite extensive study, the neurophysiology of the brain's state(s) corresponding to depression remains uncertain. METHODS: HMPAO single photon emission computed tomographic (SPECT) scans were obtained from eight adults diagnosed with major depression resistant to medication (average age 51 years; 4 men) before and immediately after 10 days of 20 Hz repetitive transcranial magnetic stimulation (rTMS) (2000 stimuli/daily 30' treatment). To maximize the likelihood that SPECT scans reflected the state of depression, rather than uncontrolled responses of patients to poorly constrained environments, HMPAO was administered while subjects performed a simple task involving continuous monitoring of the direction of a large arrow on a computer screen and continuously tapping with the left or right index finger according to the direction of the arrow. Mean baseline Beck Depression Inventory (BDI) score was 27.4 (SD = 8.3) and mean posttreatment BDI score was 17.5 (SD = 8.5). RESULTS: Treatment responders (defined by reduction in BDI score of > or = 30%) had significantly less pretreatment blood flow in the left amygdala compared with nonresponders. Responders demonstrated two patterns of change in regional blood flow with treatment: a reduction in orbitofrontal blood flow and/or a reduction in anterior cingulate blood flow. Nonresponders did not demonstrate any regional changes in blood flow with treatment. CONCLUSIONS: These results suggest that there may be either more than one state of depression, or that depression may be associated with more than one pattern of psychologic activity, which in turn defines the depressive experience for individual patients.
Publication Types:
* Clinical Trial
PMID: 12218709 [PubMed - indexed for MEDLINE]
SPECT neuropsychological activation procedure with the Verbal Fluency Test in attempted suicide patients.Audenaert K, Goethals I, Van Laere K, Lahorte P, Brans B, Versijpt J, Vervaet M, Beelaert L, Van Heeringen K, Dierckx R.
Department of Nuclear Medicine, Ghent University Hospital, Ghent University, 185 De Pintelaan, B-9000 Ghent, Belgium. kurt.audenaert@rug.ac.be
Performance on the Verbal Fluency Test, as a measure of the ability of initiating processes, is reduced in depressed suicidal patients. The hampered results in this prefrontal executive task parallel the reduction in prefrontal blood perfusion and metabolism in depressed subjects. A neuropsychological activation study with the verbal fluency paradigm could evaluate a possible blunted increase in perfusion in the prefrontal cortex in depressed suicidal patients. Twenty clinically depressed patients who had recently attempted suicide and 20 healthy volunteers were included in a single photon emission computed tomography (SPECT) split-dose activation study following a verbal fluency paradigm. Statistical parametric mapping was used to determine voxelwise significant changes. Differences in regional cortical activation between the letter fluency and category fluency tasks in attempted suicide patients were found. These patients showed a blunted increase in perfusion in the prefrontal cortex. Methodological restrictions concerning group uniformity, medication bias and subjective effort of the participants are discussed. Our findings indicate a blunted increase in prefrontal blood perfusion as a possible biological reason for reduced drive and loss of initiative in attempted suicide patients.
Publication Types:
* Clinical Trial
* Controlled Clinical Trial
PMID: 12195096 [PubMed - indexed for MEDLINE]Normalization of frontal cerebral perfusion in remitted elderly major depression: a 12-month follow-up SPECT study.
Navarro V, Gasto C, Lomena F, Mateos JJ, Marcos T, Portella MJ.
Clinical Institute of Psychiatry and Psychology, Hospital Clinic, Barcelona, Spain.
We examined global and regional cerebral blood flow abnormalities in a group of unmedicated nondemented elderly late-onset unipolar major depressed patients in acute depression and in remission (after a 12-month follow-up period). 35 somatic treatment remitter patients over the age of 60 years and 20 sex-, age-, and vascular risk factor-matched healthy controls were imaged with single photon emission computed tomography, using technetium-99m hexamethylpropylene amine oxime as a tracer. In depression, the depressed group had significantly lower uptake in the left anterior frontal region than the control group. In remission, the left frontal cerebral perfusion abnormalities disappeared, and there were no significant differences in uptake between controls and patients. No significant correlations were found between baseline clinical characteristics of patients and their regional cerebral perfusion at baseline or after a 12-month follow-up. These findings are consistent with the hypothesis that certain neuroanatomic regions of the central nervous system may be functionally and reversibly involved in unipolar major depression, particularly in the late-onset subgroup.
PMID: 12169261 [PubMed - indexed for MEDLINE]
Posted by wcfrench on December 13, 2002, at 13:36:08
In reply to Please Be Civil. » Simon Sobo MD, posted by BrittPark on December 12, 2002, at 23:29:30
I don't believe that he was being uncivil.
-Charlie
Posted by Dr. Bob on December 14, 2002, at 11:25:36
In reply to Re: Please Be Civil., posted by wcfrench on December 13, 2002, at 13:36:08
> I don't believe that he was being uncivil.
I'd like follow-ups regarding civility, and complaints about posts, to be redirected to Psycho-Babble Administration. Also, if you think someone's been uncivil, it helps a lot if you quote that part of their post and explain why you think it's a problem. Thanks,
Bob
Posted by Simon Sobo MD on December 15, 2002, at 7:25:07
In reply to Re: Drunk on Zoloft? » Simon Sobo MD, posted by BrittPark on December 13, 2002, at 12:01:53
I have absolutely no doubt that physical changes occur in depression. The sodium content of a depressed person's saliva changes, not to mention sleep EEG patterns, the immune system and a thousand other things. Nor do I doubt that successful treatment changes these abnormalities. Actually I have a link on my site by Glen Gabbard where PRT and SPECT studies are one of the main focuses. Here is a sample:
" In one study of obsessive-compulsive disorder, Baxter et al. (1992) looked at local cerebral metabolic rates for glucose using positron emission tomography scan methodology. They found that both behavior therapy and fluoxetine (Prozac) produced similar decreases in cerebral metabolic rates in the head of the right caudate nucleus, suggesting (but not proving) that this form of psychotherapy and fluoxetine have similar physiological effects at the level of the brain.There is extensive evidence that cognitive-behavior therapy is an effective treatment for panic disorder. Panic attacks can be triggered by lactate infusion in those with panic disorder. At least one study (Shear et al., 1991) has demonstrated that lactate induction of panic can be effectively reversed through successful cognitive therapy. These findings suggest that psychological interventions can alter the response of the brain to biochemical factors. Psychiatric researchers in Finland recently published a report showing that psychodynamic therapy may have a significant impact on the neurotransmitter serotonin (Viinamäki et al., 1998). At the beginning of a one-year psychotherapy process, single photon emission computed tomography (SPECT) imaging was undertaken with a 25-year-old man suffering from personality disorder and depression. Another young man with similar problems also underwent imaging but did not receive psychotherapy or other treatment.
Initial SPECT imaging showed that both patients had markedly reduced serotonin uptake in the medial prefrontal area and the thalamus compared with 10 healthy control subjects. After one year of dynamic therapy, repeat SPECT imaging showed that the patient who received the psychotherapy had normal serotonin uptake while the control patient who did not receive psychotherapy continued to have markedly reduced serotonin uptake. This study suggests that dynamic psychotherapy may normalize serotonin metabolism."
There is absolutely no doubt that the mind effects the body and the body the mind. There is no doubt that meds work by having an effect on brain chemistry. So does alcohol, cocaine and opium. I am not trying to put meds down by this analogy simply stating the obvious. And there is no doubt that we are all wired differently from birth. We may be genetically predisposed to develop certain diseases. This has been clearly demonstrated in schizophrenia and bipolar disorder and it may be a factor in all of the DSM IV disorders.
But here is where the important distinctions have to be made. Nature-Nurture has been a controversy for hundreds of years and the pendulum keeps swinging. When Freud came along people thought everything was genetic. Certain families had a genetic taint, which was a stain on them which they couldn't erase. In Germanic countries especially, so did certain racial-religious groups and the like. (When the head of the NIMH went in this direction about 10 years ago regarding genetically determined criminality he was forced out of his post)
Anyway Freud was welcomed as a liberator when he argued that trauma was more important than genetics.
On the other hand when studies such as you are quoting on this board demonstrated for instance, that ADHD was "really" a brain disorder and therefore not the "fault" of the way they are being raised, parents of ADHD kids felt exonerated. I don't think there is any point blaming parents but I am convinced that many, perhaps most cases of ADHD (I am working on a paper on ADHD, hence I keep going back to it) have very much to do with the way they have been and are being raised. Certainly some kids with ADHD were born that way, but I think the vast majority have been raised in a way that favors their symptoms. So how we interpret differences in PET as documented by brain studies is crucial. I am claiming such studies are "phony" if they are used to "prove" the whole problem is biological and therefore a drug is the answer to the problem.
Furthermore, I believe genetic "wiring" kinds of explanations are devastating to the kids. They lower expectations from teachers (as in "they can't help themselves") and more ominously convince kids that they are doomed. So much of what kids accomplish has to do with overcoming their doubts about themselves, especially when something doesn't come easily. We have all been there, tasted failure and frustration and we have been lucky this has been answered by our parents or teachers belief in us (even when they might be secretly wondering whether we have it in us to do it). I can't imagine what it must be like to believe that you are wired wrong from an early age. PARTICULARLY WHEN THE EVIDENCE IS NOT THERE!The bottom line is that there are a lot of biological kinds of studies which have been amazingly misinterpreted to "prove" most psychiatric problems are "really" physical problems. This is not a coincidence. Many biological psychiatrists are true believers. Yes they mouth truisms about psychosocial factors but they basically believe therapy's purpose is to keep patients taking their medicine.
Having been in academia when biological psychiatrists took over most psych departments, and the major psych journals, I can tell you that these problems are not theoretical but real. One side of the truth is being presented to the public and to psychiatrists in training. It was no different when therapy oriented psychiatrists controlled academia. They were not very open to biological ideas and funding, but you should know that there are reasons for the overenthusiasm in interpreting biological phenomenon in a way that favors the reigning ideology.
As for your complaints about my lack of politeness what can I say. Sorry? Let me tell you something. My profession is very polite in its discourse. There is an amazing lack of public disagreements and controversy considering the amount of garbage being accepted as truth. There is a pack-man mentality in the field, a need to hide in conformity out of fear of law suits should they not comply with "expert consenus protocols" This would be fine if we had reached a point of expertise where controversy and uncertainly were issues of the past, if we had solid knowledge that would eliminate controversy. But we are not there.
Time magazine recently ran a cover story on bipolar kids that was astoundingly wrong headed or certainly worth an uproar considering that these poor kids are going to be zonked out of their minds. I see teenagers all the time misdiagnosed with bipolar disorder who have put on 30 pounds and sleep 14 hours a day and the doctors who made the diagnosis in the hospital saw them 20 minutes.
Anyway, that is enough for now. I don't want to frighten posters on this board. Many meds are very very helpful and most doctors are doing their best and are doing their job well. Indeed it is the effectiveness of many of our newer meds that have probably led to some complacency. Moreover, I have always been a doubter of official truth (even when Freud was the God) so my statements should be put in perspective. But I would say that a degree of independent thinking is always valuable even in patients.
Posted by BrittPark on December 15, 2002, at 12:51:23
In reply to Re: Drunk on Zoloft?, posted by Simon Sobo MD on December 15, 2002, at 7:25:07
My apologies Dr. Sobo. I didn't follow the golden rule of PsychoBabble. "Don't post when peeved" ;)
I think we probably agree about more things than we disagree.
I come at psychiatry from the perspective of patient. I tend to favor the medicine side of things because that is what has been most helpful for me in my worst depressions. When in the acute phase of depression, just making it to see my therapist is almost more than I'm capable of, and the very idea of a participatory form of talk therapy seems laughable (if I could laugh). I think the best analogy for me is that of someone who has a multiple fracture of the femur. One does not expect them to start physical therapy until the bone is healed. For me the talk part of recovery becomes useful when medication has helped almost to the point of recovery. The talk then becomes a kind of post-mortem of the preceeding episode, which is indeed very helpful. This kind of therapy has made my depressive episodes less frequent and less severe over the last 20 years, for which I'm very grateful.
Now as to improper use of medicines, I don't doubt you are right about ADHD (not to mention SSRIs). I think a big part of the problem is that GPs are now treating a lot of people who would be much better off with a psychiatrist.
Looking forward to your ADHD paper,
Britt
Posted by wcfrench on December 15, 2002, at 14:43:27
In reply to Re: Drunk on Zoloft?, posted by Simon Sobo MD on December 15, 2002, at 7:25:07
I agree with your statements regarding "doomed" bipolar or ADHD children. For a long time during my depression, I believed that I was just flawed and that my problems were because of what was going on in my brain and that I would never be able to handle things as well as other people. To an extent, depression does inhibit your ability to cooperate and socialize and participate in society, BUT it is not the be-all end-all of your self esteem. We should not have children walking around feeling sorry for themselves, using a "diagnosis" as an excuse for lack of learning ability. Yes, ADHD is a real problem for many, but sometimes you just have to wonder, are you doing more harm or good telling your child that they have a mental disorder? Self esteem is so important during those fragile years of our lives. Kids would do anything to not feel different from their peers, and I think that is something doctors need to consider in diagnosing this problem.
Everyone goes through some neurosis at some point in their life, and who says to what degree requires a "diagnosis?" If I had never seen a doctor about my anxiety/depression, I wonder how I'd be doing today. Sure, maybe I might not have had the immediate relief I felt, or the ups and downs of medicines (or the side effects), or the euphoria, or the fears of death, hospital visits, oversleeping, undersleeping... Often, I think I'd be doing just about the same. Agreeing with Britt, I think medicine, (especially in severe cases) is often required to get a patient to the point of considering their options, but I believe therapy and cognitive self-reinforcement, however, are much more powerful tools long term, and so does the general research of depression.
If there were another way people could get out of cases of severe depression, I believe they would do it. But when medicine offers relief of any sort, you cling to it for dear life. Hopefully once you are back on track, you can use therapy as a tool of permanence. The brain does have control, but we have the power to control it and to change the way our thought patterns work and our chemicals and neurotransmitters flow, just as medicines do. I hope more and more people begin to embrace this idea (when possible) as it is by far the most effective permanent treatment.
Take care,
Charlie
Posted by AnneL on December 15, 2002, at 14:56:50
In reply to Re: Drunk on Zoloft?, posted by Simon Sobo MD on December 15, 2002, at 7:25:07
Dr. Sobo says,
"But I would say that a degree of independent thinking is always valuable even in patients".
I agree with your statement but feel that "independent thinking" is *especially* valuable when it comes to being a patient. Until psychiatry makes great advances in evidence-based practice, patients in particular will need to be independent thinkers. Current *standards of care* for psychiatric illnesses are certainly not standard and until our current understanding of these illnesses progress; it will ultimately be up to the consumer(patient) to decide what is in their best interest.
Posted by Geezer on December 16, 2002, at 10:04:44
In reply to Patients and Independent thinking » Simon Sobo MD, posted by AnneL on December 15, 2002, at 14:56:50
> Dr. Sobo says,
>
> "But I would say that a degree of independent thinking is always valuable even in patients".
>
> I agree with your statement but feel that "independent thinking" is *especially* valuable when it comes to being a patient. Until psychiatry makes great advances in evidence-based practice, patients in particular will need to be independent thinkers. Current *standards of care* for psychiatric illnesses are certainly not standard and until our current understanding of these illnesses progress; it will ultimately be up to the consumer(patient) to decide what is in their best interest.Very good point! I wonder way the thread was not started under psyco-babble in the first place? No disrespect intended.
Geezer
Posted by Kari on December 16, 2002, at 12:11:09
In reply to Re: Drunk on Zoloft?, posted by Simon Sobo MD on December 12, 2002, at 6:44:03
The article is extremely interesting and very much to the point.
From personal experience I found that SSRIs, while offering great relief from severe distress by causing emotional indifference, also prevent me from needing or wanting to work on the problematic areas in my life which are perpetuating my problems. The other day I was thinking that on an SSRI I wouldn't have any problem being locked up in a prison cell staring at the walls for the rest of my life. It really wouldn't matter:)
I prefer to suffer to the point of despair and to feel the consequences of my decisions in order to be driven to change, and for this reason I no longer take these meds.
This is not, however, an attempt at generalization. For many people these meds are life savers as their suffering is not so much caused by life circumstances or not relieved by any other means. I was referring to people (like me) who are tempted to use these meds as "a cover up" and to psychiatrists who encourage this behavior.
This is the end of the thread.
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