Tag: depression treatment

New Do it Yourself (more or less) Electrotherapy for Depression at Home!

OK, so the title is a little provocative; on the other hand, this is my take on a legitimate treatment for depression that was just approved by the FDA only last week. A company called Flow Neuroscience is marketing the newly approved FL-100 device for treatment of depression and their website definitely has their marketing skills down. And I definitely was reminded of a TV commercial about removing your own appendix.

That’s my smartass joke, but hang on, there’s more to it than jokes. I had to search around a while to find actual FDA web evidence that they actually did approve the FL-100, but I was saved by the reliable and trustworthy Psychiatric Times article about the FL-100 with references that I could verified the FDA’s approval.

So, I’m a retired psychiatrist and I was a clinician educator type doctor, not a neuroscientist, but I can read the FDA approval document section XV. Conclusions Drawn from Preclinical and Clinical Studies (starts on page 12). It boils down to, yeah, this device’s probable benefits outweigh its probable risks.

The Effectiveness Conclusions subsection on effectiveness outcomes at Week 10 contains what sounds like realistic answers: “The medical literature lacks consensus regarding what constitutes a clinically significant or meaningful between-group difference in HDRS-17 scores. As such, the clinical significance or meaningfulness of the between-group difference of -2.3 points on the HDRS-17 scale has not been established. Nevertheless, the 2.3 point between-group difference helps support the view that FL-100 provides probable benefit.”

I’m not familiar with the EQ-5D-3L scale of health-related quality of life but the summary says:

“The EQ-5D-3L measures a person’s health-related quality of life by assessing five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. There was no between-group statistical difference in EQ5D-3L scores at Week 10. The EQ-5D-3L frequently fails to detect mild depressive symptoms, as individuals with subclinical depression often select “no problems” on the anxiety/depression dimension. The insensitivity of EQ-5D-3L is documented in the literature.”

I happen to think that comparison of medical treatments with psychotherapy is a good idea but: “Data were not provided regarding FL-100 used adjunctively with psychotherapy or with psychotherapy and antidepressants.”

The device has no recommendation for use with patients with treatment-resistant depression:

“Patients who previously had an inadequate clinical response to two or more antidepressants at an adequate dose and duration were excluded from the study, limiting the evidence for use of the FL-100 in a more treatment resistant population.”

The potential risks are first degree skin burns if you’re not careful with the electrodes, headaches, and scalp pain. The benefit is modest but outweighs the risk.

You can use the device at home under the supervision of a clinician—they don’t do house calls so you’d presumably do this by zoom call. You can also get advice through an app on your device, which may or may not be a monotonal AI. You pay $500-800 and there won’t be any answers to questions about insurance coverage until at least next spring. But it’s being used by tens of thousands of people in Europe and beyond.

So go ahead, take your own appendix out (just kidding; put that jack knife away!). Did you know that at least one guy actually did that? A Russian surgeon, Dr. Leonid Rogozov managed it in 1961 while he was stranded in Antarctica.

It’s just my opinion, but the headset could be more stylish.

The Changing Role of the Psychiatrist in Managing Depression with Medical Illness

This post is mainly a reminiscence about my days as a consultation-liaison psychiatrist. I often evaluated patients who had chronic hepatitis C. The liver disease itself and the treatment (interferon alfa) often led to patients struggling with depression.

The impetus for this came from noticing a couple of items. One is the recent l blog post about treatment of depression by George Dawson, MD (“Are Medication Trials for Depression Too Long in Duration?”). The other is a Psychiatric Times article about the Star-*D depression treatment study published in Psychiatric Times (“Star*D: It’s Time to Atone and Retract” by Nicolas Badre, MD and Jason Compton, MD).

Back in the day, I thought it made sense to use depression rating scales in my clinic practice. I use the term “clinic practice” reservedly because in actual practice I was too often running the hospital psychiatry consultation service to see outpatients regularly.

There has been a recent call to retract the Star*D study. I wasn’t involved in the study, of course. I was too busy running around the hospital responding to consultation requests. I noticed the criticism in the Psychiatric Times article by Badre and Compton of the specific depression rating scale, the QIDS-SR (which stands for Quick Inventory of Depressive Symptomatology (Self-Report).

I tried to integrate into my practice the QIDS-SR as well as the Clinically Useful Depression Outcome Scale (CUDOS). The latter was designed by psychiatrist Dr. Mark Zimmerman around 2008. I believed in the principle of measurement-based assessment of psychiatric symptoms and did my level best to integrate them into my practice.

It was very difficult to do. My patients were typically suffering from both medical and psychiatric illness. Often, they had physical symptoms that you could attribute to either the medical problem itself or “depression”—or both. This is a common challenge in consultation psychiatry.

Returning to my experience with patients who had chronic hepatitis C, in my early career, some of them who were on interferon alfa would not uncommonly develop depressive symptoms during treatment. Sometimes that meant stopping the treatment. Moreover, they sometimes had other side effects including thyroid function abnormalities, which can also cause mood disturbance.

There have been debates about whether to count physical symptoms in depression because of the overlapping symptoms: fatigue, appetite loss, trouble sleeping and the like. There’s also what has been called the “fallacy of good reasons.” Wouldn’t you be depressed too if you were sick and tired of being sick and tired? This could lead to undertreatment of depression. Some diagnostic models suggested counting all symptoms regardless of etiology.

Some randomized controlled trials of antidepressants in the past showed antidepressants were effective in the medically ill with depression. Others showed they were not better than placebo.

Nowadays there is a new pharmacologic approach to treating hepatitis C and those are in the category of direct-acting antivirals (DAA). According to fairly recent literature, the DAAs offer a better chance of cure of hepatitis C and less psychiatric side effects. That doesn’t mean psychiatrists are no longer needed. The common issues such as comorbid substance use and cognitive disorders, highlighting the ongoing need for collaborative care between medicine and psychiatry.

The Good and the Not So Good About Mental Health Treatment

Sometimes I write “depressing” blog posts. On the other hand, I have both good and bad news today.

I found out that, according to the Treatment Advocacy Center, Iowa’s state psychiatric hospital bed availability is dismal according to 2023 figures. That’s actually not new. Although we rate last in the nation for this, we still get a Grade B overall. I’ll have more to say later about it. You can check your own state’s grade on the web site’s map graphic.

And a recently published article about antidepressant prescribing for young people is sort of depressing, there are ways to address the likelihood that adolescent females are being prescribed antidepressants more often than adolescent males.

I tend to agree with the author of another article on adopting a more nuanced perspective on what is often called “depression” in young people.  Not everybody who is distressed is depressed.

Even if we are depressed, there are healthy activities we can engage in to heal. We don’t all necessarily need antidepressants. That’s the point of a recent systematic review and meta-analysis on the role of exercise for managing depression. Exercise is effective either by itself or in addition to psychotherapy and antidepressant.

Iowa actually seems to be putting a lot of hard work in mental health outreach, such as Your Life Iowa. It’s funded by the Iowa Dept of Health and Human Services under the Division of Behavioral Health.

I’d say that’s pretty positive, overall.

Psychiatrists Cast Doubt on Idea that Antidepressants Work by Causing Apathy

Out of 60 hits on page one of a Google search using terms “emotional blunting from SSRI,” only one cast doubt on the assumption that SSRI antidepressants exert their treatment effect by causing apathy. The rest endorsed the connection.

The one article I found on this quick search which contradicted this widely held and arguably incorrect assumption is “Antidepressants Do Not Work by Numbing Emotions,” published in Psychiatric Times, Sept. 26, 2022, which was written by George Dawson, MD and Ronald W. Pies, MD.

The authors wrote a convincing rebuttal of the assumption that the SSRI mechanism of action for treating depression is by causing apathy. Based on their review, the problem is more likely due to residual depressive symptoms. It’s a good thing it turns up on the first page of a web search.