PLACEBO BIAS IN THE DEBATE ABOUT ANTIDEPRESSANTS

Depression is real. More than 25 million Americans suffer from it. Less than half of people suffering from depression, are seeking help. Depression can affect people of all ages, ethnicity and income bracket. Many suffer in silence, discouraged, hopelessly waiting for a miracle and a cure. Why? Because many people don't know whom to trust in choosing various treatment choices. Fortunately, there are many good ways to treat depression, even when severe. We should not close our minds and reject any available option. One of them is the antidepressants. This is the topic of a new article stirring a hot debate in the media. If you are depressed and looking for answers about the treatment for depression, do not discourage. Read both sides of the antidepressants debate.

The work of Irving Kirsch, Ph.D. in psychology, is the basis of an article, The Depressing News About Antidepressants, written by Sharon Begley and published in Newsweek Magazine, on February 8, 2010. Kirsch claims that, according to his statistical analysis of 38 research studies regarding the efficacy of antidepressants, they do not work much better than a placebo in the treatment of depression; therefore, they are an unwarranted way of treating depression.

The placebo effect is the mental effect of experiencing something only because we believe in it--a mental trick, if you will, that our complex minds play on us sometimes. For example, when depressed patients are given a “sugar pill” and are told that it is an antidepressant that will help them with their depression, the symptoms of depression get better based only on the person’s belief and not because of an actual effect of a chemical substance like medication. This is what Dr. Kirsch believes accounts for the beneficial effects of antidepressants.

Bias is an attitude that always favors one particular way of feeling, acting or thinking without considering other aspects of an issue. In other words, a subjective interpretation of reality--another type of mind trick that our minds play on us, making us blind to data or information or aspects of reality that are not in accordance with what we want to believe. The placebo effect and bias are produced unconsciously by our minds. If we become aware of them when they happen, they become a free choice.

Was Kirsch biased and therefore unconsciously trying to prove once again his theory that the placebo effect is the true basis of antidepressants when he meta-analyzed the data from the 38 research studies done by others?

Meta-analysis is a statistical process that combines the results of several studies addressing a set of related research hypotheses. The advantage of it is that it can draw general conclusions from the studies. But a big disadvantage of it is the fact that it leaves ample room for bias. Meta-analysis relies heavily on studies done and published by somebody else, under his own set of biased circumstances. The decision to include or to exclude certain studies from the meta-analysis is also highly subjective, as is the chosen scope of a specific meta-analysis. In medicine, these drawbacks are so significant that the results cannot be regarded, by themselves, as the definitive conclusion of a scientific debate, because meta-analysis leaves too much room for the bias and error of the researcher.

The conclusion of the article that antidepressants are not much more effective than a placebo, and therefore their use not justified, is the result of a second attempt of Kirsch to prove his point. His first attempt was in 1998. Both times he has used the meta-analysis statistical technique of taking research data and crunching them in a certain way. Is it possible that Kirsch may have wanted to prove that he was right all along since 1998 about this subject?

Kirsch is also known for his research on the placebo effect and expectancy theory. According to this theory, people’s experience depends partly on what they expect to experience. This theory has been applied to understanding not just depression but also anxiety, pain, addictions and psychogenic illnesses. Is it possible that Kirsch, the researcher who believes that the placebo effect is a very powerful element of the human psyche, has been biased by his own prior flawed research experience to attribute to the placebo effect qualities and powers that are, in reality, not quite there?

His position on depression is that it is not the result of a change in brain chemistry. Kirsch is a doctor of psychology. He is not a physician, he is not a neurobiologist, he is not a psychiatrist. And, to my knowledge, he has never been clinically depressed and tried antidepressants himself. In my opinion, he has limited expertise to make the assumption that depression is not a "real" disorder and that antidepressants don’t work any better than a placebo. Antidepressants do work. So many people can testify to that from their own experience. There is no global antidepressant conspiracy.

Patients of mine who suffer from depression are often so exhausted that rising from bed is a genuine struggle. Many think their lives are not worth living, and feel incapable of having any hope that they will ever be healthy again. Does Kirsch seriously believe, as he asserts in his article Antidepressants: The Emperor's New Drugs?, that they will get better only with physical exercise, self-help books and talk therapy at this point? Maybe not. Don’t forget prescriptions for “sugar-pill” placebos.

Unfortunately, while in crisis, the person who is contemplating suicide or the person who can barely leave his bed because of depression, will not be up to considering these other interventions, much less following them. And people suffering from depression do not have to be suicidal to know they have deal with a serious problem. Being too depressed to be able to function in everyday life is enough to make people plunge into despair. Antidepressants are very helpful in these situations. When the crisis has abated some by using antidepressants, there are various other interventions that are important and helpful—even essential. But they can not be implemented and followed by a depressed person who's symptoms have not been first quieted down with antidepressants. In order for the treatment of depression to be effective, it has to address all the symptoms of depression, not just some of them. Untreated or under-treated depression can lead to long-term disability, loss of job, income, relationships and life style.

Further complicating things, the majority of patients suffering from depression also meet the diagnosis criteria for other mental illnesses like anxiety, attention deficit or bipolar disorder. Their treatment will have to address these other problems as well. Their recovery process will look very different than that of people who suffer from depression alone, a minority. The subjects in the research studies that Kirsch has looked at were carefully selected patients that met specific depression symptoms criteria without additional complications and complexity, but they hardly reflect the reality that most people are confronted with in everyday life. Broaden the perspective on Kirsch’s statistical analysis and one finds a frightening oversimplification of the medical challenges presented by depression with its complications, complexities and dire consequences. His conclusions do not reflect and cannot be generalized to the vast majority of people suffering from depression.

Presenting a point of view based purely on meta-analysis (a statistical process) of others research studies, as Kirsch has done, while ignoring the complex clinical aspects of depression, is a grave mistake. It is a disservice done to real people, readers suffering from depression that need to consider the antidepressant option because their health depends on this decision. If they could benefit from the medication, but reject that option only because they have read the conclusions of Kirsch on the subject, and become more severely ill, that is a tragic consequence of a limited point of view too forcefully propagated by the media, without appropriate explanations for the layperson to clearly understand what it means, the pros and the cons.

I find Sharon Begely’s article both biased and narrow. And it is a disservice to their readership that Newsweek examines the controversy with seven pages presented on one side of the issue and a single page on the other side. What happened to the objective journalism? Shame! I expected so much better of Newsweek on such an important issue of health.

It is true that antidepressants are not perfect. It is also true that they have been used inappropriately sometimes and that they do not represent a magic bullet. But they do work and represent a viable option among many others that can be used to treat depression. And yes, the pharmaceutical companies have made a lot of money selling medications, not only antidepressants, especially in this country, where there is no maximum price cap as there is in Canada for example, where the government negotiated a maximum acceptable price.

There is a well researched new study from Northwest University in December 2009, saying that the SSRIs, the serotonin reuptake inhibitors, the most common kind of antidepressants used today, not only produced a marked improvement in depression compared with a placebo, but also improved patients’ behavior and personality traits unrelated to the direct improvement of depression, including an increased ability to cope with life difficulties, to see things as they are more accurately, and to have less of a doom-and-gloom attitude.

Some people are upset about antidepressants in principle. Some are upset with them because they had a negative experience using antidepressants or other medications. Many people have their own biases and fears about this issue. Also a lot of people have false expectations of medications and are bitterly disappointed when their expectations do not come to fruition.

More and more patients expect a quick fix from medication. When I tell these patients that even if they take the pill, they will still have to change their behavior or learn how to cope with stress or remove themselves from an emotionally toxic environment, they usually look at me in amazement and say, “But I thought the medication is supposed to do that for me.”
Depression is a complex problem. There is not one magic bullet that will effectively work by itself. In my clinical experience, what works well for depression, alone or linked with other mental illnesses, is a combination of interventions that are tailored carefully and specifically to fit the needs of each individual patient. This combination can include but is not limited to, mindfulness therapy, cognitive behavioral therapy, life coaching and medication--the last only if and when deemed necessary in the clinical context.

Kirsch’s comments come at a time when there is an explosion of knowledge in the field of psychiatry, neurobiology, psychopharmachology, psychology and mental health. Psychiatrists are talking more and more about genuine and lasting recovery from mental illnesses, rather than only an improvement in symptoms. New types of psychotherapies are now used on a larger scale, like cognitive behavioral therapy, acceptance and commitment therapy, mindfulness therapy, and others. Life coaching is gaining more recognition. Western medicine is beginning to be more open to complementary medicine--herbal remedies, homeopathy, acupuncture, massage therapy, yoga, etc. Patients suffering from depression or other mental illnesses need not choose between medication or therapy, but have the option of taking advantage of both, in a balanced, harmonious way.

Without trying to minimize the importance of the placebo effect, I would like to warn the readers of Kirsch that bias is also a powerful mental state and that, unconsciously, we may be inclined to read the statistics of research studies or a magazine article and register only the information that fits our beliefs. Perhaps the truth is somewhere in the middle:

· the placebo effect is real but also real is the experience of millions of patients who have benefited from the effects of antidepressants in order to heal and move forward in their lives;

· antidepressants are not the only way to treat depression; psychotherapy and other interventions are powerful and efficient treatment options;

· the competition between antidepressants and psychotherapy is an obsolete point of view; the two are not opposing but synergistic methods. Both aim to maximize patients’ healing and to enhance their quality of life and well being--whether used by themselves or in combination.

Healing from depression is possible. If you are depressed, talk to your internal medicine or your primary care doctor about it. Look for a psychiatrist. Find a psychotherapist or a counselor. Get a referral from a trusted friend or ask your insurance company for a list of mental health professionals.

Do not fear the antidepressants. They have their own role in the treatment of depression. To get full benefit from them, antidepressants have to be used wisely and cautiously.
Your doctor will help you balance the pros and cons of various medical research studies with your particular situation and needs.

Most importantly, you need to get the treatment that is right for you. You are not a statistic or an anonymous number in one research study or another, but a human being facing specific challenges and problems. That type of individualized care you can only get by working one on one with your own doctor, who will help you make an informed decision about the treatment choices available. There is no reason why you should continue to suffer from depression, alone and unaided.

NEVER IGNORE THE EMOTION FACTOR WHEN YOU MAKE A DECISION

“I do understand what my wife is saying,” said the frustrated husband. “She feels that instead of remodeling the garage, we need to remodel the kitchen. But here is why remodeling the kitchen is the wrong thing to do…” and he begins to tick off on his fingers one by one all the reasons why hers is not a good idea for the tenth time that session.

I see these conflicts more often lately. When the money is tight and a couple needs to choose between one thing or another, the woman becomes emotional and the man does not compromise.

One way out, would be to accomplish both goals; that way no one gets upset. But in this economy, we need to learn, again, how to prioritize.

With all this talk about recession, one important element is often completely ignored and left out of the debate: emotions. In tough times, people are expected to behave “rational,” to make “well thought out decisions,” and follow them without wavering; no hard feelings, just good decisions. The problem is, we are not computers. We have a great deal of feelings that, recession or not, still influence our “rational thinking,” whether we acknowledge them or not. Ignoring emotions leads to heated, endless arguments about who is “right” and who is “wrong,” when, in fact, both are being “emotional.”

During these arguments, I have frequently observed in the couples I work with that the two partners end up speaking two different languages. She said: “I feel betrayed by your decision to buy a new car when we needed new carpet.” He said: “Let me tell you why we don’t need a new carpet: the old one works just fine,” completely missing her point. Truth is, if he can figure out how to make her feel less misunderstood, she will probably stop resenting him for buying the car instead. But no, he will do this the “rational” way, when, truth be told, they shouldn’t have taken on either project because they had to borrow money for either.

Decisions need to be made together. When one partner is talking the language of feelings and the other thinks he is talking only the language of reason, ignoring all along each other’s point of view, both partners are talking the complicated, indirect and bewildering language of emotions.
I often find myself in a referee position, suggesting to the couples I work with revolutionary concepts like: “Have you thought of a compromise? What would be the one thing you can agree on together, even though neither of you gets his way?”

There is always a fair compromise that can be, with care, reached. A plan can be made to stagger the expenses, or scale back on the amount spent for each project or both. Or both projects may be delayed until there are savings for both. Or one may compromise for a concession that does not even involve money. Or another solution can be found. Good relationships and marriages can work out this compromise for the benefit and happiness of their life together. But if there are any fissures in that relationship or marriage, this will be time when the cracks will stare both partners in the face.

The moral of this story is: when you need to make a decision that involves someone you love, do not forget to take emotions into account. Those of both of you.

How do you work out compromises in your marriage or relationships? When you can’t, do you use a referee? Who would that be?

EVEN HIGH ACHIEVERS GET ANXIETY AND DEPRESSION

Who are the high achievers? The general idea is that the high achievers are those people with a great deal of motivation and free will, creative people that see an opportunity when everyone sees just a closed door and a turned down request. They tend to be extremely motivated and do not spare any effort to achieve their ambitious agenda. They do things that surpass their condition and they are not just CEOs and directors of departments; they can be anyone with these characteristics. But all these quality come, as usual, with a price. They often have to work harder to have full lives and not just successful careers and nothing else. Their identity is built around the things they do or they achieve, which makes them vulnerable to not being able to handle setbacks very well. Even the high achievers need to learn how to handle their emotions.

Anyone pushed hard enough, hit hard enough by life events in the most vulnerable areas of his beliefs and identity, can have a strong negative emotional reaction that translate into anxiety and depression, a very common combination. Although it takes a great deal of bad news to get them so down, high achievers are also vulnerable to the ups and down of life. The severity of these emotional reactions depends on the intensity of the trigger, its duration and the degree of hopelessness inflicted by it.

In high achievers, often the first symptom detected is an uncharacteristic decline of motivation--

a clear departure from their usual functional state. Gradually, if the problem persists long enough, they find that their confidence is waning. The innovative ideas they were famous for seem to dry up. They are overcome by an increasing, completely uncharacteristic, sense of hopelessness.

Because these feelings are new to them, often they do not recognize them as a reaction to the circumstances, but as a “weakness” and a sign of their own “inadequacy.” Their logic often tells them that one can’t possibly be well equipped to handle the job demands a few months ago and then, suddenly, be incapable of doing so a few months later. What has changed? They know just as much now as they did a few months ago. The only thing that changed is their emotional reaction and the way they now “feel” about things and about themselves.

Because high achievers are used to manage a fair amount of stress on a day to day basis, they initially use their usual coping mechanisms in an attempt to handle these overwhelming feelings: take one extra day off, talk to a trusted friend, pushing themselves even harder, in the hope that they can solve the problem and move on. But when these coping mechanisms that served well before are not enough to help them get out of the “funk,” they become extremely disillusioned.

Often, by this time, the depression and anxiety begins to take physical manifestations. They start having insomnia almost every night. Their appetite is diminished and they lose weight at a fast pace. Their shoulders slump and their backs stoop. All the lines of their faces are now pointing down. They forget to smile. They stop enjoying things they used to enjoy. These are changes a high achiever will often deny are happening, in the hope that they will soon find a way to make them go away. But they can’t find the way out because anxiety and depression affects the very emotional engines one needs to recover from anxiety and depression. What usually happens now is their emotions become engaged in a negative spiral they can’t escape on their own. They reach a point when they desperately need help. Usually at this point, someone in their family, most commonly the spouse, witnessing how their loved one is wasting away, finally sounds the alarm.

The high achievers will delay making the phone call to a psychiatrist not because they have something against psychiatrists in principle as long as other people need them, but because high achievers still convince themselves they are not “that bad.” Recognizing the magnitude of their emotional problem is regarded by them as a personal failure, and failure for high achievers is the biggest disaster imaginable. It is exactly what they spend all their lives finding creative ways of avoiding.

As you may imagine, by the time the high achievers find their way to the psychiatrist’s office to get help, usually with a great amount of nudging and diplomacy from their families, their symptoms have worsened significantly. That makes their recovery longer and more difficult. When I get a new high achiever patient, I know that we both will have to put a great deal of effort and care in getting him well.

The good part is that these people, by their nature very smart and creative, understand quickly the elements of the intervention plan. They ask good questions and they like to feel in control in making important choices in their recovery plan. The more initiative they take in trusting and completing these steps of the intervention, the more trusting and invested they become in its success. This is when their strongest qualities come into play. Their determination and propensity for hard work is coming to life again. They have a new goal now. They thoroughly engage on the healing path, with their eyes firmly focused on the hope of being whole again, which now feels within their reach.

My intervention in these cases is based on my Better Than Cured model. Using a combination of tools, from medication to cognitive behavior therapy, spirituality and life coaching, Better Than Cured has offered great results in helping my high achiever patient. Often, an anti-depressant/anti-anxiety medication is needed to stop the progression of symptoms (anxious feeling, hopelessness, insomnia, lack of appetite, etc.) and to start reversing them. The cognitive behavioral techniques help him learn to dominate anxiety by using the logic of his own mind. When he improves even more, we talk about insight, the driving forces of his motivation and how he relates to goals and ideals higher than himself through spirituality.

As my high achiever patient continues to feel better, he has more energy to go through the day. Getting up to go to work becomes less of an effort and the creative “juices” start flowing again. He feels more grounded and more insightful. This is usually the point when using life coaching tools we start talking about the practical steps he could take to manage the very problems that generated the emotional turmoil. Now that his mind is no longer clouded by excessive negative emotions, he can usually see many new ways out that were hidden from him before. He is now engaged on the positive spiral, where every positive step, builds on the previous one, helping him climb out from under the cloud of hopelessness. He gradually starts feeling more and more in control again—one of the most powerful antidotes against anxiety and depression.

Helping high achievers overcome their anxiety and depression is very rewarding for me. All my patients in this category have been exceptional people who found their way to wellness. Once they recover and become themselves again, it’s easy to understand how they achieved the successes they have achieved in their lives. Whether they have an unusual ability to interpret facts and to connect the dots when most people can make neither head nor tail of that information, or they have an uncanny ability to come up with solutions when most people have given up, or they have an extraordinary capacity to never give up facing rejections and setbacks, they are remarkably talented and creative people in their own fields of interest. Work and career for high achievers is even more important than for other people, the source of great satisfaction and pride, the skeleton on which their entire identity is built. This is why, when unable to perform at their usual high level at work, they feel their entire lives fall apart.

If you are a person in this category or know someone close like this, be aware of these issues. No one is immune to developing an anxiety and/or depression problem. Take corrective measures as early as you detect the signs. An early intervention leads to a faster recovery. Anxiety and depression are not character flaws. They are reactions to life is challenges or to internal struggle. They can be treated and resolved. When you have exhausted all the coping skills you usually have, and still feel anxious and depressed, do not hesitate to ask for help. It’s just like asking for a guide when you get lost in a new city. There is absolutely nothing wrong with it.

Thank you for reading this post. I am extremely interested in what you think about this issue. Your comments will help me better understand and help my patients. Please do not hesitate to write your opinions in the “comment” section below. Thank you.

I took all these pictures at Lotus Land, Santa Barbara, a very romantic property who belonged to Ganna Walska.

WORDS HAVE POWER: WE CAN PSYCH OURSELVES UP AND WE CAN PSYCH OURSELVES DOWN

I cringe every time someone says things like “Oh, I am so depressed! My hair dresser canceled on me today” or “I must be paranoid! I thought I saw my best friend’s husband with another woman!”

In psychiatry, when we talk about depression, we don’t refer to the momentary feeling of frustration one feels when things don’t go her way. Depression is a very serious condition that requires specific interventions to improve. When I hear the word “paranoid” I think immediately of schizophrenia, another serious mental illness. Maybe the passerby who thought she was “paranoid” was referring to being too afraid to admit that a certain unthinkable situation could happen. It’s not paranoia; it is flat out fear. Why, I wonder, do people misuse words so badly? And what kind of effect does that have on them when they do?

When one talks about herself as “paranoid” or “I am such an idiot to have sent that e-mail without spell checking,” she makes herself feel that she can’t do anything right; she can’t trust herself that she saw a painful reality and dismisses it thinking what she sees because it is so unlikely. Unlikely but not impossible. People have affairs and get caught all the time. Why put yourself down? Why induce in yourself a state of mind of mistrust and self-deprecation? Isn’t it better to call it as it is? “I have seen my best friend with the husband of another friend. I wonder what that is about.”

Another expression people use all the time is, “I need to put myself out there.” I don’t know about you but every time I hear it, it makes me think of some terribly embarrassing situation I have to put myself through in order to get a job interview or a date, two of the most common contexts in which it is used.

One of my patients suffering from severe anxiety kept saying how “stupid” she was because she was blurting out exactly what she was thinking in moments of frustration, coming across as “nasty” and very “rude.” At a closer look, it turned out she wasn’t doing it because she was “nasty” but because her anxiety was making her so overwhelmingly frustrated that anxiety was taking away her social filters. It was such a powerful, unbearable feeling that she had to release it immediately. Unfortunately for her, she was releasing these feelings by lashing out angrily at whomever happened to be around. It didn’t matter if it was the delivery man, her husband or even her bosses. Afterwards, because she was really a very nice person, she would torture herself with guilt and embarrassment.

Once we understood that this behavior was a manifestation of anxiety, I assured her that as soon as we got the anxiety under control, she would stop doing it. She was very uncertain about that and she said it in a quite hostile, angry way. Then she clapped her hand over her mouth and said: “See? I did it again. Do you now understand what I mean?” I know she felt really bad she was angry with me. But it was too late. Once something is said, it can’t be un-said. Her anxiety won, yet again, the battle over her best judgment in her mind. In the end, we decided she will learn to quiet down her anxiety and she agreed to take a small dose of an anti-anxiety medication. Also, we composed a short sentence she can say to herself whenever she gets impatient or irritated with others. That phrase was: “I can say everything I need to say, at anytime, and to anybody, in a polite and courteous way.” She wrote it on a piece of paper, repeated it a few times, folded it neatly and put it in her wallet.

Two weeks later, she came in excited, saying: “The medication is working! I did not blurt out my anger in two weeks, not even to my teenage niece who got in a fender bender with my husband’s car.” She then told me all about how she kept her cool throughout the unpleasant discussion the family had with the niece, who was crying and feeling miserable; and how, even though upset, she did not lash out her anger at the girl. Being more patient with her niece helped see how genuinely sorry the young girl was for getting herself in the accident, and it melted her heart.

“It’s brilliant! How did you do it?” I asked, surprised.
“I think it’s the medication.”
“I really doubt that, since Celexa needs at least two to three weeks to work.”

I knew it wasn’t the medication. It was rather the fact that she kept repeating in her mind the sentence we agreed upon, every time she was about to lash out at her guilty but repentant niece. In other words, she used powerful words to control her anxiety and change her behavior, avoiding adding more drama to a bad situation.

Why did it work? Because words have power. They can send our subconscious mind positive or negative signals which determine automatically the choice of words or behavior. This is how she avoided a potentially disastrous fight with her niece. Feeling very proud of herself was an extra bonus.

The take-home point here is, please, try to be kinder with yourself. Soften your inner dialogue. Say you are “disappointed” rather than “depressed;” say you will do an extra proof reading next time you need to send an important e-mail rather than “I’m such an idiot.” When you make a mistake, any mistake, don’t ask yourself, “How can I be so stupid?” Try instead: “Whoops! I made a blunder. But I am learning. I will do it better next time.”

Don’t think “I will put myself out there and date;” but rather, “I will try to see if I can find me a good date tonight.” Read both versions! How does each make you feel?

Have you used the wrong words in a situation and, filled with regret, not known how to correct the damage done? If you did, what did you tell to yourself at that moment? How did that make you feel?

MATISSE INSPIRATION by Christine Forest, Jan. 20,2010

(my first water color adventure)

Medication by Itself? Not the Whole Answer (follow-up on previous blog)

Thank you all for the insightful comments you left on my post, “Why you don’t need to be afraid of anti-anxiety medications.” Your comments are extremely helpful for the readers of this post and for myself as well. They made me think, and I want to share with you additional thoughts on the matter.

While there are now more and more treatment options available, the number of people suffering from anxiety and seeking treatment is still less than half of the number of all people estimated to suffer from anxiety today—40 million in the U.S. alone. Anxious people tend to avoid situations that make them uncomfortable and therefore more anxious. That includes asking for help to treat and heal from anxiety itself. If you are on the fence about this, I urge you not to wait very long before deciding to ask for help. If you feel you can no longer manage your anxiety on your own, do not be afraid to admit it. The sooner you step up the interventions to address it, the easier and faster it will be for you to fight the anxiety and recover. Fortunately, the range of effective interventions available is expanding more and more every year.

Despite many voices in the media blaming the anti-anxiety and anti-depressant medications for being the “source” of emotional problems or for not “working” at all, a consensus is emerging that the real problem is not that the medications are not effective, but that they are not always effective alone and that people do not yet take full advantage of the help they can offer, a point made very well in this article in The New York Times.

People are not well informed about the treatments available for anxiety. Many mental health and other specialists stand on opposing sides of the mental health question, claiming that one intervention is more successful than another. This is how the PhDs put down the PsyDs discussed in this article published this week in Los Angeles Times. The psychiatrists tend to discount the value of psychotherapy, trusting too much the “medical model” of treating emotional illnesses, while other specialists like life coaches, spiritual and various support group leaders are trying to do their best to help people coming to them for emotional support and guidance. These specialists lock themselves in rigid knowledge boxes, narrowing their views to their own field, and deliberately choosing to ignore the value and the experience of others.

Instead of using one type of intervention at a time, a combination of interventions utilizing the knowledge and tools from different fields of expertise will be far more effective. It is possible to create highly individualized intervention strategies that will fit like a perfectly tailored suit the neurobiological profile, personality, life experience and spiritual views of each individual suffering from anxiety, depression or other mental illnesses. That will indeed lead to a more holistic healing and to a much smaller risk of relapse.

The idea of combining interventions to address mental health problems with respect to the complexity of a human mind is not new. In the early 90s Mark Epstein, the author of “Falling to Pieces without Falling Apart,” was initiating a groundbreaking theory at that time of combining psychotherapy with Buddhism. Talking about how unsatisfying he found the use in his work of only theories like “separation and individuation” or psychoanalytic/psychodynamic techniques which, at that time, were the norm and the rage in practicing psychiatry, he started looking toward Buddhism to find additional insights. In his view, Buddhism “is actually answering a basic question that psychotherapy has struggled over the past 100 years to answer, which is how to help people be more present, more tolerant, more generous, and more loving in their lives, and that there is a method that the Buddha articulated that psychotherapy can learn how to blend and use in its own way.” Combined interventions!

Coming from the medical model, which is now all the rage, which considers mental illness strictly a medical condition and arrogantly ignores the intricate psychological and spiritual aspect of the human mind, I have discovered firsthand how unfulfilling, sterile and less effective this approach is when used by itself. The best results using medication alone is improving the symptoms of anxiety by 60 %. This is considered an acceptable standard in psychiatry today. But who wants to be only 60% well? The medical model is a gross oversimplification of mental health problems like anxiety. No wonder the public recoils every time psychiatrists and neurobiologists start talking about the “chemical imbalance of the mental illness.”

Disappointed by the results I was getting by treating my patients only with medications, I started looking for other interventions I could offer to help them better heal. This is how I discovered and learned about the cause and effect relationship between thinking and feeling in cognitive-behavioral psychotherapy; the “real life” practical strategies of life coaching; the solutions offered by Buddhist spirituality regarding accepting ourselves for who we are and being fully present in our lives. Studying the phenomena of human creativity, I realized the enormous potential for healing that the human mind has, taking in the available subjective and objective information and processing it in a radically new way, opening a whole new universe of possibilities toward healing and happiness. Using these combined techniques, my patients not only recovered from anxiety or depression—became cured, but going far beyond that, they became empowered, aware and insightful individuals, much stronger emotionally, setting their recovery goals higher and higher, firmly engaged on their individual road to happiness, becoming, in other words not only “cured” but Better Than Cured. With great success I have tested Better Than Cured intervention for over ten years with thousands of patients in my psychiatric practice. The techniques and principles I use are congenial with who I am: my training, background and my own way of thinking. But Better Than Cured is by no means the only combined technique that could work.

There are many other possible combination techniques that will be highly successful in treating anxiety and mental illness. We only need to start looking at all the methods available today in a new way.

For example, in addition to the revolution in neurobiology and the availability of many new psychiatric medications, there are new methods of psychotherapies emerging, like Acceptance and Commitment Therapy (ACT) and Mindfulness Therapy. Yoga is increasingly more accepted as beneficial for anxiety. Non-medical stress reduction techniques (massage therapy, aerobic exercises, and relaxation techniques) are now more and more recognized as helpful in the treatment of anxiety and depression. Herbal remedies and acupuncture are also gaining more acceptance as viable interventions for stress, anxiety and depression. Western medicine is beginning to pay attention to supplements, even considering their concomitant use to boost the benefits of medications; for example, using Lexapro (an anti-anxiety/anti-depressant medication) in conjunction with St. John’s wort, allowed the use of smaller doses of Lexapro to be effective for depression with fewer side effects. Different types of supplements, like vitamin B12 or vitamin D, omega-3 fatty acids and amino acids like L-tryptophan are now accepted by much of the medical world as helpful in the treatment of depression. This is an article talking about how natural products can be used as adjuvants to antidepressants, written by James Lake, M.D., from the Arizona Center for Integrative Medicine, The University Caucus on Complementary, Alternative, and Integrative Medicine (http://www.apacam.org/) The previous "alternative" medicine is now "integrative" medicine. Reputable medical journals, like Psychiatric Times, have now special sections on integrative medicine. Here it is one of the most recent articles on this.

The coming decade, and certainly the rest of this century, will be marked by increased acceptance and cooperation among many types of experts working together, converging their expertise toward a more lasting and complete healing from emotional problems. Blending their knowledge will create a larger array of choices for people in need, making mental illness less stigmatizing and leading to far better results.

WHY YOU DON’T NEED TO BE AFRAID OF ANTI-ANXIETY MEDICATIONS

Many anxious people come to see a psychiatrist when they can think of nothing more to do on their own. I can’t tell you how many times I hear, “Doc, I feel so bad that I figured I had nothing more to lose by coming to see a psychiatrist.”

Why is it that the psychiatrist, trained specifically to deal with emotional illnesses, is the person people go too as a last resort?

I am aware of the stigma associated with mental illnesses. It often comes from lack of understanding of what anxiety and other mental illnesses are. I am also aware of how little psychiatrists have done so far to reach out to the people in need, the direct beneficiaries of their knowledge and training, and explain to them how much we now know about how to heal their suffering; that anxiety is nowadays a treatable condition; people no longer need to suffer silently and be ashamed of it.

I often talk to my patients about when is the right time to consider anti-anxiety medication as an additional aid in treating their anxiety. Some examples of the clinical criteria are:

· When the symptoms of anxiety are overwhelming--panic attacks, feeling out of control, crying or being irritable, even angry, almost all the time, or when anxiety interferes with one’s ability to get through the day.
· A common complaint of anxious people who could benefit from anti-anxiety medications is: “I can’t relax no matter how hard I try or what I do. I feel I am wired and tense day and night. I feel exhausted and I don’t know what else to do.”
· Sometimes people first try psychotherapy or “talk therapy.” It can be very effective. When it isn’t, and people feel they are “spinning their wheels,” making no real progress, it’s time to consider the medication option in addition and not instead of therapy.

Anti-anxiety medications are very effective. The problems people usually have with them are because of the way they are used. Just as driving a car can get you where you want to go, but it can also get you into a tree if you are not careful, so the anti-anxiety medications can work for you or can create problems if they are not used carefully. Patients can help their psychiatrists with the selection and adjustment of the medications. They can give their doctors an accurate account of their past experiences with medications, if any, and they can provide them with important feed-back about how the medication is or isn’t working. The psychiatrist, in turn, needs to explain to the patient what to expect from the medication, its benefits and possible side effects. If a psychiatrist doesn’t address all these issues right from the beginning, or does not listen to the patient’s feed-back, the patient will be better off finding another psychiatrist that is more perceptive.

The three major groups of medications used to treat anxiety:

Benzodiazepines: These are the “as needed” medications. People use them in various specific situations, for example if they get anxious in planes or closed spaces. They can be used when the anxiety becomes sharp and unbearable—panic attacks. They work only for a limited period of time, 4-5 hours for Ativan or Xanax and 7-8 hours for Restoril or Valium. The most common side effect is sleepiness. Because of that, driving is not recommended after taking them. Care should be taken by the patient to understand exactly what “as needed” means for him. Benzodiazepines could be addictive.

Selective Serotonin Reuptake Inhibitors (SSRIs) are the medications from the Prozac’s family: Zoloft, Paxil, Celexa, Luvox, Lexapro. These medications need to be taken every day in order to work. With the exception of Lexapro, which works faster (about seven to ten days), all the others need about ten to fourteen days before they start working. They are used when high anxiety levels are experienced almost all day every day, with or without panic attacks. In these cases, an “as needed” medication will not be helpful enough. The SSRIs tend to increase the serotonin in the Central Nervous System and by doing that, they help “the brain relax.” The exact way of how that happens is still under research.
The possible side effects tend to be mild and transient: mild headaches, restlessness, nausea, sleepiness, to name only the most common ones. These medications are usually highly effective and well tolerated. If one of them causes side effects, switching to another medication in the same class may solve the problem.

Selective Serotonin-Norepinephrine Inhibitors (SNRI): These medications work on two receptors at the same time: serotonin and the norepinephrine receptors. They tend to have more side effects because of that. These medications are Effexor XR, Pristiq, Cymbalta. The SNRIs are not necessarily better than the SSRIs. The decision to use one versus another is made according to the severity of symptoms and past history of each patient. As always, the balance between the benefits and the potential side effects needs to be carefully considered.

None of the above medication should be taken without the advice and supervision of a physician, preferably a psychiatrist.

Whatever the medication plan decided upon, it needs to be followed consistently. Mixing any of these medications with alcohol or recreational drugs is a very bad idea. It will increase the propensity for side effects and it will decrease the efficacy of the medications.

Common mistakes in using

anti-anxiety medication:

· The starting dose is too high and the patient has side effects. Usually the side effects are not life threatening but can be very annoying: low grade headache, insomnia or excessive sleepiness, nausea and restlessness, etc. Reducing the starting dose and slowly going up to a more effective dose will help.
· In the desire to get a quick response to medications, psychiatrists sometimes increase the dose too fast. Increasing the strength in smaller increments and assessing the efficacy and the side effects at every level, will take care of this problem.
· Lack of communication between the patient and the psychiatrist can cause a great deal of mistakes in managing the medications well. The psychiatrist should encourage the patient to express his concerns. The patient should initiate a discussion of any and all concerns of his relevant to treatment and prescriptions.

The "Feeling Lost" Disorder

Do you have friends who keep saying they will do something that in reality they never do? For example, they could be saying "We always wanted to go to Paris. That would be lovely," yet every time they book their vacations, they invariably choose Chicago. Or have you heard of someone who is married for ages but always talks about divorce every time she is asked whether or not she is happy in her marriage--never divorcing, never even having an affair?

If you know people like this, you should know that they are not the exceptions but rather the norm. Often people dream of something they don't have or they would rather have, without taking any action to make that happen, and, of course, without ever being happy with what they already have. These people tend to be seriously disconnected from themselves and often very unhappy. Often people chasing the ghosts of unfulfilled dreams realize at some point they are feeling, in fact, lost in their own lives.

Whenever one of my patients starts talking about these never happening fantasy, I remind them that they are doing nothing to change. The general feeling that they are wasting their lives one way or another is, in general, prevalent.

Making new plans and getting ready to change will pave their way toward fulfilment and ultimately happiness. Using for guidance the often ignored post signs pointing them in the right direction, or the mild nudges from their best friends, they can find their way to either love what they already have or change to what will make them happier and more alive.

The good news for people suffering from the "feeling lost" disorder, is that better ways to live one's life are always available. Just open your eyes, look carefully around, expand your horizon, try a few new things and you will find your trail.

As a remainder that the right path for you is never lost, just hidden, I will give you a small gift. A talisman, rather:

This is a clover trail marker of the Clover Creek Trail, in Sequoia National Park. You can copy it and place it in a visible place, a reminder of the paths that are always there, even when you think you feel so stuck that you can't see, for a split moment, any way out. The truth is, a good way out is always there... Can you see it?