The sleep connection

Dr. Mark Mahowald notes some unusual and disturbing side effects in sleep caused by antidepressants, some temporary and some permanent. In particular, antidepressants are the leading medical cause of REM sleep behavior disorder, where people act out their dreams and can end up seriously injuring themselves. Additionally, antidepressants cause abnormal eye movements during non-REM sleep (what sleep specialists informally call “Prozac eyes“) and this side effect is permanent.

Mark Mahowald, M.D., is a neurologist and medical director of the Minnesota Regional Sleep Disorders Center and professor for the University of Minnesota Medical School.

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Experts talk about drug advertising

What’s in this video: A discussion of how direct to consumer advertising affects how care providers treat depression.

William Robiner, Ph.D., A.B.P.P., L.P., is a health psychologist and director of health psychology at the University of Minnesota Medical School.

Linda Muldoon, Ph.D., L.P., L.G.P., is a senior pychologist for the University Counseling & Consulting Services at the University of Minnesota.

David Adson, M.D., is a psychiatrist and associate professor for the University of Minnesota Medical School.

Jon Hallberg, M.D., is a family physician and medical director of Mill City Clinic, as well as creative director of the Center for Arts and Medicine, both in Minneapolis, MN.

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Experts discuss insurance concerns

What’s in this video: A discussion of the insurance issues both patients and care providers face when treating depression.

William Robiner, Ph.D., A.B.P.P., L.P., is a health psychologist and director of health psychology at the University of Minnesota Medical School.

Linda Muldoon, Ph.D., L.P., L.G.P., is a senior pychologist for the University Counseling & Consulting Services at the University of Minnesota.

David Adson, M.D., is a psychiatrist and associate professor for the University of Minnesota Medical School.

Jon Hallberg, M.D., is a family physician and medical director of Mill City Clinic, as well as creative director of the Center for Arts and Medicine, both in Minneapolis, MN.

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Experts tell us about their professions

If you feel you have depression, you have a choice of who to go to–a psychologist, a psychiatrist or your family doctor–but who should you choose? Psychiatrists have the most in-depth training on antidepressants but they generally don’t spend much time doing psychotherapy with their patients. On the other hand, psychologists strictly do psychotherapy and cannot prescribe medications. Family physicians do have training on antidepressants and diagnosing depression, though it tends to be more limited.

What’s in this video: An overview of the difference between psychology, psychiatry and family medicine, what type of training these fields receive in diagnosing depression and prescribing antidepressants, whether they refer to psychologists or psychiatrists for additional help in treating depressed patients, and a discussion of the cost of psychotherapy.

William Robiner, Ph.D., A.B.P.P., L.P., is a health psychologist and director of health psychology at the University of Minnesota Medical School.

Linda Muldoon, Ph.D., L.P., L.G.P., is a senior pychologist for the University Counseling & Consulting Services at the University of Minnesota.

David Adson, M.D., is a psychiatrist and associate professor for the University of Minnesota Medical School.

Jon Hallberg, M.D., is a family physician and medical director of Mill City Clinic, as well as creative director of the Center for Arts and Medicine, both in Minneapolis, MN.

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Experts discuss antidepressants

What’s in this video: How SSRIs work, the side effects of antidepressants, their effectiveness, the effect of placebo (dummy) treatment, and what else antidepressants are prescribed for.

William Robiner, Ph.D., A.B.P.P., L.P., is a health psychologist and director of health psychology at the University of Minnesota Medical School.

Linda Muldoon, Ph.D., L.P., L.G.P., is a senior pychologist for the University Counseling & Consulting Services at the University of Minnesota.

David Adson, M.D., is a psychiatrist and associate professor for the University of Minnesota Medical School.

Jon Hallberg, M.D., is a family physician and medical director of Mill City Clinic, as well as creative director of the Center for Arts and Medicine, both in Minneapolis, MN.

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Experts talk about treating depression

What’s covered in this video: The different methods for beginning treatment, who prescribes medication, and other considerations for treating depression.

What’s covered in this video: The nature of treatment schedules for antidepressants and psychotherapy, how many medications doctors try before finding the right balance, how long the duration of treatment typically lasts, and how to go about stopping antidepressant treatment.

William Robiner, Ph.D., A.B.P.P., L.P., is a health psychologist and director of health psychology at the University of Minnesota Medical School.

Linda Muldoon, Ph.D., L.P., L.G.P., is a senior pychologist for the University Counseling & Consulting Services at the University of Minnesota.

David Adson, M.D., is a psychiatrist and associate professor for the University of Minnesota Medical School.

Jon Hallberg, M.D., is a family physician and medical director of Mill City Clinic, as well as creative director of the Center for Arts and Medicine, both in Minneapolis, MN.

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SSRIs, SNRIs and triptans

Psychotherapy

There are many different types of psychotherapy, but they all have one thing in common: talking.

Cognitive behavioral therapy, or CBT, is the most common psychotherapy treatment for depression–and is effective. The National Alliance on Mental Illness defines CBT as a treatment “that focuses on patterns of thinking that are maladaptive and the beliefs that underline such thinking.”

Therapists help patients view their beliefs as hypotheses that must be tested instead of fact and ask them to monitor automatic thoughts in order to find patterns and biases. Ultimately, they try to replace negative thoughts with positive ones, working from the foundation that thought influences mood.

CBT has been shown to be as effective as antidepressants in treating depression. It also significantly reduces depression relapse rates–and does so better than some antidepressant medications.

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Out-of-pocket cost of therapy

The cost of antidepressants varies by type, between brand name and generic (if available) and by where they are purchased:

The cost of psychotherapy varies by therapist. Psychology Today provides an online therapy directory where you can find theraptists in your area and even sort them by specialty. A list of therapists in Minneapolis, Minn. specializing in depression shows that the out-of-pocket cost for psychotherapy ranges from $60 to $200 per session.

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Risks and side effects

While the specific cause of depression is not well understood, most researchers think that brain chemistry has something to do with it. Antidepressants work by altering the balance of certain chemicals in the brain, but with that come some risks and side effects that you should know about.

Most common side effects

Antidepressants carry with them a host of unpleasant side effects, some of which can turn into serious problems of their own. Some other side effects, like abnormal eye movement during non-REM phases of sleep (referred to as “Prozac eyes” by many sleep specialists), are permanent. A 2002 Toxic Exposure Surveillance System report revealed that of 26,733 patients on SSRIs, 27 percent developed significant morbidity and 93 died.

Most of these side effects are relatively benign, but there are more serious side effects to worry about. One study by University of Manchester outlined the many more severe side effects of antipsychotics and antidepressants, including: acute dystonia (brief or sustained muscle spasms), parkinsonism (neurological syndrome characterized by tremors), akathisia (extreme restlessness), tardive dyskinesia (involuntary, repetitive movements caused by medication), tardive dystonia (sustained muscle contractions as a result of medication), increased risk of seizure, serotonin toxicity (see below) and discontinuation symptoms (see below). Antidepressants can also cause REM sleep behavior disorder, which causes you to act out your dreams and can result in serious injuries.

Serotonin syndrome

This can be a life-threatening condition caused by high levels of serotonin in the body. It’s typically caused by combining drugs that affect serotonin levels, though it can also occur when you first start or increase medication that affects serotonin. A common dangerous combination is taking SSRIs or SNRIs (used to treat depression) with triptans (used to treat migraines). Even taking certain cough medicines (dextromethorphan) can increase this risk in combination with other serotonin medications. For a list of SSRIs, SNRIs and triptans <<click here>>.

Research done at Washington State University earlier this year (2008) found that during 2003 to 2004, 1.3 percent of patients prescribed a triptan or an SSRI or SNRI were prescribed the potentially fatal combination of the two together, a total of 694,276 patients affected.

Discontinuation syndrome

Although not common, some patients may experience withdrawal symptoms when stopping an antidepressant, particularly if the treatment is stopped too abruptly. The Mayo Clinic notes that it can be difficult to distinguish withdrawal symptoms from reemergence of depression, but that this should not be considered the same as withdrawal from an addictive substance. For these reasons, the NIMH advises gradual withdrawal of antidepressants when discontinuing treatment.

One study noted that many patients are continuing use of SSRIs well beyond the recommended duration of treatment in part due to fear of withdrawal symptoms. However, an article written by King’s College London indicated that withdrawal symptoms are in fact milder than the public generally assumes and can be easily managed by slowly tapering off medication.

Paroxetine (Paxil) appears to be the most prone to discontinuation syndrome, perhaps because it is the most potent inhibitor of serotonin reuptake among SSRIs. Paroxetine efficacy is similar to other SSRIs, though it is approved for a wider variety of disorders, including major depression, obsessive-compulsive disorder, panic disorder, generalized anxiety disorder, post-traumatic sterss disorder and social phobia.

Risk of suicidality

The FDA reported results from a series of clinical trials that showed a 4 percent risk of suicidality in children and adolescents taking antidepressants, as compared to a 2 percent risk with placebo.

According to the NIMH, fluoxetine (Prozac) is currently the only antidepressant approved by the FDA for use in children ages 8 and older.

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Experts talk about diagnosing depression

What’s covered in this video: The criteria for diagnosing Major Depressive Disorder, related depressive symptoms, what the experts think about that criteria, the type of people more often diagnosed, and how they go about diagnosing depression.

What’s in this video: Discussion of whether depression is over-diagnosed, misdiagnosed, or over-medicated.

William Robiner, Ph.D., A.B.P.P., L.P., is a health psychologist and director of health psychology at the University of Minnesota Medical School.

Linda Muldoon, Ph.D., L.P., L.G.P., is a senior pychologist for the University Counseling & Consulting Services at the University of Minnesota.

David Adson, M.D., is a psychiatrist and associate professor for the University of Minnesota Medical School.

Jon Hallberg, M.D., is a family physician and medical director of Mill City Clinic, as well as creative director of the Center for Arts and Medicine, both in Minneapolis, MN.

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Insurance coverage

Antidepressants are prescription medications that are covered by insurance in the same way and at the same rate as other prescription drugs. However, other treatments for depression–such as psychotherapy, other behavioral therapy and alternative treatments–are not always covered as fully as biomedical services.

Two major providers of health insurance in Minnesota, HealthPartners and Blue Cross and Blue Shield of Minnesota, appear to cover mental and behavior health services as well as biomedical services in their most popular plans.

HealthPartners’ Traditional plan, at a $1,000 deductible level, and Blue Cross’ comparable Aware Care, also with a $1,000 deductible, both cover 80 percent of mental and behavioral health services (after deductible, and up to the out-of-pocket maximum)–the same coverage they afford to most other services. While some companies and plans restrict the number of psychotherapy appointments that are covered, for example, both the HealthPartners and Blue Cross plans cover unlimited appointments within their provider networks.

Coverage for mental health services should improve across the board, thanks to a new law passed along with the recent government bailout bill that, for the first time, requires mental and physical health to be covered equally by insurance.

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The culture of depression and treatment

Mac Baird M.D., M.S., professor and head of Family Medicine and Community Health at the University of Minnesota, discusses the American culture surrounding depression diagnosis and treatment–and how that differs from the rest of world’s:

Alternative therapies for depression

Though they are understudied compared to drugs, several alternative therapies have shown promise in the treatment of depression. Perhaps their largest draw is that while it can be unclear whether or how much they help, they usually don’t hurt.

Side effects are minimal, and alternative therapies are often less expensive than biomedical treatment. According to a 2004 brief by the Center for Studying Health System Change, 6 million Americans sought alternative treatments in 2002 because of concerns about the rising cost of traditional health care.

Promising alternative therapies include:

• Supplements (such as St. John’s wort and S-adenosyl- L-methionine, or SAMe)
• Physical activity
• Stress reduction techniques (such as meditation)
• Acupuncture
• Massage
• Diet and nutrition
• Music therapy
• Art therapy

Related material: There are other options.